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Fearing Others
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Details

  • 29 tables
  • Page extent: 450 pages
  • Size: 228 x 152 mm
  • Weight: 0.854 kg

Library of Congress

  • Dewey number: 616.85/225
  • Dewey version: 22
  • LC Classification: RC552.S62 S77 2007
  • LC Subject headings:
    • Social phobia
    • Social phobia--Treatment
    • Phobic Disorders
    • Interpersonal Relations
    • Social Isolation--psychology

Library of Congress Record

Hardback

 (ISBN-13: 9780521854870)

Fearing Others
Cambridge University Press
978-0-521-85487-0 - Fearing Others: The Nature and Treatment of Social Phobia - by Ariel Stravynski
Front Matter

Fearing Others


Social phobia and disruptive social anxiety are features of the lives of many thousands of people. But exactly what is social phobia? What causes it? What is its nature and what kinds of treatments can improve it? Using key concepts and methods and a substantive body of research, this book aims to answer these questions and clarify social phobia by means of critical discussions and examination of evidence. It takes a skeptical stance towards the received view of social phobia as a species of disease caused by a deficient inner mechanism and considers and alternative construal of social phobia as a purposeful interpersonal pattern of self-overprotection from social threats. The possibility that social phobia might not actually exist in nature is also considered. Fearing Others will appeal to researchers, clinicians, and students in clinical and health psychology and psychiatry.

ARIEL STRAVYNSKI is Professor of Clinical Psychology in the Department of Psychology at the University of Montreal.





Fearing Others

The Nature and Treatment of Social Phobia


Ariel Stravynski
University of Montreal





CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, Sāo Paulo

CAMBRIDGE UNIVERSITY PRESS
The Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America by Cambridge University Press, New York

www.cambridge.org
Information on this title: www.cambridge.org/9780521671088

© Ariel Stravynski 2007

This book is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.

First published 2007

Printed in the United Kingdom at the University Press, Cambridge

A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication data

Stravynski, Ariel, 1949–
Fearing others: the nature and treatment of social phobia / Ariel Stravynski.
    p. ; cm.
 Includes bibliographical references and index.
 ISBN-13: 978-0-521-85487-0 (hardback: alk. paper)
 ISBN-10: 0-521-85487-3 (hardback: alk. paper)
 ISBN-13: 978-0-521-67108-8 (pbk.: alk. paper)
 ISBN-10: 0-521-67108-6 (pbk.: alk. paper)
 1. Social phobia. 2. Social phobia–Treatment. I. Title.  [DNLM: 1. Phobia Disorders. 2. Interpersonal Relations. 3. Social Isolation–psychology. WM 178 S912f 2006]

 RC552.S62S77 2006
 616.85′225—dc22
                           2006038543

ISBN-13 978-0-521-85487-0 hardback
ISBN-13 978-0-521-67108-8 paperback

Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this book, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.





To my wife and to the memory of my mother – who taught me to read.





Epigraph


“Brave, carefree, mocking, forceful – this is how wisdom wants us to be.”

                       Friedrich Nietzsche





Contents




List of tablespage xi
Acknowledgmentsxiii
Prefacexv
 
Part I   What is Social Phobia?1
 1  Social Phobia: a Self-Protective Interpersonal Pattern3
 2  The Genealogy of Social Phobia16
 
Part II  What is The Nature of Social Phobia?25
 3  Social Phobia as a Disorder of Social Anxiety27
 4  Social Phobia as a Disease67
 5  Social Phobia as a Hypothetical Construct75
 
Part III  What Causes Social Phobia?141
 6  Social Phobia as a Consequence of Brain Defects with Graciela P īneyro143
 7  Social Phobia as a Consequence of Cognitive Biases184
 8  Social Phobia as a Consequence of Inadequate Social Skills225
 9  Social Phobia as a Consequence of Individual History246
 
Part IV  What Helps Social Phobic Individuals?287
10 The Treatments of Social Phobia: Their Nature and Effects289
 
Part V   Concluding Remarks335
11 Conclusions and Integration337
 
References359
Author Index407
Index424




Tables



 5.1 Main defining criteria of social phobia in the International Classification of Diseases (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)page 76
 5.2 A conceptual outline of validity elements and ways of testing them81
 5.3 Reliability: agreeing about the entity of social phobia86
 5.4 Predictors of response to treatment95
 5.5 Social phobia in the family99
 5.6 Association of social phobia with other disorders106
 5.7 Social phobia as distinct from other disorders116
 5.8 Prevalence of social phobia among adults (community)126
 5.9 Prevalence of social phobia among adults (clinical)131
 6.1 Direct and indirect measures of neurotransmitter systems146
 6.2 Panicogenic challenges: peptides probes155
 6.3 Measurements of neuroendocrine function158
 6.4 Neuroimaging studies160
 6.5 Approaches to the study of genetic transmission and respective quality of evidence174
 6.6 Studies of genetic transmission179
 7.1 Comparative cognitive outcome of exposure and cognitive modification212
 7.2 Comparative cognitive outcome of treatment packages with a cognitive component and other treatments214
 7.3 Comparative cognitive outcome of cognitive and pharmacological therapies217
 7.4 Cognitive effects of pharmacotherapy (FNE)218
 8.1 Psychometric characteristics of the Scale for Interpersonal Behavior (SIB)230
 8.2 Psychometric characteristics of the Simulated Social Interaction Test (SSIT)233
 9.1 Family characteristics and their relationship with social phobia, avoidant personality disorder and social anxiety264
10.1 Comparative outcome of psychological approaches – anxiety reduction293
10.2 Comparative outcome of psychological approaches – improving social functioning301
10.3 Comparative outcome of pharmacological approaches – anxiety reduction307
10.4 Comparative outcome of various classes of medication319
10.5 Undesirable effects of medication321
10.6 Comparative outcome of psychological and pharmacological approaches322




Acknowledgments


I got underway during sabbatical leave and completed the book while on sabbatical leave – 7 years later. I thank the University of Montreal for this enlightened policy.

Much of the writing took place at the Fernand-Seguin Research Centre of the L. H. Lafontaine Hospital. I am much obliged to the directors of both Centre and Hospital, for creating conditions propitious to such a sustained intellectual effort.

Marc-Yvan Custeau, Jacqueline Rochefort and their colleagues at the library of the L. H. Lafontaine Hospital were most helpful in tracing and obtaining numerous articles from not always easily accessible journals.

Suzanne Lepage coordinated the making of the book while uncomplainingly typing and retyping references, valiantly struggling to match them with the ever-changing text. Her helpfulness and constancy are much appreciated.

I have learned much about fear and self-protection from Devi. On a more abstract plane, I have been enriched by the work of Isaac Marks, Howard Rachlin and Theodore Kemper; I wish to acknowledge these intellectual debts.

In my attempt to assimilate a vast range of publications, I have been assisted most ably and with unwavering dedication by Suzie Bond and Danielle Amado. Starting off as students, they became discerning critics and collaborators. This book would not be the same without them.

I am grateful to Nira Arbel for reading the whole manuscript and helping to straighten crooked sentences and clarifying obscurities.

I wish to thank Kieron O’Connor and Mark Freeston (chapter 7), Frank Vitaro (chapter 9) and David Greenberg (chapters 4 and 5) for their incisive comments on parts of the manuscript.

Nonetheless, errors either obstinately committed or ones of oversight are mine alone.

Chapter 8 is an updated and substantially modified version of chapter 6 in S. G. Hofmann & P. M. DiBartolo (Eds.), From social anxiety to social phobia: multiple perspectives. Boston: Allyn & Bacon, 2001. It is reprinted with the permission of the publishers.


Preface

Although the term social phobia was coined early in the twentieth century, it first found little resonance. A seminal paper authored by Marks & Gelder (1966) sparked off the modern interest in social phobia. It culminated in the creation of a clinical entity bearing that label in the DSM-III. Soon followed by the ICD-9, this formal recognition by influential institutions – respectively, the American Psychiatric Association (APA) and the World Health Organization – proved to be a watershed. Starting with a trickle – to stay with the water imagery – the stream of publications has turned to flood and continues unabated, threatening by its very abundance. For what does all this information amount to? Unfortunately, we cannot hope for knowledge to result from the accumulation of information ordering itself in a meaningful, intelligible way. The organization of the bits (of information) in different patterns while articulating the logic inherent in them and considering them critically is a task separate from the production of information. Has the wealth of research broadened and enriched our knowledge? Has it deepened our understanding? To answer these questions, we must pause, to take stock and consider. This is the main purpose of this book.

Is there really such a disease entity as the “diagnosis” purports to identify? Is social phobia a valid entity (as opposed to a fanciful albeit popular construction driven by various interests)? The vast majority of studies approach the reality of social phobia unquestioningly. Such a bold assumption, however, requires justification. After all, the history of medical psychology and psychiatry is littered with discarded entities once fashionable and carrying great conviction, and new ones (e.g. fibromyalgia) proclaimed – or is it discovered – regularly.

Can we pin down with greater accuracy what is social phobia? In what sense is it an “anxiety disorder”? Is it a clinical problem in its own right or perhaps a feature of some other entity or even entities? Causal accounts of social phobia abound; are they equally valid? These are some of the queries that need to be answered.

To attempt this, the book is structured mostly as a series of critical discussions centering on four questions: What is social phobia? What is its nature? What causes it? And what kinds of treatments are likely to help?

The best approximation to an accurate answer is likely to be achieved by viewing it from various angles. Accordingly, I have considered multiple theoretical approaches towards answering each question. Specifically, I have selected only approaches that lend themselves to critical assessment, by providing key concepts, methods for their measurement and a substantive body of research. In each case, the specific chapter includes an analysis of the key theoretical concept underpinning the approach, followed by a discussion of its assessment (the two are inextricably linked) and finally an examination of the available evidence.

Although useful for analytic purposes, such separation of perspectives is artificial and, if taken beyond a certain point, barren. What is to be gained in terms of understanding by ignoring, for example, awkward results arising from a rival perspective? Ultimately, the various perspectives are at their most illuminating when cross-referenced and considered as a meaningful whole. Thus, integration is the second purpose of this book. Although it will be attempted piecemeal throughout, the concluding chapter will be devoted to such a synthesis.

Perhaps the reader might be curious at this point to know something about where I stand. In a nutshell, I would describe my approach as naturalistic; I incline towards observing life as it is lived – rooted in its natural and social habitat. This requires a certain discipline: observation must take precedence over speculation.

As to substance, I take it as incontrovertible fact that only whole living beings – as opposed to minds or brains for instance – are afraid. Similarly, self-protection from harm is something only whole living creatures are capable of. Fearing and protecting oneself are ways of representing an integrated corporeal activity. Such response is elicited by and directed toward danger – either tangible or one foreseen. In the latter case the fearful reaction is acted out imaginatively. Fearsome circumstances and fearfulness form a unity. Attempting to understand fear without reference to the object of fear (i.e. the dangerous context) is inadequate and unsatisfactory; if elevated to principle, misguided. To paraphrase Schoppenhauer, an inquiry into fear “in between the pages of which one does not hear the tears, the weeping, the gnashing of teeth and the din of mutual universal murder” is hardly worthy of that name. Has not fear evolved and proven its worth in the context of precisely such a monstrous, murderous reality extended over millennia?

After this exposition of first principles, I shall turn to the content itself. Although much research strains to explain social phobia, astonishingly there are hardly any definitions or even descriptions of it. Paradoxically, methods of assessment have been developed but what do these measure? What then is social phobia? Clearly, there is some uncertainty about it. Part I attempts to fill the gap. Chapter 1 systematizes the description of social phobia as an integrated and extended fearful interpersonal pattern aimed at self-protection. It argues that social phobia gains from being considered holistically and contextually while emphasizing the purposeful nature of social phobic conduct as a way (albeit inadequate) of managing the terrors arising from concrete social situations. The chapter sharpens the description of social phobia in contrasting available cases from different cultures highlighting similarities and unique responses to culturally defined social demands. Chapter 2 traces the historic evolution of the notion of social phobia and its equivalents (mostly from the end of nineteenth century France) in the context of a rising interest in anxiety-related phenomena and the desire to give them a medical footing. It traces the links between that historic movement in medicine and the modern formulation of social phobia.

In part II several ideas about the nature of social phobia (i.e. what category does it belong to) are examined. Chapter 3 considers social phobia as a disorder of social anxiety – the most common construal of social phobia today. It analyzes the concept of social anxiety that underpins this perspective, with a related inquiry into issues concerning its assessment. Then, key questions concerning the existence of a specific social phobic kind of anxiety and whether it is distinguishable from normal anxieties (and other kinds of pathological anxieties) are raised.

Many treat social phobia as a disease; chapter 4 examines the grounds for considering it as such. As a preliminary, the chapter analyzes the notion of disease and its assessment (e.g. diagnosis, validating tests). Subsequently, various definitions of disease are considered and relevant research examined so as to determine whether social phobia might be considered one.

Social phobia is taken (in practice) by many as a valid natural entity recently discovered. Its validity however is not self-evident; nor does the fact that it is listed in diagnostic manuals provide proof of it. Chapter 5 examines whether there are grounds for considering social phobia a valid entity at this time. It starts from the premise that the validity of social phobia must be considered hypothetical and, therefore, put to a test, rather than assumed. It then proceeds first to outline a procedure for the process of validation of a hypothetical construct and, second, to examine critically all relevant research.

Part III is concerned with various attempts to elucidate what might cause social phobia. Chapter 6 outlines the biomedical view, highlighting the two related features central to its account of social phobia: neurobiological abnormalities (specifically brain abnormalities) and the possibility of their genetic transmission. Relevant evidence is critically reviewed. Chapter 7 outlines the cognitive account of social phobia as an instance of distorted thinking. The assessment of cognitive processes deemed central to social phobia as well as difficulties inherent in the measurement of thought in general are discussed and relevant evidence is considered critically. Chapter 8 outlines the account of social phobia as an instance of inadequate social skills. The chapter emphasizes the measurement of social skills while critically summarizing all relevant research. Chapter 9 examines historical accounts of social phobia. Two theoretical approaches are considered within a broad developmental perspective: the cornerstone of the first is the notion of temperament, and of the second, attachment. The assessment of each is set forth in detail and all relevant research is critically examined.

Part IV deals with treatment. Chapter 10 briefly describes available pharmacological and psychological approaches. These have been selected for having an extensive empirical basis of controlled studies documenting their effects. These are critically discussed.

Part V (Chapter 11) synthesizes themes previously considered in isolation. It ends with an integrated account that accords with current knowledge about what social phobia is, how it comes about, and the available treatment strategies most suited to it.


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