Changes in Individual Social Anxiety Processes Associated With Successful Treatment

Young female psychiatrist talking with despair patient
Data from a multisite study of the effectiveness of cognitive behavioral therapy (CBT) support process-focused CBT as a means of reducing social anxiety.

Changes in specific processes based on the cognitive model of social anxiety disorder (SAD) predicted subsequent symptom improvement with cognitive behavioral therapy (CBT), per study data published in the Journal of Affective Disorders. In particular, reduction in avoidance had a marked impact on future decrease in social anxiety.

The investigators analyzed data from patients with SAD (n=61) who participated in a multisite study of CBT effectiveness in primary care. Per trial protocol, patients received 9 weeks of guided self-help CBT. Changes in core SAD processes were measured at baseline and weekly during treatment with an online survey platform. The Social Probability and Cost Questionnaire measured the estimated probability and cost of negative social events; the Safety Behavior Questionnaire captured the use of safety behaviors. The Social Phobia Weekly Summary Scale was used to assess 4 maintenance factors: anticipatory processing, post-event processing, self-focused attention, and avoidance. Linear mixed effects models were used to examine the within-person effects of each SAD process on weekly symptom change.

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Of the 61 study patients, 37 (60.7%) were women, and mean patient age was 33.3±10.5 years. Mean reported age at SAD onset was 15.2±7.5 years. Subsequent symptom change was predicted by 5 of 7 studied processes: estimated probability of negative social events, estimated cost of negative social events, self-focused attention, avoidance, and safety behaviors. Avoidance also significantly predicted change in social fear in subsequent surveys. A 1-point reduction in an individual’s average safety behavior score correlated with a 3.7-point reduction in social anxiety the following week. Of note, anticipatory and post-event processing were not significantly predictive of subsequent symptoms (both P =.13). In the reverse direction, reductions in social anxiety predicted subsequent reductions in 4 processes: estimated probability, estimated cost, self-focused attention, and safety behaviors. These results suggest a “reciprocal influence” between SAD processes and outcomes.

These data support process-focused CBT as a means of reducing social anxiety. The small sample size prevented analyses of interrelations between SAD processes. Even so, these results suggest that targeting SAD processes may be crucial for the effective treatment of social anxiety with CBT.  


Santoft F, Salomonsson S, Hesser H, et al. Processes in cognitive behavior therapy for social anxiety disorder: predicting subsequent symptom change. J Anxiety Disord. 2019;67:102118.