The test of courage comes when we are in the minority. The test of tolerance comes when we are in the majority. - Ralph Sockman
In May 2013, the National Institute for Health and Clinical Excellence (NICE) published a new evidence-based clinical guideline on "Social anxiety disorder: recognition, assessment and treatment". They state: "This clinical guideline offers evidence-based advice on the recognition, assessment and treatment of social anxiety disorder in children and young people (from school age to 17 years) and adults (aged 18 years and older). It includes a recommendation on the treatment of specific phobias that updates and replaces the section of NICE technology appraisal guidance 97 that deals with phobia." I discuss the guideline and provide a series of useful links in the blog post "New NICE guidance on the recognition, assessment and treatment of social anxiety disorder".
On this page there are a collection of relevant information sheets, handouts and questionnaires. As I write in the "Diagnosis & background facts" sheet below - "About 7% of the population qualify for a full formal diagnosis of social anxiety disorder in any one year, but even those who suffer from what qualifies as only a partial syndrome can have their lives significantly affected. Social anxiety disorder makes sufferers more vulnerable to subsequent depression and, when comorbid, the depression tends to be more severe and more resistant to treatment. There may well also be comorbidity with other anxiety disorders. Social anxiety disorder is frequently not diagnosed even though it is disabling and well worth treating."
Diagnosis & background facts - this handout gives the criteria for a DSM-IV diagnosis of social phobia/ social anxiety disorder. It also gives the abstracts of four research studies illustrating how common and troublesome social anxiety can be.
I went to a workshop on the treatment of social anxiety disorder with David Clark in July 2013. It was very helpful. I've listed assessment & monitoring questionnaires that he recommended below:
As a general measure to assess and track changes in social anxiety severity, the freely available Social Phobia Inventory (SPIN) is the questionnaire recommended by the England & Wales NHS Improving Access to Psychological Therapies (IAPT) "outcomes toolkit". Interestingly David seems to prefer the Liebowitz Social Anxiety Scale (LSAS) probably because it makes a pretty full job of assessing both anxiety and avoidance.
Social Phobia Inventory - SPIN - (PDF file and Word doc): a widely used, freely available 17 item questionnaire for assessing social anxiety disorder. On the second sheet of the download, I give suggestions about what the different levels of score mean.
Liebowitz Social Anxiety Scale - LSAS - (PDF file and Word doc): this 24 item questionnaire assesses both social anxiety and avoidance. It's good and is widely used in clinical trials. On the second sheet of the download, I give scoring suggestions and some information about improvement.
Participants on David's July workshop were subsequently sent copies of four further questionnaires he recommends using. These measures were emailed as a Word doc attachment in Arial font printing out as "letter" sized handouts. They are available to download in this format here. I have also rewritten them in my preferred Tahoma font printing out as A4 sized documents and have listed them individually below:
Social Phobia Weekly Summary Scale (PDF file and Word doc): this 6 item questionnaire uses 0 to 8 numerical rating scales to assess disturbance/disablement, avoidance, other-focused/self-focused attention in general & in difficult social situations, pre-event anticipatory worry, and post-event subsequent rumination.
Social Cognitions Questionnaire (PDF file and Word doc): this questionnaire assesses the frequency and degree of belief in 22 thoughts that may go through people's minds when they feel socially frightened or anxious. There is additional space for writing down and rating less common, more personalized "catastrophic" social concerns.
Attitudes Questionnaire (PDF file and Word doc): an extensive 50 item assessment form. The instructions state - "This questionnaire lists different attitudes or beliefs which people sometimes hold. Read each statement carefully and decide how much you agree or disagree with each one ... Because people are different, there is no right or wrong answer to these statements. To decide whether a given attitude is typical of your way of looking at things, simply keep in mind what you are like most of the time."
Behaviours Questionnaire (PDF file and Word doc): this questionnaire assesses the frequency of 28 "safety behaviours" that people suffering from social anxiety may perform. It is suggested that these behaviours often seem like they help the anxiety in the short term, but in the longer term there is a real danger that they maintain the problem.
David also gave us a book chapter handout entitled "The assessment interview and getting started". Interestingly in the table on "Standardized questionnaires that are useful for collecting information in advance of the Clinical Interview" he mentions the LSAS, Cognitions, Attitudes, and Behaviours Questionnaires (all listed above). This group of four questionnaires seems to be the standard assessment bundle (plus the Weekly Summary Scale). They can be partly concentrated down to the Social Anxiety Overall Summary sheet (see below) and then individualized still further when completing the Social Anxiety Flow Chart (below).
However in the chapter table, the assessment list also includes the Beck Depression Inventory and the 1998 Mattick & Clarke Social Phobia Scale and Social Interaction Anxiety Scale. Many therapists will have alternative assessment instruments for depression other than the relatively expensive copyrighted Beck Inventory - for example IAPT recommends the PHQ-9. At the risk of gilding the lily, here are the two Mattick & Clarke questionnaires, which can in some situations provide additional useful assessment, monitoring & treatment planning details:
Social Phobia Scale (PDF file and Word doc) and the Social Interaction Anxiety Scale (PDF file and Word doc): these two 20 item scales assess social situations and aspects of social situations that are anxiety provoking.
Even if one only uses some of the above questionnaires, there is now a lot of information that has been recorded. In the book chapter handout we were given, it is suggested that it may be helpful to summarize much of what is most important from this extensive initial assessment on the following sheet:
Social Anxiety Overall Summary (PDF file and Word doc): this form provides a place to summarize information from the various questionnaires under the four general headings - feared situations, avoided situations, negative thoughts (worst fears), and safety behaviours.
Now as a cooperative effort with the social anxiety sufferer, it is recommended that one draws out a "flow chart" of what happens when they become particularly self-conscious & embarrassed. Many cognitive therapists will do this using a wall mounted whiteboard. There are advantages to developing the flow chart this way - for example in externalizing the problem and side-stepping what might feel, to the client, an over-intense eye-to-eye interview. My preference is to sit beside the client and draw out the flow chart on a piece of paper (see below) held on a clipboard. Using this format one has a sheet that can be photocopied and handed to the client to take away, think about and potentially add to. Producing the social anxiety flow chart together may well take 40 minutes or so to do well. At this stage, it is a process of description and "finding out" together rather than an explanation. Try not to rush the process - when it's done well it can lead to the sufferer feeling very understood. It is recommended that one select a specific example of a socially embarrassing situation that the client has experienced and can remember fairly easily (a recent event is often good to focus on here). One starts with a brief description of the situation (top of flow chart). Moving on to the physical anxiety symptoms that were experienced may well be a good next step (interestingly the Beck Anxiety Inventory may be useful here too). Then one can enquire and fill in details of thoughts (about perceived social dangers) and sense of self-consciousness (quite possibly linked with an image and/or felt-sense about how one is coming across to others). One might then move on to producing quite an extensive list of safety behaviours that were involved. One can add further information from other social anxiety events they have experienced and it may well be useful to give them the sheet to take home and add to after they have been through new socially challenging experiences.
Also likely to be useful is a sheet that can be used for recording behavioural experiments - a core component of this highly successful cognitive therapy treatment for social anxiety disorder:
And lastly in this list, is a copy of the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP). To measure therapist skill in treating social anxiety, Clark & colleagues have impressively developed a specific assessment scale - see "Assessing therapeutic competence in cognitive therapy for social phobia: Psychometric properties of the cognitive therapy competence scale for social phobia (CTCS-SP)." Then, crucially, they have shown that skill measured in this way is predictive of patient outcomes - see "Treatment specific competence predicts outcome in cognitive therapy for social anxiety disorder." As the authors of the "Treatment competence" paper comment " ... informal use of the cognitive therapy rating scale by students themselves is likely to be helpful. Certainly, we have found that many therapists who are learning CT for social anxiety learn a great deal about how particular procedures should be implemented by studying the particular items on the CTCS-SP and rating their own sessions according to the scale."
Besides this core series of questionnaires, here are a further few odds & ends:
The Mini-SPIN is a three item Social Phobia screening questionnaire. Here are downloadable Word doc and PDF file versions. I tend not to use the Mini-SPIN much. Possible social anxiety disorder is typically picked out when I give new clients the much more inclusive and general MINI screening questionnaire and talk to them about their symptoms. I may be wrong. Possibly I should use the Mini-SPIN more often.
10 tips for public speaking & other ideas - see the international Toastmasters website. Much more helpful than their suggestions sheets is the opportunity Toastmasters provides for real life practice and desensitization. I have encouraged and seen many social anxiety sufferers benefit from going to their local branch of Toastmasters. See the site for links to local groups in many different countries.
Blushing information - here are five research studies providing reinforcing evidence for a CBT conceptualization of blushing and social anxiety. This handout can be helpful for people who struggle with concerns about blushing.
Social avoidance scale - I can't actually remember where this scale comes from. I suspect that I put it together as an adaption of Ost's Agoraphobia Scale. This scale has obvious applications both for initial assessment, for monitoring progress, for desensitization/exposure work, and for behavioural experiments.
SPRS - I often use this questionnaire, developed by Adrian Wells - particularly to help clarify people's catastrophic fears and "safety behaviours".
You may well find further useful ideas & suggestions by clicking this website's tag on "social anxiety" and Gillian Butler's books are a helpful self-help (or better still - guided self-help) resource.