Bridging the Gap between Clinical and Developmental Perspectives: The Case of Social Phobia on Campus

1. Bridging the Gap between Clinical and Developmental Perspectives: The Case of Social Phobia on Campus Don Stewart and Mike Mandrusiak Student Counselling and Career Centre University of Manitoba June, 2007

2. Bridging the Gap between Clinical and Developmental Perspectives: The Case of Social Phobia on Campus • We intend to use social phobia as an illustration of how clinical and developmental perspectives can guide our conceptualization and interventions regarding student concerns • We hope to demonstrate how both perspectives are valid and necessary to fully address student concerns on campus • We hope to show how Student Affairs professionals, with their knowledge of student development, are uniquely positioned to bridge this gap and enhance service offerings to students

3. Overview of Presentation • Discussion of Social Phobia, including diagnostic criteria, prevalence and comorbidity data, and results from our research • Discussion of clinical and developmental perspectives, including strengths and weaknesses and sample interventions • Case study example to aid in distinguishing whether a clinical or a developmental approach may be most appropriate • Questions and discussion

4. Building a Case for the Case of Social Phobia • Why use social phobia as an illustration of the clinical-developmental perspective clash? • It is common • It is potentially very serious • It has elements that can be understood from either a clinical or a developmental perspective • It provides an opportunity to distinguish clinical symptoms from developmental issues -- an essential skill for clinicians in postsecondary settings

5. What is Social Phobia? • Persistent and excessive fear of social situations • Avoidance or intense discomfort and/or anxiety/panic attack • Recognition that the fear is excessive or unreasonable • Interference with normal routine, relationships, social activities or occupational or academic functioning • At least 6 months duration - DSM-IV-TR (APA, 2000)

6. Context • Fear of evaluation in: • Performance situations • Eg. Public speaking • Other social settings • Group social events • Other social interactions (eg. Eating w/ someone) • Generalized Social Phobia

7. Social Phobia and Cognition • From Clark and Wells (1995): • Unrealistic standards • Preoccupation with how one is perceived by others • Negative self-evaluation of performance in social settings

8. From http://www.wvu.edu/~ccpsych/Morris%20lab%20index.htm

9. Why is Social Phobia a Significant Concern for Student Affairs Professionals?

10. #1: Comorbidity • Individuals with social phobia often also experience mood disorders, other anxiety disorders and substance use disorders • 52% experienced one other disorder in their lifetime (Chartier, Walker & Stein, 2003) • Social phobia tends to precede comorbid mood disorders(71%) and substance use disorders (80%) (Stein et al, 2001) • Risk factor or indicator of incipient onset of other disorders?

11. #2: Chronicity and Severity • Full remission is rare (Wittchen & Fehm, 2003) • Widespread impairment and decreased quality of life • Enhanced risk for: • Decreased work productivity/ unemployment • Divorce and decreased satisfaction in relationships • Decreased satisfaction with leisure activities

12. #3: Prevalence in College-Aged Samples • Lifetime prevalence of 13% (APA, 2000) • More common in samples with higher percentages of adolescents and young adults (Wittchen & Fehm, 2003) • Typical age of onset: Mid-adolescence • Symptoms of social anxiety occur very frequently in college populations (Purdon, Antony, Monteiro & Swinson, 2001)

13. What does our own Research tell us about Social Phobia on Campus? • Began collecting data on social phobia in 2000 • Initially looked at symptom levels in students presenting for general intake • Found a very high level of symptoms – 47% of the respondents scored in the clinical range on the SPIN • Level of SP was correlated with poor adjustment, anxiety, depression, somatic concerns, egocentrism, and difficulty describing feelings

14. More from our Research… • We were surprised by the high levels of symptoms and level of impairment in our clinical sample • Accessed a sample of undergraduates not seeking service and administered the SPIN to them • Results indicated that 42% scored in the clinical range! • We began to wonder about the possibility of an epidemic of social phobia on our campus…

15. Still more from our Research… • Could levels of SP really be so high? • A literature review provided an alternative perspective: • Caution must be exercised in identifying SP among our students • Significant levels of social anxiety are normative • Clinical thresholds need to be re-evaluated for our population • Using a more conservative criterion, rates of SP in our samples dropped from 42% to about 23% • Using a diagnostic-referenced cutoff, rates dropped to 13% for clinical sample and 5% for non-clinical sample

16. So We Concluded from our Research… • Levels of social anxiety on campus are very high • Levels of social phobia on campus are consistent with prevalence rates in the general population • Social anxiety vs. Social phobia: an important distinction • Interventions for both should be offered on campus • Both clinical and developmental perspectives are necessary to properly address the issue

17. Some Perspective on Perspectives • What is the ‘clinical’ perspective? • Pathology-oriented • Symptom-focused • Treatment stems from diagnosis • Associated with the ‘medical model’ • What is the ‘developmental’ perspective? • Contextually and normatively focused • Life-span oriented • Associated with an ‘ages and stages’ model

18. What are the Advantages and Disadvantages of the Clinical Perspective? • Major advantages: • Systematic way of organizing information about clients • Provides focus, goals, and structure in treatment planning • Consistent with ‘evidence-based’ approaches • Major disadvantages: • Reductionistic • Ignores context of client issues • Overpathologizes clients

19. What are the Advantages and Disadvantagesof the Developmental Perspective? • Major advantages: • Understands people in context • Growth-oriented • Allows for substantial variability within ‘normalcy’ • Major disadvantages: • Normalizes ‘everything’(even pathology) • Treatment planning/goals more difficult to derive • Seen as ‘unscientific’ and ‘soft’

20. Summary Perspective on Perspectives • Both clinical and developmental perspectives have something to offer • If only one perspective is employed, however, there is a risk for students: • Students with diagnosable SP may not get needed treatment • Students with normative social anxiety may be unnecessarily pathologized • Flexible campus response allows for a range of interventions depending on level of need

21. How can We tell the Difference between Social Anxiety and Social Phobia? • Joe is a 21- year old third year student studying Biology. He seeks the help of his advisor to determine whether or not to drop his Bio 320 course. The course involves a 10-minute class presentation as a final project. Joe explains that he is very nervous about speaking in public, especially when he is being evaluated. He said that he has had bad experiences with this in the past, and described a situation when he got tongue-tied, forgot his place in the speech, started shaking and sweating, and was laughed at by some classmates. He has avoided speeches ever since, and is very worried about being embarrassedagain.

22. In addition… • Joe scored in the clinical range on the SPIN, strongly endorsing such items as: • I am bothered by blushing in front of people • Being criticized scares me a lot • Sweating in front of people causes me distress • I avoid having to give speeches • Being embarrassed or looking stupid is among my worst fears • Trembling or shaking in front of others is distressing to me

23. Social Phobia criteria: Fear of evaluation, looking anxious, being embarrassed Feared situation provokes anxiety Person recognizes that fear is excessive Feared situation is avoided or endured with intense distress Normative Social Anxiety: Fear of evaluation, looking anxious, being embarrassed Feared situation provokes anxiety Person recognizes that fear is excessive Feared situation is avoided or endured with intense distress So, what should We Look for?

24. Limitations of a Strictly Diagnostic Approach • Ignores context, both developmentally and environmentally • Consider that: • Identity issues and insecurity are normative • Sensitivity to peer impressions is very high • Ability to manage emotions is limited • Evaluation sensitivity is heightened • Pressure to perform well is high • Self-doubt is similarly high

25. Basic Guidelines to Consider in Distinguishing between Social Anxiety and Social Phobia • When did the problem start? • Where is it most evident? • Have others in the student’s life noticed or expressed concern? • How has the student been trying to deal with it? • What is likely to happen if this is not addressed? • How limiting is this in the student’s life?

26. Developmental Interventions for Social Anxiety • Basic elements involve: • Normalizing • Validating • Skill-building • Sample interventions: • Accessing existing resources • Orientation programming • Skills for success programs • Communication training

27. Clinical Interventions for Social Phobia • Basic elements involve: • Clear diagnosis and evidence of functional impairment • Sample interventions: • Pharmacotherapy • SSRIs (Effexor, Luvox, Paxil) • Cognitive-Behaviour Therapy • Individual vs. Group

28. Concluding Comments • Social Anxiety is a pervasive phenomenon on campus • Some socially anxious students may meet criteria for Social Phobia • Most socially anxious students are experiencing normative reactions to contextual and developmental challenges • Some students require a clinical intervention • Most students will benefit from developmental and skills-building programs to facilitate successful resolution of their normative challenges • Student Affairs units have a substantial role to play in addressing social anxiety on campus • Social anxiety is but one example of common student concerns that could benefit from a balanced clinical/developmental perspective