علل شناختی هراس اجتماعی: نقد مقالات

This review examined critically studies issuing from the cognitive therapy (CT) model claiming to have unveiled cognitive causal factors of social phobia. Additionally, it examined outcome studies of CT-inspired interventions and other treatments having included measurements of cognitive constructs. Overall, we found no evidence consistently supporting the claim that social phobics are characterized by typical cognitive processes. Moreover, we found neither corroborating evidence for a controlling effect of such cognitive processes on social phobic conduct, nor consistent indications that cognitive therapies or techniques effect cognitive changes differently than other approaches. The evidence suggests rather, that cognitive factors change concurrently with other features of psychopathology as part of an overall improvement during or after effective therapy, regardless of therapeutic approach.

Social phobia is a clinical pattern of self-protective social behavior characterized by an intense concern over evoking negative reactions, for example, criticism, being made fun of, found unsuitable or in the wrong, in dealing with others. Typical is a dread of and a desire to avoid social situations in which the individual is to perform in front of an attentive audience—be it formal or not. Generally, the most feared situations are those in which one is being assessed (formally or informally) by those holding considerable power over one's fate, like people in position of authority or a prospective lover (e.g., Dixon, De Monchaux, & Sandler, 1957). Typically, such performances include public presentations or interviews, or activities, such us eating, writing, and engaging in conversation that would highlight that individual's state of fearfulness. The main concerns are of being incoherent or speechless, visibly distressed (e.g., blushing, trembling, and sweating), and being socially awkward. Such patients' ultimate fears are of drawing unfavorable attention to themselves, to be overpowered, and feeling embarrassed and diminished; such prospects are anticipated and dreaded above all (see Greist, 1995). The long-standing experience of distress and the various stratagems employed to avoid it, have cumulatively serious adverse consequences on functioning in the social, interpersonal, and occupational spheres of life (Schneier et al., 1994) of social phobic individuals. Various explanatory schemes have been proposed to account for this socially anxious pattern of behavior (see Hofmann & DiBartolo, 2001). One of the most popular at the present is a cognitive therapy (CT) model. Its rise is tied to the advent of cognitive psychotherapy (Beck, 1976) that aims at correcting certain faulty hypothetical structures or operations of the mind of patients. This analysis of psychopathology was first applied generally and in the abstract to a broad range of abnormal phenomena, but has been subsequently refined and extended to social phobia as well (Beck, Emery, & Greenberg, 1985, pp. 146–164). Despite numerous statements of the CT outlook usually emphasizing its therapeutic implications, a definition of the term cognition is hard to find (see Beck et al., 1985). Conceptually, it is used either as a label for a hypothetical “information-processing” system or the product of such a process or both. It is often spoken of as a “thing,” seemingly impervious to context and contingency. A lay interpretation of the word might be that it refers to a kind of thinking that may be put into words, thus excluding the ineffable or tacit knowledge. Some of the theorizing in this area however, is suggestive of unconscious processes, for example, “automaticity” (McNally, 1995). Proponents of the CT school hold the view that faulty thinking results in emotional distress (anxiety) and inadequate behavior, which in turn generates more distress. Although they take pains to point out that “the cognitive model does not postulate a sequential unidirectional relationship in which cognition always precedes emotion…” (Clark & Steer, 1996, p. 76), it is plain that for all intents and purposes, the cognitive perspective is mostly interested in precisely this sort of causal relationship. Fodor (1983), a foremost proponent of a “cognitive science,” puts it unequivocally: “…the structure of behavior stands to mental structure as an effect stands to its cause.” (p. 8). The assertion that “…social phobics become anxious when anticipating or participating in social situations because they hold beliefs (dysfunctional assumptions) which lead them to…” ( Stopa & Clark, 1993, p. 255, italics added) illustrates this point. Cognition as a generic description of mental structures with agency is at the center of the theoretical universe of CT—hence, the name. It is for this reason that cognitive factors are considered as “maintaining” social phobia (see Amir et al., 1998 and Hackmann et al., 1998). They are therefore regarded as its linchpin and as such, are assumed to provide the necessary leverage for therapeutic change (see Wells & Papageorgiou, 1999, p. 86). On the simplest level, faulty thinking or “cognitions” (see Clark & Steer, 1996, p. 79) implies various kinds of irrational inferences, for example, exaggerating and ignoring counterevidence as gathered from the justifications patients offer for what they did or felt. On a somewhat loftier plane, inadequate thinking implies broad beliefs (“schemas”) expressing a whole outlook (e.g., the dangerousness of impropriety). Finally, various additional cognitive processes are said to be operative: for example, focus on self and self-blame, presumably driven by the overarching cognitive structures (schemas). “According to this [the CT] model, social phobics become anxious when anticipating, or participating in, social situations because they hold beliefs (dysfunctional assumptions) which lead them to predict they will behave in a way which results in their rejection or loss of status. Once triggered these negative social evaluation thoughts are said to contribute to a series of vicious circles, which maintain the social phobia. First, the somatic and behavioral symptoms of anxiety become further sources of perceived danger and anxiety (e.g. blushing is interpreted as evidence that one is making a fool of oneself). Second, social phobics become preoccupied with their negative thoughts, and this preoccupation interferes with their ability to process social cues, leading to an objective deterioration of performance. Some of the changes in the social phobics' behavior, for example, behaving in a less warm and outgoing fashion, may then elicit less friendly behavior from others and hence partly confirm the phobic's fears. Third, an attentional bias towards threat cues means that when not preoccupied with their internal dialogue, social phobics are particularly likely to notice aspects of their behavior, and the behavior of others, which could be interpreted as evidence of actual, or impending, negative social evaluation.” ( Stopa & Clark, 1993, p. 255; italics added). This is the cognitive account of social phobia in outline. An elaborate statement of the cognitive model of social phobia may be found in Clark and Wells (1995, pp. 69–93).