Is Social Anxiety Really PTSD? A Detail We've Been Missing

Social anxiety disorder is different from a number of other anxiety disorders because it doesn’t seem to be associated with “flash-forwards”—the person experiences vivid imagery of a future imagined bad outcome—but rather “flashbacks”—memories of socially embarrassing situations. Flashbacks are more commonly associated with PTSD than they are with generalized anxiety.

Research recently published in the Journal of Anxiety Disorders further analyzes the link between social anxiety disorder and flashbacks and uses an imagery rescripting approach to help social anxiety disorder sufferers heal. This mechanism of treatment is similar to trauma treatments such as EMDR and Trauma-Focused Cognitive Behavior Therapy, both of which use exposure, cognitive reappraisal, and imagery rescripting as essential components of therapy. This study further helps us understand SAD as possibly related to post-traumatic stress disorder.

Research Design:

The current study randomized 33 participants with SAD into either a single session of imagery rescripting therapy, imaginal exposure, or supportive counseling. Memory outcomes were assessed at one and two weeks post-intervention, as well at three months follow-up. Results demonstrated that the individuals who received imagery rescripting therapy were more likely to update their negative memory-derived core beliefs. While the sample group was small, this study does provide insight into the unique nature of SAD compared to other anxiety disorders.

The hypothesis was that imagery rescripting would result in changes to three outcomes:

1. Memory Content – recalling more details, positive, negative, and neutral—to create a more detailed understanding of the event.
2. Memory Appraisal – how powerful is the memory? How intrusive, vivid, and painful is it?
3. Core Belief Updating – what does the memory say about me? What core beliefs do I have, based on that memory?

Both imaginal exposure and imagery rescripting resulted in greater memory content—more detailed memories of the event, including some positive and some neutral details, which helped participants reappraise the memory. Supportive counseling had no effect on memory content.

Cognitive reappraisal means coming to a new understanding of the memory, seeing it from a more flexible and situational lens. Instead of the memory of being socially humiliated “proving” that a person is unlovable, the memory could be reappraised and seen for what it is. For example, the memory could also be demonstrating that the children who socially humiliated the study participant were being cruel and unfair.

In terms of memory appraisal—the intrusiveness, vividness, and negative affect associated with the memory—supportive counseling appeared to have some effect. Imaginal exposure also had moderate effects on memory appraisal. Imagery rescripting led to significant changes in memory appraisals. Memories were no longer as vivid, as emotionally salient, or as intrusive as they had been before imagery rescripting. This was consistent with the study hypothesis.

While imaginal exposure did result in core belief updating, it was not as effective on core belief updating as imagery rescripting was. The imagery rescripting participants were 2.5 times as likely to update their core beliefs than the supportive counseling group. The imaginal exposure group was 1.67 times as likely to revise core negative self-beliefs. The difference between imagery rescripting and imaginal exposure is not statistically significant, although both were clearly more effective than supportive counseling alone.

What is Imagery Rescripting?

Is Social Anxiety Disorder better understood as a special case of PTSD? Implications from an intervention study.

Source: Katarzyna Białasiewicz /123RF

The cognitive model of SAD proposes that negative self-imagery is central to the disorder. This negative self-imagery (I’m a loser, I’m pathetic, I’m boring) originates in specific autobiographical memories of social failures.

Delia, a patient of mine, recounts her story:

It was in a dance class, maybe Baby Ballet. Everyone had to walk the balance beam, but I just couldn’t do it. I kept falling off. The kids were snickering and one of the girls said “Maybe if she wasn’t so fat.” The teacher said nothing, and the girls kept pointing and whispering. It feels like later on that day, but maybe it wasn’t, we had to dance as if we were an animal, and I drew the horse. Everyone else had a dainty feminine part, like a cat or a bird, but I was a big, loser horse.

I was just always the slowest, the dumbest, the one who got made fun of the most. It became easier not to talk, and to just read at recess. Books are safe. I remember my fifth grade teacher, not even bothering to lower her voice, telling our new substitute teacher “Oh, that’s Delia. She mostly stays inside and reads. I think she’s a bit socially awkward.”

Imagery rescripting involves re-invoking the memory by describing it as accurately as possible, which is like what happens in the initial stages of EMDR. After that, the participant is instructed to go back into the memory as their adult self and to support their younger self through the situation. What would you tell her? What would you say to the kids? What support would you recruit from the adults?

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Prior to the intervention, participants are asked about negative core beliefs associated with the imagery. For example, a negative core belief might be “I am unlovable” or “I deserve to be rejected.” After the imagery rescripting intervention, the participants were asked to re-evaluate the core belief.

One participant, who had initially said “I am unlovable,” reappraised that as “I see unlovability as situational now, rather than inevitable. When I am with my family—my husband, kids, and chosen family—I know that I am loved and lovable."

In Clinical Practice:

Delia recounts:

I imagine myself standing there—adult, strong me, and saying to the ballet teacher, “Hello, where is your brain? Don’t you see a kid being hurt here? I’m going to sue you if you don’t do something right now.” I would tell my fifth grade teacher, “Maybe I’m socially awkward because adults like you say things like that about me, out loud, in front of everyone. Maybe it’s not me who is socially awkward. Maybe it’s you. It’s one thing if kids bully me, but you’re an adult. What’s your excuse? Did it ever occur to you that I’m suffering, and I need help, not mockery?”

Delia has received a lot of therapy over the years for her low self-esteem, her shame, and her persistent sense of being a loser. As my work with her is not a research study, it’s difficult to say that imagery rescripting was the missing piece in her treatment. However, adding an imagery rescripting component to her therapy did open the door to cognitive reappraisal for Delia. She was able to see herself not as a “loser,” but as a child who was inadequately supported and protected by the adults around her. This allowed her to update her negative views about herself. Instead of “I am a loser” her core belief became “I am competent at many things. Anything I don’t do well, I can either learn or outsource. I am good at the things I value being good at.”

The flashback nature of social anxiety disorder makes it a clinical conundrum. As a clinician, I find it’s useful to use a trauma-informed lens for SAD, seeing it as a special condition of post-traumatic stress disorder. It’s a disorder that may not have formed as the result of one single stressor, but rather as a result of an accumulation of socially painful memories. Seeing SAD through a trauma-informed lens opens the door to more effective treatment.

© Robyn Koslowitz, 2020