Psychodynamic Approaches to Social Anxiety Disorder

Social anxiety disorder is characterized by intense fears of negative evaluation in social settings, creating a proneness to avoid these situations. This chapter describes a psychodynamic formulation for social anxiety disorder and a focused psychodynamic approach to addressing contributory factors. Psychodynamic investigations have found that patients with social anxiety disorder typically view themselves as inadequate and others as critical and rejecting. The patient’s developmental history is explored to identify contributors to these fears and representations, helping patients to understand how past events lead them to overestimate current dangers. Patients typically have conflicts about anger and autonomy that they attempt to manage unconsciously with the defenses of denial and projection. Identifying and detoxifying these conflicts are key aspects of psychodynamic treatment. Additionally, the therapist clarifies disruptions in mentalization skills, as patients’ capacities to be flexible in their assessments of themselves and others are overridden by their anxieties. Therapists address underlying grandiose fantasies, when they emerge, which represent efforts to compensate for feelings of inadequacy but often trigger guilt and disappointment. The emergence of negative self and other representations and conflicts and defenses with the therapist via the transference provides an opportunity to directly address these threats. The nonjudgmental exploratory stance of the therapist helps detoxify negative self and other representations and areas of conflict. Termination provides an opportunity to address persistent fears and conflicts about anger and autonomy emerging in the context of separation from the therapist. A summary of research on psychodynamic treatment of social anxiety disorder is presented.