Question 1

Why does my socially anxious patient still avoid everything even after the SSRI is working?

Accepted Answer

SSRIs reduce the subjective distress and physiological arousal of social anxiety but do not extinguish conditioned avoidance patterns, which are maintained by negative reinforcement independent of current anxiety levels. The CAMS trial (Walkup et al., 2008, NEJM; PMID 18974308) showed 80.7% response for combination CBT+sertraline vs 54.9% sertraline alone in youth ages 7-17 with anxiety disorders. The Clark and Wells (1995) model explains why: avoidance and safety behaviors prevent disconfirmation of catastrophic predictions. Individual CBT using behavioral experiments achieves the largest effect sizes among all SAD treatments (SMD -1.56 in sub-model analysis; Mayo-Wilson et al., 2014, Lancet Psychiatry; PMID 26361000). Motivational interviewing integration (Westra et al., 2016; PMID 26985729) produces 5x higher recovery odds at 12 months for patients with severe GAD resistant to starting exposure.

Question 2

How does avoidance maintain anxiety through negative reinforcement?

Accepted Answer

SSRIs reduce the subjective distress and physiological arousal of social anxiety but do not extinguish conditioned avoidance patterns, which are maintained by negative reinforcement independent of current anxiety levels. The CAMS trial (Walkup et al., 2008, NEJM; PMID 18974308) showed 80.7% response for combination CBT+sertraline vs 54.9% sertraline alone in youth ages 7-17 with anxiety disorders. The Clark and Wells (1995) model explains why: avoidance and safety behaviors prevent disconfirmation of catastrophic predictions. Individual CBT using behavioral experiments achieves the largest effect sizes among all SAD treatments (SMD -1.56 in sub-model analysis; Mayo-Wilson et al., 2014, Lancet Psychiatry; PMID 26361000). Motivational interviewing integration (Westra et al., 2016; PMID 26985729) produces 5x higher recovery odds at 12 months for patients with severe GAD resistant to starting exposure.

Question 3

Why can't medication alone eliminate avoidance behavior in SAD?

Accepted Answer

SSRIs reduce the subjective distress and physiological arousal of social anxiety but do not extinguish conditioned avoidance patterns, which are maintained by negative reinforcement independent of current anxiety levels. The CAMS trial (Walkup et al., 2008, NEJM; PMID 18974308) showed 80.7% response for combination CBT+sertraline vs 54.9% sertraline alone in youth ages 7-17 with anxiety disorders. The Clark and Wells (1995) model explains why: avoidance and safety behaviors prevent disconfirmation of catastrophic predictions. Individual CBT using behavioral experiments achieves the largest effect sizes among all SAD treatments (SMD -1.56 in sub-model analysis; Mayo-Wilson et al., 2014, Lancet Psychiatry; PMID 26361000). Motivational interviewing integration (Westra et al., 2016; PMID 26985729) produces 5x higher recovery odds at 12 months for patients with severe GAD resistant to starting exposure.

Question 4

How do I use motivational interviewing to get an avoidant patient into exposure?

Accepted Answer

SSRIs reduce the subjective distress and physiological arousal of social anxiety but do not extinguish conditioned avoidance patterns, which are maintained by negative reinforcement independent of current anxiety levels. The CAMS trial (Walkup et al., 2008, NEJM; PMID 18974308) showed 80.7% response for combination CBT+sertraline vs 54.9% sertraline alone in youth ages 7-17 with anxiety disorders. The Clark and Wells (1995) model explains why: avoidance and safety behaviors prevent disconfirmation of catastrophic predictions. Individual CBT using behavioral experiments achieves the largest effect sizes among all SAD treatments (SMD -1.56 in sub-model analysis; Mayo-Wilson et al., 2014, Lancet Psychiatry; PMID 26361000). Motivational interviewing integration (Westra et al., 2016; PMID 26985729) produces 5x higher recovery odds at 12 months for patients with severe GAD resistant to starting exposure.

PsychHQ

Why SSRIs Don't Fix Avoidance: The Medication-Resistant Behavioral Pattern in Social Anxiety