I looked into social anxiety and how it can affect people, and CBT. first going over general disadvantages to having untreated social anxiety, then looking deeper into loneliness, depression and emotional regulation, then CBT.
The effects social anxiety can have on people
The silent struggle
It is a constant internal battle that requires high levels of energy put into performance of normancy and hiding intense discomfort. Many become experts at hiding their internal distress and anxiety but may apper composed on the outside.
Effects on physical health
It can lead to chronic physical health problems such as compromised immunity, digestive issues, and risk of cardiovascular disease. Avoidance behaviours can often lead to lifestyle patterns that affect physical health.
Psychological impact
Increased risk of depression and additional anxiety disorders. The mind gets stuck in a cycle of catastrophic thinking and mind-reading, personalising neutral events and discounting positive experiences.
Self-isolation and missed opportunities
Distorted thinking patters operate subconsciously, automatically filtering experiences and maintaining anxiety. Anxiety about large gatherings or public speaking can extent to even smaller groups in the everyday, then one-to-one interactions, and eventually even down to text messages or phone calls. This progressive avoidance leads to social isolation which becomes self-reinforcing since the more one avoids social interaction, the more anxiety inducing it becomes.
A significant long-term effect of social anxiety is the buildup of missed opportunities across everything, beyond personal experiences, but to professional networks, educational advancements, and participation in communities. Over time the gap between the life a person wants and the one as a product of their anxiety widens more and more.
Loneliness and emotion regulation
I found a study that found that people with SAD (Social Anxiety Disorder) report more problematic levels of loneliness, mental health symptoms and difficulties regulating their emotions compared to people with NOSAD (No Social Anxiety Anxiety). They specifically replicated studies that show difficulty in emotional awareness and clarity, which are important factors associated with loneliness, strongly evident in people with SAD.
The participants with SAD were recruited from an on-campus psychology clinic where they showed interest in a group therapy program, and the NOSAD samples were recruited online through social media advertising and online forums. Both samples ranged from undergraduate students to non-students. 26.2% of SAD ppts (participants) were unemployed, whereas for NOSAD, 11.9% were unemployed, which is way less, which is interesting considering 71.4% of SAD were not studying and 42.9% of NOSAD were also not studying (It doesn’t have to do with how many of the participants were full time students).
Both groups took the Emotion regulation questionnaire (ERQ; Gross & John, 2003) which measures two emotional regulation strategies: Cognitive Reappraisal (CR) and Expressive Suppression (ES). CR is a helpful, antecedent‐focused strategy, affecting the early cognitive stages of emotional activity. ES is a less helpful response‐focused plan of action implemented after an emotional response fully developed, focus is then put onto inhibiting and not letting it express physically. Both are measured through a scale from 1-7 (strongly disagree- strongly agree), example item for CR being I control my emotions by changing the way I think about the situation I am in and for ES I keep my emotions to myself.
They found problematic levels of loneliness and severe depressive and anxiety symptoms participants with SAD. Previous research has shown that loneliness works as part of a feedback cycle where increased perceived social isolation leads to hypervigilant responses to potential social threats (Cacioppo & Hawkley, 2009), previous research has also shown that approximately 50% of people with SAD have depression (Adams, Balbuena, Meng, & Asmundson, 2016). They were over reliant on unhelpful emotional regulation strategies, maintaining SAD. People with SAD display a disruption to the situation selection component of emotion regulation which manifests as increased sensitivity to social threat detection and further avoidance of fearful or performance‐based situations. Thus, people with SAD may have more difficulties regulating emotions because they remove themselves from engaging in situations that may be perceived as threatening. This avoidance leads people with SAD to struggle with identifying and understanding their emotions. Looking into these regulation techniques should help reduce loneliness.
Treatment for social anxiety – Cognitive Behavioural Therapy (CBT)
The term CBT is used as a generic label to which things are added. the client and therapist work together systematically with repeated practice, wit the client them continuing outside of work. They include exposure, applied relaxation and general social skills training. It includes a form of restructuring practice like.
The client must fully experience the feared situation for the treatment to be effective in behavioural symptoms, but exposure doesn’t lead to the unlearning of the feared response but instead generates new ambiguous learning to compete with the original fear response without ever replacing it.
The client and the therapist brainstorm an anxiety hierarchy of feared situations which they will then enact both in and out of sessions.
However, the subtle avoidance of simply distancing yourself from the situation internally can defeat exposure. Clients will often tell themselves “This is just roleplay” during a session. Because exposure is so important, this can be as bad as physical avoidance, so the client must be instructed to focus on the situation to prevent subtle avoidance.
A similar but conceptually distinct form of subtle avoidance is the use of safety behaviours which are employed by people with social anxiety when attempting to reduce perceived probability of negative evaluation by others. For example, clients who are public speakers may speak with their hands behind their back or rigidly by their sides to prevent themselves from shaking, and one scared of appearing stupid will rehearse what they will say in their head repeatedly. They often attribute their successes to these behaviours, even though they can often have negative consequences like being less expressive and appear less competent during a speech or may be less spontaneous in casual conversations or struggle to answer questions properly. The clients never consider the feared consequence happening if they engage in their safety behaviours, which means habituation or modification of negative beliefs is prevented, halting the efficacy of exposure.
Applied relaxation
Progressive muscle relaxation is a technique for managing the physiological arousal that comes with anxiety; however, it isn’t very effective when treating SAD, but it does form an underlying basis for applied relaxation, which has some efficacy. Clients are trained in PMR and then instructed to practice it during daily activities and eventually when confronting feared situations. This employs a combination and adaptation of the general PMR techniques and gradual exposure to provide clients with new useful coping responses.
Social skills training
Social skills training is often justified using a skills deficit model of social anxiety which says that people with SAD have poor social skills and their anxiety is derivative from that. The treatment therefore involves being taught and practicing social skills with a combination of modelling said behaviour, corrective feedback, and positive reinforcement. However, SAD isn’t equivocal to poor social skills, there is some that simply struggle to enact their skills because of their anxiety and negative beliefs, making them simply appear to have a social skill deficit. This means that not all parts of the treatment may be useful to all clients, but the exposure to the feared situation is still relevant for all.
Cognitive restructuring
The use of cognitive restructuring is based on the idea that the thoughts the person has about the situation are the problem, and not the situation. The client and therapist work together to identify negative inaccurate automatic thoughts which produce distress. The client then works on disputing these thoughts in and out of sessions, and it would be practiced before, during, and after exposure to enhance effects.
Medication
Some directly compared the efficacy of CBT and medication, both being effective at respectively .74 and .62 from a meta-analysis, however it doesn’t include follow-up data. And most that were on the medication ended up relapsing, whereas the ones on CBT were far more unlikely to. Sometimes the medication was more effective than CBT, but it was short-term. In a study by Liebowitz et al (1999), 50% of clients on phenelzine relapsed, whereas only 17% on Cognitive Behavioural Group Therapy (CBGT) did. This suggests that CBGT helped patients gain new coping skills and maintain them while phenelzine provided immediate effects. Therefore, medication is not a great treatment for SAD on its own, and so it’s suggested that it is used alongside CBT.
Sources
Eres, R., Lim, M. H., Lanham, S., Jillard, C., & Bates, G. (2021). Loneliness and emotion regulation: implications of having social anxiety disorder. Australian Journal of Psychology, 73(1), 46–56. https://doi.org/10.1080/00049530.2021.1904498
Thomas L. Rodebaugh, Robert M. Holaway, Richard G. Heimberg, The treatment of social anxiety disorder, Clinical Psychology Review, Volume 24, Issue 7, 2004, Pages 883-908, ISSN 0272-7358, https://doi.org/10.1016/j.cpr.2004.07.007.
How will I make us of this research?
I want to incorporate this into the narrative and character building. I want to utilise what I found into the way the character talks to herself. For example, I want her to try to understand herself on her own and see how she tries to improve her own thinking to free herself from anxiety to perform better, for instance when she finds a quiet zone her character attempts applied relaxation, just to end up feeling like a disappointment all over again when she fails to take control of her anxiety. I also want people to understand that people with SAD are often self-aware.
How the room she lives in represents her internal feelings. Many with SAD can struggle with depression, so I want to explore whether my character will reflect that. Many with SAD feel isolated and don’t want to leave their home, so I could reflect that by giving her a messy and disorganised room with fast food bags she orders to avoid going out. Messy rooms can feel claustrophobic and create more anxiety.
I could make it so that in-between levels, the character begins going to therapy and engages in CBT or CBGT, and is given medication to try out, which could be incorporated into a perk or a powerup. Overall, I believe that the game should get easier as it progresses if I went in this direction, so I could instead make it so the character gets those perks or skills gained from going to therapy, but the player has to learn how to use them effectively, so making the game “easier” is more of a conscious effort that makes the player feel proud of themselves.
I’ve already decided that the hostile NPCs attack you verbally, increasing your anxiety, just like the girl “attacks” herself in the mirror sometimes. Prior to therapy the character should internalise those “attacks”, agree and confirm them due to her low self-esteem, but post-therapy, she should begin to try countering those attacks and denying them, but in minigame form to allow the player to get better at it overtime. I will consider whether or not to include the minigame when she talks to herself as well or whether it should just play out in dialogue form.