11 General introduction such as depression and other anxiety disorders (Fehm, Beesdo, Jacobi, & Fiedler, 2008; Lépine & Pélissolo, 2000). Several theoretical models try to explain the maintenance of SAD (Clark & Wells, 1995; Heimberg & Rapee, 1997; Hofmann, 2007; Spence & Rapee, 2016; Wong & Rapee, 2016). All these models share similar aspects, for example increased self-focused attention, negative self-perception and attention to (perceived) social threat. Moreover, these models emphasize the maintaining role of behavioral processes. Specifically, avoidance and safety behaviors. Avoidance refers to the behavioral strategy to prevent exposure to the feared social situation (e.g., avoiding giving a speech or going to a party) whereas safety behaviors refer to all actions aimed to reduce or eliminate social threat while being in the social situation (e.g. holding notes or avoiding eye contact). Avoidance and safety behaviors are thought to play a crucial role in these models since they create a negative feedback loop by which the (social) anxiety remains or increases. That is, when individuals with SAD engage in these behaviors they try to prevent being rejected resulting in a momentary reduction of fear. However, as a result it becomes impossible to critically evaluate their feared outcomes and therefore the anxiety is maintained (Hofmann, 2007; Wong & Rapee, 2016). Cognitive behavioral therapy and exposure for SAD Cognitive behavioral therapy (CBT), is one of the psychological treatments of choice for SAD (Canton, Scott, & Glue, 2012; Pilling et al., 2013, Dutch Treatment Guidelines). CBT can be delivered individually or in a group and is considered the most efficacious and empirically supported treatment for SAD and other anxiety disorders (Hofmann & Smits, 2008a; Norton & Price, 2007; Tolin, 2010). Long term studies show that CBT can have long lasting effects (Leichsenring et al., 2014; Willutzki, Teismann, & Schulte, 2012). However, still many adults with SAD do not benefit from CBT. Response rates (the percentage of the treatment group that is classified as a “responder”) vary between 45–55% (Loerinc et al., 2015). In line with the proposed theoretical models of SAD, CBT aims to challenge dysfunctional beliefs about the likelihood of anticipated social danger (e.g., social rejection), by using cognitive techniques (e.g., keeping thought records and challenging automatic thoughts) as well as behavioral techniques, such as exposure (Hofmann, 2008; Smits, Julian, Rosenfield, & Powers, 2012). Exposure is thought to be one of the most crucial interventions in CBT protocols (Hofmann & Smits, 2008a; Norton & Price, 2007). Exposure treatment involves repeated confrontation with feared stimuli in the absence of the feared outcome. The process of fear extinction, which can be seen as a laboratory 1
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