A wealth of empirical evidence suggests that cognitive-behavioral treatment (CBT) is the first-line treatment of social anxiety disorder (SAD). The effectiveness of CBT is maximized when treatment targets both situation-specific triggers (for instance, if I give my opinion at this meeting, I’ll look stupid) and core triggers (for instance, fear of rejection, worthlessness, and shame). When constructing the hierarchy of feared situations, it is important to assess specific situations that trigger anxiety, along with cognitive and behavioral responses to those triggers. These items on the hierarchy are useful precisely because they trigger anxiety currently and because they are tools through which core beliefs and emotions can be accessed and processed.
Core beliefs and emotions are the driving force behind disparate situation-specific triggers, and therefore behind the anxiety disorder as a whole. Anxiety is not always the only core emotion. In fact, emotions such as shame, regret, guilt or resentment are commonly associated with social anxiety disorder. Awareness that situation-specific triggers emanate from the same core beliefs and emotions improves treatment compliance and distress tolerance. Core beliefs and emotions may be apparent at the outset; however exposure to situation-specific fears accesses, identifies, and processes core fears that are not initially apparent. Treatment outcome is maximized when all core beliefs and emotions are identified and processed.