Social phobia is a rather new diagnostic entity; it was
included as a separate condition for the first time in
1980 in DSM-III. It is characterized by a persistent and
exaggerated fear of humiliation or embarrassment in
social situations, leading to high levels of distress and
possible avoidance of those situations. The fear may be
of speaking, meeting other people, eating or writing in
public, and relates to the fear of appearing nervous
or foolish, making mistakes, being criticized or being
laughed at. Often physical symptoms of anxiety such
as blushing, trembling, sweating and tachycardia are
triggered when the patient feels under evaluation or
scrutiny. Recent epidemiologic studies have shown a
life-time prevalence of social phobia in the general
population ranging from 2.4%1to 16%.2
Social phobia is a chronic disorder with an early,
insidious onset in adolescence and a continuous, un-
remitting course, resulting in a substantial degree of
disability and suffering.3Both pharmacotherapy and
psychological treatment have been proven effective.4–8
Exposure therapies are used commonly to treat social
phobia, and treatment programmes including education
and exposure instructions have been developed.9,10
Usually these programmes are applied in mental health
care for individual or group treatment. There are no
earlier studies of psychological treatment for social
phobia by GPs. We have conducted a study of the effect
of exposure therapy, either alone or in combination with
medication, for patients with social phobia in primary
Why in general practice?
In general practice, about one-third of patients have a
psychiatric disorder, mainly anxiety and depression.11
Only half of the patients with psychiatric disorders are
identified by GPs mainly because primary care patients
usually present somatic symptoms and only rarely
mention their psychological problems.12,13The diagnosis
social phobia is almost never applied in general practice.
The patients are given more general diagnoses such as
anxiety or depressive conditions, sleeping problems, sub-
stance abuse or somatization such as myalgia, gastritis or
© Oxford University Press 2000
Vol. 17, No. 2
Printed in Great Britain
The treatment of social phobia in general practice.
Is exposure therapy feasible?
Tone Tangen Haug, Kerstin Hellstrøm, Svein Blomhoff,
Mats Humble, Hans-Petter Madsbu and Jan Egil Wold
Haug TT, Hellstrøm K, Blomhoff S, Humble M, Madsbu H-P and Wold JE. The treatment of social
phobia in general practice. Is exposure therapy feasible? Family Practice 2000; 17: 114–118.
Background. Exposure therapy is an effective treatment for generalized social phobia. Most
patients with social phobia are treated in primary care, but family doctors are not usually trained
to perform exposure therapy. We have conducted a study in primary care of the effect of exposure
therapy alone or in combination with sertraline on generalized social phobia.
Objectives. The purpose of this article is to describe the training of GPs and the application of
the treatment programme in general practice.
Method. Forty-five GPs were trained for ~30 h in assessing patients with social phobia and
conducting exposure therapy. The training programme included scoring of videotaped inter-
views of five patients on several social phobia scales, and a videotape demonstrating different
steps of an exposure therapy was used as a model for role play in group training.
Results. All of the GPs completed the training programme. The doctors expressed satisfaction
with the programme and also found it useful in the treatment of patients with conditions other
than social phobia. There was a significant difference in response between the treatment groups
(P = 0.001), and the combination of exposure therapy and sertraline seemed to be particularly
Keywords. Exposure, general practice, social phobia.
Received 21 June 1999; Revised 15 October 1999; Accepted
26 October 1999.
Department of Psychiatry, University of Bergen, 5021
Haukeland University Hospital, Bergen, Norway.
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Exposure therapy in general practice
Nearly all patients with anxiety and depressive con-
ditions are treated by family doctors, whereas only a few
are seen by psychiatrists.14,15Given this distribution of
care, it is important to ensure that GPs are well trained
in psychiatric assessment, diagnosis and treatment. Valid
and reliable diagnostic procedures and efficacious treat-
ment strategies for anxiety disorders have been developed
in psychiatric settings over the past two decades.
Application of these diagnostic and treatment methods
has not been well studied in primary care settings, although
there is some indication that both presentation of illness
and effective treatment interventions may differ from
those in specialized psychiatric settings. There is, there-
fore, a need to facilitate dissemination of efficacious
methodologies to primary care settings.
Recognition programmes of psychological problems
in primary care have been developed where the
physicians are taught skills enhancing their ability to
recognize and respond to verbal and non-verbal cues,
making empathic comments and using patient-directed,
open-ended interviewing strategies.16There are also
several studies of brief psychological treatment for
primary care patients. Barkham17has described a three-
session cognitive–behavioural intervention, and White
and Keenan18have applied a group didactic ‘course’
on anxiety management strategies. Brief problem-
solving therapy has been proven to be as effective as
benzodiazepine treatment of patients with anxiety,19
and Swinson et al.20showed that panic disorder
patients provided with psychoeducation and exposure
instructions had a significantly better outcome than
those not so informed.
Why exposure therapy?
There are now well proven efficacious treatments for
social phobia using medication and psychotherapy alone
and in combination.4,7,8These treatments have not been
well studied in primary care settings, and thus their
effectiveness remains to be documented. The psycho-
therapeutic approach in this study had to meet four basic
criteria: (i) it must be possible to conduct the therapy
within the frame of a GP consultation; (ii) the therapy
had to be standardized in such a way that a manual was
available for the instruction of the therapists; (iii) only a
limited number of therapeutic interventions were to be
applied; and (iv) there must be some evidence of efficacy
for the approach for patients with social phobia.
Exposure therapy has been proven effective in the treat-
ment of social phobia,21,22and brief treatment pro-
grammes with structured manuals have been developed.
In exposure therapy, mainly behavioral techniques such
as scheduling activities, graded task assignment, distrac-
tion and relaxation are applied, while cognitive strat-
egies for managing the problematic situation are only
used to a limited degree. On the basis of these consider-
ations, brief exposure therapy based on a self-treatment
manual developed by Isaac Marks9was chosen as the
psychotherapeutic approach. We wanted to test if it was
possible to describe a standard psychological treatment
for social phobia which could be applied in a primary
care setting and if it was feasible to train GPs to conduct
this therapy at an adequate competence level within a
relatively short time.
The purpose of this article is to describe the training of
the GPs in the treatment programme, and its application
in general practice.
Design of the outcome study
Three hundred and eighty-seven patients with general-
ized social phobia (mean age 40 years, female/male 234/
153) were included in the study. A total of 238 patients
were recruited from general practice and 149 from
advertising in newspapers. Requirements for inclusion
were generalized social phobia (DSM-IV) of at least
moderate severity (score ?34 on the Clinical Global
Impression Scale, CGI-S), lasting for at least 1 year.
Exclusion criteria were other axis-I diagnoses, treat-
ment for social phobia within the last 6 months, suicide
risk, alcohol or substance abuse and expected bad
Assessments of anamnestic data, somatic symptoms
and psychological factors were made by GPs and by
self-rating. Forty-three GPs and two psychiatrists
participated in the study. The ratings by the physicians
were tested for reliability before the study. The
assessments were made in a screening interview and in
a baseline interview after 1 week. Before the baseline
interview, the patients performed self-ratings on several
questionnaires. The following instruments were
applied: Mini International Neuropsychiatric Interview
(MINI-R)22assessed DSM-IV psychiatric diagnoses,
CGI-S,23Social Phobia Scale (SPS)24and Marks Fear
Questionnaire25measured the level of generalized
All patients also identified 1–3 ‘target complaints’
which they assumed to be important and wanted to work
on in therapy, if they were selected for the therapy group.
The targets covered a range of social situations where
the patients feared a negative evaluation and had a
substantial degree of avoidance such as attending lunch
breaks, speaking up at meetings, going to parties, etc.
Each of the target complaints was scored on a scale from
1 to 4 where a higher score indicated a higher degree of
the problem. At the end of treatment, the patients made
an evaluation where they assessed the efficacy of the
Anamnestic data were also registered and the patients
had a general physical examination. All patients signed
an informed consent to take part in the study.
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Family Practice—an international journal
After the baseline interview, the patients were assigned
randomly to exposure therapy or general medical care.26
In the general medical care group, the interaction with
the patients was limited to discussion of clinical history,
explanation of the disease and general support, such as
encouragement, acceptance, ventilation and abreaction.
The exposure therapy focused on the specific ‘target
complaints’ identified by the patients at the assessment
interview. The patients also defined their own goals of
treatment. A booklet containing general information
about social phobia and its treatment, describing the
principles of exposure therapy including graded task
assignment with coping strategies such as distraction,
breathing exercises and rational self-talk, was dis-
tributed. The booklet also contained a self-registration
task of anxiety symptoms and coping strategies usually
applied by the patients themselves and forms for
registration of daily homework assignments.
The therapy included eight sessions, each lasting 15–
20 min. The first four sessions were conducted weekly,
and the last four sessions every other week. The time
course of the exposure therapy was 12 weeks. The aim
of the exposure therapy was to let the patients expose
themselves gradually to situations they usually feared
and avoided and thus learn new coping strategies. They
were told to stay as long as they could in the phobic
situations, ideally until the anxiety decreased.
All patients did homework between sessions where
they continued to expose themselves to defined anxiety-
provoking situations. During homework, the patients made
a written report of the training to bring with them to the
next session for discussion. The task of the physician was
to help the patients to identify goals of therapy and new
coping strategies, collaborate with the patients in planning
realistic exposure tasks and to offer guidance and support.
In the first therapy session, the patients were given
general information about social phobia and exposure
therapy. They were given the self-treatment booklet and
the first homework assignment was to read the booklet.
In the second session, the practical goals for treatment
were identified and the diary was introduced. In the next
sessions, the patients and physicians reviewed the home-
work done by the patient, discussed coping strategies
and new homework was assigned. In the last session, the
focus was on relapse prevention The coping strategies
the patient had learned during therapy were repeated
and the patients were encouraged to continue to expose
themselves to feared situations.
All patients additionally were randomized to medical
treatment with sertraline (50–150 mg daily) and match-
ing placebo according to a 2 × 2 design of the study. The
patients were medically treated for 24 weeks.
Assessments were made at 12 weeks and at 24 weeks.
Social phobia, social avoidance and ‘target complaints’
were assessed applying the same scales as at baseline.
Outcome variables were changes in degree of social
phobia rated by CGI-L, severity subscale and improve-
ment subscale, SPS and Marks Fear Questionnaire. In
addition, the effect of treatment was assessed by changes
in scores on ‘target complaints’. Response was defined as
a reduction of at least 50% on SPS compared with base-
line, a CGI-L global improvement rating of 1–2 (markedly
or moderately improved) and CGI-L overall severity in
the range 1–3 (no–mild mental illness) at week 24. Non-
response was defined as ?25% reduction in SPS com-
pared with baseline or CGI-L global improvement rated
at least 4 (no change). Partial response was defined as all
The training programme
The goal of the training programme was to teach the GPs
to carry out reliable scorings effectively on the different
assessment forms and to attain a certain degree of
mastery of the treatment approach. The standardization
of training should ensure relatively uniform as well as
adequate administration of the treatment condition
across research sites.
The training programme included lectures, videotapes
and group supervision. The doctors were trained in
DSM-IV criteria and MINI-R interviewing to identify
social phobia and co-morbid disorders. They were also
trained in scoring of the CGI-S scale. Consensus ratings
between five trained psychiatrists/psychologists and one
GP on five videotaped patient interviews were defined
as the ‘golden standard’ of severity rating. After the
training programme, all doctors had to rate the CGI-S
scale on 12 videotaped patient interviews to assess inter-
rater reliability. An inter-rater reliability of at least
0.7 compared with the ‘golden standard’ was required to
be accepted as an investigator. Thirty-nine doctors
were accepted as investigators during this procedure;
three withdrew during the training period. The remain-
ing investigators were given further individual training
and then rated another four videotapes. During this
procedure, six additional doctors were accepted and a
total of 45 GPs were included as investigators in the
To illustrate the different steps of the exposure
therapy, an instruction video showing five of the eight
sessions (first to fourth session and the last session)
of therapy for a patient with social phobia was shown.
The video was shown during the training sessions and
each GP had a copy of the video for their own studies. In
addition, the GPs were given some written material
about social phobia and exposure therapy. The GPs were
trained in groups of 10 for a total of 30 h during three
weekend sessions. The Norwegian GPs were trained by
the psychiatrists in the steering committee (SB, TTH and
JEW) and the Swedish GPs were trained by a clinical
psychologist (KH) and a psychiatrist (MH). During
sessions, the doctors carried out role playing of different
by guest on October 20, 2015
Exposure therapy in general practice
tasks in exposure therapy such as focusing the problems,
planning homework, discussing coping mechanisms and
giving support to the patients. The groups had super-
vision by the training psychiatrists and psychologist
throughout the study.
Evaluation of the training programme
The GPs were all experienced family doctors with an
average of 16 (1–30) years of experience in this position.
Mean age was 48.8 years. Their main occupation was
in clinical work, seeing ~90 (17–164) patients with all
kinds of problems every week. Three GPs had worked
in psychiatric settings previously and had taken short
courses in psychotherapy/behaviour therapy.
The GPs themselves expressed satisfaction with the
training programme. They pointed out the importance of
learning a structured treatment of psychological problems,
focusing on coping strategies of defined targets. They
found the duration of exposure therapy applicable in the
GP setting, adjusted to the limited time of a consultation.
They also found that the techniques applied could be
useful in the treatment of psychiatric patients with con-
ditions other than generalized social phobia.
The results of the outcome study revealed that ex-
posure therapy alone, the combination of exposure
therapy and medication, and medication all were
significantly superior to placebo combined with general
The target complaints identified by the patients at
baseline are described in Table 1. The most frequent
targets were attending meetings, going to parties and
speaking to audiences. A total of 534 of the targets were
connected to performance situations such as public
speaking, drinking or eating in front of others or entering
a room where there are people already present, while
313 of the targets were connected to interactional
situations such as speaking to strangers, going to social
gatherings or interaction with the opposite sex,27in-
dicating that the patients had generalized social phobia
covering a wide range of difficult social situations.
There was a significant reduction in score on target
complaints from baseline to week 12 and week 24
between groups (P = 0.016 and P = 0.0005, respectively)
and the largest reduction was in the group with the
combined treatment. The percentage of patients scoring
3 and 4 (moderate and severe problem) on intensity of
target 1 over time is shown in Figure 1. Exposure therapy
alone and in combination with medication was sig-
nificantly superior to general medical care at week 12
(P = 0.001). At week 24, all active treatment groups were
significantly superior to placebo (P = 0.001). Similar
findings emerged for targets 2 and 3.
The patients themselves rated the active treatments to
be more effective than placebo (P = 0.005), and there was
a high correlation between the doctors’ and the patients’
evaluations of the effect of treatment (kappa 0.83).
More detailed results of the study will be described
In this study, there was a significant improvement in
response from pre- to post-test in all four treatment
groups. Exposure therapy combined with medication
and medication alone were significantly superior to the
combination of general medical care and pill–placebo,
while exposure therapy alone approached statistical
significance. The patients had generalized social phobia
covering a large range of social situations and there was
a significantly larger reduction in scores on target com-
plaints from baseline to week 24 for all treatment groups
compared with placebo. Brief exposure therapy admin-
istered by GPs, alone or in combination with sertraline,
Target complaints for patients with social phobia (n = 362);
each patient had up to three target complaints
1. Attend meetings171
2. Visit family, friends147
3. Speak to an audience124
4. Go to shops, banks, etc.117
5.Do something while being watched 66
6.Speak to authorities 49
7. Lunch breaks 47
8. Travel by bus or train46
9. Eat in restaurants45
10. Schools, studies35
Percentage of patients scoring 3 and 4 (moderate
and severe) on intensity of target 1, over time
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Family Practice—an international journal
seemed to be an effective treatment modality. There are
no other studies of psychological treatment of social
phobia in general practice. Earlier studies have been
conducted in mental health care settings by experienced
psychiatrists or psychologists. In a study by Mattick
et al.,28exposure therapy, cognitive restructuring, a com-
bination of these and a waiting list control group were
compared. The combination and cognitive restructuring
groups improved significantly on all variables, whereas
the exposure therapy group showed changes on phobic
avoidance. Heimberg et al.29 compared cognitive–
behavioural group treatment with credible placebo
control. In this study, both treatment groups improved,
but the cognitive–behavioural group patients were rated
as more improved than controls with less anxiety and
significantly fewer negative self-statements. Gelernter
et al.7compared a cognitive behavioural group treatment
programme with pharmacotherapy with phenelzine,
alprazolam and pill–placebo plus directions for self-
directed exposure to feared stimuli and reported a sub-
stantial improvement in all treatment groups. In another
study by Heimberg,8cognitive–behavioural group therapy,
educational supportive group therapy, phenelzine and
pill–placebo were compared. Cognitive therapy and
phenelzine led to superior response rates and a greater
change on dimensional measures than did either control
condition. Based on the results from these studies, it can
be concluded that GPs, after a limited training programme,
are able to reach a certain competence level of exposure
therapy to conduct treatment programmes which produce
results as good as treatments conducted in mental health
The GPs expressed satisfaction with the training pro-
gramme and found the techniques they were taught use-
ful in treatment of patients with psychiatric conditions
other than generalized social phobia. The patients found
the treatment helpful and this was reinforced by the low
drop-out rate. In conclusion, we can make the statement
that it is possible to provide a standard short-term train-
ing programme for GPs to use exposure therapy effect-
ively. The treatment is feasible to apply in daily practice
and well accepted by both patients and family doctors.
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