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A Meta-Analytic Review of Psychological Treatments for Social Anxiety Disorder
Abstract
This meta-analysis multiple well-controlled studies were combined to help clarify the overall impact of psychological treatments for social anxiety disorder. A comprehensive literature search produced 32 randomized controlled trials (N = 1,479) that were included in the final analyses. There was a clear overall advantage of treatment compared to waitlist (d = 0.86), psychological placebo (d = 0.34), and pill-placebo (d = 0.36) conditions at posttreatment on the primary, domain specific outcome measures. The average treated participant scored better thin 80% of the waitlist and 66% of the placebo participants. Treatment also faired better than control conditions across secondary, outcomes including cognitive measures (d = 0.55), behavioral measures (d = 0.62), and general subjective distress measures (d = 0.47). Treatment gains were maintained at follow-up (d = 0.76). Combined exposure and cognitive therapy (vs. control: d = 0.61.) was not significantly different from exposure (vs. control: d = 0.89; p = 0.33) or cognitive treatments (vs. control: d = 0.80; p = 0.70). Likewise, group treatments (vs. control: d = 0.68) were not significantly different from individual treatments (vs. control: d = 0.69; p = 0.62). Effect sizes were not associated, with treatment dose (p = 0.91), sample size (p = 0.53), or publication year (p = 0.77). The results add confidence to previous meta-analytic findings Supporting the use of psychological treatments for social anxiety disorder with no significant differences in treatment type or format.
... Furthermore, several meta-analyses on psychological treatment for SAD included group treatment in their analyses Aderka, 2009;Mayo-Wilson et al., 2014;Powers, Sigmarsson, & Emmelkamp, 2008) and there is one meta-analysis that specifically focused on the controlled efficacy of CBGT (Wersebe, Sijbrandij, & Cuijpers, 2013). While group psychotherapy was consistently evaluated as being superior to wait list control groups with effect sizes ranging from 0.64 (Wersebe et al., 2013) to 0.92 (Mayo-Wilson et al., 2014), the evidence on comparisons to active control conditions and alternative treatment approaches is still scarce and provides an unclear picture. ...
... While group psychotherapy was consistently evaluated as being superior to wait list control groups with effect sizes ranging from 0.64 (Wersebe et al., 2013) to 0.92 (Mayo-Wilson et al., 2014), the evidence on comparisons to active control conditions and alternative treatment approaches is still scarce and provides an unclear picture. Aderka (2009) found higher effect sizes for studies treating patients in an individual format as compared to the group format, while other meta-analyses did not detect significant differences Powers et al., 2008). Wersebe et al. (2013) reported significant positive effects of group therapy in comparison to active control groups such as placebo and treatmentas-usual. ...
... However, the effect of the specific delivery format was only investigated for full CBT treatments, while effects of other psychotherapeutic approaches (e.g., exposure therapy alone and psychodynamic therapy) were not differentiated by format. Additionally, all inferences made on the differential effects of group psychotherapy and other active treatments Aderka, 2009;Mayo-Wilson et al., 2014;Powers et al., 2008) were derived from information that stemmed at least partly from between-study comparisons and might be confounded by differing study characteristics. ...
Group psychotherapy for social anxiety disorder (SAD) is an established treatment supported by findings from primary studies and earlier meta-analyses. However, a comprehensive summary of the recent evidence is still pending. This meta-analysis investigates the efficacy of group psychotherapy for adult patients with SAD. A literature search identified 36 randomized-controlled trials examining 2171 patients. Available studies used mainly cognitive-behavioral group therapies (CBGT); therefore, quantitative analyses were done for CBGT. Medium to large positive effects emerged for wait list-controlled trials for specific symptomatology: g = 0.84, 95% CI [0.72; 0.97] and general psychopathology: g = 0.62, 95% CI [0.36; 0.89]. Group psychotherapy was also superior to common factor control conditions in alleviating symptoms of SAD, but not in improving general psychopathology. No differences appeared for direct comparisons of group psychotherapy and individual psychotherapy or pharmacotherapy. Hence, group psychotherapy for SAD is an efficacious treatment, equivalent to other treatment formats.
... Avoidant personality disorder related beliefs were assessed with the Personality Disorder Belief Questionnaire (PDBQ; Dreessen & Arntz, 1995). Research has shown that exposure therapy without cognitive components can affect cognitions (Powers et al., 2008). The avoidant subscale of the PDBQ contains 10 items to assess the strength of beliefs assumed to be specific to avoidant personality disorder. ...
... Cohen's d estimations (Table 2) were based on the mean pre-to postassessment change of the active treatment group minus the mean pre-to postassessment change of the waiting-list group, divided by the pooled preassessment standard deviation (Morris, 2008). According to a power calculation (two-sided, power = 80%, alpha = 0.05; G*Power 3.1) based on an effect size of exposure therapy in a meta-analysis (Powers et al., 2008), 22 participants in each condition were sufficient to detect differences between treatment groups and waiting-list. Due to logistical reasons, data collection was discontinued after two years which resulted in two participants less in each condition. ...
... Although VRET effectively reduced anxiety and avoidance in social situations, it did not significantly reduce fear of negative evaluation, which represents a cognitive core feature of SAD. Pure exposure therapy can lead to cognitive changes in SAD (Powers et al., 2008) and iVET significantly reduced fear of negative evaluation in the present study. Yet, the need to directly address cognitions might be higher during VRET than during iVET. ...
... It is typically delivered to groups of 6–8 individuals by two co-therapists over 12 weekly sessions. The most common comparison group for CBGT, a waitlist control consistently has been found to be inferior (Powers, Sigmarsson, & Emmelkamp, 2008 ). Most studies also found that CBGT was superior to an educational supportive group therapy (Heimberg, Dodge, Hope, Kennedy, & Zollo, 1990; Heimberg, Salzman, Holt, & Blendell, 1993; Heimberg et al., 1998), as well as to medication placebo (Blanco et al., 2010; Clark & Agras, 1991; Davidson et al., 2004; Heimberg et al., 1998). ...
... In addition, tailoring treatment is less possible within a group compared to individual treatment. Although meta-analyses have found no difference between the efficacy of group and individual therapy (Powers et al., 2008), two direct comparison studies found that individual therapy for SAD was more effective than group or medication focused treatments (Mörtberg, Clark, Sundin, & Wistedt, 2007; Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003). Thus, there may be reason to favor individual therapy over group therapy in terms of efficacy. ...
... Meta-analyses generally report few differences between standard CBT and its various components (Powers et al., 2008), and that cognitive or behavioral changes are unrelated to the treatment modality (Alden et al., 1978; Bögels & Voncken, 2008; Borgeat et al., 2009; Linehan, Goldfried, & Goldfried, 1979; Newman, Hofmann, Trabert, Roth, & Taylor, 1994). A recent study reported a trend for greater gains with the combined treatment over exposure and cognitive restructuring alone (Nortje & Poshumus, 2012) while another study found that the combined treatment was more effective only over cognitive therapy alone (Otto, Hearon, & Safren, 2010). ...
Social anxiety disorder (SAD) is a chronic and debilitating condition that appears to be growing in the United States. A number of changes proposed for the DSM-5 attempt to correct prior problems with the diagnosis and are based on empirical evidence. Recent models of SAD emphasize a multi-faceted approach incorporating both hard-wired (ethology, genetics, temperament, neurobiology) and psychosocial factors (life events, parenting styles and interactions, peer relationships, cognitive and behavioral models) in an effort to understand who develops clinical symptoms and how symptoms are maintained. More research is necessary to determine the variance contributed by implicated factors and the interplay between them. A better integration among cognitive and learning theory formulations is especially needed. Cognitive Behavior Therapy (CBT) and serotonergic medications both have a strong empirical basis in the treatment of social anxiety and appear to have similar rates of efficacy. Whereas CBT appears to be more durable and better tolerated than medications, it has a slower onset of treatment effects. Findings from component analyses suggest that treatments that emphasize cognitive or behavioral strategies have similar rates of efficacy although combining both may produce the most gains. Preliminary results also show that technology-guided protocols are effective in treating SAD, provide greater access to CBT, and may be more cost-effective. However, more studies are needed to compare technology-guided protocols to traditional CBT treatments. Future studies are also needed to examine factors that may impact or mediate therapeutic outcomes in order to maximize effects.
... Each of these treatment components can contribute to the efficacy of the treatment package to some extent. Most evidence for the differential efficacy of specific treatment components comes from underpowered clinical trials that lack rigorous control over treatment integrity [36][37][38][39][40]. The most reliable evidence concerning different components and their combinations to date comes from meta-analyses, but the conclusions are inconsistent. ...
... Although previous findings have indicated that psychoeducation and exposure are important and possibly sufficient components in the treatment of SAD [39,[75][76][77], to our knowledge, the present study is the first to find a significant superiority of interventions containing exposure or psychoeducation compared to interventions without these components. This may be due to the scarcity of research investigating the effects of individual treatment components, as well as the limited research comparing "pure" uncontaminated versions of different treatment components and their insufficient power. ...
Introduction: Many studies have demonstrated that social anxiety disorder (SAD) can be effectively treated with psychotherapy, particularly cognitive-behavioral therapy (CBT), including internet-based CBT (ICBT). Despite evidence-based treatments, many individuals do not sufficiently benefit from them. Identifying the active components could help improve the effectiveness of SAD treatment. This study tested the effects of four treatment components (psychoeducation, cognitive restructuring, attention training, and exposure) within ICBT for SAD to investigate its active components. Methods: This randomized full factorial trial consisted of four factors (i.e., treatment components) and 16 conditions. A total of 464 adults with a diagnosed SAD were recruited from the community. The primary outcome was SAD symptoms at 8 weeks (post-assessment). Secondary outcomes included SAD diagnosis, SAD symptoms at follow-up (4 months after post), depression and anxiety symptoms, quality of life, client satisfaction, and adverse effects. Results: Conditions including psychoeducation and exposure were significantly more effective in reducing SAD symptoms at post compared to conditions without these components. Conditions including cognitive restructuring and attention training did not show superiority over conditions without them at post. However, all treatment conditions significantly reduced symptoms compared to the condition without a treatment component. At follow-up, the superiority of psychoeducation and exposure was not significant anymore due to the version without the respective components catching up. Conclusion: The findings suggest that while all treatment components of ICBT for SAD are beneficial compared to no treatment, psychoeducation and exposure include specific active components that significantly improve treatment outcomes more quickly in ICBT for SAD.
... Beyond these comprehensive reviews, several meta-analyses of RCTs have been published on the efficacy of psychotherapy focusing on single anxiety disorders, i.e. GAD (Cuijpers et al., 2014;Hunot, Churchill, Silva de Lima, & Teixeira, 2007) and SAD (Acarturk, Cuijpers, van Straten, & de Graaf, 2009;Barkowski et al., 2016;Mayo-Wilson et al., 2014;Powers, Sigmarsson, & Emmelkamp, 2008;Wersebe, Sijbrandij, & Cuijpers, 2013). For PD with/without agoraphobia, two meta-analyses (Sánchez-Meca, Rosa-Alcazar, Marin-Martinez, & Gomez-Conesa, 2010;Trull, Nietzel, & Main, 1988) and one network meta-analysis (Pompoli et al., 2016) have been published. ...
... Moreover, our head-to-head comparisons of individual and group treatment revealed non-significant differences as found by Burlingame et al. (2016) and Gould et al. (2012), but contradicting findings from the study by Carpenter et al. (2018). Additionally, our study pool shows substantial overlap with disorderspecific reviews on the efficacy of group therapy (SAD: Acarturk et al., 2009;Barkowski et al., 2016;Mayo-Wilson et al., 2014;Powers et al., 2008;Wersebe et al., 2013;GAD: Cuijpers et al., 2014;Hunot et al., 2007;PD: Schwartze et al., 2017). Hence, our results are in line with the effects reported in previous reviews on similar research questions. ...
Objective: This meta-analysis evaluates the efficacy of group psychotherapy in the treatment of anxiety disorders.
Method: A comprehensive literature search using PubMed, PsychInfo, Web of Science, CENTRAL, and manual searches was conducted to locate randomized controlled trials. We found 57 eligible studies (k = 76 comparisons) including 3656 participants receiving group psychotherapy or an alternative treatment for generalized anxiety disorder, social anxiety disorder, and panic disorder.
Results: Effect size estimates show that group psychotherapy reduces specific symptoms of anxiety disorders more effectively than no-treatment control groups (g = 0.92, [0.81; 1.03], k = 43) and treatments providing common unspecific treatment factors (g = 0.29 [0.10; 0.48], k = 12). No significant differences were found compared to individual psychotherapy (g = 0.24 [−0.09; 0.57], k = 7) or pharmacotherapy (g = −0.05 [−0.33; 0.23], k = 6). The effects were unrelated to factors of the group treatment. Within head-to-head studies, a significant moderating effect emerged for researcher allegiance.
Conclusions: Our results support the efficacy of group psychotherapy for anxiety disorders. They indicate that mixed-diagnoses groups are equally effective as diagnosis-specific groups, although further evidence is required. Future primary studies should address differential effectiveness, include a wider range of therapeutic approaches as well as active comparison groups.
... This model, along with two similar group approaches (Clark & Wells, 1995; Rapee & Heimberg, 1997), was the focus of 28 outcome studies published over the past decade (Table 16.1). A recent meta-analysis (Powers, Sigmarsson, & Emmelkamp, 2008) summarizing a portion of these studies estimated identical effectiveness for group (d = .68) and individual treatments (d = .69). ...
... The Sobell, Sobell, and Agrawal (2009) study randomly assigned alcohol and drug dependent patients to short-term individual versus group treatment (4 sessions) with equivalent outcomes but an economic advantage for group (41.4% less therapist time). The picture is less clear with social phobia, where reviewers come to contradictory conclusions noting advantages of individual therapy on effect sizes and attrition rates (Aderka, 2009; Stangier et al., 2003) or equivalence (Powers et al., 2008). Similarly, contradictory results were found for trauma-related disorders (advantages of individual treatment for political prisoners suffering from PTSD, Salo, Punamäi, Qouta, & Sarraj, 2008; equivalence or economic advantages of group treatment for childhood sexual abuse survivors, Ryan et al., 2005; McCrone et al., 2005). ...
... This disorder is further associated with increased risk for comorbid disorders [3] and functional impairment [4]. Group and individual cognitive behavior interventions have been shown to be effective in treating SAD [5]. The cognitive component of cognitive behavior therapy helps clients with SAD to identify and test dysfunctional beliefs accompanying certain behavior patterns [6]. ...
... The rationale behind exposure is that experiencing feared social situations without avoidance will teach the client that the experienced anxiety will eventually decrease and that feared outcomes will not occur. Research indicates that interventions involving a combination of exposure and cognitive components were not significantly more effective than exposure alone [5]. ...
Background and objectives:
Research on virtual reality exposure therapy (VRET) has demonstrated good treatment efficacy with regards to several anxiety disorders. Yet, there is lack of knowledge about the value of integrating interaction between clients and virtual humans in VRET. Such interaction might prove effective in treating psychological complaints that involve social interactions, such as social anxiety.
Methods:
A VRET system specifically designed to expose clients with social anxiety disorder to anxiety provoking social situations was applied to 16 and 18 individuals with high and low levels of social anxiety, respectively. Participants engaged in two exposure sessions in several free speech dialogues with virtual humans while being monitored by a therapist.
Results:
Participants with high levels of social anxiety reported significantly lower levels of social anxiety three months after exposure to two virtual reality interaction sessions than before treatment (p < 0.01). In the group with low levels of social anxiety, no significant change of social anxiety was reported between pre-treatment and follow-up. Additionally, participants in both groups reported higher self-efficacy three months after treatment than before treatment (ps ≤ 0.001).
Conclusion:
These findings indicate that virtual reality technology that incorporates social interactions may be successfully applied for therapeutic purposes.
... The goal of the CBT is to acquire skills to identify , interrupt, and correct dysfunctional assumptions in order to develop behavior more adapted to social situations, e.g., no unrealistic fear of being judged by others negatively. The CBT also uses repeated exposure to feared situations in order to reduce the fear responses (Stangier et al., 2003; Powers et al., 2008; Bandelow and Wedekind, 2014; Craske et al., 2014). However, the efficacy of CBT is not fully satisfactory and leaves a substantial number of non-responders (Fedoroff and Taylor, 2001; Craske et al., 2014). ...
... The causal relationship between presence and fear is a matter of debate (Bouchard et al., 2008), actual aspects are discussed in a recent review (Diemer et al., 2015). The literature shows that although the quality of the simulation is not yet comparable to real-life situations, VR offers an approach to simulate the complexity of real-world experiences in a laboratory environment in the context of phobias (Mühlberger et al., 2006 Powers et al., 2008; Shiban et al., 2013). Furthermore, the capability of VR to model acquisition, extinction, spontaneous recovery, and generalization of fear has been extensively shown for classical conditioning of non-social stimuli (e.g., Ewald et al., 2014; Glotzbach et al., 2012; Mühlberger et al., 2014; for an overview, see Schoon et al., 2013). ...
In human beings, experiments investigating fear conditioning with social stimuli are rare. The current study aims at translating an animal model for social fear conditioning (SFC) to a human sample using an operant SFC paradigm in virtual reality. Forty participants actively (using a joystick) approached virtual male agents that served as conditioned stimuli (CS). During the acquisition phase, unconditioned stimuli (US), a combination of an air blast (5 bar, 10 ms) and a female scream (95 dB, 40 ms), were presented when participants reached a defined proximity to the agent with a contingency of 75% for CS+ agents and never for CS– agents. During the extinction and the test phases, no US was delivered. Outcome variables were pleasantness ratings and physiological reactions in heart rate (HR) and fear-potentiated startle. Additionally, the influence of social anxiety, which was measured with the Social Phobia Inventory scale, was evaluated. As expected after the acquisition phase the CS+ was rated clearly less pleasant than the CS–. This difference vanished during extinction. Furthermore, the HR remained high for the CS+, while the HR for the CS– was clearly lower after than before the acquisition. Furthermore, a clear difference between CS+ and CS– after the acquisition indicated successful conditioning on this translational measure. Contrariwise no CS+/CS– differences were observed in the physiological variables during extinction. Importantly, at the generalization test, higher socially fearful participants rated pleasantness of all agents as low whereas the lower socially fearful participants rated pleasantness as low only for the CS+. SFC was successfully induced and extinguished confirming operant conditioning in this SFC paradigm. These findings suggest that the paradigm is suitable to expand the knowledge about the learning and unlearning of social fears. Further studies should investigate the operant mechanisms of development and treatment of social anxiety disorder.
... Einige Metaanalysen bestätigten die Wirksamkeit der KVT gegenüber Wartelisten-, psychologischen Placebo-und Pillenplacebo-Bedingungen (Acarturk et al., 2009;Fedoroff u. Taylor, 2001;Norton u. Price, 2007;Powers et al., 2008). Allerdings sieht eine Metaanalyse eine geringere Wirksamkeit bei den schwereren Fällen und geringere Unterschiede gegenüber Placebobedingungen (Acarturk et al., 2009). ...
... Other findings reported that CBT for social anxiety disorder evidenced a medium to large effect size at immediate post-treatment as compared to control or waitlist treatments, with significant maintenance and even improvement of gains at follow-up [45]. Further, exposure, cognitive restructuring, social skills training, and both group/individual formats were equally efficacious [46], with superior performance over psychopharmacology in the long term [47]. ...
Objectives: Socially disconnected widows usually live a lonely and depressing life with anxiety and low self-worth. Many have contemplated suicide and others have become a victim of suicide already. Evolving an intervention to provide succor to them to take control of their lives may help a great deal. This paper presents the results of a nonrandomized study assessing the potency of cognitive reframing (CR) in reducing social disconnectedness (SD) among the widows.Methods: The pre- and post-data was collected from a non-randomized sample of 41 widows in the treatment group and 45 in the waitlist control group. The mean age of the participants was 41.383 ± 6.730 [95% CI = 39.940–42.940] (min. = 25 - max. = 56) years. The cognitive reframing administered spanned for eight weeks.Results: Analysis of the data collected suggests that cognitive reframing is significantly effective in reducing socially disconnected behavior among the widows in the study. The social disconnected behavior among the widows reduced by 40.95% compared to 8.29% observed in the waitlist control group.Conclusions: The CR technique may be helpful in reducing social disconnectedness in widows. However, further study may be required in a randomized sample to enhance generalization.
... Anxiety disorders are the most common mental disorders and they account for approximately one-third of all mental health care costs (Greenberg et al., 1999; Johansson, Carlbring, Heedman, Paxling, & Andersson, 2013;). Fortunately, meta-analyses show exposure-based therapy is effective for most patients with anxiety disorders (Olatunji, Davis, Powers, & Smits, 2013; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010; Powers, Sigmarsson, & Emmelkamp, 2008; Wolitzky-Taylor, Horowitz, Powers, & Telch, 2008 ). Based on such findings , international treatment guidelines recommend exposure therapy for anxiety disorders as the gold standard (e.g. ...
Anxiety disorders are the most common mental disorders and they account for approximately one-third of all mental health care costs. Fortunately, meta-analyses show exposure-based therapy is effective for most patients with anxiety disorders. Based on such findings, international treatment guidelines recommend exposure therapy for anxiety disorders as the gold standard. For example, the Institute of Medicine stated “the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD” (p. 97) but they did not find sufficient evidence for any other psychotherapy or pharmacotherapy. Following these guidelines should be uncomplicated, but in general therapists seem to prefer to use their clinical experience rather than research findings to improve their practice.Although well supported for over 50 years, most people with anxiety disorders still do not receive exposure therapy. In fact, most people with emotional disorders do not receive any treatment. This gap in what is known and what is available to patients is frustrating. Examination of obstacles to dissemination reveals how recent advances in technology may help bridge the gap. Below we briefly review some of the proposed obstacles to successful dissemination and potential technological solutions for each.
... The Liebowitz Social Anxiety Scale Self-report (LSAS-SR) was used to estimate social anxiety and avoidance. LSAS-SR is a frequently used, self-report questionnaire in studies of treatment for SAD [32] and has demonstrated adequate psychometric properties [33]. ...
Performance anxiety, which could be regarded as a type of social anxiety disorder, is a common and debilitating condition among professional artists. In spite of this, no clinical research has previously been done on treatment methods for professional actors with PA. In the current study A-B single case experimental designs and parametric statistics were used to report the treatment process of five actors with PA who were treated with 11-12 sessions of Individual Cognitive Therapy (ICT). ICT was found to reduce PA in four of the five cases, and resulted in significantly lower frequencies of safety behaviors and negative social thoughts. It was concluded that ICT could be an effective course of treatment for actors with PA.
... At post-assessment, after the second therapy weekends, large effect sizes occurred, and more than half of the pa- tients reached clinically significant changes. Response rates are favourable and comparable with those of other trials in the field of SAD (e.g., Leichsenring et al., 2013;Powers et al., 2008;Stangier et al., 2003). It has to be noted that it is not possible to disentangle the effects of the com- bination of both treatments due to the lack of a control group with two weekends of the same intervention (TCT-TCT or CT-CT). ...
The current study examines the efficacy of intensified group therapy for social anxiety disorder with fear of blushing. Task concentration training (TCT) and cognitive therapy (CT) were applied during one weekend and compared with a waiting list condition in a randomized controlled trial including 82 patients. On a second weekend, another intervention was added (resulting in TCT–CT and CT–TCT sequences) to examine order effects.
Task concentration training and CT were both superior to the waiting list and equally effective after the first therapy weekend. Also, no differences were found between the sequences TCT–CT and CT–TCT at post‐assessment. At 6‐ and 12‐month follow‐up, effects remained stable or further improved. At the 6‐month follow‐up, remission rates in completers, established by diagnostic status, were between 69% and 73%.
Intensified group therapy is highly effective in treating social anxiety disorder with fear of blushing. Group formats for patients sharing a common primary concern may contribute to the dissemination of cognitive–behavioural therapy. Copyright © 2015 John Wiley & Sons, Ltd.
Key Practitioner Message: This study focuses on blushing from fearful individuals within the SAD spectrum to improve evidence for treatment efficacy in those whose social fears are centred around observable bodily sensations.
This study integrates task concentration training into the SAD model of Clark and Wells to combine two evidence‐based treatments for SAD under one treatment model.
This study uses an innovative format of brief, intensified group therapy, conducted on two full‐day weekend group sessions delivered over two weekends, with strong observed effect sizes.
... Exposure therapy has demonstrated clear efficacy for the anxiety disorders, offering clinically meaningful advantages over psychological placebo conditions and showing improvements in symptoms comparable to established pharmacotherapies (Barlow, Gorman, Shear, & Woods, 2000; Blanco et al., 2010; Goodson et al., 2011; Hofmann & Smits, 2008; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010; Powers, Sigmarsson, & Emmelkamp, 2008; Simpson et al., 2013). However, many patients who receive exposure therapy either fail to respond or continue to experience some residual symptoms following treatment discontinuation (Barlow et al., 2000; Blanco et al., 2010; Hofmann & Smits, 2008; Simpson et al., 2013 ). ...
Brain-derived neurotrophic factor (BDNF) is associated with synaptic plasticity, which is crucial for long-term learning and memory. Some studies suggest that people suffering from anxiety disorders show reduced BDNF relative to healthy controls. Lower BDNF is associated with impaired learning, cognitive deficits, and poor exposure-based treatment outcomes. A series of studies with rats showed that exercise elevates BDNF and enhances fear extinction. However, this strategy has not been tested in humans. In this pilot study, we randomized participants (N = 9, 8 females, MAge = 34) with posttraumatic stress disorder (PTSD) to (a) prolonged exposure alone (PE) or (b) prolonged exposure+exercise (PE+E). Participants randomized to the PE+E condition completed a 30-minute bout of moderate-intensity treadmill exercise (70% of age-predicted HRmax) prior to each PE session. Consistent with prediction, the PE+E group showed a greater improvement in PTSD symptoms (d = 2.65) and elevated BDNF (d = 1.08) relative to the PE only condition. This pilot study provides initial support for further investigation into exercise augmented exposure therapy.
... Social anxiety disorder (SAD) is a prevalent and debilitating disorder (Kessler et al., 2005) characterized by a fear of social and performance situations (Cox, Fleet, & Stein, 2004). Although gold-standard interventions for SAD exist (Powers, Sigmarsson, & Emmelkamp, 2008), many people are not helped by these interventions, prompting a search for alternative treatments. For example, mindfulness-based stress reduction (MBSR; KabatZinn, 1990) has recently been embraced as a popular integrative medicine intervention (Hofmann, Sawyer, Witt, & Oh, 2010), while aerobic exercise (AE) has been gaining momentum as an alternative to traditional treatments for a variety of anxiety disorders (see review by Asmundson et al., 2013). ...
We examined whether social anxiety severity at pre-treatment would moderate the impact of mindfulness-based stress reduction (MBSR) or aerobic exercise (AE) for generalized social anxiety disorder. MBSR and AE produced equivalent reductions in weekly social anxiety symptoms. Improvements were moderated by pre-treatment social anxiety severity.
Mindfulness-based stress reduction (MBSR) and aerobic exercise (AE) are effective in reducing symptoms of social anxiety. Pre-treatment social anxiety severity can be used to inform treatment recommendations. Both MBSR and AE produced equivalent reductions in weekly levels of social anxiety symptoms. MBSR appears to be most effective for patients with lower pre-treatment social anxiety symptom severity. AE appears to be most effective for patients with higher pre-treatment social anxiety symptom severity.
© 2015 The British Psychological Society.
... Meta-analyses of CBT for SAD report controlled medium to large effect sizes of Cohen's d = 0.70–0.86 (Acarturk et al., 2009; Powers et al., 2008). Although effective treatments exist, less than half of sufferers seek treatment (Crome et al., 2014; Gross et al., 2005; Issakidis and Andrews, 2002). ...
Social anxiety disorder (SAD) is a common, chronic and disabling mental disorder. Cognitive Behaviour Therapy (CBT) is a highly effective treatment of SAD and internet CBT (iCBT) offers a cost-effective and convenient alternative to face to face approaches, with high fidelity and demonstrated efficacy. The aim of the current paper was to evaluate the effectiveness of an iCBT programme for SAD (The This Way Up Clinic Shyness Programme) when delivered in routine practice through two different pathways. Patients in the prescription pathway (Study 1, N = 368, 50% female, mean age = 34) were ‘prescribed’ the Shyness Programme by a registered practitioner of the This Way Up Clinic who supervised their progress throughout the programme. Patients in the referral pathway (Study 2, N = 192, 50% female, mean age = 36) were referred to the This Way Up Clinic and supervised by a specialist CBT clinician at the clinic. Intention-to-treat marginal model analyses demonstrated significant reductions in primary outcomes of social anxiety symptoms (Mini-SPIN) and psychological distress (K10), corresponding to large effect sizes (Cohen's d = .82-1.09, 95% CIs .59-1.31) and secondary outcomes of impairment (WHODAS-II) and depressive symptoms (PHQ9), corresponding to small effect sizes (Cohen's d = .36-.46, 95% CIs .19-.68) for patients in both pathways. Results provide evidence of the effectiveness of iCBT for social anxiety disorder when delivered in routine practice.
... Likewise, two treatment studies of SAD provide evidence of a facilitative effect of cognitive techniques when combined with exposure therapy based on observed treatment gains on behavioral tests of avoidance and measures of phobia (Mattick & Peters, 1988; Mattick, Peters, & Clarke, 1989). However, other studies found no evidence of enhanced outcome for SAD patients assigned to exposure plus cognitive therapy relative to exposure therapy alone (Salaberria & Echeburua, 1998; Scholing & Emmelkamp, 1993a, 1993b), which is consistent with conclusions of a recent meta-analysis of 34 RCTs investigating treatments for SAD (Powers, Sigmarsson, & Emmelkamp, 2008). Finally, we identified only one small-scale treatment study for OCD that directly compared exposure alone vs. combined with a cognitive intervention (Emmelkamp & Beens, 1991). ...
Exposure therapy represents a collection of potent therapeutic strategies based on an evolving science of fear attenuation. Having people confront feared objects, sit- uations, and activities dates back to 1924 when Mary Cover Jones first helped 3- year-old Peter overcome his fear of white rabbits through the repeated, graduated presentation of a white rabbit while simultaneously presenting Peter’s favorite food. Thirty years later, Joseph Wolpe published his seminal work describing remarkable success using a similar technique, coined systematic desensitization, in the treat- ment of neurosis (Wolpe, 1958). From their early beginnings, exposure-based treat- ments have expanded procedurally to accommodate the full range of clinical presen- tations of pathological fear ranging from circumscribed fears to complex, debilitating clinical syndromes.
An observer not familiar with exposure therapy might be surprised to learn that administering repeated inhalations of CO2 gas to a panic patient, having a patient with obsessive-compulsive disorder (OCD) listen to an audiotape of frightening thoughts, having a social anxiety patient intentionally seek out repeated rejection from members of the opposite sex, or encouraging a trauma patient to repeatedly recount a traumatic memory, are all examples of exposure therapy. Further, one might wonder what these divergent strategies have in common to warrant their categorization as exemplars of this potent set of therapeutic techniques.
We have organized this chapter around a series of key questions to address the nature, clinical application, efficacy and effectiveness, and change mechanisms of expo- sure therapy. We further address whether changing procedural parameters of expo- sure therapy influence its efficacy, and whether exposure therapy can be enhanced by combining it with other psychological or pharmacological strategies. We conclude by offering several recommendations for future research.
... Both individual and group formats of CBT for SAD have demonstrated efficacy, and current evidence does not conclusively support the superiority of one modality over the other (Powers, Sigmarsson, & Emmelkamp, 2008). The treatment formats cover the same therapeutic interventions (detailed descriptions of group treatment for SAD are available elsewhere; Bieling et al., 2006;Heimberg & Becker, 2002). ...
Cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD) is an empirically-supported, time-limited, psychological treatment. In this chapter, we review both core and adjunct components of CBT for SAD, including core strategies of psychoeducation, cognitive strategies, and behavioral strategies as well as optional adjunct strategies of applied relaxation, social skills training, video feedback, virtual reality-based exposure, attention training, and imagery rescripting. We also review the application of CBT for SAD in diverse populations and in individuals with comorbid conditions.
... Likewise, two treatment studies of SAD provide evidence of a facilitative effect of cognitive techniques when combined with exposure therapy based on observed treatment gains on behavioral tests of avoidance and measures of phobia (Mattick & Peters, 1988; Mattick, Peters, & Clarke, 1989). However, other studies found no evidence of enhanced outcome for SAD patients assigned to exposure plus cognitive therapy relative to exposure therapy alone (Salaberria & Echeburua, 1998; Scholing & Emmelkamp, 1993a, 1993b), which is consistent with conclusions of a recent meta-analysis of 34 RCTs investigating treatments for SAD (Powers, Sigmarsson, & Emmelkamp, 2008). Finally, we identified only one small-scale treatment study for OCD that directly compared exposure alone vs. combined with a cognitive intervention (Emmelkamp & Beens, 1991). ...
... In prior research, 85% of schizotypal frequent cannabis users indi- cated interest in general psychiatric/psychological treatment, whereas only 25% indicated interest in cannabis use treatment (Cohen et al., 2010a). Thus, cognitive behavioral therapy for social anxiety (e.g., Powers et al., 2008) could be used to restructure anxious and depressive thoughts, challenge socially-based and affectively-related cannabis use expectancies, identify alternative coping skills to address affective reasons for use, and improve drug refusal skills. ...
Emerging research suggests that cannabis use might be related to psychosis onset in people vulnerable to developing schizophrenia-spectrum disorders. Furthermore, individuals with high-positive and disorganized schizotypy traits report more cannabis use and cannabis-related problems than controls. Social anxiety, a frequently co-occurring schizotypal feature, is related to increased cannabis-related problems in the general population. Building on this research, we explored the impact of social anxiety, measured by the Social Interaction Anxiety Scale (SIAS), and depression and trait anxiety reported on the Brief Symptom Inventory (BSI), on the relationship of schizotypy, measured by the Schizotypy Personality Questionnaire-Brief Revised (SPQ-BR), to cannabis use (n=220 schizotypy, 436 controls) and frequent use and cannabis-related problems among users (n=88 schizotypy, 83 controls) in college undergraduates. Among cannabis users, social anxiety moderated the relationships of schizotypy to frequent cannabis use and more cannabis-related problems in the total schizotypy group, and across high-positive, negative, and disorganized schizotypy subgroups. Depression and trait anxiety also moderated the relationship of schizotypy to frequent cannabis use and more cannabis-related problems, but results varied across high-positive, negative, and disorganized schizotypy subgroups. Results suggest therapeutically targeting negative affective states may be useful in psychosocial intervention for cannabis-related problems in schizotypy.
Yaygın olarak görülen psikolojik sorunlardan olan Sosyal kaygı bozukluğu (SKB), bireylerin hayatlarının çeşitli alanlarında ciddi zorluklar yaratmakta ve başka psikolojik sorunlarla sıklıkla bir arada görülmektedir. SKB’yi açıklamak için çeşitli bilişsel davranışçı modeller önerilmiş ve bu modelleri temel alan tedavi protokolleri geliştirilmiştir. Bu çalışmada ilgili alanyazın gözden geçirilmiş ve yaygın olarak kullanılan bilişsel davranışçı terapi programları hakkında detaylı bilgiler sunulmuştur. Tedavi programları incelendiğinde bireylerin sosyal durumlara ilişkin uyumsuz inançlarına yönelik bilişsel müdahaleler ile korkulan duruma yönelik maruz bırakma uygulamalarının birçok tedavi programında temel bileşenler olduğu görülmektedir. SKB’nin tedavisine yönelik güncel araştırmaların sonuçları en etkili tedavi yöntemlerinden birinin BDT olduğunu ve elde edilen kazanımların uzun vadede de sürme eğiliminde olduğunu göstermektedir. Öte yandan önemli sayıda sosyal kaygılı bireyin bilişsel davranışçı terapiden yeterli faydayı göremediği anlaşılmıştır.
Written by internationally recognized experts, this comprehensive CBT clinician's manual provides disorder-specific chapters and accessible pedagogical features. The cutting-edge research, advanced theory, and attention to special adaptations make this an appropriate reference text for qualified CBT practitioners, students in post-graduate CBT courses, and clinical psychology doctorate students. The case examples demonstrate clinical applications of specific interventions and explain how to adapt CBT protocols for a range of diverse populations. It strikes a balance between core, theoretical principles and protocol-based interventions, simulating the experience of private supervision from a top expert in the field.
Public speaking anxiety (PSA) is a prevalent condition with disabling occupational, educational, and social consequences. Exposure therapy is a commonly utilized approach for treating PSA. Traditionally, this intervention has been delivered as in vivo exposure therapy (IVET). Limitations inherent to in vivo as a mode of delivery have been identified and studies have increasingly explored the use of Virtual Reality Exposure Therapy (VRET) as an alternative. Understanding the efficacy of both VRET and IVET as psychological interventions for PSA is important. A systematic search identified 11 studies with 508 participants. Meta-analysis yielded a large significant effect wherein VRET resulted in significant reductions in PSA versus control of -1.39 (Z = 3.96, p < .001) and a similar large significant effect wherein IVET resulted in significant reductions in PSA versus control of -1.41 (Z = 7.51, p < .001). Although IVET was marginally superior to VRET, both interventions proved efficacious. Given the advantages of utilizing VRET over IVET future research and clinical practice could explore VRET as a treatment option for PSA.
Introduction: Classical well-established treatments of social anxiety disorder (SAD) are now complemented by more recent therapeutic strategies. This review aims to summarize available therapies for SAD and discuss recent evidence-based findings on the management of this disorder.
Areas covered: Recent guidelines recommend psychotherapy, particularly cognitive-behavioral therapy (CBT), and pharmacotherapy, as first-line treatments of patients with SAD, without a clear superiority of one option over the other. CBT includes classical approaches such as in vivo exposure to social situations and cognitive therapy, but new modalities and techniques have been recently developed: third-wave approaches, internet-delivered therapy, virtual reality exposure, and cognitive bias modification. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors have been also extensively studied and shown to be effective in SAD. Two alternative strategies have been developed to treat SAD with disappointing results: cognitive bias modification, and pharmacological augmentation of psychotherapy using D-cycloserine during exposure sessions.
Expert opinion: Personalized treatments for SAD patients are now available. Innovative strategies such as online psychotherapy and virtual reality exposure are useful alternatives to CBT and SSRIs. Future developments and optimization of attention bias modification and of pharmacological augmentation of psychotherapy can be promising.
The purpose of this study is to analyze psychological treatment in social phobia, identifying levels of effectiveness,
treatment length, treatment cost and techniques used. The sample consists of 51 patients, average age 30.14 (SD = 8.309),
mainly women (60.8%), single (78.4%), and students (64.7%). Descriptive analyses for sociodemographic characteristics
and therapy cost were performed; besides, the sample was divided into two groups (patients who achieved discharge
and patients who dropped-out), and differences between the two groups were made. Finally, cluster analysis techniques
were performed and multivariate analyses were conducted to know what techniques predicted therapeutic success. Of
the patients, 61% are discharged, with an average duration of 20 sessions and a treatment cost of €1,200. The techniques
which predict success are exposure and use of other techniques (p < .05). The use of protocols for social phobia which
include the aforementioned techniques is suggested.
Theories of anxiety disorders and phobias have ascribed a critical role to avoidance behavior in explaining the persistence of fear and anxiety, but knowledge about the role of avoidance behavior in the maintenance of anxiety in social anxiety disorder relative to specific phobia is lacking. This study examined the extent to which avoidance behavior moderates the relationship between general anxiety at baseline and 18 months later in women with a diagnosed social anxiety disorder (n = 91) and women with a diagnosed specific phobia (n = 130) at baseline. Circumscribed avoidance of social and specific situations were clinician-rated using the Anxiety Disorders Interview Schedule-Lifetime (ADIS-IV-L), and general anxiety was measured using the Beck Anxiety Inventory (BAI). Moderated regression analyses revealed that (a) general anxiety at baseline predicted general anxiety at follow-up in both women with a specific phobia and women with a social anxiety disorder and (b) avoidance behavior moderated this relationship in women with a specific phobia but not in women with a social anxiety disorder. Specifically, high avoidance behavior was found to amplify the effect between general anxiety at baseline and follow-up in specific phobia. Reasons for the absence of a similar moderating effect of avoidance behavior within social anxiety disorder are discussed.
Background:
Test anxiety is a common condition in students, which may lead to impaired academic performance as well as to distress. The primary objective of this study was to evaluate the effectiveness of two cognitive-behavioral interventions designed to reduce test anxiety. Test anxiety in the participants was diagnosed as social or specific phobia according to DSM-IV. Subsequently subjects were randomized to three groups: a moderated self-help group, which served as a control group, and two treatment groups, where either relaxation techniques or imagery rescripting were applied.
Methods:
Students suffering from test anxiety were recruited at two German universities (n=180). The randomized controlled design comprised three groups which received test anxiety treatment in weekly three-hour sessions over a period of five weeks. Treatment outcome was assessed with a test anxiety questionnaire, which was administered before and after treatment, as well as in a six-month follow-up.
Results:
A repeated-measures ANOVA for participants with complete data (n=59) revealed a significant reduction of test anxiety from baseline to six-month follow-up in all three treatment groups (p<.001).
Limitations:
Participants were included if they had a clinical diagnosis of test anxiety. The sample may therefore represent only more severe forms of text anxiety . Moreover, the sample size in this study was small, the numbers of participants per group differed, and treatment results were based on self-report. Due to the length of the treatment, an implementation of the group treatments used in this study might not be feasible in all settings.
Conclusions:
Group treatments constitute an effective method of treating test anxiety, e.g. in university settings. Imagery rescripting may particularly contribute to treatment efficacy.
In Germany, group psychotherapy is a very common treatment in inpatient settings whereas outpatient group psychotherapy is less provided. This article gives an overview of the current status of group psychotherapy in the health care service and its importance in current treatment guidelines. Additionally, guideline recommendations were compared to current meta-analytic evidence on the efficacy of group psychotherapy. In doing so we focus on different anxiety disorders such as social phobia, panic disorder, generalized anxiety disorder, obsessive compulsive disorder, and posttraumatic stress disorder. There is still a discrepancy between empirical evidence, guideline recommendations, and the provision of group psychotherapy in outpatient treatments settings. Although empirical findings on the efficacy of group psychotherapy are promising, treatment guidelines still give preference to individual psychotherapy. To improve the provision of group psychotherapy in the outpatient service treatment guidelines need to be updated and barriers for implementing group psychotherapy should be reduced.
In diesem Kapitel wird ausgehend von verschiedenen Strategien der Wirksamkeitsbeurteilung von (Gruppen-)Psychotherapien die Evidenz für die Wirksamkeit von Gruppentherapien im Vergleich zu Einzeltherapien in Abhängigkeit von der formalen Veränderungstheorie, dem Setting und den behandelten Störungen beschrieben. Behandlungsökonomische Aspekte, mögliche Einflussfaktoren im Hinblick auf den Effekt von Gruppentherapien und Überlegungen zu negativen Wirkungen von Gruppen schließen sich an.
The present research is a randomized controlled trial in which the effects of a Dutch version of «Talk to me», an Internet-based cognitive-behavioral treatment for fear of public speaking were investigated. Forty one participants with a formal diagnosis of social phobia were assigned at random to either «Talk to me», or a waiting list control group. The group treated by an Internet-based cognitive-behavioral treatment resulted in significant improvement from pre-test to pos-test on all social phobia measures and in social and work impairment. Talk to me was significantly more effective than the control group on a number of measures: fear and avoidance to the target behaviors, fear of public speaking and work impairment. Regarding to the effect size (Cohen-d) for the measures related to social phobia the Internet treatment had a high within-group (d = 1.13) and between-groups effect size (d = .86). Results achieved with the Talk to me program are comparable to results of face-to-face treatment of social phobia. Finally, it is important to emphasize that Talk to me was well accepted by the participants.
Internet-based interventions hold specific advantages and disadvantages in the treatment of social anxiety disorder (SAD). The present review examines different approaches in the internet-based treatment of SAD and reviews their efficacy and effectiveness. 21 studies investigated the potential of guided and unguided internet-based cognitive-behavioral treatments (ICBT) for SAD, comprising a total of N = 1,801 socially anxious individuals. The large majority of these trials reported substantial reductions of social anxiety symptoms through ICBT programs. Within effect sizes were mostly large and comparisons to waitlist and more active control groups were positive. Treatment gains were stable from 3 months to 5 years after treatment termination. In conclusion, ICBT is effective in the reduction of social anxiety symptoms. At the same time, not all participants benefit from these treatments to a sufficient degree. Future research should focus on what makes these interventions work in which patient populations, and at the same time, examine ways to implement internet-based treatment in the routine care for socially anxious patients.
We describe the development of a novel, Internet-based, self-help intervention for social anxiety disorder (SAD) in adults, and report data on the preliminary efficacy of the program when administered with minimal therapist support delivered via a common videoconferencing platform. Participants (n = 13) completed the intervention, which consists of 8 weekly modules and a brief weekly videoconferenced check-in with a therapist. The intervention program is derived from an acceptance-based CBT program that utilizes traditional behavioral interventions (e.g., exposure) within the context of a model emphasizing mindful awareness and psychological acceptance of distressing subjective experiences. Assessments revealed that participants experienced a significant reduction in SAD symptoms and improvements in psychosocial functioning, and that treatment gains were maintained over a 3-month follow-up period. The effect sizes for the main outcome measures were large to very large (d = 0.90 to 1.47), and comparable to other Internet-based treatment programs as well as in-person trials for SAD (e.g., Feske & Chambless, 1995; Tulbure, 2011). Participants also rated the treatment program as highly acceptable. This pilot study provides preliminary evidence that an Internet-based intervention grounded in basic behavioral and acceptance-based principles is effective for the treatment of SAD, and that videoconferenced therapist support may be useful in enhancing treatment compliance. Implications and future directions are discussed.
Reductions in judgmental biases concerning the cost and probability of negative social events are presumed to be mechanisms of treatment for SAD. Methodological limitations of extant studies, however, leave open the possibility that, instead of causing symptom relief, reductions in judgmental biases are correlates or consequences of it. The present study evaluated changes in judgmental biases as mechanisms explaining the efficacy of CBT for SAD. Participants were 86 individuals who met DSM-IV-TR criteria for a primary diagnosis of SAD, participated in one of two treatment outcome studies of CBT for SAD, and completed measures of judgmental (i.e., cost and probability) biases and social anxiety at pre-, mid-, and posttreatment. Treated participants had significantly greater reductions in judgmental biases than not-treated participants; pre-to-post changes in cost and probability biases statistically mediated treatment outcome; and probability bias at midtreatment was a significant predictor of treatment outcome, even when modeled with a plausible rival mediator, working alliance. Contrary to hypotheses, cost bias at midtreatment was not a significant predictor of treatment outcome. Results suggest that reduction in probability bias is a mechanism by which CBT for SAD exerts its effects.
Copyright © 2015 Elsevier Ltd. All rights reserved.
Objective: Internet-based cognitive-behavioral therapy (ICBT) has received increased attention as an innovative approach to improve access to evidence-based psychological treatments. Although the efficacy of ICBT for social anxiety disorder has been established in several studies, there is limited knowledge of its effectiveness and application in clinical psychiatric care. The purpose of this study was to evaluate the effectiveness of ICBT in the treatment of social anxiety disorder and to determine the significance of patient adherence and the clinic’s years of experience in delivering ICBT. Method: A longitudinal cohort study was conducted using latent growth curve modeling of patients (N = 654) treated with ICBT at an outpatient psychiatric clinic between 2009 and 2013. The primary outcome measure was the Liebowitz Social Anxiety Scale–Self-Rated. Results: Significant reductions in symptoms of social anxiety were observed after treatment (effect size d = 0.86, 99% CI [0.74, 0.98]). Improvements were sustained at 6-month follow-up (d = 1.15, 99% CI [0.99, 1.32]). Patient adherence had a positive effect on the rate of improvement. A positive association between the clinic’s years of experience with ICBT and treatment outcome was also observed. Conclusions: This study suggests that ICBT for social anxiety disorder is effective when delivered within the context of a unit specialized in Internet-based psychiatric care and may be considered as a treatment alternative for implementation within the mental health care system.
Despite the availability of effective interventions, most individuals with social anxiety disorder do not seek treatment. Given their fear of negative evaluation, socially anxious individuals might be especially susceptible to stigma concerns, a recognized barrier for mental health treatment. However, very little is known about the stigma specific to social anxiety disorder. In a design similar to Feldman and Crandall (2007), university undergraduate students read vignettes about target individuals with a generic mental illness label, major depressive disorder, and social anxiety disorder. Subjects rated each of 3 people in the vignettes on social distance and 17 dimensions including dangerousness, heritability and prevalence of the disorder, and gender ratio. Results indicated that being male and not having experience with mental health treatment was associated with somewhat greater preferred social distance. Multiple regression analyses revealed that being embarrassed by the disorder and dangerousness predicted social distance across all 3 vignettes. The vignette for social anxiety disorder had the most complex model and included work impairment, more common among women, and more avoidable. These results have implications for understanding the specific aspects of the stigma associated with social anxiety disorder. Public service messages to reduce stigma should focus on more accurate information about dangerousness and mental illness, given this is an established aspect of mental illness stigma. More nuanced messages about social anxiety might be best incorporated into the treatment referral process and as part of treatment. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
Method:
Data came from the CT arm of a multicentre RCT with n = 244 patients having DSM-IV SAD. CT was conducted according to the manual by Clark and Wells. Severity of SAD was assessed at baseline and end of treatment with the Liebowitz Social Anxiety Scale (LSAS). Multiple linear regression analyses and logistic regression analyses were applied.
Results:
Up to 37% of the post-treatment variance (LSAS) could be explained by all pre-treatment variables combined. Symptom severity (baseline LSAS) was consistently negatively associated with end-state functioning and remission, but not with response. Number of comorbid diagnoses was negatively associated with end-state functioning and response, but not with remission. Self-esteem was positively associated with higher end-state functioning and more shame with better response. Attrition could not be significantly predicted.
Conclusions:
The results indicate that the initial probability for treatment success mainly depends on severity of disorder and comorbid conditions while other psychological variables are of minor importance, at least on a nomothetic level. This stands in contrast with efforts to arrive at an empirical-based foundation for differential indication and argues to search for more potent moderators of therapeutic change rather on the process level.
Key practitioner message:
Personality, self-esteem, shame, attachment style and interpersonal problems do not or only marginally moderate the effects of interventions in CT of social phobia.Symptom severity and comorbid diagnoses might affect treatment outcome negatively.Beyond these two factors, most patients share a similar likelihood of treatment success when treated according to the manual by Clark and Wells. Copyright © 2014 John Wiley & Sons, Ltd.
Virtual reality exposure therapy (VRET) has been shown to be effective in treatment of anxiety disorders. Yet, there is lack of research on the extent to which interaction between the individual and virtual humans can be successfully implanted to increase levels of anxiety for therapeutic purposes. This proof-of-concept pilot study aimed at examining levels of the sense of presence and anxiety during exposure to virtual environments involving social interaction with virtual humans and using different virtual reality displays. A non-clinical sample of 38 participants was randomly assigned to either a head-mounted display (HMD) with motion tracker and sterescopic view condition or a one-screen projection-based virtual reality display condition. Participants in both conditions engaged in free speech dialogues with virtual humans controlled by research assistants. It was hypothesized that exposure to virtual social interactions will elicit moderate levels of sense of presence and anxiety in both groups. Further it was expected that participants in the HMD condition will report higher scores of sense of presence and anxiety than participants in the one-screen projection-based display condition. Results revealed that in both conditions virtual social interactions were associated with moderate levels of sense of presence and anxiety. Additionally, participants in the HMD condition reported significantly higher levels of presence than those in the one-screen projection-based display condition (p = .001). However, contrary to the expectations neither the average level of anxiety nor the highest level of anxiety during exposure to social virtual environments differed between the groups (p = .97 and p = .75, respectively). The findings suggest that virtual social interactions can be successfully applied in VRET to enhance sense of presence and anxiety. Furthermore, our results indicate that one-screen projection-based displays can successfully activate levels of anxiety in social virtual environments. The outcome can prove helpful in using low-cost projection-based virtual reality environments for treating individuals with social phobia.
Narrative reviews conclude that behavioral therapies (BTs) produce better outcomes than control conditions for cannabis use disorders (CUDs). However, the strength and consistency of this effect has not been directly empirically examined. The present meta-analysis combined multiple well-controlled studies to help clarify the overall impact of behavioral interventions in the treatment of CUDs. A comprehensive literature search produced 10 randomized controlled trials (RCTs; n = 2,027) that were included in the final analyses. Analyses indicated an effect of BTs (including contingency management, relapse prevention, and motivational interviewing, and combinations of these strategies with cognitive behavioral therapy) over control conditions (including waitlist [WL], psychological placebo, and treatment as usual) across pooled outcomes and time points (Hedges' g = 0.44). These results suggest that the average patient receiving a behavioral intervention fared better than 66% of those in the control conditions. BT also outperformed control conditions when examining primary outcomes alone (frequency and severity of use) and secondary outcomes alone (psychosocial functioning). Effect sizes were not moderated by inclusion of a diagnosis (RCTs including treatment-seeking cannabis users who were not assessed for abuse or dependence vs. RCTs including individuals diagnosed as dependent), dose (number of treatment sessions), treatment format (either group vs. individual treatment or in-person vs. non-in-person treatment), sample size, or publication year. Effect sizes were significantly larger for studies that included a WL control comparison versus those including active control comparisons, such that BT significantly outperformed WL controls but not active control comparisons.
Attentional bias modification (ABM) represents one of a number of cognitive bias modification techniques which are beginning to show promise as therapeutic interventions for emotional pathology. Numerous studies with both clinical and non-clinical populations have now demonstrated that ABM can reduce emotional vulnerability. However, some recent studies have failed to achieve change in either selective attention or emotional vulnerability using ABM methodologies, including a recent randomised controlled trial by Carlbring et al. Some have sought to represent such absence of evidence as a sound basis not to further pursue ABM as an online intervention. While these findings obviously raise questions about the specific conditions under which ABM procedures will produce therapeutic benefits, we suggest that the failure of some studies to modify selective attention does not challenge the theoretical and empirical basis of ABM. The present paper seeks to put these ABM failures in perspective within the broader context of attentional bias modification research. In doing so it is apparent that the current findings and future prospects of ABM are in fact very promising, suggesting that more research in this area is warranted, not less.
Psychological models of mental disorders guide research into psychological and environmental factors that elicit and maintain mental disorders as well as interventions to reduce them. This paper addresses four areas. (1) Psychological models of mental disorders have become increasingly transdiagnostic, focusing on core cognitive endophenotypes of psychopathology from an integrative cognitive psychology perspective rather than offering explanations for unitary mental disorders. It is argued that psychological interventions for mental disorders will increasingly target specific cognitive dysfunctions rather than symptom-based mental disorders as a result. (2) Psychotherapy research still lacks a comprehensive conceptual framework that brings together the wide variety of findings, models and perspectives. Analysing the state-of-the-art in psychotherapy treatment research, "component analyses" aiming at an optimal identification of core ingredients and the mechanisms of change is highlighted as the core need towards improved efficacy and effectiveness of psychotherapy, and improved translation to routine care. (3) In order to provide more effective psychological interventions to children and adolescents, there is a need to develop new and/or improved psychotherapeutic interventions on the basis of developmental psychopathology research taking into account knowledge of mediators and moderators. Developmental neuroscience research might be instrumental to uncover associated aberrant brain processes in children and adolescents with mental health problems and to better examine mechanisms of their correction by means of psychotherapy and psychological interventions. (4) Psychotherapy research needs to broaden in terms of adoption of large-scale public health strategies and treatments that can be applied to more patients in a simpler and cost-effective way. Increased research on efficacy and moderators of Internet-based treatments and e-mental health tools (e.g. to support "real time" clinical decision-making to prevent treatment failure or relapse) might be one promising way forward. Copyright © 2013 John Wiley & Sons, Ltd.
While we know that social anxiety disorder (SAD) is today's most common anxiety disorder knowledge on its prospective long-term course is sparse. We conducted a systematic literature search using databases Medline and PsycINFO for naturalistic and psychotherapy outcome studies with follow-up durations of at least 24 months. Four naturalistic cohorts and nine psychotherapy trials were included in the review. The naturalistic course in clinical was less favorable than in non-clinical samples (27% vs. 40% recovery rate after 5 years). Psychotherapy trials, all applying (cognitive) behavioral methods, yielded stable outcomes with overall large pre- to follow-up effect sizes on self-report scales. Observer rated remission rates varied considerably (36% to 100%) depending on study design and follow-up length. The results of psychotherapy trials and that of naturalistic studies can hardly be compared due to differences in methodology. More standardized remission and recovery criteria are needed to enhance the understanding of the longitudinal course.
PurposeAlcohol-related violence is a major public health problem, which can be tackled at a number of different levels, including societal, contextual, familial, social, and individual. The focus in this paper is on individual treatments to reduce the risk of violence associated with social drinking.Methods
This is a narrative review of the processes by which alcohol increases the likelihood of violence, with an emphasis on its deleterious effects on social information processing.ResultsAlcohol priming promotes aggression cognitions and behavior; the drinking context presents triggers for violence; alcohol focuses attention on aggression cues; alcohol outcome expectancies predict drinking; anxious antisocial people who drink to increase social confidence may be at increased risk for aggression; hypermasculine values play a part in aggressive responding; emotional responses of anger, fear and excitement play a part in aggressive responses to perceived provocation; having a broad and accessible aggressive response repertoire, along with positive evaluations of aggressive responses predict aggressive behavior.Conclusions
Additional intervention components that could improve the effectiveness of individual-level interventions for alcohol-related violence are suggested. These could augment conventional interventions, but there is a considerable amount of work to be done in developing applications specifically for alcohol-related violence and evaluating outcomes.
The primary aim of this study was to assess the overall effectiveness of individual and group outpatient cognitive behavioral therapy (CBT) for adults with a primary anxiety disorder in routine clinical practice.
We conducted a random effects meta-analysis of 71 nonrandomized effectiveness studies on outpatient individual and group CBT for adult anxiety disorders. Standardized mean gain effect sizes pre- to posttreatment, and posttreatment to follow-up are reported for disorder-specific symptoms, depression, and general anxiety. The mean dropout from CBT is reported.
Outpatient CBT was effective in reducing disorder-specific symptoms in completer (d=0.90-1.91) and intention-to-treat samples (d=0.67-1.45). Moderate to large (d=0.54-1.09) and small to large effect sizes (d=0.42-0.97) were found for depressive and general anxiety symptoms posttreatment. Across all anxiety disorders, the weighted mean dropout rate was 15.06%. Posttreatment gains for disorder-specific anxiety were maintained 12months after completion of therapy.
CBT for adult anxiety disorders is very effective and widely accepted in routine practice settings. However, the methodological and reporting quality of nonrandomized effectiveness studies must be improved.
Over the past 25 years researchers have made enormous strides in the implementation of cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD), although considerable work remains to be done. The present paper discusses a treatment refractory case seen in our clinic. The young man presented numerous interrelated obstacles, such as low treatment expectations, poor homework compliance, and comorbid depression and alcohol dependence. We highlight the challenges presented by this complex presentation, as well as issues that arose over the course of treatment. We then elaborate on techniques that could have improved his outcome. The promise of motivational interviewing and behavioral activation techniques for these complex clients is discussed. Future research and treatment directions for refractory cases are considered.
Cognitive behavioral therapy (CBT) refers to a popular therapeutic approach that has been applied to a variety of problems. The goal of this review was to provide a comprehensive survey of meta-analyses examining the efficacy of CBT. We identified 269 meta-analytic studies and reviewed of those a representative sample of 106 meta-analyses examining CBT for the following problems: substance use disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, general stress, distress due to general medical conditions, chronic pain and fatigue, distress related to pregnancy complications and female hormonal conditions. Additional meta-analytic reviews examined the efficacy of CBT for various problems in children and elderly adults. The strongest support exists for CBT of anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Eleven studies compared response rates between CBT and other treatments or control conditions. CBT showed higher response rates than the comparison conditions in 7 of these reviews and only one review reported that CBT had lower response rates than comparison treatments. In general, the evidence-base of CBT is very strong. However, additional research is needed to examine the efficacy of CBT for randomized-controlled studies. Moreover, except for children and elderly populations, no meta-analytic studies of CBT have been reported on specific subgroups, such as ethnic minorities and low income samples.
The present study aimed at investigating how frequently and intensely depersonalization/derealization symptoms occur during a stressful performance situation in social phobia patients vs. healthy controls, as well as testing hypotheses about the psychological predictors and consequences of such symptoms. N=54 patients with social phobia and N=34 control participants without mental disorders were examined prior to, during, and after a standardized social performance situation (Trier Social Stress Test, TSST). An adapted version of the Cambridge Depersonalization Scale was applied along with measures of social anxiety, depression, personality, participants' subjective appraisal, safety behaviours, and post-event processing. Depersonalization symptoms were more frequent in social phobia patients (92%) than in controls (52%). Specifically in patients, they were highly positively correlated with safety behaviours and post-event-processing, even after controlling for social anxiety. The role of depersonalization/derealization in the maintenance of social anxiety should be more thoroughly recognized and explored.
Based upon the concept of supportive-expressive therapy (SET), we developed a psychodynamic group treatment manual for social phobia, with a special focus on the patients' individual core conflictual relationship themes, their universality, as well as interventions promoting group processes and therapeutic factors of group therapy. We introduce the new concept and report results of a pilot case study (N=8). Analyses revealed a pre-post-treatment effect size of g=0.64 (95% CI [0.29; 1.00]) on the primary outcome measure, the Liebowitz Social Anxiety Scale (LSAS). Furthermore we obtained positive evidence with regard to acceptance, safety and feasibility of the psychodynamic group therapy concept for social phobia. Subsequent proof-of-concept studies are required to foster treatment development and to proof the replicability of results.
© Georg Thieme Verlag KG Stuttgart · New York.
The purposes of this study were to determine the proportion of papers which contain negative results (results which fail to reject the null hypothesis), and whether there is some selection in the papers published such that negative results are unlikely to be published. An examination of current psychological journals indicated that studies with negative results constitute about 9 per cent of the total volume of published papers. However, data from several unpublished sources indicate that negative results are less likely to be published. The reasons for their neglect - chiefly author selection and the greater editorial scrutiny they get - were presented. The practical, statistical and heuristic value of negative results was also discussed.
"It is often said that psychologists are captivated by the magic of words." One example of this is the epidemic use by psychologists of the word 'design.' " "Despite glib talk about using factor analysis to test hypotheses, practically no users of factor analysis ever test hypotheses." A psychologist may "trudge off weighted down with a box full of statistical tools in search of a research problem that permits him to display skill with his tools." Most psychologists "without intentional eavesdropping know that occasionally their theory oriented colleagues simply discard all data of an experiment as bad data if not in agreement with the theory, and start over. The theory is, of course, always good." The theorist who has the one and only approach and solution to all, or nearly all, psychological problems "tends to lure those among us who have a low tolerance for the ambiguity that flourishes in psychology." This "model business is nothing more than a new name for old hat stuff… . The question of the usefulness of mathematical models and, to a certain extent, the value of high powered statistical techniques is debatable." (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The present study evaluated the initial effects of two types of paradoxical directives. Socially anxious males were randomly assigned to three groups: symptom prescription without reframing, symptom prescription with reframing, and a wait-list control condition. The assessment of outcome consisted of various measures administered pretreatment, posttreatment, and at 1-month followup, as well as daily self-ratings that were obtained throughout the course of the study. Subjects who were exposed to symptom prescription with reframing showed significantly greater improvement than the subjects in the other groups, both at posttreatment and at followup. In contrast, the subjects who were exposed to symptom prescription alone manifested only limited improvement and were not significantly less socially anxious after treatment than the subjects in the wait-list control group. The findings support the view that paradoxical treatments are clinically useful when their effects include changes in the meaning clients attribute to their symptoms.
The development of a new, comprehensive and multicomponent treatment for social phobia is described. Initial results of a pilot study with the new treatment also are reported. The treatment was found to be effective with severe (generalized) social phobics, most of whom had co-occurring Axis I and/or II conditions. In addition to significant change on a host of outcome variables, a normative-based endstate functioning index was used to determine treatment efficacy. The results are discussed with respect to the implementation of the treatment and in terms of the need for a comprehensive approach to treating social phobia.
The aim of this work was to test the contribution of cognitive therapy to exposure in vivo in the group treatment of generalized social phobia. Seventy-one severely disabled social phobics, selected according to DSM-III-R criteria, were assigned at random to: (a) self-exposure in vivo, (b) self-exposure in vivo with cognitive therapy, or (c) a waiting-list control group. A multigroup experimental design with repeated measures of assessment (pretreatment, posttreatment, and 1-, 3-, 6-, and 12-month follow-ups) was used. Additionally, half of the patients in both therapeutic groups were given self-help manuals for managing anxiety. Most patients that were treated (64%) showed significant improvement at the 12-month follow-up, but there were no differences between the two therapeutic models. No improvement was shown by the control-group participants at the 6-month follow-up. The results of the present trial do not support the beneficial effects of adding cognitive therapy or a self-help manual to exposure alone. Finally, several topics that may contribute to future research in this field are discussed.
This article presents results of the acute treatment phase of a 2-site study comparing cognitive behavioral group therapy (CBGT) and treatment with the monoamine oxidase inhibitor phenelzine sulfate for social phobia.
One hundred thirty-three patients from 2 sites received 12 weeks of CBGT, phenelzine therapy, pill placebo administration, or educational-supportive group therapy (an attention-placebo treatment of equal credibility to CBGT). The "allegiance effect," ie, the tendency for treatments to seem most efficacious in settings of similar theoretical orientation and less efficacious in theoretically divergent settings, was also examined by comparing responses to the treatment conditions at both sites: 1 known for pharmacological treatment of anxiety disorders and the other for cognitive behavioral treatment. RESULTs: After 12 weeks, phenelzine therapy and CBGT led to superior response rates and greater change on dimensional measures than did either control condition. However, response to phenelzine therapy was more evident after 6 weeks, and phenelzine therapy was also superior to CBGT after 12 weeks on some measures. There were few differences between sites, suggesting that these treatments can be efficacious at facilities with differing theoretical allegiances.
After 12 weeks, both phenelzine therapy and CBGT were associated with marked positive response. Although phenelzine therapy was superior to CBGT on some measures, both were more efficacious than the control conditions. More extended cognitive behavioral treatment and the combination of modalities may enhance treatment effect.
The efficacy of cognitive behaviour therapy (CBT) in social phobia has been demonstrated in several controlled trials and meta-analyses, but no comparison of CBT with supportive therapy (ST) can be found in the literature.
The aim of the trial was to study the effectiveness of CBT versus ST carried out 'as usual'. Sixty-seven DSM-4 social phobic patients (89% generalized subtype, most with avoidant personality) were randomly allocated into two groups. Group 1 (CBT) received 8 1-hour sessions of individual cognitive therapy (CT) for 6 weeks, followed by 6 2-hour sessions of social skills training (SST) in group weekly. Group 2 received ST for 12 weeks (6 half-hour sessions), then the patients were switched to CBT. All patients agreed not to take any medication during the whole trial. In group 1, 29 patients reached week 6, 27 reached week 12, and 24 weeks 36 and 60 (endpoint). In group 2, 29 patients reached week 6, 28 reached weeks 12 and 18, 26 week 24, and 23 reached weeks 48 and 72 (endpoint).
At week 6, after CT, group 1 was better than group 2 on the main social phobia measure. At week 12, after SST, group 1 was better than group 2 on most of the measures and demonstrated a significantly higher rate of responders. This finding was replicated after switching group 2 to CBT. Sustained improvement was observed in both groups at follow-up. Compliance with abstinence from medication increased over time.
CBT was more effective than ST and demonstrated long-lasting effects. This may suggest that social phobia management requires more than a simple and inexpensive psychological intervention.
No controlled trial of treatment of generalised social phobia has been conducted in general practice.
To examine the efficacy of sertraline or exposure therapy, administered alone or in combination in this setting.
Study was of a randomised, double-blind design. Patients (n = 387) received sertraline 50-150 mg or placebo for 24 weeks. Patients were additionally randomised to exposure therapy or general medical care.
Sertraline-treated patients were significantly more improved than non-sertraline-treated patients (chi(2)=12.53, P<0.001; odds ratio=0.534; 95% Cl 0.347-0.835). No significant difference was observed between exposure- and non-exposure-treated patients (chi(2)=2.18, P=0.140; odds ratio=0.732; 95% Cl 0.475-1.134). In the pairwise comparisons, combined sertraline and exposure (chi(2)=12.32; P<0.001) and sertraline (chi(2)=10.13; P=0.002) were significantly superior to placebo.
Sertraline is an effective treatment for generalised social phobia. Combined treatment with sertraline and exposure therapy, conducted by the general practitioner, may enhance the treatment efficacy in primary care.
Neurofunctional changes underlying effective antianxiety treatments are incompletely characterized. This study explored the effects of citalopram and cognitive-behavioral therapy on regional cerebral blood flow (rCBF) in social phobia.
By means of positron emission tomography with oxygen 15-labeled water, rCBF was assessed in 18 previously untreated patients with social phobia during an anxiogenic public speaking task. Patients were matched for sex, age, and phobia severity, based on social anxiety questionnaire data, and randomized to citalopram medication, cognitive-behavioral group therapy, or a waiting-list control group. Scans were repeated after 9 weeks of treatment or waiting time. Outcome was assessed by subjective and psychophysiological state anxiety measures and self-report questionnaires. Questions were readministered after 1 year.
Symptoms improved significantly and roughly equally with citalopram and cognitive-behavioral therapy, whereas the waiting-list group remained unchanged. Four patients in each treated group and 1 waiting-list patient were classified as responders. Within both treated groups, and in responders regardless of treatment approach, improvement was accompanied by a decreased rCBF-response to public speaking bilaterally in the amygdala, hippocampus, and the periamygdaloid, rhinal, and parahippocampal cortices. Between-group comparisons confirmed that rCBF in these regions decreased significantly more in treated groups than control subjects, and in responders than nonresponders, particularly in the right hemisphere. The degree of amygdalar-limbic attenuation was associated with clinical improvement a year later.
Common sites of action for citalopram and cognitive-behavioral treatment of social anxiety were observed in the amygdala, hippocampus, and neighboring cortical areas, ie, brain regions subserving bodily defense reactions to threat.
Generalized social phobia is common, persistent, and disabling and is often treated with selective serotonin reuptake inhibitor drugs or cognitive behavioral therapy.
We compared fluoxetine (FLU), comprehensive cognitive behavioral group therapy (CCBT), placebo (PBO), and the combinations of CCBT/FLU and CCBT/PBO.
Randomized, double-blind, placebo-controlled trial.
Two academic outpatient psychiatric centers.
Subjects meeting a primary diagnosis of generalized social phobia were recruited via advertisement. Seven hundred twenty-two were screened, and 295 were randomized and available for inclusion in an intention-to-treat efficacy analysis; 156 (52.9%) were male, 226 (76.3%) were white, and mean age was 37.1 years.
Treatment lasted for 14 weeks. Fluoxetine and PBO were administered at doses from 10 mg/d to 60 mg/d (or equivalent). Group comprehensive cognitive behavioral therapy was administered weekly for 14 sessions.
An independent blinded evaluator assessed response with the Brief Social Phobia Scale and Clinical Global Impressions scales as primary outcomes. A videotaped behavioral assessment served as a secondary outcome, using the Subjective Units of Distress Scale. Adverse effects were measured by self-rating. Each treatment was compared by means of chi2 tests and piecewise linear mixed-effects models.
Clinical Global Impressions scales response rates in the intention-to-treat sample were 29 (50.9%) (FLU), 31 (51.7%) (CCBT), 32 (54.2%) (CCBT/FLU), 30 (50.8%) (CCBT/PBO), and 19 (31.7%) (PBO), with all treatments being significantly better than PBO. On the Brief Social Phobia Scale, all active treatments were superior to PBO. In the linear mixed-effects models analysis, FLU was more effective than CCBT/FLU, CCBT/PBO, and PBO at week 4; CCBT was also more effective than CCBT/FLU and CCBT/PBO. By the final visit, all active treatments were superior to PBO but did not differ from each other. Site effects were found for the Subjective Units of Distress Scale assessment, with FLU and CCBT/FLU superior to PBO at Duke University Medical Center, Durham, NC. Treatments were well tolerated.
All active treatments were superior to PBO on primary outcomes. Combined treatment did not yield any further advantage. Notwithstanding the benefits of treatment, many patients remained symptomatic after 14 weeks.
Correcting patients' faulty beliefs concerning social evaluative threats is the hallmark of cognitive-behavioral treatment of social anxiety disorder. The current study examined the efficacy of two videotape feedback procedures as adjuncts to exposure-based treatment. Participants suffering from social phobia (N=77) were randomly assigned to one of four conditions: (a) credible placebo treatment (PLA); (b) exposure + no feedback (EXP); (c) exposure + videotape feedback of performance (PER); or (d) exposure + videotape feedback of audience responses (AUD). Contrary to prediction, the videotape feedback procedures did not enhance the effects of exposure-based treatment. Clinical and theoretical implications are discussed.
Social anxiety disorder (SAD) is common and debilitating. Although exposure therapy is one of the most effective forms of psychotherapy for this disorder, many patients remain symptomatic. Fear reduction in exposure therapy is similar to extinction learning, and early clinical data with specific phobias suggest that the treatment effects of exposure therapy for SAD may be enhanced with d-cycloserine, an agonist at the glutamatergic N-methyl-d-aspartate receptor.
To determine whether short-term treatment with 50 mg of d-cycloserine enhances the efficacy of exposure therapy for SAD.
Randomized, double-blind, placebo-controlled augmentation trial examining the combination of d-cycloserine or pill placebo with exposure therapy for SAD.
Patients were self-referred from the general community to 1 of 3 research clinics.
Twenty-seven participants meeting DSM-IV criteria for SAD with significant public speaking anxiety.
Following a diagnostic interview and pretreatment assessment, participants received 5 therapy sessions delivered in either an individual or group therapy format. The first session provided an introduction to the treatment model and was followed by 4 sessions emphasizing exposure to increasingly challenging public speech situations with videotaped feedback of performances. One hour prior to each session, participants received single doses of d-cycloserine or placebo.
Symptoms were assessed by patient self-report and by clinicians blind to the randomization condition before treatment, after treatment, and 1 month after the last session.
Participants receiving d-cycloserine in addition to exposure therapy reported significantly less social anxiety compared with patients receiving exposure therapy plus placebo. Controlled effect sizes were in the medium to large range.
The pilot data provide preliminary support for the use of short-term dosing of d-cycloserine as an adjunctive intervention to exposure therapy for SAD.
There is a paucity of controlled trials examining the effectiveness of individual psychotherapy in personality disorders, especially in patients with cluster C disorders.
To compare the effectiveness of brief dynamic therapy and cognitive-behavioural therapy as out-patient treatment for people with avoidant personality disorder.
Patients who met the criteria for avoidant personality disorder (n=62) were randomly assigned to 20 weekly sessions of either brief dynamic therapy (n = 23) or cognitive-behavioural therapy (n=21), or they were assigned to the waiting-list control group (n = 18). After the waiting period, patients in the control group were randomly assigned to one of the two therapies.
Patients who received cognitive-behavioural therapy showed significantly more improvements on a number of measures in comparison with those who had brief dynamic psychotherapy or were in the waiting-list control group. Results were maintained at follow-up.
Cognitive-behavioural therapy is more effective than waiting-list control and brief dynamic therapy. Brief dynamic therapy was no better than the waiting-list control condition.
A new cognitive therapy (CT) program was compared with an established behavioral treatment. Sixty-two patients meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria for social phobia were randomly assigned to CT, exposure plus applied relaxation (EXP = AR), or wait-list (WAIT). CT and EXP = AR were superior to WAIT on all measures. On measures of social phobia, CT led to greater improvement than did EXP = AR. Percentages of patients who no longer met diagnostic criteria for social phobia at posttreatment-wait were as follows: 84% in CT, 42% in EXP = AR, and 0% in WAIT. At the 1-year follow-up, differences in outcome persisted. In addition, patients in EXP = AR were more likely to have sought additional treatment. Therapist effects were small and nonsignificant. CT appears to be superior to EXP = AR in the treatment of social phobia.
Seventy-two social phobics were Tandomly assigned to behavioral (flooding) or drug treatment with atenolol or placebo. Treatment was administered over a 3-month period of time, and duration of treatment effects was determined at a 6-month follow-up assessment. Multiple measures of outcome were used, including self-report, clinician ratings (including assessment by independent evaluators), behavioral assessment, and performance on composite indexes. The results indicated that flooding consistently was superior to placebo, whereas atenolol was not. Flooding also was superior to atenolol on behavioral measures and composite indexes. Those subjects who improved during treatment maintained gains at the 6-month follow-up regardless of whether they received flooding or atenolol. The variability of outcome on different measures in social phobia research is discussed, and the need for broad-based treatment strategies to address the pervasive deficits associated with social phobia is noted.
Divided 45 18-65 yr old social phobia outpatients into 3 groups of 15 Ss each: Group 1 received exposure with anxiety management. Group 2 received exposure with a nonspecific "filler" treatment instead of anxiety management. Group 3 served as a waiting-list control. Results show that Groups 1 and 2 improved more than Group 3 and the improvement was maintained for 6 mo. At the end of treatment, Group 1 had lower scores than Group 2 on 2 cognitive measures of social anxiety. Six months later, Group 1 had lower scores on 4 additional measures. No S in Group 1 requested additional treatment within a year, while 40% of Group 2 did so. It is suggested that anxiety management increases the effect of exposure treatment because it helps Ss adapt to unpredictable situations, relaxation and distraction are useful techniques, and emphasis on self-help and rationale are important. (22 ref) (PsycINFO Database Record (c) 2006 APA, all rights reserved).
We investigated the usefulness of a hand-held computer as a therapeutic adjunct to cognitive-behavioral group treatment (CBGT) for social phobia. Social phobics (n = 54) were randomly assigned to a 12-session CBGT, 8-session CBGT utilizing a hand-held computer (CaCBGT) to facilitate homework assignments, or to a wait-list control group (WL). At posttreatment, CBGT was significantly better than WL on all self-report measures and most measures of a behavioral assessment test. CaCBGT was significantly better than WL on most measures of the behavioral assessment test, but there were no significant differences on self-report measures. At posttreatment and at follow-up there were no significant differences between CBGT and CaCBGT except that participants in the CaCBGT had significantly more positive thoughts than did participants in the CBGT at posttreatment (but not follow-up). CBGT initially appeared to have stronger effects than CaCBGT on reducing social phobia symptoms. However, by follow-up, CBGT and CaCBGT appeared to be equally effective in reducing symptoms and improving behaviors associated with social phobia.
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The differential response of two forms of social failure-primary and secondary-to two forms of treatment—a skills-acquisition procedure and an anxiety-reduction technique-was studied. Twenty socially unskilled (primary) patients and 20 socially phobic (secondary) patients were given either systematic desensitization (SD) or social skills training (SST). The unskilled patients responded more to SST, as predicted, in that they reported significantly less difficulty in social situations, went out more, and improved on their personal behavioral deficits. The phobic patients responded equally well to both therapies. The success of SST in both kinds of problems is explained in terms of an unpredicted dual role, in that it reduced anxiety as well as facilitated behavior change. This is discussed in the light of current theories of anxiety reduction.
Empirical studies of the behavioral or cognitive—behavioral treatment of social phobia have appeared with increasing frequency over the last decade, and there is reason for cautious optimism in the evaluation of treatment effectiveness. However, few studies have reported systematic followup data, and there is little information available about the durability of change in treated social phobics. We report on the followup evaluation of cognitive—behavioral group therapy (CBGT) for social phobia. Patients who received CBGT or a credible alternative treatment were recontacted after a period of 4.5 to 6.25 years and completed a battery of self-report questionnaires, an individualized behavioral test, and a structured interview with an independent assessor. Patients who received CBGT remained more improved than alternative treatment patients on measures from all assessment modalities. However, due to the long followup period, only a portion of the original study sample could be assessed, and these patients may have been less severely impaired than patients who did not participate in the long-term followup. Limitations of the current study and issues of sample attrition in the conduct of long-term followup studies are discussed.
Forty-nine patients participated in a study comparing cognitive-behavioral group treatment (CBGT) for social phobia with a credible placebo control. CBGT consisted of exposure to simulated phobic events, cognitive restructuring of maladaptive thoughts, and homework for self-directed exposure and cognitive restructuring between sessions. Control patients received a treatment package consisting of lecture-discussion and group support that was comparable to CBGT on measures of treatment credibility and outcome expectations. At pretest, posttest, and 3- and 6-month follow-ups, patients completed assessments that included clinician ratings, self-report measures, and behavioral, physiological, and cognitive-subjective measures derived from a behavioral simulation of a personally relevant phobic event. Both groups improved on most measures, but, at both posttest and follow-up, CBGT patients were rated as more improved than controls and reported less anxiety before and during the behavioral test. At follow-up, CBGT patients also reported significantly fewer negative and more positive self-statements than controls on a thought-listing task following the behavioral test. Regardless of treatment condition, follow-up changes in clinician-rated phobic severity were significantly related to changes on the thought-listing measure.
The importance of individual response patterns in the treatment of phobic patients was examined in the present study. Forty psychiatric outpatients with social phobia were assessed with a social interaction test which was videotaped. Heart rate was continuously monitored during the test. On the basis of their reactions in the test situation, the patients were divided into two groups showing different response patterns; behavioral and physiological reactors. Within each group half of the patients were randomly assigned to a behaviorally focused method (social skills training) while the other half received a physiologically focused method (applied relaxation). The patients were treated individually in 10 sessions. The within-group comparisons showed that both treatments yielded significant improvements on most measures. The between-group comparisons showed that for the behavioral reactors, social skills training was significantly better than applied relaxation on six out of ten measures, and for the physiological reactors applied relaxation was significantly better than social skills training on three of the measures. The results support the hypothesis that greater effects are achieved when the method used fits the patient's response pattern.
The present study is the first psychotherapy outcome study comparing social phobia with and without avoidant personality disorder (APD). Eight social phobic subjects with APD and eight phobic subjects without APD received 8 sessions of behaviorally oriented group therapy for their public speaking anxiety. Before and after treatment, severity measures were taken and subjects were asked to give a talk in front of a small audience. Treatment resulted in the same degree of improved social anxiety and fear of public speaking for both groups. These results add to the literature that questions the validity of distinguishing between avoidant personality disorder and social phobia.
Cognitively oriented treatment was compared to a desensitization intervention employing the use of relaxation as a coping skill for socially anxious community residents. Pretreatment anxiety level was also varied (high vs moderate scores on the Social Avoidance and Distress scale) and crossed with treatment procedure (systematic rational restructuring, self-control desensitization, rational restructuring plus self-control desensitization, and waiting-list control). Dependent measures consisted of self-report indexes of interpersonal, nonsocial, and general anxiety, as well as behavioral observations and pulse-rate measures for an in vivo social interaction. The clearest findings emerged only on the self-report measures, which reflected the relative effectiveness of rational restructuring. There was also a greater tendency for the cognitively oriented treatments to result in generalization of anxiety reduction to nonsocial situations. No interaction was found between effectiveness of treatment procedure and initial level of anxiety.
The relationship between subtypes of social phobia and avoidant personality disorder (APD) and their effects on severity of impairment and outcome of cognitive behavioral treatment were examined. Before treatment, most assessment measures differentiated only between generalized and nongeneralized subtypes of social phobia. Individuals with generalized social phobia were younger when they developed social phobia and achieved higher scores on measures of depression, social anxiety and avoidance, and fear of negative evaluation. During treatment, subjects with generalized social phobia and nongeneralized social phobia improved similarly, but subjects with generalized social phobia remained more impaired after treatment. APD was not predictive of treatment outcome, but several subjects who received a diagnosis of APD before treatment no longer met criteria for APD after treatment.
Cognitive Behavioral Group Therapy (CBGT) is the most widely researched intervention program for social anxiety disorder (SAD, also known as social phobia), with a number of studies demonstrating its effectiveness. Another common treatment, social skills training (SST), has also been shown to be efficacious for SAD. The present study compared the standard CBGT intervention with a protocol in which SST was integrated into CBGT. Participants met diagnostic criteria for the generalized subtype of SAD, and most also met criteria for avoidant personality disorder and other comorbid Axis I disorders. The results revealed improvement in a variety of outcome measures for both treatments, but significantly greater gains for the CBGT plus SST condition. In fact, the effect sizes obtained for this treatment were among the largest found to date in any study of SAD. Clinical implications are discussed, and directions for future research are suggested.
A meta-analytic comparison of studies testing cognitive behavior therapy (CBT; n = 12) and exposure treatment (n = 9) for social phobia indicates that the treatment modalities are equally effective. Compared to exposure, CBT did not lead to greater pretest-posttest or pretest-follow-up improvement on self-report measures of social anxiety, cognitive symptoms, or depressed/anxious mood. Length of treatment was generally unrelated to outcome, although a larger number of exposure sessions produced better results on measures of social anxiety at posttest.
Forty-three social phobics were assigned to exposure (EXP), cognitive restructuring without exposure (CR-alone), or to an intervention combining these techniques (COMB), in a wait-list controlled (WLC) trial. Treatment integrity assessment showed compliance with instructions consistent with the treatments. Within-group analyses showed that the COMB and CR-alone groups improved significantly on all variables, whereas the EXP group showed changes on phobia but not attitudinal measures. Between-group analyses indicated COMB to be superior to EXP on two phobia measures. CR-alone was inferior to EXP and COMB on behavioral approach after treatment, but showed continued improvement relative to the exposure groups on this and other variables by follow-up. The relative ability of treatment-induced changes in fear of negative evaluation (FNE), locus of control, and irrational beliefs to predict long-term improvement was assessed. Changes in these variables were predictive of improvement. The change in FNE accounted for the majority of the explained variance.
Examined the effect of a "pure" performance-based exposure treatment (i.e., without cognitive intervention) on the anxiety-related cognitions of 36 adults (mean age 46.57 yrs) with social phobia (public speaking anxiety). Pairs of Ss matched by age, sex, and severity of phobia were randomly assigned to either a treatment or waiting-list control group. 18 Ss received a purely behavioral treatment for 8 sessions over 8 wks. Subjective, cognitive, and behavioral measures of anxiety were taken pre- and posttreatment. Results show that a purely behavioral treatment led to improvement in measures of behavioral, subjective, and cognitive anxiety. This research adds to the literature on cognitive or behavioral treatment of social phobia showing that cognitive restructuring can occur without specific cognitive treatment, and that interventions for phobia are not necessarily mode-specific.
A controlled study of systematic desensitisation and social skills training was carried out on a sample of socially inadequate psychiatric patients. The results showed that both treatments led to significant improvements in the patients' social lives, which, in the case of social skills training were maintained at 6 months follow-up. Neither treatment, however, led to significantly greater anxiety reduction, improvements in social skills or clinical adjustment than the untreated control. Systematic desensitisation ran into a number of procedural difficulties and there was a substantial drop-out rate during treatment. Both treatments are discussed in the light of these mixed results and suggestions made for further research in this area.
In the present study, the role of individual response patterns in the treatment of social phobic patients was investigated. Seventy-four patients were diagnosed as social phobics. On the basis of extreme scores on a behavioral test (the Simulated Social Interaction Test) and on a cognitive measure (the Rational Behavior Inventory), the response patterns of 39 patients were analyzed, and the patients themselves were classified as either 'behavioral reactors' or 'cognitive reactors'. Half of the patients with each response pattern received a behavioral focused treatment, i.e. social skills training (SST), while the other half received a cognitive oriented treatment, i.e. rational emotive therapy (RET). Patients received group therapy in eight weekly sessions. Within-group differences showed a considerable improvement in all treatment groups. Between-group differences failed to lend support to the hypothesis that treatment that fits a response pattern (i.e. SST for behavioral reactors and RET for cognitive reactors) will result in a greater improvement than one that does not.
Exposure in vivo, rational-emotive therapy and self-instructional training were compared with 34 social phobics. Each of the three therapeutic procedures resulted in significant decrements in anxiety at the post-test after six treatment sessions. Exposure in vivo was superior to the cognitive treatments on pulse rate only. Changes in dependent measures were restricted to those consonant with the treatment approach.
The importance of individual response patterns in social phobics was examined in the present study. Thirty-nine outpatients with social phobia were assessed in a social interaction test which was videotaped. Heart rate was measured continuously during the test and the patient's cognitive reactions were assessed immediately after the test. On the basis of their reactions the patients were divided into physiological and cognitive reactors. Within each class the patients were randomly assigned to a physiologically-focused method (applied relaxation, AR), a cognitively-focused method (self-instructional training, SIT) or a waiting-list control group (WL). The patients were treated individually for 10 sessions. The within-group comparisons showed that both treatments yielded significant improvements on most measures. The between-group comparisons showed that for the physiological reactors the groups did equally well on most measures. On two self-report measures AR actually improved less than SIT, which was contrary to the hypothesis. Among the cognitive reactors SIT improved more than AR on 4/11 measures, thus to some extent corroborating the hypothesis. The conclusion that can be drawn is that the classification of social phobics into physiological and cognitive reactors did not predict different outcomes with a physiologically- and a cognitively-focused method, respectively.
Seven patients who experienced clinically significant anxiety in situations involving public speaking or heterosexual performance and who had received a DMS-III diagnosis of social phobia participated in a 14-week program of cognitive-behavioral treatment. Treatment was conducted in a group format and consisted of: imaginal exposure, in which patients visualized their own participation in phobic events; performance-based exposure, in which patients enacted simulated phobic situations during sessions; cognitive restructuring, in which patients' cognitions experienced during exposure situations were assessed and analyzed; and systematic homework assignments involving the confrontation of environmental events previously simulated in the group. Self-report, behavioral, and physiological measures of anxiety were collected weekly during baseline and treatment periods, and additional measures were collected before and after treatment. After treatment, most patients demonstrated significant gains, and improvements were maintained at 3-month and 6-month follow-ups.
The efficacy of Heimberg's (1991) Cognitive-Behavioral Group Therapy (CBGT) [Unpublished manuscript] for social phobia has been demonstrated in several studies in recent years. However, little is known about the mechanisms underlying the treatment's success. In order to determine whether the cognitive restructuring component of CBGT is essential, this study compared CBGT to an exposure-based treatment without formal cognitive restructuring. A wait-list control was also included. In general, Ss in the active treatment conditions improved and control Ss did not improve on a variety of self-report, clinician, and behavioral measures. Limited evidence indicated that Ss in the non-cognitive treatment may have made somewhat greater gains on some measures. Although CBGT Ss reported more improvement than exposure-alone Ss in subjective anxiety during an individualized behavioral test at posttreatment, this difference disappeared at 6-month follow-up. Surprisingly, CBGT was less effective than in previous controlled trials, and possible reasons for this are discussed. Implications of the results for cognitive theory and cognitive-behavioral therapy for social phobia are addressed.
Thirty-four social phobic patients were treated with either exposure in vivo or an integrated treatment, consisting of rational emotive therapy, social skills training and exposure in vivo. Comparison with a waiting-list control group showed the effectiveness of both treatments. Contrary to expectations, the integrated approach was not superior over exposure in vivo alone. Also, the long-term effectiveness of both treatments was equally good.
Social phobic patients (n = 30) with fear of blushing, sweating or trembling as the predominant complaint were randomly assigned to three treatment conditions: (1) exposure in vivo followed by cognitive therapy, (2) cognitive therapy followed by exposure in vivo, or (3) a cognitive-behavioural treatment in which both strategies were integrated from the start. Each treatment condition consisted of 16 sessions, given in two treatment blocks of 4 weeks each, separated by a no-treatment phase of 4 weeks. Self-report assessments were held before and after the treatment blocks and at 3-months follow-up. No significant differences were found between effects of the first treatment block vs those of the 4-weeks waiting-list period. After the second block treatment was significantly more effective than waiting-list. The analyses showed significant time effects after both treatment blocks and at follow-up, indicating improvement for the group as a whole. After two treatment blocks and at follow-up no significant differences among the different treatment packages were found on target problems, avoidance of social situations, cognitions and somatic complaints. After discussion of the results recommendations for further research will be given.
Patients with generalized social phobia (n = 73) were randomly allocated to two treatment modalities: (1) group or (2) individual treatment, and to three treatment packages: (1) two blocks of exposure in vivo (2) a block cognitive therapy followed by a block exposure in vivo, or (3) two blocks cognitive-behavioural treatment in which both strategies were integrated from the start. All treatments consisted of 16 sessions, given in two treatment blocks of 4 weeks each, separated by a no-treatment phase of 4 weeks. Self-report assessments were held before and after the treatment blocks and at 3-months follow-up. Significant differences were found between effects of the first treatment block vs those of the 4-weeks waiting-list period. Repeated measures MANOVA's demonstrated significant time effects after both treatment blocks and at follow-up, indicating improvement for the group as a whole. After the first treatment block the integrated treatment did significantly worse than either exposure in vivo or cognitive therapy in decreasing somatic complaints. On the other variables no differences among the treatments were found. At follow-up a significant interaction was found between treatment package and modality on the variable cognitions: largest progress was found in the group treatment with cognitive therapy followed by exposure in vivo; smallest progress was found in the integrated group treatment. Results are discussed and recommendations for further research are given.
With the development of cognitive-behavioral theories and treatments for the emotional disorders, there is an increased need for the development and utilization of assessment devices to quantify cognitive constructs. This is especially important in the study and treatment of social phobia, an anxiety disorder that appears to have a significant cognitive component. In this paper, I review and evaluate the use of cognitive assessment strategies in studies of the cognitive-behavioral treatment of social phobia. Although much useful data have been collected, studies that included any form of cognitive assessment relied heavily on questionnaire assessment of fear of negative evaluation or irrational beliefs, with only occasional use of other methods such as thought listing or self-statement questionnaires. In the latter part of the review, I focus on the potential utility of other measures including those derived from the growing literature on the processing of information among persons with social phobia or other anxiety disorders. Studies that have demonstrated differences between social phobics and comparison groups are reviewed, and the potential uses of these information processing techniques are examined. The cognitive assessment of social phobia and its response to cognitive-behavioral interventions remains in its childhood, although the transition to adolescence may be on the horizon.
This study investigated the long-term follow-up effectiveness of (cognitive-) behavioural group and individual treatments for generalized social phobia. Patients were reassessed 18 months after they had finished one of the following treatment packages: (1) exposure in vivo; (2) cognitive therapy followed by exposure in vivo; or (3) a cognitive-behavioural treatment in which both strategies were integrated from the start. Half of the patients were individually treated, the other half in a group. Self-report assessments were held before and after treatment and at 3-month and 18-month follow-ups. Repeated measures MANOVAs on the patients who completed the long-term follow-up (n = 50) demonstrated significant time effects, indicating lasting improvement compared with the pretest. Between the posttest and the 18-month follow-up no significant changes were observed. ANCOVAs either with the pretest or the posttest as covariate showed a significant interaction at 18-month follow-up between treatment package and treatment modality on three of the four compound outcome variables. The group treatment with exposure in vivo alone had been the most effective in the longer term, the integrated group treatment the least effective, while the individual treatments had given improvements in-between. Results are qualified in view of numbers of dropouts, additional treatments in the respective treatment conditions, and clinical relevance.
This study investigated the long-term effectiveness of cognitive-behavioral treatments for patients with a specific type of social phobia: fear of showing bodily symptoms (blushing, sweating, or trembling). Patients were reassessed 18 months after they had finished one of the following treatments: (a) exposure in vivo followed by cognitive therapy, (b) cognitive therapy followed by exposure in vivo, or (c) a cognitive-behavioral treatment in which both strategies were integrated from the start. All patients were individually treated. Self-report assessments were held before and after treatment and at 3-month and 18-month follow-ups. Repeated measures MANOVAs for the patients who completed the 18-month follow-up (n = 26) demonstrated significant time effects from pretest to follow-up, indicating overall improvement. Between the posttest and the 18-month follow-up, no significant change was observed. No differences among the treatment packages were found, although the cognitive-exposure treatment showed a trend to be less effective than both other treatments.
A meta-analysis was conducted using 42 treatment-outcome trials for social phobia. Six conditions were compared: Waiting-list control, placebo, EXP (within-session exposure and homework exposure), CT (cognitive restructuring without exposure exercises), CT + EXP, and SST (social skills training). All interventions, including placebo, had larger effect sizes than that of the waiting-list control, and the interventions did not differ in drop-out proportions. Only CT + EXP yielded a significantly larger effect size than placebo. Effects of treatments tended to increase during the follow-up period. These results support the use of cognitive-behavioral treatments for social phobia, especially the use of CT + EXP.
Cognitive restructuring (CR) is commonly used to treat social phobia, although its contribution to treatment efficacy has not been established. CR requires the person to think about and discuss feared social events with his or her therapist and thus entails some degree of exposure to social stimuli. CR also is thought to enhance the efficacy of therapeutic exposure exercises (EXP). Four predictions were tested based on this model: Relative to a control intervention matched for the exposure inherent in CR, CR is more effective in (1) reducing social phobia, (2) reducing negative social cognitions, (3) increasing positive cognitions, and (4) enhancing the effects of subsequent EXP. People with generalized social phobia (N = 60) were randomly assigned to CR followed by EXP or to a control intervention followed by EXP. Support was found for predictions 1 to 3, but not 4.
The impact of personality disorders (PDs) on exposure in vivo treatment for social phobia was investigated in three groups of social phobics: social phobia without any PD (n = 30), social phobia with a single diagnosis of avoidant PD (n = 18) and social phobia with multiple PDs (n = 13). We hypothesized parallel change for social phobia with and without an avoidant PD with the latter group being more impaired before and after treatment. In order to test this hypothesis, confidence intervals for change were computed. In line with our hypothesis, social phobics in all three groups improved significantly during treatment and no interaction effects were found on the repeated MANOVAs. By using a confidence interval, parallel change was found on most measures. The impact of additional anxiety and mood disorders on treatment outcome was investigated separately. The analyses showed that an additional anxiety or mood disorder also did not predict outcome of exposure treatment.
Treatments for social phobia result typically in significant anxiety and avoidance reduction; the repercussions in terms of social functioning, however, are not clear. This controlled study compared two approaches designed to improve the social functioning of social phobics.
Sixty-eight socially phobic patients were randomly assigned to two treatments focused on improving interpersonal relationships either with or without social skills training or a waiting list; 60 completed treatment and 59 a 1-year follow-up. Treatment was administered in small groups, 14 sessions altogether.
No clinically meaningful change was observed during the waiting period. A statistically significant and equivalent improvement obtained in both treatment conditions.
Both treatments resulted in reduced anxiety, avoidance, general psychopathology and better social functioning that maintained over follow-up. Continuing improvement in remission rates was noted; fully 60% of the patients no longer fulfilled criteria for social phobia at the end of 1-year follow-up.
There is a growing body of evidence that social phobia may be treated effectively by either pharmacologic or cognitive-behavioral interventions. but few studies have examined the relative benefits of these treatments. In this study, we examined the relative efficacy of pharmacotherapy with clonazepam and cognitive-behavioral group therapy (CBGT) for treating social phobia. In addition, we examined potential predictors of differential treatment response. Outpatients meeting Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised) criteria for social phobia were randomly assigned to treatment. Clinician-rated and patient-rated symptom severity was examined at baseline and after 4, 8, and 12 weeks of treatment. All clinician-rated assessments were completed by individuals blind to treatment condition. Patients in both conditions improved significantly, and differences between treatment conditions were absent, except for greater improvement on clonazepam on several measures at the 12-week assessment. Symptom severity was negatively associated with treatment success for both methods of treatment, and additional predictors-sex, comorbidity with other anxiety or mood disorders, fear of anxiety symptoms, and dysfunctional attitudes-failed to predict treatment outcome above and beyond severity measures. In summary, we found that patients randomized to clinical care with clonazepam or CBGT were equally likely to respond to acute treatment, and pretreatment measures of symptom severity provided no guidance for the selection of one treatment over another.
A meta-analysis of psychological and pharmacological treatments for social phobia was conducted to evaluate whether the various treatments differ in their efficacy for treating social phobia, whether they are more effective than wait-list and placebo controls, whether rates of attrition differ, and whether treatment gains are maintained at follow-up. A total of 108 treatment-outcome trials for social phobia met inclusion/exclusion criteria for the meta-analysis. Eleven treatment conditions were compared: wait-list control, pill placebo, benzodiazepines (BDZs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors, attention placebo, exposure (EXP), cognitive restructuring (CR), EXP plus CR, social skills training, and applied relaxation. The most consistently effective treatments for social phobia were pharmacotherapies. BDZs and SSRIs were equally effective and more effective than control conditions. Dropout rates were similar among all the active treatment conditions. Assessment of the durability of treatment gains for pharmacotherapies was not possible because an insufficient number of drug studies included follow-up data. The treatment gains of psychological therapies, although moderate, continued during the follow-up period. BDZs and SSRIs seem to be effective treatments for social phobia, at least in the short term. Recommendations for future research include assessing the long-term outcome for pharmacotherapies and evaluating the inclusion of a cognitive-behavioral treatment during the drug tapering period.
Ninety individuals with social phobia (social anxiety disorder) participated in a randomized controlled trial and completed cognitive-behavioral group therapy, exposure group therapy without explicit cognitive interventions, or a wait-list control condition. Both treatments were superior to the wait-list group in reducing social anxiety but did not differ from one another at posttest. Changes in estimated social cost mediated treatment changes in both treatment conditions from pre- to posttest. However, only participants who received cognitive-behavioral therapy showed continued improvement from posttest to 6-month follow-up, which was associated with a reduction of estimated social cost from pretest to posttest. These results suggest that cognitive intervention leads to better maintenance of treatment gains, which is mediated through changes in estimated social cost.
The effects of intensive cognitive-behavioral group treatment (CBGT) for social phobia (DSM-IV) were studied in 26 patients randomly assigned either to a treatment group (TG) or to a 6-month waiting list control group (WG). Treatment involved 2 weeks of daily treatment sessions separated by 1 week of homework assignments. TG was superior to WG at all assessment points, i.e., at 3 weeks and at 3 and 6 months of post-treatment. After 6 months, significant treatment effects were found in the majority of social phobia measures indicating decreased levels of social anxiety and avoidance, safety-behaviors and symptoms influence on daily life. The WG received treatment following the waiting list period and was combined with the TG in order to evaluate the outcome in a larger sample. Treatment gains at 3 weeks were maintained or improved at 1-year follow-up. Average effect sizes of social phobia measures ranged from 0.56 at post-treatment, 0.68 at 3 months and 0.81 at 6 months and 1 year, respectively.
There is much debate as to whether the treatment effects achieved in well-controlled studies such as randomized controlled trials (RCTs) are generalizable to more "naturalistic" clinical populations, such as that seen in private practice. The current study sought to examine this issue in relation to social phobia.
A benchmarking strategy was used to compare the effectiveness of a cognitive-behaviour therapy group programme for social phobia that was developed and evaluated in a research unit, to that of a private practice population.
Fifty-eight participants from a university research unit and 54 participants from an independent private practice who met the principal diagnostic criteria for social phobia completed the 10-session group programme. Symptom severity was measured at pre-treatment, post-treatment, and 3 months after treatment.
No significant treatment differences were found between the research unit and private practice groups. Both groups showed significant treatment effects that were maintained at 3-month follow-up.
These findings suggest that treatments developed for RCTs are potentially transportable to private practice settings.