Cognitive-behavioral group therapy versus group psychotherapy for social anxiety disorder among college students: a randomized controlled trial

Objective: In this randomized controlled trial, cognitive–behavioral group therapy (CBGT) for social anxiety disorder (SAD) was compared to group psychotherapy (GPT), a credible, structurally equivalent control condition that included only nonspecific factors of group treatment (such as group dynamics). Methods: Participants were 45 college students at the University of Colorado with a primary diagnosis of SAD. Each treatment condition comprised eight group sessions lasting 2 hr each. Independent assessors (blind to treatment assignment) assessed participants at baseline and posttreatment with the Clinical Global Impression Scale (CGI) and the Liebowitz Social Anxiety Scale (LSAS). Results: Both treatments were found to be equally credible. There were five noncompleters in the CBGT condition (21.7%) and only one in the GPT condition (4.3%). There were no statistically significant differences posttreatment (controlling for pretreatment scores) between the two treatment conditions, and both treatments were found to be efficacious. Effect sizes for CBGT were similar to earlier studies, and adherence ratings revealed excellent adherence. Conclusions: Treatment of SAD appears to be moving toward individual CBT, partly because of high attrition rates and underutilization of group dynamics in group CBT. However, group therapy has unique therapeutic ingredients, and it may be too early to give up on group treatment altogether. Discussion of these findings included future directions with this treatment modality, especially whether these two types of group treatment could be combined and whether such combination might serve to decrease attrition, enhance efficacy, and facilitate dissemination. Depression and Anxiety, 2011. © 2011 Wiley Periodicals, Inc.     

Pharmacotherapy of social anxiety disorder.

Over the last few years, a number of medications have demonstrated their efficacy in the acute treatment of social anxiety disorder. At present, selective serotonin reuptake inhibitors probably constitute the first line treatment, based on their safety, tolerability, and efficacy in the treatment of social anxiety disorder and common comorbid conditions. Data from single trials suggest that clonazepam, bromazepam, and gabapentin may have efficacy similar to the serotonin reuptake inhibitors, but further studies are needed to confirm these findings. The monoamine oxidase inhibitor phenelzine appears to be at least as efficacious as these other agents, but should be reserved for cases that fail to respond to these safer medications. Among the reversible inhibitors of monoamine oxidase A, brofaromine may also be an effective drug, while moclobemide appears to be less potent.Future research directions should include delineating ways to achieve remission (as opposed to response); developing strategies for augmenting partial responders and treating nonresponders to first line approaches; studying the long-term response to medication and prevention of relapse when medication is discontinued; clarifying ways to integrate psychosocial and pharmacological treatment approaches; developing predictors of which patients do best with which treatments; and the treatment of social anxiety disorder in children and adolescents.     

Reduction of depersonalization during social stress through cognitive therapy for social anxiety disorder: A randomized controlled trial

Symptoms of depersonalization during feared social situations are commonly experienced by individuals with social anxiety disorder (SAD). Despite its clinical relevance, it is not addressed in standard treatment manuals and it remains unclear if depersonalization is reduced by well-established treatments. This study investigated whether cognitive therapy (CT) for SAD effectively reduces depersonalization and whether pre-treatment severity of depersonalization predicts or mediates treatment outcome.In a randomized controlled trial, patients underwent the standardized Trier Social Stress Test before and after CT (n = 20) or a waitlist period (n = 20) and were compared to healthy controls (n = 21). Self-reported depersonalization was measured immediately after each stress test.Depersonalization significantly decreased following CT, especially in treatment responders (η_p² = 0.32). Pre-treatment depersonalization did neither predict nor mediate post-treatment severity of social anxiety.Further prospective studies are needed for a better scientific understanding of this effect. It should be scrutinized whether SAD-patients suffering from depersonalization would benefit from a more specific therapy.     

Cluster A personality pathology in social anxiety disorder: A comparison with panic disorder

Abstract

Background: Social anxiety disorder (SAD) has been associated with cluster A personality disorder (PD) traits, mainly paranoid and schizoid traits. Aim: The aim of the study was to further investigate cluster A personality pathology in patients with SAD. Methods: Self-reported PD traits were investigated in a clinical sample of 161 participants with SAD and in a clinical comparison group of 145 participants with panic disorder with or without agoraphobia (PAD). Results: A diagnosis of SAD was associated with more paranoid and schizotypal PD traits, and an association between depression and personality pathology could indicate a state-effect of depression on PD traits. Conclusions: Patients with SAD had more cluster A personality pathology than patients with PAD, with the most solid indication for paranoid personality pathology.     

Cognitive-behavioral therapy: applications for the management of bipolar disorder

Objectives: This paper reviews cognitive-behavioral therapy (CBT) for bipolar disorder (BD). Data on the poor outcome of about 50% of patients diagnosed with BD supports the addition of a psychosocial intervention for the treatment of this recurring disorder. The psychoeducational nature of CBT, the effectiveness of CBT in increasing compliance to pharmacological treatment, and the ability of CBT to prevent relapse in unipolar depression (UD) are well suited to the treatment of BD. Method: Psychosocial interventions for BD will be briefly reviewed. Individual and group CBT interventions (published and unpublished) will also be reviewed. The significance of comorbid anxiety disorders regarding response to treatment will also be discussed. A review of the treatment protocol with the specific cognitive-behavioral interventions as applied to BD will be presented. Finally, a case example will be presented to illustrate the application of CBT to BD. Results: Preliminary results indicate that CBT may be an effective adjunctive, intervention for the treatment of BD. Specifically CBT may be helpful in increasing compliance, improving quality of life and functioning, help early symptom recognition, decrease relapse and decrease depressive symptomatology. Conclusions: Preliminary data on CBT for BD are promising but more rigorous randomized clinical trials are needed to confirm the efficacy of CBT for BD. An other area of research should be to pursue the understanding of cognitive processes in BD which would allow us to refine and develop CBT interventions unique to this disorder.     

Mini-SPIN: A brief screening assessment for generalized social anxiety disorder.

The objectives of this study are to develop a brief self-rated screening instrument for generalized social anxiety disorder (GSAD) and to test the efficiency of the instrument. The Social Phobia Inventory (SPIN), a 17-item self-administered scale for GSAD, was given to 263 individuals with GSAD and controls. A subset of three items yielding high sensitivity and specificity for the diagnosis of GSAD was identified. This abbreviated version of the SPIN (Mini-SPIN) was administered to a group of managed care patients in conjunction with an epidemiological study of GSAD. Patients (n = 7,165) were sent a questionnaire comprising the Mini-SPIN and a brief depression screener. Respondents screening positive for GSAD on the Mini-SPIN (n = 344) were interviewed using the social phobia module of the Structured Clinical Interview for DSM-IV (SCID) to verify the diagnosis. A random sample of those who screened negative for GSAD on the Mini-SPIN were administered a similar interview to identify two control groups without GSAD for comparison (n = 673). With this information, the sensitivity, specificity, and positive and negative predictive values for the Mini-SPIN were determined (weighted for sampling). Using a cutoff score of 6 or greater, the Mini-SPIN demonstrated a sensitivity of 88.7%, specificity of 90.0%, positive predictive value of 52.5%, and negative predictive value of 98.5%. The scale possessed 90% accuracy (efficiency) in diagnosing the presence or absence of GSAD in a managed care population. The Mini-SPIN demonstrates good efficiency, supporting its utility as a screening tool for generalized social anxiety disorder.     

The experience of disability and quality of life in social anxiety disorder

Although disability is a concept most often associated with role dysfunction, and quality of life is most often associated with life satisfaction, these terms are frequently used interchangeably in the literature. In contrast, this study proposes that disability and quality of life are independent but related constructs. Additionally, we propose that disability partially mediates the relationship between symptoms and quality of life. That is, greater symptoms are associated with more impairment, which is, in turn, associated with less satisfaction with one's life. Ninety-six individuals with social anxiety disorder were given measures of social anxiety symptoms, disability, and quality of life. The results of the study suggest that disability and quality of life are, in fact, distinct concepts, and the experience of disability partially mediates the relationship between a patient's experience of symptoms and his or her perceived life satisfaction.     

Childhood trauma and current psychological functioning in adults with social anxiety disorder

Etiological models of social anxiety disorder (SAD) suggest that early childhood trauma contributes to the development of this disorder. However, surprisingly little is known about the link between different forms of childhood trauma and adult clinical symptoms in SAD. This study (1) compared levels of childhood trauma in adults with generalized SAD versus healthy controls (HCs), and (2) examined the relationship between specific types of childhood trauma and adult clinical symptoms in SAD. Participants were 102 individuals with generalized SAD and 30 HCs who completed measures of childhood trauma, social anxiety, trait anxiety, depression, and self-esteem. Compared to HCs, individuals with SAD reported greater childhood emotional abuse and emotional neglect. Within the SAD group, childhood emotional abuse and neglect, but not sexual abuse, physical abuse, or physical neglect, were associated with the severity of social anxiety, trait anxiety, depression, and self-esteem.     

社交焦虑障碍的认知行为集体治疗的初步结果

目的探讨社交焦虑障碍(SAD)的认知行为集体治疗(CBGT)的方法和初步结果。方法上海市精神卫生中心就诊的SAD患者中自愿参加CBGT者,符合DSM-IV关于SAD的诊断标准,性别年龄不限。每个治疗小组6-8人,治疗8周,每周1次,每次2.5小时,内容包括认知重建、放松训练、社交技巧训练、系统暴露、现场暴露和家庭作业。治疗期间患者均未服用治疗SAD药物。疗效评定由两位心理治疗师进行,主要工具为Liebowitz社交焦虑评定量表(LSAS),计总分、恐惧因子分、回避因子分,统计分析用配对T检验。结果符合入组条件58例,年龄16-48岁,起病年龄11-34岁,病程6个月-19年。LSAS总分治疗前后75.89±28.82和47.00±23.71(t=12.60,p<0.01);恐惧因子分治疗前后39.28±13.12和25.39±12.42(t=8.267,p<0.01);回避因子分治疗前后36.39±16.44和22.17±13.29(t=8.067,p<0.01),均有统计学显著性差异。结论CBGT治疗SAD有很好的疗效,尤其对SAD的回避行为效果似更显著,值得推广。     

The impact of social skills training for social anxiety disorder: A randomized controlled trial

ObjectiveSocial anxiety disorder (SAD) impacts social, occupational and academic functioning. Although many interventions report change in social distress, improvement in social behavior remains under-addressed. This investigation examined the additive impact of social skills training (SST) for the treatment of SAD.MethodUsing a sample of 106 adults who endorsed SAD across numerous social settings, participants were randomized to exposure therapy (imaginal and in vivo) alone, a combination of SST and exposure therapy known as Social Effectiveness Therapy (SET), or a wait list control. The assessment strategy included self-report measures, blinded clinical ratings and blinded assessment of social behavior.ResultsBoth interventions significantly reduced distress in comparison to the wait list control and at post-treatment, 67% of patients treated with SET and 54% of patients treated with exposure therapy alone no longer met diagnostic criteria for SAD, a difference that was not statistically significant. When compared to exposure therapy alone, SET produced superior outcomes (p < .05) on measures of social skill and general clinical status. In addition to statistical significance, participants treated with SET or exposure reported clinically significant decreases on two measures of self-reported social anxiety and several measures of observed social behavior (all ps < .05).ConclusionsBoth interventions produced efficacious treatment outcome, although SET may provide additional benefit on measures of social distress and social behavior.     

Paroxetine in social anxiety disorder: a randomized placebo-controlled study.

OBJECTIVE: The aim of this study was to evaluate the utility of paroxetine treatment in social anxiety disorder. METHOD: Previously undiagnosed and untreated subjects with social anxiety disorder (generalized social phobia) were selected from among responders to a newspaper advertisement. They were randomized to double-blind treatment with paroxetine 20-50 mg daily or placebo for 3 months. Outcome measures were self-rated social anxiety and avoidance behaviour, and clinician-rated global assessment of improvement. RESULTS: Significant differences in efficacy between treatments (intent-to-treat analysis: 44 subjects on paroxetine and 48 subjects on placebo) were noted after 4-6 weeks, increasing through the treatment period in the paroxetine group. Nine subjects on paroxetine and 3 subjects on placebo discontinued the treatment due to adverse events. Sexual side-effects were noted by 18 subjects on paroxetine and 4 subjects on placebo. CONCLUSION: Paroxetine was effective in alleviating symptoms and avoidance behaviour in social anxiety disorder.     

Subtyping social anxiety disorder in developed and developing countries

Background: Although social anxiety disorder (SAD) is classified in the fourth edition of The Diagnostic and Statistical Manual (DSM‐IV) into generalized and non‐generalized subtypes, community surveys in Western countries find no evidence of disjunctions in the dose–response relationship between number of social fears and outcomes to support this distinction. We aimed to determine whether this holds across a broader set of developed and developing countries, and whether subtyping according to number of performance versus interactional fears would be more useful. Methods: The World Health Organization's World Mental Health Survey Initiative undertook population epidemiological surveys in 11 developing and 9 developed countries, using the Composite International Diagnostic Interview to assess DSM‐IV disorders. Fourteen performance and interactional fears were assessed. Associations between number of social fears in SAD and numerous outcomes (age‐of‐onset, persistence, severity, comorbidity, treatment) were examined. Additional analyses examined associations with number of performance fears versus number of interactional fears. Results: Lifetime social fears are quite common in both developed (15.9%) and developing (14.3%) countries, but lifetime SAD is much more common in the former (6.1%) than latter (2.1%) countries. Among those with SAD, persistence, severity, comorbidity, and treatment have dose–response relationships with number of social fears, with no clear nonlinearity in relationships that would support a distinction between generalized and non‐generalized SAD. The distinction between performance fears and interactional fears is generally not important in predicting these same outcomes. Conclusion: No evidence is found to support subtyping SAD on the basis of either number of social fears or number of performance fears versus number of interactional fears. Depression and Anxiety, 2010. © 2009 Wiley‐Liss, Inc.     

社交焦虑障碍的认知行为集体治疗效果的影响因素

目的 探讨社交焦虑障碍的认知行为集体治疗疗效的影响因素。方法 上海市精神卫生中心就诊的社交焦虑障碍患者中自愿参加认知行为集体治疗者,每个治疗小组6～8人,治疗8周,每周1次2．5小时,内容包括认知重建、放松训练、社交技巧训练、系统暴露、现场暴露和家庭作业。疗效评定工具为Liebowitz社交焦虑评定量表。结果 58例患者中社交焦虑评定量表总分、恐惧因子分和回避因子分治疗前后差异均有统计学显著性意义。在研究可能影响治疗的20种因素中有19种因素有显著的影响作用。结论 认知行为集体治疗社交焦虑障碍有效,但影响疗效因素较多,应用该治疗方案时应予充分考虑。     

Posttraumatic stress and social anxiety: the interaction of traumatic events and interpersonal fears

Posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD) are frequently comorbid among veteran and community samples. Several studies have demonstrated significant comorbidity between trauma, PTSD, and social anxiety (SA), and a growing number of studies have explored the nature of this association. Although a diagnosis of either PTSD or SAD alone can result in significant impairment in social and occupational functioning, these difficulties are often magnified in persons suffering from both disorders. This review describes the current state‐of‐the‐art regarding the co‐occurrence of trauma, PTSD, and SA. First, we provide an overview of empirical data on the prevalence of co‐occurring trauma, PTSD, and SAD. Second, we describe possible explanatory models of the co‐occurrence, with a specific focus on the shared vulnerability model. Third, we review the available empirical data addressing the postulates of this model, including both genetic and psychological vulnerabilities. Fourth, we describe additional factors—guilt, shame, and depressive symptoms—that may help to explain the co‐occurrence of PTSD and SA. A better understanding of this complex relationship will improve the efficacy of treatment for individuals suffering from both disorders. We conclude with key areas for future research. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Oxytocin levels in social anxiety disorder

Oxytocin is a neuropeptide recently associated with social behavior in animals and humans, but the study of its function in populations with social deficits such as autism, schizophrenia, and social anxiety disorder has only recently begun. We measured plasma oxytocin in 24 patients with Generalized Social Anxiety Disorder (GSAD) and 22 healthy controls using an enzyme-linked immunosorbent assay. There were no significant differences in oxytocin level (pg/mL) between patients (M = 163.0, SD = 109.4) and controls (M = 145.0, SD = 52.9, z = 0.21, P = 0.8). Within the GSAD sample, however, higher social anxiety symptom severity adjusted for age and gender was associated with higher oxytocin level (R²= 0.21, β= 0.014, SE = 0.006, t = 2.18, P = 0.04). In addition, dissatisfaction with social relationships was associated with higher oxytocin levels (R²= 0.18, β=–0.20, SE = 0.10, t =–2.01, P = 0.05). Our data provide preliminary support for a link between social anxiety severity and plasma oxytocin. These findings may suggest a possible role for oxytocin as a facilitator of social behavior, an effect which may not be fully utilized in individuals with severe social anxiety.     

Relative effects of cognitive and behavioral therapies on generalized anxiety disorder,social anxiety disorder and panic disorder: A meta-analysis

Although cognitive and behavioral therapies are effective in the treatment of anxiety disorders, it is not clear what the relative effects of these treatments are. We conducted a meta-analysis of trials comparing cognitive and behavioral therapies with a control condition, in patients with social anxiety disorder (SAD), generalized anxiety disorder (GAD) and panic disorder. We included 42 studies in which generic measures of anxiety were used (BAI, HAMA, STAI-State and Trait). Only the effects of treatment for panic disorder as measured on the BAI (13.33 points; 95% CI: 10.58–16.07) were significantly (p = 0.001) larger than the effect sizes on GAD (6.06 points; 95% CI: 3.96–8.16) and SAD (5.92 points; 95% CI: 4.64–7.20). The effects remained significant after adjusting for baseline severity and other major characteristics of the trials. The results should be considered with caution because of the small number of studies in many subgroups and the high risk of bias in most studies.