Psychological Treatments for Social Anxiety Disorder

Abstract

Social anxiety disorder (SAD) is characterized by fear of being negatively evaluated by others in social situations. Multiple psychological interventions have been developed to treat SAD. The most widely studied of these interventions stem from cognitive-behavioral, acceptance-based, interpersonal, and psychodynamic conceptualizations of SAD. In cognitive-behavioral therapy (CBT), patients learn to identify and question maladaptive thoughts and engage in exposures to feared situations to test the accuracy of biased beliefs. Mindfulness and acceptance-based approaches to treating SAD focus on mindful awareness and acceptance of distressing internal experiences (i.e., psychological and physiological symptoms) with the ultimate goal of behavior change and living a meaningful life based on identified values. Interpersonal psychotherapy links SAD to interpersonal problem areas and aims to reduce symptoms by targeting interpersonal difficulties. Psychodynamic psychotherapy for SAD focuses on identifying unresolved conflicts that lead to SAD symptoms, fostering insight and expressiveness, and forming a secure helping alliance. Generally, CBT is the most well-studied of the psychological treatments for SAD, and research demonstrates greater reductions in social anxiety than pill placebo and waitlist controls. Results from randomized controlled trials (RCTs) suggest that mindfulness—and acceptance-based therapies may be as efficacious as CBT, although the body of research remains small; four of five RCTs comparing these approaches to CBT found no differences. RCTs comparing CBT to IPT suggest that CBT is the more efficacious treatment. Two RCTs comparing CBT to psychodynamic psychotherapy suggest that psychodynamic psychotherapy may have efficacy similar to CBT, but that it takes longer to achieve similar outcomes. RCTs examining CBT and pharmacotherapy suggest that the medications phenelzine and clonazepam are as efficacious as CBT for treating SAD and are faster acting, but that patients receiving these medications may be more likely to relapse after treatment is discontinued than patients who received CBT. Research generally does not indicate added benefit of combining psychotherapy with pharmacotherapy above each monotherapy alone, although this body of research is quite variable. Effectiveness studies indicate that CBT is equally effective in community clinics and controlled research trials, but studies of this nature are lacking for other psychological approaches.