Recent Advances in the Treatment of Social Phobia: Introduction to the Special Issue

Abstract

Social phobia (social anxiety disorder) is the most common anxiety disorder and the third most common mental disorder in the population. If untreated, the disorder typically follows a chronic, unremitting course, leading to substantial impairments in vocational and social functioning. Despite its high prevalence and degree of interference, social phobia has only recently become the focus of clinical research. Contemporary treatment protocols for social phobia include cognitive-behavioral group therapy (CBGT), exposure therapy, and social skills training. Of these interventions, CBGT is the most validated approach (e.g., Heimberg & Becker, 1991). The efficacy of CBGT has been shown in a number of earlier studies (Gelernter et al., 1991; Hofmann, Moscovitch, Kim, & Taylor, 2004; Heimberg, Salzman, Holt, & Blendell, 1993; Heimberg et al., 1998; Hofmann, 2004) and is currently considered to be the "gold standard" psychological treatment approach for social phobia. The treatment protocol was developed based on Beck and Emery's (1985) cognitive therapy for anxiety disorders. Although well-controlled clinical trials suggest that CBGT is statistically more effective than no treatment or a placebo-control condition, a significant subset of patients fail to achieve optimal benefit from this treatment. For example, in the most recent study on the efficacy of CBGT, 133 patients with generalized social phobia were randomly assigned to phenelzine (Nardil, an MAOI commonly used to treat social phobia), educational support group therapy (ESGT), a pill placebo, or CBGT (Heimberg et al., 1998). After 12 weeks, both the phenelzine (65%) and the CBGT conditions (58%) had higher proportions of responders than the pill placebo (33%) or ESGT (27%), which served as a psychotherapy placebo condition. The criterion for treatment response was based on a 7-point rating of change on the Social Phobic Disorders Severity Change Form (Liebowitz et al., 1992). Patients rated as markedly or moderately improved were classified as responders. Using a stricter improvement criterion, Mattick and Peters (1988) had found that only 38% of individuals with social phobia who completed a treatment very similar to Heimberg's protocol achieved "high end state functioning." More recent cognitive-behavioral therapy protocols include comprehensive cognitive-behavioral therapy (CCBT), Edna Foa and colleagues, and a cognitive therapy protocol developed by David Clark and colleagues. The treatment protocol by Foa was included as a treatment condition in a recently published clinical trial (Davidson et al., 2004). The treatment protocol is derived in part from CBGT (Heimberg & Becker, 1991) and combines exposure techniques, Beckian cognitive restructuring therapy, and social skills training. It is conducted in the form of 14 weekly group sessions. The treatment differs from CBGT primarily in that it includes specific social skills training. Furthermore, the role-plays are shorter and the treatment is 2 sessions longer than CBGT. The study by Davidson and associates (2004) suggests that CCBT shows efficacy rates that are similar to CBGT. Specifically, the study randomized 295 patients with generalized social phobia to one of 5 groups: (1) fluoxetine, (2) CCBT, (3) placebo, (4) CCBT combined with fluoxetine, or (5) CCBT combined with placebo. The results showed that all active treatments were superior to placebo, and the combined treatment was not superior to the other treatments. The response rates in the intention-to-treat sample (using the Clinical Global Impressions scale) were 50.9% (fluoxetine), 51.7% (CCBT), 54.2% (CCBT/fluoxeline), 50.8% (CCBT/placebo), and 31.7% (placebo). These findings are comparable to other clinical trials using conventional cognitive-behavioral therapy and suggest that many participants remain symptomatic after standard cognitive behavioral intervention. The authors, therefore, wondered whether changes in the delivery of cognitive-behavioral therapy would improve the results. …