23 - Treatment of social anxiety disorder  pp. 260-270

Treatment of social anxiety disorder

By Franklin Schneier, Kristin Pontoski and Richard G. Heimberg

Image View Previous Chapter Next Chapter



Introduction

Over the past three decades, a dramatic expansion of research on social anxiety disorder (SAD), also known as social phobia, has yielded an emerging consensus on first-line evidence-based pharmacotherapy and psychotherapy (Ballenger et al. 1998, Ipser et al. 2008, Powers et al. 2008). Selective serotonin reuptake inhibitors (SSRIs) and the serotonin–norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor XR) each help a majority of patients with SAD, as demonstrated in short-term randomized controlled trials of 8–12 weeks. Cognitive–behavioral therapy (CBT) in several forms, administered over 12–24 weeks, yields roughly similar response rates in controlled trials. Gains have been shown to be well maintained during continuation therapy with medication for up to a year (e.g., Stein et al. 2003) and at follow-up assessments after a course of CBT for up to five years (e.g., Heimberg et al. 1993).

Beyond this consensus, however, many aspects of the treatment of SAD remain poorly understood. Little is known about predictors of response to specific treatments. Relapse after treatment discontinuation appears more common after pharmacotherapy, but individualized predictors of which patients are vulnerable to relapse are lacking. Although SAD tends to be highly chronic, few treatment studies have followed patients for more than a year, and although SAD usually occurs with comorbid disorders, few studies have examined the impact of comorbidity on treatment outcome.

Öst L.-G. (1987). Applied relaxation: description of a coping technique and review of controlled studies. Behaviour Research and Therapy, 25, 397–409.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th edn, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association.
Ballenger J. C. , Davidson J. R. , Lecrubier Y. , et al. (1998). Consensus statement on social anxiety disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry, 59(Suppl. 17), 54–60.
Barnett S. D. , Kramer M. L. , Casat C. D. , Connor K. M. , & Davidson J. R. (2002). Efficacy of olanzapine in social anxiety disorder: a pilot study. Journal of Psychopharmacology, 16, 365–368.
Basoglu M. , Marks I. M. , Kilic C. , Brewin C. R. , & Swinson R. P. (1994). Alprazolam and exposure for panic disorder with agoraphobia: attribution of improvement to medication predicts subsequent relapse. British Journal of Psychiatry, 164, 652–659.
Birmaher B. , Axelson D. A. , Monk K. , et al. (2003). Fluoxetine for the treatment of childhood anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 415–423.
Blanco C. , Heimberg R. G. , Schneier F. R. , et al. (2010). A placebo-controlled trial of phenelzine, cognitive behavioral group therapy and their combination for social anxiety disorder. Archives of General Psychiatry, 67, 286–295.
Blanco C. , Schneier F. R. , Schmidt A. , et al. (2003). Pharmacological treatment of social anxiety disorder: a meta-analysis. Depression and Anxiety, 18, 29–40.
Blomhoff S. , Haug T. T. , Hellstrøm K. , et al. (2001). Randomized controlled general practice trial of setraline, exposure therapy, and combined treatment in generalized social phobia. British Journal of Psychiatry, 179, 23–30.
Book S. W. , Thomas S. E. , Randall P. W. , & Randall C. L. (2007). Paroxetine reduces social anxiety in individuals with a co-occurring alcohol use disorder. Journal of Anxiety Disorders, 22, 310–318.
Borge F. M. , Hoffart A. , Sexton H. , et al. (2008). Residential cognitive therapy versus residential interpersonal therapy for social phobia: a randomized clinical trial. Journal of Anxiety Disorders, 22, 991–1010.
Buckner J. D. , Eggleston A. M. , & Schmidt N. B. (2006). Social anxiety and problematic alcohol consumption: the mediating role of drinking motives and situations. Behavior Therapy, 37, 381–391.
Buckner J. D. , Ledley D. R. , Heimberg R. G. , & Schmidt N. B. (2008). Treating comorbid social anxiety and alcohol use disorders: combining motivation enhancement therapy with cognitive–behavioral therapy. Clinical Case Studies, 7, 208–223.
Chambless D. L. , & Ollendick T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–716.
Clark D. B. , & Agras S. (1991). The assessment and treatment of performance anxiety in musicians. American Journal of Psychiatry, 148, 598–605.
Clark D. M. , & Wells A. (1995). A cognitive model of social phobia. In R. G. Heimberg , M. R. Liebowitz , D. A. Hope , & F. R. Schneier , eds., Social Phobia: Diagnosis, Assessment, and Treatment. New York, NY: Guilford Press.
Clark D. M. , Ehlers A. , Hackman A. , et al. (2006). Cognitive therapy versus exposure plus applied relaxation in social phobia: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 74, 568–578.
Clark D. M. , Ehlers A. , McManus F. , et al. (2003). Cognitive therapy versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. Journal of Consulting and Clinical Psychology, 71, 1058–1067.
Connor K. M. , Cook J. L. , & Davidson J. R. (2006). Botulinum toxin treatment of social anxiety disorder with hyperhidrosis: A placebo-controlled double-blind trial. Journal of Clinical Psychiatry, 67, 30–36.
Connor K. M. , Davidson J. R. T. , Potts N. L. S. , et al. (1998). Discontinuation of clonazepam in the treatment of social phobia. Journal of Clinical Psychopharmacology, 18, 373–378.
Dalrymple K. L. , & Herbert J. D. (2007). Acceptance and commitment therapy for generalized social anxiety disorder. Behavior Modification, 31, 543–568.
Davidson J. R. , Foa E. B. , Huppert J. D. , et al. (2004). Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. Archives of General Psychiatry, 61, 1005–1013.
Davidson J. R. , Potts N. L. , Richichi E. , et al. (1993). Treatment of social phobia with clonazepam and placebo. Journal of Clinical Psychopharmacology, 13, 423–428.
Erwin B. A. , Heimberg R. G. , Juster H. , & Mindlin M. (2002). Comorbid anxiety and mood disorders among persons with social anxiety disorder. Behaviour Research and Therapy, 40, 19–35.
Fedoroff I. C. , & Taylor S. (2001). Psychological and pharmacological treatments for social anxiety disorder: a meta-analysis. Journal of Clinical Psychopharmacology, 21, 311–324.
Feske U. , & Chambless D. L. (1995). Cognitive behavioral versus exposure only treatment for social phobia: A meta-analysis. Behavior Therapy, 26, 695–720.
Foa E. B. , & Kozak M. J. (1986). Emotional processing of fear: exposure to corrective information. Psychological Bulletin, 99, 20–35.
Foa E. B. , Franklin M. E. , & Moser J. (2002). Context in the clinic: how well do cognitive–behavioral therapies and medications work in combination? Biological Psychiatry, 52, 987–997.
Franklin M. E. , Jaycox L. H. , & Foa E. B. (1999). Social skills training. In M. Hersen & A. S. Bellack , eds., Handbook of Comparative Interventions for Adult Disorders, 2nd edn. Hoboken, NJ: Wiley.
Furmark T. , Tillfors M. , Marteinsdottir I. , et al. (2002). Common changes in cerebral blood flow in patients with social phobia treated with citalopram or cognitive–behavioral therapy. Archives of General Psychiatry, 59, 425–433.
Gelernter C. S. , Uhde T. W. , Cimbolic P. , et al. (1991). Cognitive–behavioral and pharmacological treatments of social phobia: a controlled study. Archives of General Psychiatry, 48, 938–945.
Gould R. A. , Buckminster S. , Pollack M. H. , Otto M. , & Yap L. (1997). Cognitive behavioral and pharmacological treatment for social phobia: a meta-analysis. Clinical Psychology: Science and Practice, 4, 291–306.
Guastella A. J. , Richardson R. , Lovibond P. F. , et al. (2008). A randomized controlled trial of d-cycloserine enhancement of exposure therapy for social anxiety disorder. Biological Psychiatry, 63, 544–549.
Haug T. T. , Blomhoff S. , Hellstrøm K. , et al. (2003). Exposure therapy and sertraline in social phobia: 1-year follow-up of a randomised controlled trial. British Journal of Psychiatry, 182, 312–318.
Heimberg R. G. , & Becker R. E. (2002). Cognitive–Behavioral Group Therapy for Social phobia: Basic Mechanisms and Clinical Strategies. New York, NY: Guilford Press.
Heimberg R. G. , Dodge C. S. , Hope D. A. , et al. (1990). Cognitive–behavioral group treatment of social phobia: comparison to a credible placebo control. Cognitive Therapy and Research, 14, 1–23.
Heimberg R. G. , Liebowitz M. R. , Hope D. A. , et al. (1998). Cognitive–behavioral group therapy versus phenelzine in social phobia: 12 week outcome. Archives of General Psychiatry, 55, 1133–1141.
Heimberg R. G. , Salzman D. G. , Holt C. S. , & Blendell K. A. (1993). Cognitive–behavioral group treatment for social phobia: Effectiveness at five-year follow-up. Cognitive Therapy and Research, 17, 325–339.
Hofmann S. G. , & Smits J. A. J. (2008). Cognitive–behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621–632.
Hofmann S. G. , Meuret A. E. , Smits J. A. J. , et al. (2006). Augmentation of exposure therapy with d-cycloserine for social anxiety disorder. Archives of General Psychiatry, 63, 298–304.
Hope D. A. , Heimberg R. G. , & Turk C. L. (2006). Managing Social Anxiety: a Cognitive–Behavioral Therapy Approach (Therapist Guide). New York, NY: Oxford University Press.
Hope D. A. , Heimberg R. G. , Juster H. , & Turk C. L. (2000). Managing social anxiety: a Cognitive–Behavioral Therapy Approach (Client Workbook). New York, NY: Oxford University Press.
Ipser J. C. , Kariuki C. M. , & Stein D. J. (2008). Pharmacotherapy for social anxiety disorder: a systematic review. Expert Reviews in Neurotherapeutics, 8, 235–257.
Joormann J. , Kosfelder J. , & Schulte D. (2005). The impact of comorbidity of depression on the course of anxiety treatments. Cognitive Therapy and Research, 29, 561–591.
Kobak K. A. , Griest J. H. , Jefferson J. W. , & Katzelnick D. J. (2002). Fluoxetine in social phobia: a double-blind placebo controlled pilot study. Journal of Clinical Psychopharmacology, 22, 257–262.
Koszycki D. , Benger M. , Shlik J. , & Bradwejn J. (2007). Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behaviour Research and Therapy, 45, 2518–2526.
Ledley D. R. , Heimberg R. G. , Hope D. A. , et al. (2009). Efficacy of a manualized and workbook-driven individual treatment for social anxiety disorder. Behavior Therapy, 40, 414–424.
Ledley D. R. , Huppert J. D. , Foa E. B. , et al. (2005). Impact of depressive symptoms on the treatment of generalized social anxiety disorder. Depression and Anxiety, 22, 161–167.
Leichsenring F. , Beutel M. , & Leibing E. (2007). Psychodynamic psychotherapy for social phobia: A treatment based on supportive-expressive therapy. Bulletin of the Menninger Clinic, 71, 56–83.
Liebowitz M. R. (1987). Social phobia. Modern Problems in Pharmacopsychiatry, 22, 141–173.
Liebowitz M. R. , Gorman J. M. , Fyer A. J. , & Klein D. F. (1985). Social phobia: review of a neglected anxiety disorder. Archives of General Psychiatry, 42, 729–736.
Liebowitz M. R. , Heimberg R. G. , Schneier F. R. , et al. (1999). Cognitive–behavioral group therapy versus phenelzine in social phobia: Long-term outcome. Depression and Anxiety, 10, 89–98.
Liebowitz M. R. , Schneier F. , Campeas R. , et al. (1992). Phenelzine vs atenolol in social phobia. A placebo-controlled comparison. Archives of General Psychiatry, 49, 290–300.
Lipsitz J. D. , Gur M. , Vermes D. , et al. (2008). A randomized trial of interpersonal therapy versus supportive therapy for social anxiety disorder. Depression and Anxiety, 25, 542–553.
Lucas R. A. , & Telch M. J. (1993). Group versus individual treatment of social phobia. Paper presented at the annual meeting of the Association for Advancement of Behavior Therapy, Atlanta, GA, November 1993.
Mörtberg E. , Clark D. M. , Sundin Ö. , & Wistedt A. A. (2007). Intensive group cognitive treatment and individual cognitive therapy vs. treatment as usual in social phobia: a randomized controlled trial. Acta Psychiatrica Scandinavica, 115, 142–154.
Magee L. , Erwin B. A. , & Heimberg R. G. (2009). Psychological treatment of social anxiety disorder and specific phobia. In M. M. Antony & M. B. Stein , eds., Oxford Handbook of Anxiety and Related Disorders. New York, NY: Oxford University Press.
March J. S. , Entusah A.R. , Rynn M. , Albano A. M. , & Tourian K. A. (2007). A randomized controlled trial of venlafaxine ER versus placebo in pediatric social anxiety disorder. Biological Psychiatry, 62, 1149–1154.
Miller W. R. , Zweben A. , DiClemente C. C. , & Rychtarik R. G. (1992). Motivational Enhancement Therapy Manual: a Clinical Research Guide for Therapists Treating Individuals with Alcohol Abuse and Dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
Montgomery S. A. , Nil R. , Dürr-Pal N. , Loft H. , & Boulenger J.P. (2005). A 24-week randomized, double-blind, placebo-controlled study of escitalopram for the prevention of generalized social anxiety disorder. Journal of Clinical Psychiatry, 66, 1270–1278.
Moscovitch D. A. , Hofmann S. G. , Suvak M. K. , & In-Albon T. (2005). Mediation of changes in anxiety and depression during treatment of social phobia. Journal of Consulting and Clinical Psychology, 73, 945–952.
Muehlbacher M. , Nickel M. K. , Nickel C. , et al. (2005). Mirtazapine treatment of social phobia in women: A randomized, double-blind, placebo-controlled study. Journal of Clinical Psychopharmacology, 25, 580–583.
Ossman W. A. , Wilson K. G. , Storaasli R. D. , & McNeill J. W. (2006). A preliminary investigation of the use of acceptance and commitment therapy in a group treatment for social phobia. International Journal of Psychology and Psychological Therapy, 6, 397–416.
Otto M. W. , Pollack M. H. , Gould R. A. , et al. (2000). A comparison of the efficacy of clonazepam and cognitive–behavioral group therapy for the treatment of social phobia. Journal of Anxiety Disorders, 14, 345–358.
Pande A. C. , Davidson J. R. , Jefferson J. W. , et al. (1999). Treatment of social phobia with gabapentin: a placebo-controlled study. Journal of Clinical Psychopharmacology, 19, 341–348.
Pande A. C. , Feltner D. E. , Jefferson J. W. , et al. (2004). Efficacy of the novel anxiolytic pregabalin in social anxiety disorder: a placebo-controlled, multicenter study. Journal of Clinical Psychopharmacology, 24, 141–149.
Powers M. B. , Sigmarsson S. R. , & Emmelkamp P. M. G. (2008). A meta-analytic review of psychological treatments for social anxiety disorder. International Journal of Cognitive Therapy, 1, 94–113.
Rapee R. M & Heimberg R. G. (1997). A cognitive–behavioral model of anxiety in social phobia. Behavior Research and Therapy, 35, 741–756.
Schneier F. R. , Blanco C. , Campeas R. , et al. (2003). Citalopram treatment of social anxiety disorder and comorbid major depression. Depression and Anxiety, 17, 191–196.
Seedat S. , & Stein M. B. (2004). Double-blind, placebo-controlled assessment of combined clonazepam with paroxetine compared with paroxetine monotherapy for generalized social anxiety disorder. Journal of Clinical Psychiatry, 65, 244–248.
Stangier U. , Heidenreich T. , Peitz M. , Lauterbach W. , & Clark D. M. (2003). Cognitive therapy for social phobia: Individual versus group treatment. Behaviour Research and Therapy, 41, 991–1007.
Stein D. J. , Stein M. B. , Pitts C. D. , Kumar R. , & Hunter B. (2002a). Predictors of response to pharmacotherapy in social anxiety disorder: an analysis of 3 placebo-controlled paroxetine trials. Journal of Clinical Psychiatry, 63, 152–155.
Stein D. J. , Versiani M. , Hair T. , & Kumar R. (2002b). Efficacy of paroxetine for relapse prevention in social anxiety disorder. Archives of General Psychiatry, 59, 1111–1118.
Stein D. J. , Westenberg H. G. , Yang H. , Li D. , & Barbato L. M. (2003). Fluvoxamine CR in the long-term treatment of social anxiety disorder: the 12- to 24-week extension phase of a multicentre, randomized, placebo-controlled trial. International Journal of Neuropsychopharmacology, 6, 317–23.
Taylor S. (1996). Meta-analysis of cognitive–behavioral treatments for social phobia. Journal of Behavior Therapy and Experimental Psychiatry, 27, 1–9.
Turner S. M. , Beidel D. C. , & Jacob R. G. (1994). Social phobia: a comparison of behavior therapy to atenolol. Journal of Consulting and Clinical Psychology, 62, 350–358.
Vaishnavi S. , Alamy S. , Zhang W. , Connor K. M. , & Davidson J. R. (2007). Quetiapine as monotherapy for social anxiety disorder: a placebo-controlled study. Progress in Neuropsychopharmacology and Biological Psychiatry, 31, 1464–1469.
Van Ameringen M. , Mancini C. , Oakman J. , et al. (2007). Nefazodone in the treatment of generalized social phobia: a randomized, placebo-controlled trial. Journal of Clinical Psychiatry, 68, 288–295.
van Vliet I. M. , den Boer J. A. , Westenberg H. G. M. , & Pian K. L. (1997). Clinical effects of buspirone in social phobia: a double-blind placebo-controlled study. Journal of Clinical Psychiatry, 58, 164–168.
Vasile R. G. , Bruce S. E. , Goisman R. M. , Pagano M. , & Keller M. B. (2005). Results of a naturalistic longitudinal study of benzodiazepine and SSRI use in the treatment of generalized anxiety disorder and social phobia. Depression and Anxiety, 22, 59–67.
Wagner K. D. , Berard R. , Stein M. B. , et al. (2004). A multicenter, randomized, double-blind, placebo-controlled trial of paroxetine in children and adolescents with social anxiety disorder. Archives of General Psychiatry, 61, 1153–1162.
Walker J. R. , Van Ameringen M. A. , Swinson R. , et al. (2000). Prevention of relapse in generalized social phobia: Results of a 24-week study in responders to 20 weeks of sertraline treatment. Journal of Consulting and Clinical Psychology, 33, 448–457.