Social Anxiety Help is a founding regional clinic of the National Social Anxiety Center (NSAC):
by Winnie Eng, Deborah A. Roth and Richard G. Heimberg
Temple University Philadelphia, PA
Journal of Cognitive Psychotherapy: An International Quarterly
Volume 15, Number 4, 2001
Social anxiety disorder, a once neglected disorder (Liebowitz, Gorman, Fyer, & Klein, 1985), has been increasingly recognized as an important clinical problem. This recognition has led to a surge of research, including numerous studies focusing on approaches to treatment. In this article, we briefly describe cognitive-behavioral treatments for social anxiety disorder (also known as social phobia), provide a critical evaluation of their effectiveness, and discuss the characteristics of patients which may influence response to treatment.
Social anxiety disorder is characterized by an extreme fear of social or performance situations. Individuals with social anxiety disorder fear that they will do or say something humiliating or embarrassing in such situations (or that they will look visibly anxious), resulting in negative evaluation by others (American Psychiatric Association, 1994). Frequently feared situations include public speaking, going to parties, meeting strangers and talking to people in authority (Holt, Heimberg, Hope, & Liebowitz, 1992).
COGNITIVE MODELS OF SOCIAL ANXIETY DISORDER
Current cognitive models of social anxiety disorder (Clark &Wells, 1995; Rapee & Heimberg, 1997) suggest that when socially anxious persons find themselves in social situations, their attention shifts such that they view themselves from the perspective of the audience or observer. They then compare how they believe the audience views them and their performance to the expectations that they perceive the audience holds for them. Because socially anxious persons are very likely to assume that others hold them to strict and exacting standards, the chances that they will judge their performance to fall short of expectations are quite high. The likelihood of this outcome is increased by socially anxious persons' tendency to allocate disproportionate resources to negative social cues in the environment (e.g., noticing the one bored or critical member of an audience to the exclusion of others). Because socially anxious persons believe that others are inherently critical, negative evaluation and other negative social consequences (rejection, loss of social status, etc.) are inevitable outcomes of failure to meet the perceived standards of the audience.
Once socially anxious persons perceive that they have been negatively evaluated by the audience - based on their own internal representation of self as seen by the audience, cues they glean from the environment, or memories of similar failed situations in the past - they begin to experience behavioral, cognitive and physical symptoms of anxiety. These symptoms serve as further "proof" that they will be or are being negatively evaluated by others. Furthermore, anxiety symptoms provide input into the internal representation of the self as seen by the audience, adjusting it downward, and increasing its perceptions that the next time it finds itself in a socially threatening situation, the chances of social failure are even higher. This cycle can also occur in anticipation of threatening situations, as the person imagines himself or herself failing to meet the expected standards of the audience-to-be.
Inherent in these models of social anxiety is an emphasis on both cognitive and behavioral components of the disorder. These models have greatly informed (and been informed by) the development of cognitive-behavioral interventions, which emphasize the interdependence of the socially anxious person's dysfunctional belief system and patterns of behavioral avoidance. Therefore, for current purposes, we concentrate on approaches to treatment that attempt to change behavior and reduce anxiety at least partially through the use of techniques that target negative thinking and distorted beliefs, most typically in combination with graduated exposure to feared social situations. Depending on how one defines the term "cognitive-behavioral," however, there are a number of treatment strategies that may be included in this domain. Treatments based solely on exposure, social skills training, or relaxation techniques are often classified as cognitive-behavioral treatments but will not be the focus here.
Heimberg's cognitive-behavioral group therapy (CBGT; Heimberg & Becker, in press) serves as an example of cognitive-behavioral treatment for social anxiety disorder. In this empirically supported treatment protocol, patients are initially provided with education about social anxiety and oriented to their role in its treatment. The cognitive-behavioral view of the maintenance and modification of social anxiety is explained, and its relevance to each patient's specific concerns is elucidated. Core behavioral techniques are introduced, and self-monitoring is initiated to identify the thinking errors in patients' evaluation of social situations. The use of cognitive techniques is then integrated into subsequent therapist-directed in-session exposures. These exposures permit patients to role-play their feared situations in a graduated manner in the supportive group setting. In vivo exposures accompanied by self-administered cognitive restructuring exercises are also assigned to encourage real-life application of techniques learned within the session. Over the course of treatment, the focus shifts toward confrontation of more difficult situations and restructuring of core beliefs that may underlie negative thinking in these situations. Heimberg and his colleagues (Hope, Heimberg, Juster, & Turk, 2000) have also developed an individual treatment program for social anxiety based on the techniques employed in CBGT which is currently being evaluated in empirical studies.
EVIDENCE OF EFFECTIVENESS
Does Cognitive Therapy (CT) Produce Recovery?
Comparisons With No-Treatment, Wait-List, and/or Placebo Controls. There are now a number of reviews of the efficacy of various forms of cognitive-behavioral treatments for social anxiety (e.g., Juster &Heimberg, 1998; Otto, 1999; Turk, Fresco, & Heimberg, 1999). In controlled studies, cognitive-behavioral treatments have, without exception, surpassed waiting-list control groups across a range of outcome measures. Several studies have also compared cognitive-behavioral treatments to an attention-control treatment, all demonstrating an advantage for cognitive-behavioral treatments. CBGT was shown to be significantly more effective than educational supportive group therapy (ES), a group intervention designed to be equivalent to CBGT in terms of therapist contact, treatment credibility, and expectations for positive treatment outcome (Heimberg et al., 1990). Lucas and Telch (1993) reported similar results in a study comparing the efficacy of CBGT, ES, and an individual version of the CBGT protocol (ICBT). Patients in the CBGT and ICBT conditions evidenced similar treatment gains, both superior to patients in the ES condition. The two cognitive-behavioral treatments were equal in efficacy, the group intervention performing better than the individual intervention only on measures of cost effectiveness. This finding should be encouraging to clinicians who do not have the resources to mount a cognitive-behavioral group treatment program for social anxiety disorder but who wish to provide empirically supported treatment to their social anxious patients.
Clinical Significance of Outcomes. While studies have demonstrated the statistical significance of treatment outcomes for social anxiety, it is imperative to examine the clinical significance of these outcomes as well. One way to do so is to compare the clinical functioning of treated patients to that of a normative sample. Clinically significant change is demonstrated if the score of a treated patient falls within the distribution of scores of a normative sample, or, if those data are not available, is substantially different (usually 2 or more standard deviations) from the pretreatment mean of the patient sample (e.g., Kendall & Grove, 1988). Empirical studies of social anxiety have not routinely reported normative comparisons. However, using a criterion of two or more standard deviations beyond the pretreatment mean, Heimberg and associates (1990) found that, at 6-month follow-up, 65% of patients receiving CGBT were improved compared to 35% of patients receiving ES. Another way to approach the issue of clinical significance of treatment outcome is to examine how changes in targeted symptoms are related to changes in subjective well-being and overall functioning. Immediately following CBGT, patients demonstrated significant improvement in self-perceived quality of life (Safren, Heimberg, Brown, & Holle, 1997), an improvement that was maintained for several months after treatment (Eng, Coles, Heimberg, & Safren, in press). However, their scores still fell below the normative range at all assessment points.
Does CT Produce Enduring Change?
Follow- Up and Relapse Prevention Data. Follow-up assessments of up to one year after cognitive-behavioral treatment for social anxiety have shown maintenance of therapeutic gains or better. For instance, in a meta-analysis of outcomes of cognitive-behavioral treatments for social anxiety, Taylor (1996) reported that effect sizes at follow-up assessments (averaging 3 months) were significantly larger than post-treatment effect sizes. A smaller number of studies have examined longer-term outcomes. In a five-year follow-up evaluation of CBGT versus educational supportive group therapy (ES), patients who had received CBGT evidenced greater improvement on social anxiety and life-functioning indices, suggesting that these patients continued to use cognitive-behavioral techniques for managing their social anxiety long after formal treatment had terminated (Heimberg, Salzman, Holt, k. Blendell, 1993). CBGT may also offer greater protection from relapse compared to pharmacological treatments (see below).
How Does CT Compare With Alternative Interventions?
Direct Comparisons With Clearly Specified Alternative Treatments. Several studies have attempted to dismantle the cognitive-behavioral treatment package in order to address the relative contributions of the "cognitive" and "behavioral" components. The majority of these investigations compared exposure alone to exposure plus a cognitive intervention. However, only a few studies demonstrated that cognitive techniques added to the efficacy of exposure therapies. These outcomes, plus findings that solely behavioral treatments may also be associated with cognitive change, have led some to suggest that cognitive restructuring techniques are an unnecessary part of the effective treatment of social anxiety disorder. However, as we have reviewed elsewhere (Turk et al., 1999), these studies were typically flawed in their administration of cognitive techniques, being hampered by insufficient power or being grossly misinterpreted. Regarding the latter, a study which shows equal outcomes for exposure alone versus exposure plus cognitive restructuring may just as correctly be interpreted to suggest that cognitive restructuring techniques reduce the amount of time that must be devoted to exposure without compromising outcomes.
Meta-analytic techniques have also been employed to examine the relative importance of separate components and to compare cognitive-behavioral treatments to other behavioral interventions. In Feske and Chambless's (1995) meta-analysis, cognitive-behavioral and exclusively exposure-based treatments did not differ in drop-out rates and yielded similar effect sizes on both post-treatment and follow-up measures of social anxiety, cognitive symptoms, depression and general anxiety. The meta-analysis conducted by Gould, Buckminster, Pollack, Otto, and Yap (1997) showed that psychosocial treatments that included an exposure intervention yielded significantly larger effect sizes than either cognitive restructuring alone (i.e., cognitive restructuring without in vivo exposure or behavioral experiments) or social skills training. Taylor (1996) compared the effect sizes of wait-list control groups, placebo treatments, cognitive restructuring alone, exposure treatments, cognitive-behavioral treatments (i.e., cognitive restructuring combined with exposure), and social skills training. The effect sizes of all active and placebo treatments were significantly larger than the effect size for the wait-list control condition, with no significant differences among treatment conditions in attrition rates. However, only cognitive-behavioral treatments achieved significantly better results than placebo controls.
Only a few studies have directly compared the efficacy of cognitive-behavioral treatments to that of medication treatments for social anxiety disorder. The majority of the studies on this topic have been difficult to interpret or of limited significance because they evaluated medications that were themselves of questionable value for the treatment of social anxiety (e.g., buspirone, atenolol) or because they included instructions for in vivo exposure as part of the medication treatments. Only one currently published study has compared cognitive-behavioral treatment to a medication that had proved superior to placebo treatments in earlier trials while explicitly prohibiting the inclusion of exposure instructions in the medication conditions. This large, multisite study compared CBGT, the monoamine oxidase inhibitor phenelzine, ES and pill placebo in 133 patients with social anxiety disorder (Heimberg et al., 1998). After 12 weeks of treatment, CBGT and phenelzine were associated with similar rates of treatment response (75% and 77%, respectively, for treatment completers; 58% and 65%, respectively, for the intent-to-treat sample), and both were superior to the control conditions. Whereas patients receiving phenelzine were more likely to have responded to treatment after the first 6 weeks and had a better outcome on a subset of measures after 12 weeks, CBGT responders were less likely than phenelzine responders to relapse during a 6month treatment-free follow-up period. This difference was especially pronounced among patients with generalized social anxiety disorder (Liebowitz et al., 1999). We are currently examining the efficacy of combining CBGT with phenelzine to explore the possible synergistic effects of more rapid symptom reduction with phenelzine and greater long-term maintenance with CBGT.
Cognitive-behavioral treatments and pharmacotherapy for social anxiety disorder were associated with similar effect sizes in a meta-analysis of studies that examined the independent effectiveness of these two modes of treatments (Gould et al., 1997). A more recent meta-analysis attempted to provide a more fine-grained assessment of the efficacy of cognitive-behavioral therapy and pharmacotherapy for social anxiety disorder. Federoff and Taylor (in press) reported that, while the pharmacotherapies and cognitive-behavioral therapies are grossly equivalent, the benzodiazepines, but not the monoamine oxidase inhibitors or selective serotonin reuptake inhibitors, produced larger effects than cognitive-behavioral treatments on self-report measures of social anxiety. This effect was not apparent on observer-rated measures of social anxiety.
In evaluating the relative utility of cognitive-behavioral therapy and phar-macotherapy for social anxiety disorder, it is also necessary to consider aspects of treatment other than efficacy (Federoff & Taylor, in press). For instance, use of benzodiazepines raises issues of sedation, addiction, and abuse potential, monoamine oxidase inhibitors are associated with risk of a hypertensive crisis and the need to comply with a low-tyramine diet, and selective serotonin reuptake inhibitors are associated with significant risk of sexual dysfunction. There are also differences in cost to consider. Gould and colleagues (1997) examined the cost-effectiveness of treatments as part of their meta-analysis and determined that cognitive-behavioral treatments, especially CBGT, are less costly than medications for social anxiety disorder.
Who Benefits From CT?
Known Patient Factors That Predict Treatment Response. Several moderators of treatment outcome for social anxiety have been identified (e.g., Chambless, Tran, & Glass, 1997; Hofmann, 2000). Higher pretreatment level of depression (e.g., Chambless et al., 1997) has been associated with poorer response to treatment, suggesting that the increased pessimism or lack of energy common to depression may interfere with the patient's involvement in the treatment process. In support of this notion, low expectancy for treatment outcome (Chambless et al., 1997; Safren, Heimberg, & Juster, 1997) has been shown to be predictive of poor treatment outcome, even when pretreatment severity of symptoms has been taken into account. Similarly, poor compliance with homework assignments has been associated with a less favorable response (Edelman & Chambless, 1995; Leung & Heimberg, 1996).
The generalized subtype of social anxiety disorder (e.g., Brown, Heimberg, R Juster, 1995; Hope, Herbert, & White, 1995) has also been related to poor treatment response. Patients with the generalized subtype of social anxiety disorder appear to start treatment more impaired than patients with the nongeneralized subtype. While they show similar degrees of improvement over 12-15 weeks of treatment, they remain more impaired at post-treatment assessment, possibly suggesting that a prolonged course of treatment would benefit this group. An additional diagnosis of avoidant personality disorder has sometimes been associated with less favorable treatment response (e.g., Feske, Perry, Chambless, Renneberg, &Goldstein, 1996; Hoffman, Newman, Becker, Taylor, & Roth, 1995). However, this has not been the case in other studies that also classified patients into subtypes of social anxiety disorder, and further research is needed.
Finally, it would be useful for researchers to expand the field of variables typically included in studies of factors affecting treatment outcome. Almost no effort has been devoted to studies of the process of cognitive-behavioral treatment for social anxiety disorder and how it may be related to outcome. Aspects of the patient's interpersonal functioning, attachment history, experience of traumatic events, and cognitive style may also moderate response to treatment and should be investigated.
In sum, cognitive-behavioral treatments produce reliable and robust improvement in many patients with social anxiety disorder. Studies of cognitive-behavioral treatment have consistently demonstrated the efficacy of these interventions in modifying both the behavioral and cognitive aspects of social anxiety, with improvements above and beyond wait-list controls and placebo control treatments. Cognitive-behavioral treatment is roughly equivalent in efficacy to medication and is more cost-effective. Although it may have a slower onset of action, cognitive-behavioral treatment may confer greater protection against relapse. The possible incremental value of combining the two approaches requires further investigation as does the relative efficacy of cognitive-behavioral treatment and newer medications.
At present, cognitive-behavioral treatment is an efficacious and cost-effective treatment strategy for social anxiety disorder. However, some patients show only a partial response, and some do not benefit at all. Identifying predictors of response to treatment is a priority for future research.
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Offprints. Requests for offprints should be addressed to Richard G. Heimberg, PhD, Adult Anxiety Clinic of Temple, Department of Psychology, Weiss Hall, Temple University, 1701 North 13th Street, Philadelphia, PA 19122-6085.
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