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Revista de Psiquiatria do Rio Grande do Sul

Print version ISSN 0101-8108

Rev. psiquiatr. Rio Gd. Sul vol.31 no.3 Porto Alegre Sept./Dec. 2009

https://doi.org/10.1590/S0101-81082009000300007 

REVIEW ARTICLE

 

Effectiveness of cognitive-behavioral therapy in social anxiety disorder

 

 

Sara Costa Cabral MululoI; Gabriela Bezerra de MenezesII; Leonardo FontenelleIII, Marcio VersianiIV

IGraduada, Psicologia, Mestranda, Programa de Ansiedade e Depressão, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
IIDoutora, Psiquiatria, Pesquisadora, Programa de Ansiedade e Depressão, Instituto de Psiquiatria, UFRJ, Brazil
IIIDoutor, Psiquiatria, Pesquisador, Programa de Ansiedade e Depressão, Instituto de Psiquiatria, UFRJ, Brazil
IVDoutor, Psiquiatria, Diretor, Professor titular e Pesquisador, Programa de Ansiedade e Depressão, Instituto de Psiquiatria, UFRJ, Brazil

This study was conducted in the Anxiety and Depression Research Program, Institute of Psychiatry, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil

Correspondence

 

 


ABSTRACT

INTRODUCTION: To ascertain whether cognitive and/or behavioral treatment of patients with social anxiety disorder is superior in terms of efficacy than other types of therapeutic interventions, including pharmacotherapy.
METHODS: Systematic analysis of all randomized clinical trials on cognitive and/or behavioral therapy vs. other forms of treatment, published until March 2009, indexed in the following databases: MEDLINE, PsycINFO, Cochrane Controlled Trials Register, LILACS and ISI Web of Science.
RESULTS: The reported results do not suggest significant differences in the efficacy of cognitive and/or behavior therapy and pharmacotherapy. Such combined treatments did not show higher efficacy than interventions alone. Compared with the control group, cognitive and/or behavior therapy was superior in reducing social anxiety disorder, either in the standard model or in the novel techniques. The only exception was the social skills training, which was not effective for patients with social anxiety disorder. Cognitive and/or behavior therapy was also superior to other psychotherapeutic interventions.
CONCLUSION: Cognitive and/or behavior therapy is an efficacious treatment for patients with social anxiety disorder. However, the heterogeneity of the clinical trials evaluated, with reference to treatment features (time of treatment and different protocols) or characteristics of the patients (the severity of their clinical picture and how they were recruited) made comparison of results between different treatments difficult. More research on cognitive and/or behavior treatment and new reviews regarding these interventions are necessary to better assess our findings.

Keywords: Social phobia, cognitive therapy, behavior therapy, social anxiety disorder, review.


 

 

INTRODUCTION

Social anxiety disorder (SAD) is characterized by extreme anxiety in various social settings. Individuals fear public inadequacy (performing poorly or showing anxiety) as well as reproach and criticism by other people.

Although patients avoid social situations or tolerate them with great anxiety and suffering, they also desire the social contact they fear. Phobic avoidance behavior is seriously harmful for individuals, whether at the workplace, at school or in everyday personal relationships.

The prevalence of SAD during life is 12.1%1 and, in clinical samples, patients with SAD account for 10 to 20% of individuals with anxiety disorders, which makes it the most prevalent anxiety disorder2.

SAD had traditionally received little attention, and until the mid-1980s, it was considered to be a neglected disorder3. It was officially recognized as a psychiatric disorder after the DSM-III was published, in 1980. From then on, a growing number of publications has emerged, thus revealing growing interest in the topic.

Although the number of studies on SAD has been increasing, there are still unanswered questions regarding specific treatments for this disorder, such as handling patients who do not respond to treatments considered to be the first choice for roughly 30 to 40% of patients with SAD4.

The primary objective of this article is to systematically review controlled studies which have examined the effectiveness of cognitive behavioral therapy (CBT) in adult patients with SAD. This study assesses the effectiveness of CBT in SAD from the comparison between CBT [behavioral techniques (TBehav) or cognitive therapy (TCog)] and other kinds of intervention: pharmacological treatment, other types of psychotherapy and waiting-list (WL) control group.

 

METHOD

Clinical trials of cognitive/behavioral treatment for adult patients with SAD were identified through a search in the following databases: Base ISI/Web of science, MEDLINE, PsycINFO, Cochrane Central Register of Controled Trials, LILACS and related articles. The following combination of phases was used in digital queries: (CBT OR cognitive behavior therapy OR behavior therapy OR cognitive therapy) AND (social anxiety disorder OR social phobia OR social anxiety). Controlled and randomized clinical trials published until March, 2009, were included without language restrictions.

Inclusion criteria were: 1) studies whose participants had a primary diagnosis of SAD according to DSM-III, DSM-III-R, DSM-IV or CID-10; 2) studies involving TCog or TBehav, whether in individual or group sessions, whether compared with pharmacological treatment, other mode of psychotherapy or WL control group.

In the investigation conducted in MEDLINE, 377 articles were found, 29 of which were included. In PsycINFO, out of 79 studies found, 14 were set aside: 10 of which in common with MEDLINE plus four new ones. In the Cochrane Controlled Study Register, 597 studies were located; 27 of which met the inclusion criteria. However, all of these had been found in previous queries. In LILACS, two out of 215 studies found met the inclusion criteria. The ISI/Web of science database returned 874 articles, 36 of which had already been selected in previous queries and three new ones. Four other essays were included through related articles. The review therefore included a total of 42 articles.

In terms of categorization of results, treatments were considered as CBT when associating TCog with TBehav, for example, rational emotive behavior therapy (REBT) plus exposure (EXP), cognitive restructuring (CR) plus EXP, TCog plus task concentration training (TCT) or TCog plus social skills training (SST) (Figure 1).

 

RESULTS

CBT compared to pharmacological treatment

CBT versus antidepressants, benzodiazepines and beta blockers

In 11 studies, the effectiveness of psychotherapy (whether it is CBT or TCog and TBehav isolated) and psychopharmacological drugs (antidepressants, benzodiazepines or beta blockers) in the treatment of SAD. Six clinical trials have underscored the superiority of psychotherapy, three have shown the superiority of drugs and two found no difference between the interventions (Table 1).

The first5 of the studies with positive results has compared 60 patients with generalized SAD assigned participants to the following groups: TCog, fluoxetine plus EXP or placebo plus EXP. Results have shown that the TCog group obtained better results than the two treatments combined in the post-test and gains were maintained after 12 months.

Two studies assessing moclobemide have shown the effectiveness of both CBT in the post-test and follow-up (1, 2, 15 and 24 months) and the combination of CBT plus moclobemide. In the first, Prasko et al.6 assessed 66 patients with generalized SAD by using three types of interventions: moclobemide plus support guide, moclobemide plus CBT (combined treatment) or CBT plus placebo, and found that both groups that involved CBT were equally more effective. The study by Oosterbaan et al.7 randomly assigned 82 patients with SAD for TCog or double-blind pharmacological treatment with moclobemide or placebo, having shown that TCog treatment obtained better results than drugs.

In the study by Clark et al.8, 34 musicians suffering from performance anxiety were assigned to one of four intervention arms: buspirone, group CBT plus buspirone, group CBT plus placebo or placebo. Buspirone was not found to be an effective treatment for SAD when compared to CBT. In the group who had undergone CBT, there has been a significant reduction in anxiety in the post-test and at the 1-month follow-up.

The results of EXP by flooding achieved better results than atenolol and placebo in a research9 with 62 patients with SAD. At the 6-month follow-up, all patients who had shown improvement, both those submitted to flooding and those who used atenolol, maintained the benefits.

Mortberg et al.10 assessed 100 randomized patients for intensive group TCog, individual TCog or treatment with selective serotonin reuptake inhibitor antidepressants or moclobemide or benzodiazepine. After treatment, at the 1-year follow-up, results showed that individual TCog was more effective than group treatment.

Three studies have shown superior effectiveness of drugs when compared to CBT. In the first11, phenelzine has shown better results than CBT in the post-test and at the 6-month follow-up12. The 133 patients with SAD assessed were divided into group CBT, phenelzine, placebo or educational support group therapy.

In another study, Otto et al.13 randomly assigned 45 patients with SAD for group CBT or clonazepam. After the intervention, all initially randomized patients achieved the same mean reduction of social anxiety, although those who completed the entire treatment have experienced greater benefits from clonazepam.

Sertraline has shown contradictory results in the study by Blomhoff et al.14 with 387 patients with generalized SAD assigned to the groups: sertraline, sertraline plus EXP and EXP plus placebo. In the post-test, sertraline was more effective; however, at the 1-year follow-up, the EXP group has been the only one to sustain therapeutic benefits observed during treatment.

No difference was observed between psychotherapy and pharmacological treatment in two other studies comparing CBT to fluoxetine and to phenelzine and alprazolam, respectively. In the latter15, 65 patients were divided into group CBT, phenelzine plus EXP instructions (that is, instructions for self-directed EXP, without therapeutic intervention), alprazolam plus EXP instructions or placebo plus EXP instructions. Both in the post-test and in the 2-month follow-up, CBT and pharmacological treatment were equally more effective than placebo in reducing social phobic symptoms.

In another clinical trial16, 295 patients with generalized SAD were randomly assigned to five groups: fluoxetine, group CBT, placebo, fluoxetine plus group CBT, and group CBT plus placebo. The fluoxetine and CBT alone groups have achieved equivalent SAD reduction after treatment, whereas combined interventions have shown no additional benefit.

CBT compared to other forms of psychotherapy

TCog with SST versus support therapy

In the clinical trial of Cottraux et al.17, the TCog plus SST group showed better results than the support therapy group (that is, empathic listening and positive feedback about patients' discourse) for the 67 participants with SAD (Table 2).

TCog versus associative therapy

The effectiveness of TCog was assessed in the first treatment arm of the study by Taylor et al.18, which compared 60 patients with SAD divided into two groups: individual CR followed by group EXP and individual associative therapy followed by group EXP. After comparing the results of the first post-test (and also of the 3-month follow-up) between CR and associative therapy, it was observed that the first group showed significant improvement and reduction of symptoms, greatly superior to associative therapy.

CBT versus educational support therapy

CBT was superior to educational support 19 (which involves psychoeducation regarding SAD and the dysfunctional beliefs as well as training in assertiveness without EXP), both after the treatment and at the 3-month, 6-month and 5-year follow-ups20, in a study involving 49 patients with SAD divided into group CBT and educational support therapy.

CBT and associations in comparison to the control

CBT versus WL

Three studies have demonstrated that group CBT was more effective than WL in the reduction of social phobia symptoms. In the first21, 31 patients with generalized SAD were randomized for group CBT or WL for 12 weeks and then evaluated in the post-test. The second22 involved 26 patients divided into intensive group CBT (3 weeks of daily sessions) or WL, with evaluations in the post-test and at the 6-month and 1-year follow-ups. Finally, in the third study23, 32 patients with SAD were allocated into group CBT or WL, with a reduction of the attentional bias of the treatment group to socially threatening words and faces (Table 3).

Internet-based CBT versus WL

Internet-based CBT has emerged as an alternative for people who live in regions where specific treatment is not available or for those who are afraid of seeking help, and it has proven to be effective in reducing the level of social anxiety in six controlled trials. In the first, Andersson et al.24 allocated 64 patients either to an Internet-based CBT self-help program or to WL. In another study, Carlbring et al.25 evaluated, in the post-test and at the 1-year follow-up, 29 patients with SAD treated with an Internet-delivered CBT with telephone support by a therapist in comparison to 28 patients in the WL.

In another study26, 105 patients with SAD were randomized for an internet-based CBT program with minimal therapist contact for 10 weeks via e-mail or for WL. Both in the post-test and at the 6-month follow-up27, the treatment group showed better improvement in mood and social skills, with anxiety reduction.

This trial was replicated with 88 other patients28, and the same outcome (improvement of CBT program group compared to control group) was observed in the post-test and at a 6-month follow-up evaluation26.

Another Internet-based CBT program29, with minimal therapist contact (in person, rather than via e-mail), was also more effective than WL for 21 patients with mild to moderate SAD at the 8-week post-test and at the 3-month reassessment.

Titov et al.30 have compared the treatment of Internet-based CBT with minimal therapist contact via email not only to WL, but also to an internet-based CBT program with no therapist contact for 98 patients with SAD. The most efficacious intervention was the group who underwent internet-based CBT with therapist contact, and there was no difference between the internet-based CBT with no therapist contact and the WL.

CBT and self-help (with or without therapist assistance) versus WL

In a study conducted by Rapee et al.31, 224 patients with severe generalized SAD underwent guided self-help, guided self-help augmented by minimal therapist assistance and standard CBT. It was observed that both conventional CBT and the alternative self-help treatment (non-presential) were equally efficacious in reducing the symptoms of social anxiety (Table 3).

CBT with computer-assisted homework assignments versus WL

The use of a computer to facilitate homework assignments in the CBT treatment was considered efficacious in a study conducted by Gruber et al.32. Fifty-four patients with SAD were randomly assigned to group CBT utilizing a hand-held computer to facilitate homework assignments (to prepare patients before in-vivo EXP), to group CBT with homework assignments carried out without the use of a computer and to WL.

CBT, TCog and EXP versus control

Nine clinical trials showed the efficaciousness of CBT, TCog and EXP (either isolated or in combination with one another) in the reduction of social phobia symptoms when compared to the control group.

Two clinical trials comparing CBT, EXP and WL, one including 90 patients33 and another including 40 patients with SAD34 found positive outcomes for psychotherapy in reducing the initial symptoms of anxiety, when compared to the WL.

Patients who underwent TCog, both individually and in group, obtained significant SAD improvement in the post-test, in comparison to WL participants in a study by Stangier et al.35.

In two other studies, EXP and TCog showed positive results when compared to WL. In the first36, 43 patients with SAD were treated with EXP, CR, EXP plus CR or WL and, in the second37, the 71 patients with generalized SAD were randomly assigned to EXP, EXP plus TCog and WL.

A new program of TCog and EXP associated to applied relaxation38 was assessed by Clark et al. and also showed significant improvement in comparison to WL in a study with 62 patients with SAD.

In two studies by Scholing et al., significant differences were observed, after 8 weeks of treatment and at follow-up, between EXP, TCog followed by EXP, EXP followed by TCog and CBT, compared to 4 weeks of non-treatment, which was considered as control group. The study analyzed 70 patients with generalized SAD39 allocated to three conditions: two arms of EXP, one arm of TCog followed by an arm of EXP or integrated CBT from the start, in the post-test and at the 3-month follow-up40. In the second clinical trial, 30 patients41 with SAD with fear of sweating, trembling or blushing, were assigned to TCog followed by EXP, EXP followed by TCog or integrated CBT from the start, in the post test and at the 18-month follow-up42.

Eighty-five patients with SAD were randomly assigned to EXP plus CR, to EXP followed by CR, or to CR followed by EXP43 (the latter had been the control group 3 months earlier). The outcomes have confirmed that the three interventions are equally effective in reducing SAD; that is, both simultaneous cognitive and behavioral treatment (EXP + CR) and both treatments applied separately at different times (EXP followed by CR and CR followed by EXP) showed better results than the control group.

TCT with TCog versus WL

Bogels et al.44 assessed 65 patients with SAD with fear of blushing, trembling, sweating and/or freezing in public. Participants were randomly assigned to TCT followed by TCog or to applied relaxation followed by TCog. The association of TCog with other TBehav (not only EXP) has proven to be effective in reducing SAD, when compared to WL.

TBehav compared to WL

EXP and associations versus WL

TBehav have shown positive results in the treatment of SAD when compared to WL in two studies. In the first study45, assessing 36 patients with public speaking anxiety, outcomes of the post-test have shown superiority of EXP over WL. In the second46, 31 patients with SAD with fear of blushing were randomly assigned to EXP, CBT or WL(Table 4).

EXP associated to other techniques has proven to be more effective than WL in the treatment of social phobia symptoms in three of the controlled clinical trials. In the first, Butler et al.47 allocated 45 patients to three groups: EXP with anxiety management, EXP with non-specific intervention, or WL. In another trial, Mersch et al.48 randomly assigned 34 patients to three groups: EXP, integrated treatment (REBT plus SST and EXP) and WL. In the last one49, 30 female undergraduate students with SAD whose primary fear was public speaking were randomly assigned to a group of EXP plus self-instructional and breathing training or to a control group. Both in the post-test and at the 2-year follow-up, participants of EXP have shown greater reduction of anxiety responses, when compared to the control group.

Only in the post-test of the study by Smits et al.50 - in which 77 patients with SAD were assigned to EXP, placebo treatment, EXP with video feedback of patient performance and EXP with video feedback of the responses of the audience who watched EXP - all three treatments have shown equivalent improvement of SAD symptoms in comparison to the placebo. However, at the 1-month follow-up, this advantage was not maintained, and intervention groups with EXP have shown negative results in comparison to the placebo group. The duration of treatment for this study was 1 week.

SST versus non-specific treatment

SST, assessed in the study by Stravynski et al.51 with 68 participants with SAD, did not show difference in outcomes between the post-test and the 1-year follow up regarding the social functions of patients, when compared to non-specific treatment without SST or to the period prior to intervention, considered as WL.

 

DISCUSSION

Controlled trials suggest the effectiveness of cognitive and behavioral interventions (such as EXP and CBT), both alone and combined with other techniques (relaxation and breathing training), in the reduction of SAD symptoms17-19 when compared to other types of psychotherapy approaches or control group21-26.28-34.41,43. These findings are confirmed by Acarturk et al.52 in a recent meta-analysis which also found that such effectiveness tends to be maintained and, in some cases, even improve in follow-up measurements. However, in the analysis among subsets which included CR, EXP, SST and applied relaxation, high effect sizes were not found, once most of the trials analyzed mixed these techniques and only a few others investigated them in isolation.

EXP has shown significant effectiveness, both alone45 and combined to other resources, such as anxiety management43.44, SST and REBT48. Only one study50 has shown negative outcomes, which could be explained by the short duration of the treatment employed. Whereas in this study therapeutic intervention lasted 1 week in trials that have shown positive outcomes, 45-50 patients underwent at least 6 weeks of treatment.

The exception among the analyzed TBehav was SST, which, alone, did not show significant effectiveness in reducing social phobia symptoms51. When combined with TCog17 or EXP48, SST has proven to be effective, suggesting a need for new clinical trials which offer a better assessment of this intervention's effectiveness.

New forms of CBT presentation, such as self-help aided by a guide-book31, internet-based therapy24-26.28-30, and computer-assisted homework assignments32, emerge as promising alternatives in the treatment of SAD. The practice of CBT requires skilled, trained therapists, who are not always available, in addition to transportation costs and fees. In that sense, these interventions would mean important alternatives, thus increasing the accessibility and availability of treatment.

The comparison between pharmacological treatment and CBT carried out by some clinical trials has not led to conclusive outcomes. Both have been effective in most of the analyzed studies and, although some outcomes suggest the superiority of CBT compared to drugs, the data analyzed do not allow for generalization of these findings.

Results were inconsistent in some studies. Two studies involving phenelzine, for example, have presented contradicting outcomes, with superiority of drugs over CBT in one study11 and no significant difference found in the other study15. A similar situation was observed with fluoxetine, which has shown inferior effectiveness compared to TCog and EXP in one clinical trial5 while found to be as effective as CBT by another trial15. In the case of these two substances, there was difference in the dosages administrated, which, combined to the heterogeneity of the cognitive and behavioral interventions used, made the outcomes difficult to analyze. Further controlled clinical trials are requires in order to better assess these interventions.

Unlike the premise used in clinical practice, there is no clinical evidence of greater effectiveness for the combined treatment, CBT plus drugs or TCog plus TBehav, when compared to the same interventions in isolation. Combination was shown to be less effective than TCog5, EXP14, and CBT and fluoxetine16 used separately. In another clinical trial, the combination of therapy and drugs was as effective as TCC6. It is important, however, to question why these scientific outcomes appear to be so distant, and even diverging, from what is observed in the clinical practice of the treatment of this disorder, once it is increasingly recommended that therapists look for support and update their therapeutic practice by looking into the outcomes of high-quality controlled clinical trials published in their area of expertise.

In studies assessing the use of follow-up measurements, different monitoring follow-ups were adopted, varying from 1 month8 to 5 years20, which makes it difficult to analyze results comparatively. There is no consensus regarding the ideal treatment time for SAD, which makes it difficult to properly analyze the maintenance of benefits gained.

The number and the duration of sessions varied according to the different treatment protocols. The severity of SAD was also different across the studies: whereas some studies selected patients with mild to moderate SAD29, others6 used severe generalized SAD as an inclusion criteria. The patient recruitment method was also different among the studies, often excluding patients with SAD who had not looked for help, whose condition could potentially be more serious and more restraining. Such heterogeneity in the selected studies makes it difficult to compare outcomes and does not allow for consistent conclusions regarding the effectiveness of the therapeutic interventions assessed.

Since our systematic review is descriptive, it has some methodological limitations which do not allow for generalization of the outcomes and suggest the need for new investigations in order to provide a more accurate assessment of the various interventions described.

 

CONCLUSION

The data assessed suggest the effectiveness of the different CBT techniques in SAD; however, there are plenty of questions left unanswered. A significant percentage of patients does not respond to the proposed interventions or presents residual symptoms and there is a lack of studies investigating this population. Careful investigation of resistant patients is required, and possible predictors of response to treatment need to be further clarified.

Despite of the growing number of studies investigating CBTs in the treatment of SAD, there are gaps to be discussed regarding treatment of these patients. New clinical trials with less heterogeneous intervention protocols, standardized assessment measurements and reviews comparing specific CBT techniques are extremely relevant to better understand this scenario. Additionally, new systematic meta-analytical reviews would allow for a more accurate comparison between the interventions assessed, with improved clarification of outcomes.

Considering that CBT is not limited to its techniques, it is the beginning of an investigation that allows us to carefully examine how the disorder affects each subject, in order to expand our conceptualization regarding the patiens' way of thinking, feeling and acting.

 

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Correspondence
Sara Costa Cabral Mululo
Rua Voluntários da Pátria, 283/703
CEP 22270-000, Bairro Botafogo, Rio de Janeiro, RJ - Brasil
Fax: (21) 2239.4919
E-mail: saramululo@yahoo.com.br

Received on 3/31/09.
Accepted on 8/4/09.

 

 

No conflicts of interest declared concerning the publication of this article.

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