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On-line version ISSN 1809-452X
Rev. Bras. Psiquiatr. vol.26 no.2 São Paulo June 2004
Daniela Zippin Knijnik; Flávio Kapczinski; Eduardo Chachamovich; Regina Margis; Claudio Laks Eizirik
Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul e Hospital de Clínicas de Porto Alegre. Porto Alegre, RS, Brasil
OBJECTIVES: The aim of this study is to
assess the effectiveness of psychodynamic group therapy in patients with generalized
METHODS: Thirty patients were included in a randomized single-blind clinical trial comparing psychodynamic group treatment (PGT) with a credible placebo control group (CPC). PGT was carried out within a 12-session psychodynamically-oriented group psychotherapy. Control patients received a treatment package of lecture-discussion and support group for 12 weeks which was compared to PGT. Each participant completed the Liebowitz Social Anxiety Scale (LSAS), the Hamilton Anxiety Scale (HAS) and the Clinical Global Impression Scale(CGI) at pretreatment assessment and after 12 weeks of treatment. Data analysis was carried out using a repeated measures ANOVA. Patients were excluded if they were under any kind of pharmacotherapy or psychotherapic treatment.
RESULTS: Both groups demonstrated significant pretreatment-to-posttreatment change on most measures. On the LSAS, PGT patients were rated as more improved than controls at posttest assessment (F1,28=4.84, p=0.036). Baseline data of completers did not show differences between both groups in the demographic variables and outcome variables used.
CONCLUSIONS: The present study showed that PGT was superior to a credible placebo control group in the treatment of generalized social phobia, in a 12-week randomized single-blind clinical trial.
Keywords: Phobic disorders. Axiety disorders. Psychotherapy, group.
Social phobia is an anxiety disorder characterized by fear of humiliation and embarrassment while engaged in social interaction or performing in front of others. A review published in 1985 by Liebowitz et al. referred to social phobia as a "neglected anxiety disorder",1 and interest in social phobia has increased dramatically since then. However, further research is needed to address gaps in our knowledge concerning the best way to help patients suffering from this disorder.
There is firm evidence suggesting that drugs such as monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are superior to placebo in treating patients with social phobia.2 Data from randomized clinical trials2 have shown that some types of psychotherapies can also help patients with social phobia. Some authors argue that psychotherapy could offer some advantages to these patients, as much of what is learned during the psychotherapy could be used through the life of the patient and work as a "relapse prevention tool". A recent study investigated whether psychosocial treatments changed in the last decade. The latter study showed that the percentage of patients who receive psychosocial treatments for anxiety disorders declined from 1991 to 1995-6.3 Psychodynamic therapy remained the most frequently used method, however it lacks empirical validation. Methods like Behavioral and Cognitive Therapy, which are empirically validated, are less commonly used.3 A recent review of outcomes research after of psychological therapies did not mention any study or psychodynamic group therapy for social phobia.4 The aim of the present study is to assess the effectiveness of short term PGT in patients with social phobia. Our hypothesis was that PGT is superior to CPC in the treatment of generalized social phobia.
Subjects were 40 outpatients (14 women and 26 men) who sought treatment at the Clinical Hospital de Clínicas de of Porto Alegre - Brazil. Patients were eligible for study participation if they were between the ages of 18 and 60, met diagnostic criteria for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)5 generalized social phobia as a primary diagnosis, and were willing to participate in a randomized clinical trial. Patients were recruited from media advertisements and clinical referral. All patients provided written informed consent, underwent a structured clinical interview for DSM-IV6 to establish diagnoses. Severity of social phobia was rated by interviewers according to the Clinical Global Impression Scale,7 with scores ranging from 1 ("not ill") to 7 ("among most severely ill"). The improvement criteriona was the CGI scores, namely 1 (much improved) and 2 (very much improved). This criteria is widely used either in psychotherapy or in pharmacotherapy research. Baseline severity of the social phobia was also assessed with the Liebowitz Social Anxiety Scale(LSAS),8 with scores ranging 0 to-144. Baseline severity of anxiety was assessed with the Hamilton Anxiety Scale(HAM-A).9 The selected outcome measures used were LSAS, HAM-A and CGI Scores. Patients were excluded if they had a diagnosis of organic brain disorder and antisocial personality disorder and concurrent major depression, or received a score above exceeding 18 on the 21-item Hamilton Rating Scale for Depression.10 Patients were also excluded if they met DSM-IV criteria for another anxiety disorder apart from social phobia and the symptoms of the second disorder were judged to be as severe as their social phobic symptoms and if they were under any kind of psychotherapy. If a patient had been treated with pharmacotherapy, a 4- week wash-out period was required before entering the study. Twenty-one men and nine women completed the study. Five patients of each group dropped-out exclusively for schedule reasons. Completers demographic characteristics are described on Table 1.
Subjects were randomly assigned to Psychodynamic Group Therapy (PGT) or Credible Placebo Control Group (CPC). There were two groups per condition, with 7 or 8 subjects per group. Groups met for 12 weekly 90-minute sessions. All subjects participated in a preliminary interview in which individualized treatment goals were derived. Patients then completed pretreatment assessment, which included clinician-rating measures. Assessments were repeated after 12 weeks of treatment.
Group sessions were conducted by the first author. The first author is a psychiatrist and psychotherapist with previous trainning in psychoanalytic psychotherapy, as well as being an experienced therapist in two different kinds of group therapies, namely dynamic psychotherapy with elderly patients and cognitive therapy with patients with generalized social phobia.
The therapist was supervised on a weekly basis for one and a half hour by means ofthrough a detailed reading of the description (descriptivebing??) notes taken about each group session. The third and fourth authors performed the assessments blind to the subject' subject's treatment condition. The second author was the supervisor for the CPC Group and the last author was the supervisor for the PGT Group. The second author is a qualified psychiatrist and a cognitive therapist (Beck Institute at Philadelphia). The last author is a qualified psychoanalyst, member of the International Psychoanalytical Association (IPA). This study was approved by the ethicss committee of the Clinical Hospital de Clínicas deof Porto Alegre-Brazil. Complete outcome measures are described on Table 2.
Psychodynamic Group Therapy (PGT)
The conceptual orientation of Psychodynamic Group Therapy is psychoanalytic, based on the hypothesis that recurrent and unconscious internal conflicts are connected to the symptoms.11 The main contributions for this model of PGT derive from Bions contributions about working groups and basic assumptions groups (dependence, fight-flight and pairing).12,13 The therapist aims at identifying unconscious thoughts and conflicts possibly connected to the phobic symptom, and carefully trying carefully es to bring them(??) into consciousness. These interpretations promote insights that can lead to psychic changes, and self- recognition of the patientshis/her defense mechanisms. Through focal interpretations, patients may cope in a better way with the feared situations. Special attention is given to resistance and role distribution in the group setting and to the therapists counter-transferenceof the therapist.11 A manual for psychodynamic group therapy with phobic patients was prepared, tested and used in this study.14
Sessions 1-3: focus formulation through the description of the patients personal history. Since the beginning of treatment, the participation of patients has beenis encouraged.
Sessions 4-10: interpretation of possible symptom-conflict relationship and analysis of individualized specific situations, searchinglooking for common areas in and between conflicts. Encouragement of discussion and exposition of the conflictual situations.
Sessions 11-12: interpretation of the separation anxiety related to each patients specific background. Therapist intervention: Active data obtained from each patient and patients as a group, focus formulation and its elaboration through questioning, clarifying and extra-transferential psychodynamic interpretations, focusing the interventions oin each participant but, when possible, always trying to link common aspects between situations experienced by patients, emphasizing the conflictual situations that are hidden behind their phobic symptoms.
Clinical Vignette 1
J. E., 27 years old, female. J. E. suffers from generalized social phobia. J. E. hasd developed a severe fear of interacting with new people at work or with old friends at parties or pubs. She has also experienced intense anxiety and mainly blushing whenever a "human being", as she calls people in general, came to her even to say hello. When forced to confront these feared situations, her face would become completely red and she would stumble over her words and also would not be able to complete a sentence. In one of the sessions another patient did not recall her name and wanted to mention something about her. When he asked the therapist, and not her, what her name was, she got completely red, did not say a word and started to hide her face and cry. The whole group remained in silence for several minutes. The therapist saidys to the group:
T: What is each one of you feeling within this situation?
J. E.: I feel completely ridiculous, because it is not normal to get this red even here in the group where we are all victims of the same problem. I find it impossible to communicate with people, but that is ok, someday I will get over it...but he just asked you what my name is and I freeze.
T: What's difficult about being mentioned by R. R. ?
J. E.: I don´t know.
T: Try to think for a while, what comes to your mind?
J. E.: (crying) That when I was a little girl and was responsible for taking care of my younger brother well- being(??), during the day, while my parents went to work I felt bad about it. I never understood what exactly my mother expected from me...and every night when she came home she would open the door and call me, and the first question was always regarding my brother, not me.
T: So did you haved had to take care of him when you were also young. How old were you then?
J. E.: 7, 8, 9...and evenalso today that both of us are grown ups and live here alone I feel the same about him.
T: How do you fell about him?
J. E.: Responsible but unable to take care of him.
T: So you had to take care of him while your parents were out working. I wonder if when you were mentioned in the group you felt, as in the past, responsible for answering without being able to do so.
J. E.: Maybe yes...participating here in the group and mainly having their attention driven to me is the same as feeling responsible for my brother and having to answer my mother about my performance during the day.
Clinical Vignette 2
D. S., 50 years old, male. D.S. suffers from generalized social phobia. D. S. is constantly fearing to exposein(in??) fear of exposing himself. He mentions a lot of anger directed towards his wife. He uses to act as an ally of his daughter against his wife in domestic arguments and uses this alliance as a means to verbally abuse his son. In one of the sessions in which several patients were missing the therapist asks to the group:
T: What do you imagine that happened so that so many people missed the session?
D: (immediately says) I always think that I am the one to blame. With my son I feel that I am destroying him mentally, somehow. Here I am feeling that the other colleagues are not present today because of the things I spoke about last session. I am usually the only one who speaks , I steal everybody´s time in the session.
T: So, you feel badly and threatened by your son because you attacked him and possibly feel the fear that this attack might come back to you. You are feeling the same way with your colleagues here.
In the end of the session the therapist offers an interpretation suggesting that there is something common to all patients, in the sense that they have angry feelings against other people and the fear that this same feeling would returncome back into them. "What you throw around always comes around".
The two vignettes above exemplify the basic understanding of social phobia and its application to each patient according to his personal history and object relationship(??).. The therapist uses mainly individual extra transference interpretations and also takes advantage of the group dynamics to formulate transference interpretations in order to increase partial insights. It is possible to see , in both situations, that the two patients in a sense are enacting their conflicts in the group situation, and the therapist tries to show them , as well as to the group as a whole, how each new situation might represent the relief fromving of a specific situation that is possibly linked to the current symptom. J.E. and D., in their communications to the group, atin the end of the session, seem to be understanding this kind of connection.
Credible Placebo Control (CPC) Group
The credible placebo control group is a set of standardized procedures developed by Heimberg et al.15 These procedures were created as a waymeans to offer a comparator comparison with to active treatments mirroring the placebo controlled randomized clinical trials performedcarried out using drugs. CPC combines educational presentations and supportive group psychotherapy. The initial session focused on introductions, rules and the development of the treatments rationale. In the first part of sessions 2-12, a series of lecture-demonstration-discussions about relevant topics was presented according to relevant on topics of relevance to individuals with social phobia.15
In the second part of the sessions 2-12, group members shared their activities of the previousast week and concerns about upcoming anxiety-provoking events. They have also suggested methods they may hadve used to cope with situations that were commoncurrent for other group members. This supportive part of each session was relatively unstructured. To help the therapist in keeping the discussion focused, a seriesset of questions was provided for each session, linking them to the educational discussion in the first half of the session. Unlike Cognitive Behavioral Group Therapy, therapists refrained from providing specific encouragement or instructions for patients to seek out and confront phobic situations (i.e. exposure). As opposed to and unlike Psychodynamic Group Therapy, therapists refrained from providing insight- oriented interventions and/or interpretations for patients to deal with the phobic situation. However, patients were instructed to discuss whatever topics they chose and to use the group as a forum in which they may prepare themselves for upcoming phobic events.15
Student t-test and Chi-square/Fisher exact tests were performed to compare baseline data, followed by repeated measures ANOVA for the outcome measures (LSAS, HAS, CGI). The level of significance was 5%.
While both groups demonstrated significant pretreatment-to-posttreatment change (F1,28=29.89, p<0.001) in the total score of LSAS, PGT patients' symptoms were rated as significantly less severe than those of CPC patients at posttest assessment (F1,28=4.84, p=0.036). Ratings on Hamilton Anxiety Scale revealed an improvement in both groups along the 12-week period (F1,28=10.58, p=0.003). However, no significant differences between both groups were found (F1,28=0.51, p=0.506). Ratings on Clinical Global Impression Scale revealed an improvement in both groups along the 12-week period (F1,28=204.45, p<0.001). However, no significant differences between both groups were found (F1,28=0.31, p=0.582) (Table 2). Overall, patients did not differ in their baseline assessment (Table 1). Baseline data of completers did not show differences between both groups in the demographic variables (Table 1) and outcome variables (Table 2) used.
The present study examined the effectiveness of psychodynamic group therapy for generalized social phobia. The PGT package was found to produce statistically and clinically significant reduction on social anxiety, particularly avoidance symptoms, as compared to the control group. While in other treatment modalities (cognitive-behavioral therapy, pharmacotherapy) we are aware of the meaningful changes in anxiety, to our knowledge the present study is the first one to be conducted using a psychodynamic approach. The present findings are significant because PGT was found to produce results superior on the LSAS to those achieved by a credible comparison condition.
Psychodynamic Group Therapy appears to be a viable treatment for individuals who experience generalized social phobia. The fact of being performed in a group setting is specially relevant since the group itself provides a source of improvement of anxiety symptoms. One possible advantage of PGT and perhaps a reason to understand our results is the fact that the group experience and the partial insight on the unconscious conflicts might have a synergic effect on the clinical improvement.
Observing the written reports of sessions from both groups, it was possible to see that PGT patients apparently were facing more directly their conflicts, thus having a shared opportunity to face the external and hidden contents at the same time. On the other hand, patients of CPC group were not able have such a shared experience of discussing not only symptoms, but also feelings and conflicts overly.
It can be argued that psychodynamically oriented treatments would take longer periods to present its therapeutic effects. Further studies are needed to assess whether long-term PGT could provide better results.
Heimberg et al.15 have shown that cognitive behavioral group therapy (CBT) is superior to a credible placebo treatment in patients with social phobia. The duration of the treatment package used by Heimberg et al.15 was equal to the time spent in PGT in our clinical sample. It is not possible to make direct comparisons between PGT and CBT in the treatment of social phobia, as such comparison was not yet accomplished. However, our results suggest that when selecting short-term group treatments for social phobia, with current data, CBT may provide the best results, but PGT has also to be considered.
Unfortunately, long-term psychoanalytic treatment is difficult to be empirically studied, and most of what is known about it for social phobia originates from case reports.16,17 In an exploratory study with 23 patients under psychoanalytic treatment, 35% were diagnosed as avoidant personality disorder (which commonly overlaps with generalized social phobia) at baseline, and 22 of them clearly improved after 1 year of twice-a-week therapy. The mentioned study had a rather small sample and was not controlled.18 The present study is a first attempt to compare PGT with a control group using a randomized method.
For some patients with social phobia and several personality disturbances, clinically manifested by weak ego boundaries, an unclear identity, and low selfesteem, cognitive-behavioural therapy and psychopharmacological treatment may also be non-effective. In these situations, a short-term psychodynamic therapy might allow patients to expose themselves to anxiety-producing situations with less symptoms.19
Other therapy modalities apart from CBT are needed in social phobia for several reasons: 1) established treatments (CBT and pharmacological) do not help all patients who seek help; 2) for many patients the standard treatment provides only partial decrease in symptoms and patients may experience recurrence of symptoms in long-term follow-up.20
There are several limitations in the present study: the fact that the same therapist performed both treatments has advantages and disadvantages. One potential advantage is that there is no change in the figure of the therapist, which is known to influence all kinds of psychotherapy. The potential disadvantage would arise from the possible affiliation of the therapist to a certain kind of therapy in detriment of the other. This could lead to a systematic bias, which would favor, consciously and unconsciously, one of the interventions. As far as we know, there was no bias against the psychodynamic approach, since this study was designed and conceptualized as a means to expand the applications of psychodynamic brief therapy. Another possible limitation of this study was the fact that only four groups were constituted, two of each kind of intervention. Perhaps with more groups chaired by different and experienced therapists in each technique, different outcomes could be obtained. This is an idea for future studies.
This promising field needs careful and systematic investigation and perhaps a more appropriate way to do it would be through the use of qualitative methods jointly with the quantitative methodology which was used in the present report.
This study showed that PGT was not superior to a credible placebo control group in the treatment of generalized social phobia. As far as we are aware this is the first attempt to compare PGT to a control treatment in this group of patients.
In the present study, PGT was used in a short-term, structured package. It can be argued that psychodynamically-oriented treatments would take longer periods to present theirits therapeutic effects. In this vein, the present study does not rule out the effectiveness of PGT in generalized social phobia. Further studies are needed to assess whether longer-term PGT packages could providedeliver better results than control treatments. However, the means and standard deviations of both PGT and control groups were almost identical at endpoint. This suggest that short-term PGT, in thea short-term basis, may not provide the necessary framework for the improvement of symptoms of generalized social phobia.
Heimberg et al.15 have shown that cognitive-behavioral group therapy (CBT) is superior to a credible placebo treatment in patients with social phobia. The duration of the treatment package used by Heimberg et al.15 was equal to the time spent in PGT in our clinical sample. It is not possible to make direct comparisons between PGT and CBT in the treatment of social phobia, as such comparison was not yet accomplishedcarried out. However, our results suggest that when selecting short-term group treatments for social phobia, with current data, CBT may provide the best results.
Further studies with longer periods of treatment and a larger sample are needed to assess the capability of PGT to improve symptoms of generalized social phobia. A direct comparison between PGT and CBT would also be useful in providing evidence as to whether or not CBT is superior to alternative group treatments in generalized social phobia.
Unfortunately, long-term psychoanalytic treatment is difficult to be empirically studiedy empirically, and most of what is known about itthis for social phobia originatescomes from case reports.16,17 In an exploratory study withof 23 patients under psychoanalytic treatment, 35% were diagnosed as avoidant personality disorder (which commonly overlaps with generalized social phobia) at baseline, and 22 of them clearly improved clearly after 1 year of twice-a-week therapy. The mentionedlater study hads a rather small sample and wasis not controlled.18 The present study was also small, but it was a first attempt to compare PGT with a control group using a randomized single-blind short-term clinical trial.
For some patients with social phobia andwith several personality disturbances, clinically manifested by weak ego boundaries, an unclear identity, and low self-steem, cognitive-behavioural therapy and psychopharmacological treatment may be also not be be effective. In these situations, a long-term psychodynamic therapy might allowmake it possible for the patients to expose themselveshimself to anxiety-producing situations with less symptoms.19
Other therapy modalities apart from CBT are needed in social phobia for several reasons: 1) established treatments (CBT and pharmacologic) do not help allevery patients who seeks help; 2) for many patients the standard treatment provides only partial decrease in symptoms and patients may experience recurrence of symptoms in long-term follow-up.20
There are several limitations in the present study: tThe fact that the same therapist performed both treatments has advantages and disadvantages. One potential advantage is that there is no change in the figure of the therapist, which is known to influence all kinds of psychotherapy. The potential disadvantage would arise from the possible affiliation of the therapists affiliation to a certain kind of therapy in detriment of the other. This could lead to a systematic bias, which would favour consciously and unconsciously, one of the interventions. However, if there was a bias, the bias was in favour of PGT, as the main hypothesis was that PGT would be superior to the CPC. As far as we knoware aware, there was no bias against the psychodynamic approach, since this study was designed and conceptualized as a means to expand the applications of psychodynamic brief therapy. Another possible limitation of this study was the fact that only four groups were constituted, two of each kind of intervention, maybe perhaps wwith more groups chaired by different and experienced therapists in each technique, different outcomes could be obtained. This is an idea for future studies.
It is clear that the psychoanalytical approach is dependent upon insights which are acquired through withthe time. A fundamental concept in psychoanalysis is the process of working through. It is possible that the limitations of time did not allow for a proper working through of the conflicts uncovered, at least partially, in the sessions, with those patients.
This promising field needs careful and systematic investigation and maybe perhaps aa more appropriate way to do it would be through the use of qualitative methods jointly with the quantitative methodology which was used in the present report.
The present study showed that PGT was superior to a credible placebo control group in the treatment of generalized social phobia in a 12- week randomizedized single-blind clinical trial. Further studies, with new designs, might bring new evidences about the efficacy of psychoanalytically-oriented approaches.
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Daniela Zippin Knijnik
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