Hostname: page-component-586b7cd67f-gb8f7 Total loading time: 0 Render date: 2024-11-28T01:07:19.184Z Has data issue: false hasContentIssue false

Cognitive-Behavioral Therapy for Social Anxiety Disorder: Supporting Evidence and Future Directions

Published online by Cambridge University Press:  07 November 2014

Abstract

The present paper examines the role of cognitive-behavioral therapy (CBT) in the treatment of social anxiety disorder (SAD). A cognitive-behavioral model of SAD is first presented. Different modalities of CBT for SAD are then described, including exposure, cognitive restructuring, relaxation training, and social skills training, and evidence supporting their efficacy is reviewed. The comparative and combined impact of CBT and pharmacotherapeutic interventions is also explored. CBT appears to be an efficacious treatment for SAD. However, the overall efficacy CBT may be increased by closer examination of the active ingredients of treatment. Such analyses may also enable more successful integration of the different CBT techniques and of CBT and pharmacotherapy in the treatment of SAD.

Type
Review
Copyright
Copyright © Cambridge University Press 2003

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Washington, DC: American Psychiatric Press, Inc.; 1994.Google Scholar
2.Kessler, RC, McGonagle, KA, Zhao, S, et al.Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:819.CrossRefGoogle ScholarPubMed
3.Narrow, WE, Rae, DS, Robins, LR, Regier, DA. Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys' estimates. Arch Gen Psychiatry. 2002;59:115123.CrossRefGoogle ScholarPubMed
4.Weiller, E, Bisserbe, J-C, Boyer, P, Lepine, JP, Lecrubier, Y. Social phobia in general health care: an unrecognized, undertreated, disabling disorder. Br J Psychiatry. 1996;168:169174.CrossRefGoogle Scholar
5.Whisman, M, Sheldon, C, Goering, P. Psychiatric disorders and dissatisfaction with social relationships: does type of relationship matter? J Abnorm Psychol. 2000;109:803808.CrossRefGoogle ScholarPubMed
6.La Greca, AM, Lopez, N. Social anxiety among adolescents: linkages with peer relations and friendships. J Abnorm Child Psychol. 1998;26:8394.CrossRefGoogle ScholarPubMed
7.Wittchen, H, Fuetsch, M, Sonntag, H, Muller, N, Liebowitz, M. Disability and quality of life in pure and comorbid social phobia-findings from a controlled study. Eur Psychiatry. 1999;14:118131.CrossRefGoogle ScholarPubMed
8.Schneier, FR, Johnson, J, Hornig, CD, et al.Social phobia. Comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry. 1992;49:282288.CrossRefGoogle Scholar
9.Lelliott, P, McNamee, G, Marks, I. Features of agora, social, and related phobias and validation of the diagnoses. J Anxiety Disord. 1991;5:313322.CrossRefGoogle Scholar
10.Ballenger, J, Davidson, J, Lecrubier, Y, et al.Consensus statement on social anxiety disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry. 1998;59(suppl. 17):5460.Google Scholar
11.Stein, M, McQuaid, J, Laffaye, C, et al.Social phobia in the primary medical care setting. J Fam Pract. 1999;49:514519.Google Scholar
12.Mannuzza, S, Schneier, F, Chapman, T, et al.Generalized social phobia. Reliability and validity. Arch Gen Psychiatry. 1995;52:230237.CrossRefGoogle ScholarPubMed
13.Olfson, M, Fireman, B, Weissman, M, et al.Mental disorders and disability among patients in a primary care group practice. Am J Psychiatry. 1997;154:17341740.CrossRefGoogle Scholar
14.Schneier, F, Heckelman, L, Garfinkel, R, et al.Functional impairment in social phobia. J Clin Psychiatry. 1994;55:322331.Google ScholarPubMed
15.Rapee, RM, Heimberg, RG. A cognitive-behavioral model of anxiety in social phobia. Behav Res Ther. 1997;35:741756.CrossRefGoogle ScholarPubMed
16.Turk, CL, Lerner, J, Heimberg, RG, Rapee, RM. An integrated cognitive-behavioral model of social anxiety. In: Hofmann, SG, DiBartolo, PM, eds. From Social Anxiety to Social Phobia: Multiple Perspectives. Needham Heights, Mass: Allyn & Bacon; 2001:281303.Google Scholar
17.Roth, DA., Heimberg, RG. Cognitive-behavioral models of social anxiety disorder. In: Schneier, FR, ed. Psychiatric Clinics of North America: Social Anxiety Disorder. vol. 24. New York, NY: W. B. Saunders Company; 2001:753771.Google ScholarPubMed
18.Rapee, RM. Descriptive psychopathology of social phobia. In: Heimberg, RG, Liebowitz, MR, Hope, DA, Schneier, FR, eds. Social Phobia: Diagnosis, Assessment, and Treatment. New York, NY: Guilford Press; 1995:4166.Google Scholar
19.Kagan, J, Snidman, N. Infant predictors of inhibited and uninhibited profiles. Psychol Science. 1991;2:4044.CrossRefGoogle Scholar
20.Schwartz, CE, Snidman, N, Kagan, J. Adolescent social anxiety as an outcome of inhibited temperament in childhood. J Am Acad Child Adolesc Psychiatry. 1999;38:10081015.CrossRefGoogle ScholarPubMed
21.Matheny, A Jr.Children's behavioral inhibition over age and across social situations: genetic similarity for a trait during change. J Pers. 1989;57:215235.CrossRefGoogle ScholarPubMed
22.Kendler, KS, Neale, MC, Kessler, RC, et al.The genetic epidemiology of phobias in women. The interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia. Arch Gen Psychiatry. 1992;49:273281.CrossRefGoogle ScholarPubMed
23.Coles, ME, Heimberg, RG. Memory biases in the anxiety disorders: current status. Clin Psychol Review. 2002;22:587627.CrossRefGoogle ScholarPubMed
24.Hackmann, A, Clark, DM, McManus, F. Recurrent images and early memories in social phobia. Behav Res Ther. 2000;38:601610.CrossRefGoogle ScholarPubMed
25.Foa, EB, Franklin, ME, Perry, KJ, Herbert, JD. Cognitive biases in generalized social phobia. J Abnorm Psychol. 1996;105:433439.CrossRefGoogle ScholarPubMed
26.Clark, DM, Wells, A. A cognitive model of social phobia. In: Heimberg, RG, Liebowitz, MR, Hope, DA, Schneier, FR, eds. Social Phobia: Diagnosis, Assessment, and Treatment. New York, NY: Guilford Press; 1995:6993.Google Scholar
27.Heimberg, RG. Cognitive-behavioral therapy for social anxiety disorder: current status and future directions. Biol Psychiatry. 2002;51:101108.CrossRefGoogle ScholarPubMed
28.Foa, EB, Kozak, MJ. Emotional processing of fear: exposure to corrective information. Psychol Bull. 1986;99:2035.CrossRefGoogle ScholarPubMed
29.Wells, A, Papageorgiou, C. Social phobia: effects of external attention on anxiety, negative beliefs, and perspective taking. Behav Ther. 1998;29:357370.CrossRefGoogle Scholar
30.Beck, AT, Rush, J, Shaw, BF, et al.Cognitive Therapy of Depression. New York, NY: Guilford Press; 1987.Google Scholar
31.Wells, A, Clark, DM, Salkovskis, P, et al.Social phobia: the role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behav Ther. 1995;26:153161.CrossRefGoogle Scholar
32.Morgan, H, Raffle, C. Does reducing safety behaviours improve treatment response in patients with social phobia? Aust N Z J Psychiatry. 1999;33:503510.CrossRefGoogle ScholarPubMed
33.Heimberg, RG, Becker, RE. Cognitive-Behavioral Treatment for Social Phobia: Basic Mechanisms and Clinical Strategies. New York, NY: Guilford Press; 2002.Google Scholar
34.Wolpe, J. Psychotherapy by Reciprocal Inhibition. Stanford, Calif: Stanford University Press; 1958.Google Scholar
35.Bernstein, DA, Borkovec, TD. Progressive Relaxation Training: A Manual for the Helping Professions. Champaign, Ill: Research Press; 1973.Google Scholar
36.Bernstein, DA, Borkovec, TD, Hazlett-Stevens, H. New Directions in Progressive Relaxation Training: A Guidebook for Helping Professionals. Westport, CT: Praeger Publishers/Greenwood Publishing Group, Inc.; 2000.Google Scholar
37.Ost, LG. Applied relaxation: description of a coping technique and review of controlled studies. Behav Res Ther. 1987;25:397409.CrossRefGoogle ScholarPubMed
38.Halford, K, Foddy, M. Cognitive and social skills correlates of social anxiety. Br J Clin Psychol. 1982;21:1728.CrossRefGoogle ScholarPubMed
39.Stopa, L, Clark, DM. Cognitive processes in social phobia. Behav Res Ther. 1993;31:255267.CrossRefGoogle ScholarPubMed
40.Glasgow, RE, Arkowitz, H. The behavioral assessment of male and female social competence in dyadic heterosexual interactions. Behav Ther. 1975;6:488498.CrossRefGoogle Scholar
41.Rapee, RM, Lim, L. Discrepancy between self- and observer ratings of performance in social phobics. J Abnorm Psychol. 1992;101:728731.CrossRefGoogle ScholarPubMed
42.Turner, SM, Beidel, DC, Cooley, MR, et al.A multicomponent behavioral treatment for social phobia: social effectiveness therapy. Behav Res Ther. 1994;32:381390CrossRefGoogle ScholarPubMed
43.Feske, U, Chambless, DL. Cognitive behavioral versus exposure only treatment for social phobia: a meta-analysis. Behav Ther. 1995;26:695720.CrossRefGoogle Scholar
44.Cohen, J. Statistical Power Analysis for the Sciences. New York, NY: Academic Press; 1977.Google Scholar
45.Chambless, DL, Hope, DA. Cognitive approaches to the psychopathology and treatment of social phobia. In: Salkovskis, PM, ed. Frontiers of Cognitive Therapy. New York, NY: Guilford Press; 1996:345382.Google Scholar
46.Fedoroff, IC, Taylor, S. Psychological and pharmacological treatments of social phobia: a meta-anlaysis. J Clin Psychopharmacol. 2001;3:311324.CrossRefGoogle Scholar
47.Gould, RA, Buckminster, S, Pollack, MH, et al.Cognitive-behavioral and pharmacological treatment for social phobia: a meta-analysis. Clin Psychol: Sci Prac. 1997;4:291306.Google Scholar
48.Taylor, S. Meta-analysis of cognitive-behavioral treatments for social phobia. J Behav Ther Exp Psychiatry. 1996;27:19.CrossRefGoogle ScholarPubMed
49.Newman, MG, Hofmann, SG, Trabert, W, et al.Does behavioral treatment of social phobia lead to cognitive changes? Behav Ther. 1994;25:503517.CrossRefGoogle Scholar
50.Scholing, A, Emmelkamp, PM. Exposure with and without cognitive therapy for generalized social phobia: effects of individual and group treatment. Behav Res Ther. 1993;31:667681.CrossRefGoogle ScholarPubMed
51.Scholing, A, Emmelkamp, PM. Treatment of generalized social phobia: results at long-term follow-up. Behav Res Ther. 1996;34:447452.CrossRefGoogle ScholarPubMed
52.Mattick, RP, Peters, L. Treatment of severe social phobia: effects of guided exposure with and without cognitive restructuring. J Consult Clinl Psychol. 1988;56:251260.CrossRefGoogle ScholarPubMed
53.Mattick, RP, Peters, L, Clarke, JC. Exposure and cognitive restructuring for social phobia: a controlled study. Behav Ther. 1989;20:323.CrossRefGoogle Scholar
54.Blanco, C, Antia, SX, Liebowitz, MR. Pharmacotherapy of social anxiety disorder, Biol Psychiatry. 2002;51:109120.CrossRefGoogle ScholarPubMed
55.Clark, DB, Agras, WS. The assessment and treatment of performance anxiety in musicians. Am J Psychiatry. 1991;148:598605.Google ScholarPubMed
56.Turner, SMBeidel, DC, Jacob, RG. Social phobia: a comparison of behavior therapy and atenolol. J Consult Clin Psychol. 1994;62:350358.CrossRefGoogle ScholarPubMed
57.Gelernter, CS, Uhde, TW, Cimbolic, P, et al.Cognitive-behavioral and pharmacological treatments of social phobia. A controlled study. Arch Gen Psychiatry. 1991;48:938945.CrossRefGoogle ScholarPubMed
58.Otto, MW, Pollack, MH, Gould, RA, Worthington, JJ 3rd, McArdle, ET, Rosenbaum, JF. A comparison of the efficacy of clonazepam and cognitive-behavioral group therapy for the treatment of social phobia. J Anxiety Disorders. 2000;14:345358.CrossRefGoogle ScholarPubMed
59.Heimberg, RG, Liebowitz, MR, Hope, DA, et al.Cognitive behavioral group therapy vs. phenelzine therapy for social phobia: 12-week outcome. Arch Gen Psychiatry. 1998;55:11331141.CrossRefGoogle ScholarPubMed
60.Liebowitz, MR, Heimberg, RG, Schneier, FR, et al.Cognitive-behavioral group therapy versus phenelzine in social phobia: long-term outcome. Depress Anxiety. 1999;10:8998.3.0.CO;2-5>CrossRefGoogle ScholarPubMed
61.Basoglu, M, Marks, IM, Kilic, C, Brewin, CR, Swinson, RP. Alprazolam and exposure for panic disorder with agoraphobia. Attribution of improvement to medication predicts subsequent relapse. Br J Psychiatry. 1994;164:652659.CrossRefGoogle ScholarPubMed
62.Falloon, IR, Lloyd, GG, Harpin, RE. The treatment of social phobia. Real-life rehearsal with nonprofessional therapists. J Nerv Ment Dis. 1981;169:180184.CrossRefGoogle ScholarPubMed
63.Blomhoff, S, Haug, TT, Hellström, K, et al.Randomised controlled general practice trial of sertraline, exposure therapy, and combined treatment in generalised social phobia. Br J Psychiatry. 2001;179:2330.CrossRefGoogle ScholarPubMed
64.Heimberg, RG. The understanding and treatment of social anxiety: what a long strange trip it's been (and will be). Presidential address presented at: Annual Meeting of the Association for Advancement of Behavior Therapy; November 15-17, 2002; Reno, Nev.Google Scholar
65.Stein, MB. Is the combination of medication and psychotherapy better than either alone? Paper presented at: Annual Meeting of the Anxiety Disorders Association of America; March 21-24, 2002; Austin, Tex.Google Scholar
66.Otto, MW, Pollack, MH, Sachs, GS, et al.Discontinuation of benzodiazepine treatment: efficacy of cognitive-behavioral therapy for patients with panic disorder. Am J Psychiatry. 1993;150:14851490.Google ScholarPubMed