8 1998 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 1998 Volume 2 Pages 107-113
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Therapeutic strategies for patients with social phobia RJ BOERNER AND HJ MOLLER
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Psychiatric Hospital and Outpatient Clinic of the University of Munich
Correspondence Address Dr.Dr.med. Dip1.-Psych. R.J. Boerner, Psychiatrische Klinik und Poliklinik der Ludwig-Muximilans-Universitat Munchen, Nussbaumstr. 7, D-80336 Munich, Germany Tel: +49 89 5160 3370 3355 Far: +49 89 5160 4548
Social phobia is a serious condition in the range of anxiety disorders which, until quite recently, has not been given due attention in research. In this paper we compare existing studies and follow-up results of behaviour therapy and phamacotherapy. We have endeavoured to work out an effective therapy for this serious condition. Apart from psychological education as a basic therapeutic element, the use of effective drugs promises to yieZd good results, especially in conjunction with behaviour therapy, including training in social skills, cognitive therapy and exposure therapy. Whicheverform of treatment is chosen depends on the patient’s preference and the availability of services. I f the patient does not respond, the possible causes should be examined thoroughly and new types of treatment considered. A combination of behaviour and drug treatments might be provided for special groups. (Int J Psych Clin Pruct 1997; 2: 107-113)
Received 23 July 1997; accepted for publication 23 December 1997
INTRODUCTION ocial phobia a common anxiety disorder whose S clinical and therapeutic significance has only recently received appropriate The life-time prevalence is
varies between 2%’ and 13.3%; depending on the criteria selected. On account of the multitude of symptoms and the varying severity of this disorder, a distinction is made between a generalized subtype and a specific subtype, the generalized subtype being characterised by more pervasive anxiety and distress and more severe symptoms.’ The disorder characteristically has an early onset, and a chronic course’. Another typical feature is the high prevalence of lifetime comorbidity with other psychiatric disorders. Judd6 testifies to a lifetime coexistence with simple phobia (59%), agoraphobia (45%), major depression (17%), dysthymia (12%), alcohol dependency ( 19%)and drug dependency (13%). Patients with comorbid social phobia are more susceptible to suicidal ideas and suicide attempts.’ Furthermore, patients with social phobia experience considerable impediments in various social areas such as education, employment and occupational opportunities. Although their intelligence and proficiency may be of a high standard, they are less likely to receive adequate
training, limiting the chances of suitable employment and advancement, and increasing 10neliness.~~~ The efficacy of various behaviour therapies such as selfassertiveness training, cognitive therapy and exposure therapy has been established and these are now recognized as standard services.’ Various pharmacological approaches have also been shown to be beneficial, especially the introduction of moclobemide and SSRIS.~-’’ According to Bassler,” short-term and focal therapy for up to 30 hours, medium-term analytical psychotherapy of between 30 and 120 hours, and long-term psychoanalytical therapy are all used to treat social anxieties. Unfortunately, no statements regarding specific disturbances can be made as no studies were performed in people meeting DSM or ICD criteria. To date, only individual case histories and condensed case reports are available. Further intensive research will have to be carried out on this disorder. Case reports. are not satisfactory for clinical and practical purposes, as pertinent queries concerning therapeutic approaches have not been discussed sufficiently. More information is required with regard to the use of behaviour therapy plus cocomitant medication: the duration of such a treatment, the efficacy and availability of facilities, and the procedure for comorbid patients, as well as therapeutic alternatives for patients who do not respond. We present a critical survey of important studies in the
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fields of behaviour therapy and pharmacotherapy; a rationale for a diversified treatment will be discussed and evaluated. We include studies whose results allow an evidence-based statement to be made about the long-term effects of various therapeutic procedures.’
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BEHAVIOURAL APPROACHES Heimberg et a12313 compared 49 patients having group cognitive behaviour therapy, including cognitive restructuring and self-exposure as well as cognitive restructuring as homework. Twelve sessions were held, of 2 hours each, with the emphasis on psychoeducational principles. On completion of the study, no real differences in the effectiveness of the treatment approaches could be shown; in the 6-month follow-up examination the patients given cognitive behaviour therapy were superior to control subjects in nearly all variables. At the 5-year follow-up, there was no difference in 19 patients although, clinically, the behaviour therapy group had fewer noticeable symptoms than their counterparts and a lower impairment of routine activities. Newman et all4 examined 36 patients undergoing exposure therapy, either in a group or individually, compared with a control group on the waiting list. Both treatment approaches led to adverse changes in the patients’ cognition although this was not actually intended as a therapeutic management policy. From this study it can be concluded that behaviour therapy-irrespective of the original method selected-produces marked changes in the patient’s behaviour and awareness. The efficacy of behavour therapy approaches may depend on variables other than the duration of frequency of treatment. Butler et all5 compared the effectiveness of exposure and anxiety management in 45 patients subjected to a socalled ‘associative therapy’, as against a waiting group given seven one-hour therapy sessions. At the end of the therapy, and at the 6-month follow-up, two ‘booster sessions’ were conducted, which showed no difference between the efficacy of these treatments. Emmelkamp et all6 observed in-vivo exposure in 34 patients who were treated on a rational-emotive principle and who received six group sessions of self-instruction training. As a whole, the differences in efficacy were not appreciable and were difficult to interpret. Mattick et aP7>’*carried out the most comprehensive and best-controlled studies, using a cognitive-behavioural treatment pattern. In one of their studies,’* involving 51 patients, they utilised four treatments, namely guided exposure, cognitive restructuring, cognitive restructuring combined with rational - emotive therapy, and guided exposure combined with cognitive restructuring. There was also a waiting-list group for comparison. The therapy was conducted in six group sessions of 120 minutes each, followed by an examination 3 months later. The results were not conclusive, but, conservatively interpreted, it can
be said that all treatments produced a significant improvement in behaviour. Mattick and Peters17set out their findings of a follow-up study in which 51 patients of the control group on the waiting list were offered a treatment consisting of guided exposure with or without cognitive restructuring. This was also carried out in groups, with 2 hours of therapy per week over a period of 6 weeks. At the end of treatment, the group which had received the combination of therapies was found, on external ratings, to be only slightly better than the group which had received exposure therapy only, and patients’ self-ratings showed no difference at all. In the 3month follow-up, 48% of the ‘exposure’ patients still showed definite ‘evasive’ behaviour, in contrast to 14%of the combination group; and 47% .of the exposure-only patients were in need of additional treatment, whereas 24% of the combination group were in need of further treatment. The efficacy of ‘social skills training’ (SST) was shown in a study by Stravynski et all9 who examined 22 patients. Their therapy comprised 12 individual sessions of 95 minutes each. At the 6-months follow-up, no difference in efficacy was found as compared with patients who had participated in an additional cognitive training project. Mersch et a120 investigated social skills training augmented by additional homework training in 74 patients, and compared the results with another group receiving rational- emotive therapy in 2-hourly sessions. At the end of the study, no substantial difference in efficacy between these two groups was found. In the 2-year follow-up, 44% of .57 patients required further treatment for social phobia, 38% showed an improvement in behaviour, and 28%of the patients relapsed. In a study by Wlazlo et al’l the long-term effectiveness of the following therapy approaches were compared: specific exposure in vivo, either as a group or individually, and social skills training. The duration of treatment was similar (34 versus 37.5 hours); the social skills training was carried out in groups of 6-8 persons twice a week, involving a total of 25 half-hour sessions over a period of 3 months. Of the 167 patients with social phobia, originally diagnosed according to DSM-111 criteria, 20 rejected treatment; 14 dropped out. Thirty patients were excluded from the analysis because of severe comorbidity. Of the remaining 103 patients (62%), 78 were given follow-up examinations after 1 to 5.5 years (average 2.5 years). All three treatments resulted in a clinical and statistically significant improvement in social competence and social anxiety decreased. Scholing and Emmelkamp,22~23 in their studies of 30 and 73 patients respectively, could not find any significant differences in efficacy between exposure therapy and cognitive therapy, either at the time when the treatment was finished or at the 3-month follow-up. In the authors’ main study,” 89 patients were originally found eligible, but 16 refused to be included; 25% of the ‘completers’and 36% of the ‘drop-outs’ were given regular concomitant medica-
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Therapeutic strategies for social phobia
tion, mostly benzodiazepines or beta-blockers. The therapy was carried out by advanced students of clinical psychology, who had received an intensive training lasting up to 100 hours. At the 3-month follow-up, 11 patients needed further attention, and at the 12-month follow-up, 16 patients (27%). Four out of the 14 patients who dropped out gave as their reason, the lack of clinical improvement. The records suggested that the drop-outs had more severe symptoms than the completers. Turner et a124treated 17 patients whose improvement they ascribed to the social effectiveness therapy developed by them. The average age of onset was 13 years, the mean duration of the disorder was 23 years. One-third of the patients also suffered from generalized anxiety or dysthymia; ten patients (58.8%) also had either an evasive personality disorder and/or an obsessive-compulsive neurosis diagnosed by means of the SCID interview; four patients withdrew from the study, leaving only 13 to be examined. When the therapy was finished, eight patients (67%) could be classified as moderately improved and two (17%) as substantially improved. The same authors then initiated a 2-year follow-up study.25 Unfortunately, only eight out of the 13 patients could be contacted, and interviewed by telephone. Those patients whose behaviour had improved during intensive treatment remained stable afterwards. A marked improvement could be seen in terms of self-esteem, severity of symptoms and reduction in generalized anxiety. In summary, the findings of these studies of behaviour therapy give some evidence of the efficacy of social skills training, exposure therapy and cognitive intervention. There are no indications of any specific differences between the therapeutic effectiveness of these methods. Different clinical paths are available for treating patients with social phobia, and whichever seems to be the most fitting can be selected. The study suggests that the duration of treatment required to achieve the desired results is limited to about 40 hours. Though behaviour therapy for social phobics is obviously easy to learn, it requires enormous practice and empathy with the patient to achieve a satisfactory relationship and successful treatment. However, it is wise not to have too high an expectation of the effectiveness of behaviour therapy and the indication for it. The number of cases treated has been decidedly small; and, in particular, comparative studies of different types of treatment have too few participants in the groups to enable guidelines to be established. Another questionable point is the mode of recruitment. It makes a great difference whether patients are assembled through a newspaper advertisement or whether they seek contact of their own accord because they wish to be treated. Even though in most of the studies the DSM-I11 or DSM-IIIR criteria were adhered to, it is perhaps doubtful whether the patients were genuinely ‘disturbed in the clinical sense, or whether they merely stated they suffered from increased
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social fears or social incompetence. Furthermore; there are no details available on the efficacy of behaviour therapy in comorbid patients. The patients in Wlazlo’s study” were excluded from the review, and in Turner’s studyz4 the numbers of comorbid patients were too low to be generalisable to wider practice.
PHARMACOLOGICAL APPROACHES Reviews conducted by Den Boer et allo and by Boerner and Mdllerg have confirmed the efficacy of various compounds, especially reversible and irreversible MA0 inhibitors, but also certain benzodiazepines and selective serotonin reuptake inhibitors (SSRIs). Among the high potency benzodiazepines, clonazepam has been extensively researched. Of the 75 patients examined by Davidson et a1,26 42% showed a marked improvement with ‘acute’ therapy, and another 42% were rated as improved. However, no details are recorded about the results of the follow-up examination after stopping the drug.
SSRls As far as SSRIs are concerned, hardly any results of placebocontrolled studies have been published. In a double-blind, placebo-controlled cross-over study undertaken by Katzelnick et al?’ involving 12 patients, sertraline proved effective in 52% of patients, as against 9% of the patients given placebo. Stein et a128have shown that paroxetine is also effective in the treatment of social phobia. A 12-week study demonstrated that paroxetine was better than placebo from week 2 (Figure 1). Patients on paroxetine achieved better CGI scores (very much improved, much improved) than patients on placebo (Figure 2). The large number of patients (91) in this study is relevant. Thus, paroxetine or other SSRI can be seen as a possible treatment with good results in the short term.
Paroxetine social phobia study (382) LSAS total score (change from baseline; ITT sample; LOCF dataset) Weeks 0 1 2 3 4 5 6 7 8 9 101112
..-- --
i.
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* - - - _*_- - - - - -
Paroxetine
- - - _ _* _
-40 Baseline scores: paroxtine 78; placebo 83
*p10.01 Figure 1 Patients treated with paroxetine showed improved CCI levels compared with the placebo group; reproducedfrom Stein et a1 (1994)28
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Paroxetine social phobia study (382)
CGI global improvement (In sample; LOCF dataset)
CGI Very much improved 1 I Much improved
2
1
I
J
Minimally improved 3
1
No change Minimallv worse Much worse Very much worse
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W Paroxetine (n=91)
7
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0
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10
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20 30 Patients (%)
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Figure 2 [Reproduced from Stein et al (1994)”; see also Figure 21
MA0 INHIBITORS Conversely, evidence as to the therapeutic benefits of MA0 inhibitors is more abundant. In a study with 78 patients, Versiani et alZ9compared phenelzine at a dosage of 3090 mg/day, moclobemide at 200- 600 mg/day and placebo. After 16 weeks, using a ‘combined efficacy’ measuring system, it was found that 91% of the patients had improved with phenelzine, 82% with moclobemide and 43% with placebo. After week 16, 50% of the responders were switched to placebo, which promptly resulted in a relapse; the other 50% of patients who continued with active treatment showed no recurring symptoms. Brofaromine, a reversible MA0 inhibitor, was evaluated by Van Vliet et a130 in a placebo-controlled study involving 30 patients. In week 8, a major difference in efficacy was shown in favour of brofaromine; at the end of the study (week 12) 73% of brofaromine-treated patients had responded whereas the response to placebo was zero. In subsequent trials over another 12 weeks of treatment, brofaramine continued to be proved superior to placebo. Comprehensive research has been made into the efficacy of the reversible MA0 inhibitor, moclobemide.11v31 Nutt and Montgome$’ reported the findings of a study of 578 patients in which 300 - 600 mg/day moclobemide was administered over 12 weeks, and compared to placebo. The average duration of the patients’ disorder was 16.5 years; 70% reported that their social life had deteriorated, and only 50% were fully employed at the time of entering the study. Thirteen percent exhibited generalized anxiety and 49% an ‘evasive personality disorder’.” After 12 weeks, 21% of the patients treated with 600 mg/ day and 12%of those treated with 300 mg/day were found to have improved satisfactorily (CGI=l), as compared with only 7% who had been given placebo. Patients treated with 600 mg/day showed a more significant improvement on the Liebowitz-scale(0.09%);than those treated with 300 mg/day
(0.05%). Moclobemide was particularly effective in the severe and extreme forms of social phobia, with a response rate of 52% (as against 37%) responding to 300 mg/day; only 30%responded to placebo. In patients with mild to moderate Symptoms, the differences were less pronounced: under 600 mg/day, 45% responded, under 300 mg/day 42%, and under placebo 35%. This study also indicates that the response rate of patients with medium- to long-term social phobia was higher with 600 mg/day (52%) than with 300 mg/day (39%) or placebo (28%). Moclobemide was well tolerated by all but 9%of the patients; these discontinued the study on account of the adverse effects, approximately the same rate as for patients allocated to placebo. Of special interest is the long-term study of Versiani et al.32 Their patients had been receiving moclobemide for 2 years (phase l), before medication was suspended for 2 -4 months. Relapsing patients continued to be treated with moclobemide for another 2 years. Of the original 101 patients included in the study, 58.4% completed the first phase, 59.2% of these being responders. After the suspension phase, the responder rate dropped to 8.1%, but the relapse rate was 96.1%. This group of patients was again treated with moclobemide. After 6 months, the responder rate was now 45.5%. The author’s interpretation of the high rate of relapsers is that social phobia must be regarded as a chronic condition requiring long-term pharmacological treatment. In addition, special mention is made of the high degree of comorbidity, including dysthymia (21%), generalized anxiety (26%), previous major depression (13%), alcohol abuse (32%), dependent personality (16%), and evasive personality disorder (72%) which may, however, reduce the pharmacologic efficacy. Schneir et alj3 found, in an 8-week trial, an extremely low response rate (17.5%) for the moclobemide group (maximum 400 mg/day) and 13.5% for placebo-the difference was not significant. Only for 2 of 10 primary outcome measures and 9 of 20 scondary measures does there exist significant group differences. Some limitations in this study were discussed: the dosage, which could be too low, the possibility of a treatment refractory sample and the short duration of the study. The authors argue that it could be possible that moclobemide is not a highly efficacious treatment for social phobia.
COMPARATIVE STUDIES: BEHAVIOUR THERAPY AND PHARMACOTHERAPY At present, there have been four studies comparing behaviour therapy treatment, pharmacological treatment, or combination treatment. Falloon et aP4 examined 16 patients who attended social skills training (SST) in combination with either propanolol or placebo. The SST took place in two 6-hour
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POSSIBLE DIFFERENTIAL STRATEGIES groups. After completion, no difference between those who had received the medication and those who had received OF TREATMENT placebo could be shown; in the 6-month follow-up study an When considering the treatment of social phobia, the most improvement was seen in both groups. important thing is how best to alleviate the patient’s Gelernter et al,35 in a study involving 65 patients with condition; we need to know which therapies’ effectiveness social phobia over 12 weeks, used four treatment methods: have been proved beyond doubt. In addition, therapists cognitive behaviour therapy, phenelzine, alprazolam and placebo; in each case the patient was instructed about ‘self- should also consider multimodal theories and therapeutic concepts which imply that social phobia has multiple exposure’. Each patient was seen once a week. At the end of causes. the study, 69% had improved with phenekine, 38% with Evaluation of studies of behaviour therapy as compared alprazolam, 24% under cognitive therapy and 20% under with pharmacotherapy, and the short-term and long-term placebo. At the 2-month follow-up, the response with effects, show that behaviour therapy is apparently more phenelzine was significantly higher than with placebo, whereas the alprazolam group had only one relapsing successful. The number of surveys of behaviour therapy for this disorder is much greater than that of reviews of patient. Unfortunately, the authors gave no information on pharmacological treatment, taking into account follow-up the cognitive therapy group. In one of four therapy groups, Clark and A g r a ~ ~data ~ showing that with behaviour therapy the patient’s condition remains stable for a long time. examined the effects of several forms of therapy on 34 On the one hand, many studies of behaviour therapy musicians with social phobia: cognitive behaviour therapy show a statistically significant improvement; on the other plus placebo, cognitive behaviour therapy plus buspirone, hand, many studies give no details about the extent of buspirone alone and placebo alone. Buspirone (50-60 mgl rehabilitation or whether complete and permanent day) plus placebo were given in a double-blind design over recovery, or at least a partial remission, had been 6 weeks. Both cognitive therapy groups were treated in five individual sessions per week. After one month, the follow- achieved. To answer this question, statistically significant up study showed a great improvement in the level of social results relating to before-and-after comparisons with functions: 83% of the patients with cognitive behaviour placebo would be most useful. In their investigations, therapy plus placebo, 50% with cognitive behaviour Mattick and peter^""^ specifically refer to non-responders and point out that some 47% of the patients, intensively therapy plus buspirone, 50% with buspirone alone, but and successfully treated by behaviour therapy, still require zero under placebo. In the study by Turner et a12472 sufferers from social treatment, even during the short interval between treatment and follow-up. phobia were given treatment with assisted exposure Moreover, attention must be drawn to certain selection training, atenolol or placebo. The groups given atenolol criteria for these studies, and the exclusion of very and placebo were treated over 3 months; they were complicated cases, as well as the drop-out rates. Since examined twice a week during the first month, and some of the studies do not specify any particular method of thereafter once a week, for a total of 16 appointments. The recruitment, it is likely that some patients incorporated into exposure group was checked twice a week during the first 2 the investigation were not ill patients, but rather months and once a week thereafter, a total of 20 sessions. individuals with low self-assertiveness. In addition, 31% of the patients had an additional Axis-I On the grounds of the relatively small numbers, it also disorder (generalized anxiety or dysthymia), and 35% an remains unclear which of the elements in behaviour Axis41 disorder (evasive personality or compulsive distherapy should be given priority. At the present time, turbance). exposure training, cognitive training and self-assertiveness Measured by means of a specially designed improvetraining seem to be equally effective. ment index, 89% of the exposure patients could be classed It must also be emphasized that therapist competence is as significantly improved, versus 27% under atenolol and very important, which is why therapists receive extensive 44% under placebo. In the 6-month follow-up those training of up to 100 hours before meeting patients. patients who had already improved during treatment, were Although certain qualifications are required of therapists found to have sustained their improvement. for social phobia, the additional need for experience and Critically viewed, the individual test groups do not specialist training may make the overall care of patients include enough patients, so the results must be regarded suffering from this epidemiologically severe disorder with reservations. This subject needs to be further extremely expensive. researched before definite statements can be made as to Behaviour therapy cannot therefore be recommended the superiority or inferiority of certain modes of treatment unreservedly as the only therapy, or as the treatment of first or concomitant effects of certain pharmaceutical drugs choice. With reference to drug treatment, a variety of taken concurrently with psychotherapeutic procedures. classes, for example the recently marketed M A 0 inhibitors The drugs mainly tested were buspirone, alprazolam and such as moclobemide, have been found to produce good to atenolol, whose efficacy in social phobia could not be excellent response rates in acute treatment. The findings of conclusively or adequately confirmed.
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Table 1 Phased programme for the treatment of social phobia
the few long-term follow-up studies, however, are rather disappointing; for instance, the paper by Versiani et a13’ simply shows the results of a somewhat unsuitably selected random test with moclobemide. Pharmacological treatment is a convincing alternative not only for patients who do not favour behaviour therapy, but also for patients who need acute treatment. Since no studies on differential indications have yet been published, an individual decision must be made in favour of one or the other alternative. The good, longlasting response to behaviour therapy-if available-within a short period of time is strongly in its favour, whereas the prompt availability and quick action of pharmaceutical drugs endorse the use of medication. Independent of any ideological treatment preferences, the decisive factors should be patient-orientated and based on clinical experience. A phased therapy programme has been developed, as shown in Table 1. Psychoeducation can be looked upon as an essential component of therapy, informing the patient about the characteristics of socal phobia, its possible origin and the most encouraging behavioural approaches such as exposure therapy. From the economy and efficiency aspects, too, psychoeducation should be a basic concept of any therapy, as cited in the study by Heimberg et al?’ who claim that psychoeducation is as good as cognitive behaviour therapy. Whether or not treatment is effective, depends largely on the severity of the disorder, and whether or not the patients has comorbid problems. However, it is likely that after 12 weeks of therapy, the patient will have responded and reached a stage of improvement at least 50% of that expected. But if, after this period, the patient’s condition has not improved sufficiently and if no obvious causes for a failure to respond (such as non-compliance, lack of qualification of the therapist, etc) can be seen, then the therapy should be changed over to medication followed by
behaviour therapy, or vice versa. The possible additive or negative effects of the combination of behaviour therapy plus pharmacotherapy have not yet been adequately researched. Such a combination seems to be plausible, if the patient has been informed about the disorder and its treatment. At the present time, such combined therapy should only be given to particular patients: individuals who do not respond adequately to the sequential management of medication and/or behaviour therapy, or individuals who are so badly affected by the disorder and/or comorbidity that neither medication nor behaviour therapy alone would produce an appreciable improvement. Only a very few of the authors mentioned above concern themselves with comorbid social phobia; most discuss only social phobia as a separate disorder. To just* the successful psychoanalytical treatment of social phobia, Bassler” stresses that continued patient care by the same therapist is of vital importance and should be integrated into the therapy programme along with other specific elements of behaviour therapy. These include exposure instruction, familiarizing the patient with the psychophysiological models of anxiety and training in recognising ‘catastrophic’ conditions. Combining this treatment concept with pharmacotherapy may be particularly relevant if the patient’s behaviour is chronically evasive, and extreme symptoms of social anxiety are manifested. For social phobics suffering from major depression, treatment with antidepressants is indicated in any case, since these substances have been proved to be of great therapeutic value in both the disorders?’ Not until there is a reduction of depressive symptoms, together with a lowering of anxiety, can any improvement be expected from the implementation of behaviour therapy strategies and social skills training. It is to be hoped that in future therapeutic studies and systematic clinical experience will be utilized to develop specific forms of treatment, to enable such patients to be treated more widely and effectively.
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REFERENCES 1. Agras SW, Silvester D, Oliveau D (1969) The epidemiology of common fears and phobias. Comp Psychiatry 10: 439-47. 2. Heimberg RE, Liebowitz MR, Hope DA, Schneier FS (1996) Social phobia. Diagnosis, assessment, and treatment. Guilford Press, New York. 3. Turner SM, Beidel DC, Dancu CV et a1 (1986) Psychopathology of social phobia and comparison to avoidant personality disorder. J Abnorm Psychol 95: 389-94. 4. Kessler RC, McGonagle KH, Zhao S et a1 (1994) Lifetime and 12-month prevalence of DSM-111-R psychiatric disorders in the United States. Arch Gen Psychiatry 51: 8- 19. 5. Turner SM, Beidel DC, Townsley RM (1992) Social phobia: a comparison of specific and generalized subtypes and avoidant personality disorder. J Abnorm Psychol 101: 326-31. 6. Judd LL (1994) Social phobia: a clinical overview. J Clin Psychiatry 55: 5-9. 7. Schneier FR, Johnson J, Hornig CD et a1 (1992) Social phobia: comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry 49: 282- 7. 8. Liebowitz MR, Gorman JM, Fyer AJ et a1 (1985) Social phobia. Arch Gen psychiatry 42: 729 - 36. 9. Boerner RJ, Moller HJ (1996) Pharmakotherapie der sozialen Phobie. Nervenheilkunde 15: 459-63. 10. Den Boer JA, van Vliet IM, Westenberg HGM (1995) Recent developments in the psychopharmacology of social phobia. Eur Arch Psychiatry Clin Neurosci 224: 309 - 16. 11. International Multicenter Clinical Trial Group on Moclobemide in Social Phobia (1997) Moclobemide in social phobia: A double-blind, placebo-controlled clinical study. Eur Arch Psychiatry Clin Neurosci 247: 71 - 80. 12. Bassler N (1997) Analytische Psychotherapie und Psychodynamik von sozialen Angsten. In: Psychotherapie und Psychopharmaka (ed P Buchheim), 93- 101. Schattauer, Stuttgart. 13. Heimberg RG, Salzman DG, Holt CS et a1 (1993) Cognitivebehavioral group treatment for social phobia: effectiveness at five-year follow-up. C o p Ther Res 17: 325-39. 14. Newman MG, Hofmann SG, Trabert W et a1 (1994) Does behavioral treatment of social phobia lead to cognitive changes? Behav Ther 25: 503 - 17. 15. Butler G, Cullington A, Munby M et a1 (1984) Exposure and anxiety management in the treatment of social phobia. J Consult Clin Psychol 52: 642 - 50. 16. Emmelkamp PMG, Mersch PPA, Vissia E, van der Helm M (1985) Social phobia: A comparative evaluation of cognitive and behavioural interventions. Behaviour Res Ther 23: 365 - 9. 17. Mattick RP, Peters L (1988) Treatment of severe social phobia: effects of guided exposure with and without cognitive restructuring. J Consult Clin Psychol 56: 251-60. 18. Mattick RP, Peters L, Clarke JC (1989) Exposure and cognitive restructuring for severe social phobia. Behavior Ther 20: 3-23. 19. Stravynski A, Marks 1, Yule W (1982) Social skill problems in neurotic outpatients: social skills training with and without cognitive modification. Arch Gen Psychiatry 39: 1378- 85. 20. Mersch PPA, Emmekamp PMG, Lips C (1991) Social phobia: individual response patterns and the long-term effects of behavioral and cognitive interventions. A follow-up study. Behav Res 7'her 29: 357-62.
21. Wlazlo Z, Schroeder-Hartwig K, Hand I et a1 (1990) Exposure in vivo vs social skills training for social phobia: long-term outcome and differential effects. Behav Res Ther 28: 181-93. 22. Scholing A, Emmelkamp PMG (1993) Cognitive and behavioral treatment of fear of blushing, sweating or trembling. Behav Res Ther 31: 155- 70. 23. Scholing A, Emmelkamp PMG (1993) Exposure with and without cognitive therapy for generalized social phobia: effects of individual and group treatment. Behav Res Ther 31: 667-81. 24. Turner SM, Beidel DC, Cooley MR et a1 (1994). A multicomponent behavioral treatment for social phobia: social effectiveness therapy. Behav Res Ther 32: 381-90. 25. Turner SM, Beidel DC, Cooley-Quille MR (1995) Two-year follow-up of social phobia treated with social effectiveness therapy. Behav Res Ther 33: 553-5. 26. Davidson JRT, Ford SM, Smith RD et a1 (1991) Long-term treatment of social phobia with clonazepam. J Clin Psychiatry 52: 16-20. 27. Katzelnick DJ, Kobak KA, Greist JH et a1 (1995) Sertraline in social phobia: a double-blind, placebo-controlled crossover study. Am J Psychiatry 152: 1368-71. 28. Stein MB, Chartier MJ, Kroft CDL et a1 (1994) Social phobia pharmacotherapy with paroxetine: open-label treatment and double-blind placebo-substitution studies. Presented at 33rd ACNP Congress, Puerto Rico, 1994. 29. Versiani M, Nardi AE, Mundin FD et a1 (1992) Pharmacotherapy in social phobia: a controlled study with moclobemide and phenelzine. Br J Psychiatry 161: 353-60. 30. Van Vliet IM, den Boer JA, Westenberg HGM (1992) Psychopharmacological treatment of social phobia: clinical and biochemical effects of brofaromine, selective MA0 inhibitors. Eur Neuropharmacol 2: 21 - 9. 31. Nutt D, Montgomery SA (1996) Maclobemide in the treatment of social phobia. Int Clin Psychopharmacol 11: 77-82. 32. Versiani M, Nardi AE, Mundin FD et a1 (1996). The long-term treatment of social phobia with moclobemide. Int Clin Psychopharmacol 11: 83-8. 33. Schneier FR, Goetz D, Campeas R et a1 (1998) Placebocontrolled trial of moclobemide in social phobia. Br J Psychiatry 172: 70-77. 34. Falloon IR, Lloyd GG, Harpin RE (1981) The treatment of social phobia: real-life rehearsal with nonprofessional therapists. J Nerv Ment Dis 169: 180-4. 35. Gelemter CS, Uhde TW, Cimbolic P et a1 (1991) Cognitivebehavioral and pharmacological treatment of social phobia. Arch Gen Psychiatry 48: 938-45. 36. Clark DB, Agras WS (1991) The assessment and treatment of performance anxiety in musicians. Am J Psychiatry 148: 598605. 37. Heimberg RG, Dodge CS, Hope DA et a1 (1990) Cognitive behavioral treatment for social phobia: comparison to a credible placebo control. C o p Ther Res 14: 1- 23. 38. Boerner RJ, MBller HJ (1998) Depression and anxiety disorders - epidemiology, theoretical concepts and therapy potentials in cases of comorbidity. Int J Psychiatry Clin Prac 2: (in press).
International Journal of Psychiatry in Clinical Practice 1998 Volume 2 Pages 107-113
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Therapeutic strategies for patients with social phobia RJ BOERNER AND HJ MOLLER
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Psychiatric Hospital and Outpatient Clinic of the University of Munich
Correspondence Address Dr.Dr.med. Dip1.-Psych. R.J. Boerner, Psychiatrische Klinik und Poliklinik der Ludwig-Muximilans-Universitat Munchen, Nussbaumstr. 7, D-80336 Munich, Germany Tel: +49 89 5160 3370 3355 Far: +49 89 5160 4548
Social phobia is a serious condition in the range of anxiety disorders which, until quite recently, has not been given due attention in research. In this paper we compare existing studies and follow-up results of behaviour therapy and phamacotherapy. We have endeavoured to work out an effective therapy for this serious condition. Apart from psychological education as a basic therapeutic element, the use of effective drugs promises to yieZd good results, especially in conjunction with behaviour therapy, including training in social skills, cognitive therapy and exposure therapy. Whicheverform of treatment is chosen depends on the patient’s preference and the availability of services. I f the patient does not respond, the possible causes should be examined thoroughly and new types of treatment considered. A combination of behaviour and drug treatments might be provided for special groups. (Int J Psych Clin Pruct 1997; 2: 107-113)
Received 23 July 1997; accepted for publication 23 December 1997
INTRODUCTION ocial phobia a common anxiety disorder whose S clinical and therapeutic significance has only recently received appropriate The life-time prevalence is
varies between 2%’ and 13.3%; depending on the criteria selected. On account of the multitude of symptoms and the varying severity of this disorder, a distinction is made between a generalized subtype and a specific subtype, the generalized subtype being characterised by more pervasive anxiety and distress and more severe symptoms.’ The disorder characteristically has an early onset, and a chronic course’. Another typical feature is the high prevalence of lifetime comorbidity with other psychiatric disorders. Judd6 testifies to a lifetime coexistence with simple phobia (59%), agoraphobia (45%), major depression (17%), dysthymia (12%), alcohol dependency ( 19%)and drug dependency (13%). Patients with comorbid social phobia are more susceptible to suicidal ideas and suicide attempts.’ Furthermore, patients with social phobia experience considerable impediments in various social areas such as education, employment and occupational opportunities. Although their intelligence and proficiency may be of a high standard, they are less likely to receive adequate
training, limiting the chances of suitable employment and advancement, and increasing 10neliness.~~~ The efficacy of various behaviour therapies such as selfassertiveness training, cognitive therapy and exposure therapy has been established and these are now recognized as standard services.’ Various pharmacological approaches have also been shown to be beneficial, especially the introduction of moclobemide and SSRIS.~-’’ According to Bassler,” short-term and focal therapy for up to 30 hours, medium-term analytical psychotherapy of between 30 and 120 hours, and long-term psychoanalytical therapy are all used to treat social anxieties. Unfortunately, no statements regarding specific disturbances can be made as no studies were performed in people meeting DSM or ICD criteria. To date, only individual case histories and condensed case reports are available. Further intensive research will have to be carried out on this disorder. Case reports. are not satisfactory for clinical and practical purposes, as pertinent queries concerning therapeutic approaches have not been discussed sufficiently. More information is required with regard to the use of behaviour therapy plus cocomitant medication: the duration of such a treatment, the efficacy and availability of facilities, and the procedure for comorbid patients, as well as therapeutic alternatives for patients who do not respond. We present a critical survey of important studies in the
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fields of behaviour therapy and pharmacotherapy; a rationale for a diversified treatment will be discussed and evaluated. We include studies whose results allow an evidence-based statement to be made about the long-term effects of various therapeutic procedures.’
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BEHAVIOURAL APPROACHES Heimberg et a12313 compared 49 patients having group cognitive behaviour therapy, including cognitive restructuring and self-exposure as well as cognitive restructuring as homework. Twelve sessions were held, of 2 hours each, with the emphasis on psychoeducational principles. On completion of the study, no real differences in the effectiveness of the treatment approaches could be shown; in the 6-month follow-up examination the patients given cognitive behaviour therapy were superior to control subjects in nearly all variables. At the 5-year follow-up, there was no difference in 19 patients although, clinically, the behaviour therapy group had fewer noticeable symptoms than their counterparts and a lower impairment of routine activities. Newman et all4 examined 36 patients undergoing exposure therapy, either in a group or individually, compared with a control group on the waiting list. Both treatment approaches led to adverse changes in the patients’ cognition although this was not actually intended as a therapeutic management policy. From this study it can be concluded that behaviour therapy-irrespective of the original method selected-produces marked changes in the patient’s behaviour and awareness. The efficacy of behavour therapy approaches may depend on variables other than the duration of frequency of treatment. Butler et all5 compared the effectiveness of exposure and anxiety management in 45 patients subjected to a socalled ‘associative therapy’, as against a waiting group given seven one-hour therapy sessions. At the end of the therapy, and at the 6-month follow-up, two ‘booster sessions’ were conducted, which showed no difference between the efficacy of these treatments. Emmelkamp et all6 observed in-vivo exposure in 34 patients who were treated on a rational-emotive principle and who received six group sessions of self-instruction training. As a whole, the differences in efficacy were not appreciable and were difficult to interpret. Mattick et aP7>’*carried out the most comprehensive and best-controlled studies, using a cognitive-behavioural treatment pattern. In one of their studies,’* involving 51 patients, they utilised four treatments, namely guided exposure, cognitive restructuring, cognitive restructuring combined with rational - emotive therapy, and guided exposure combined with cognitive restructuring. There was also a waiting-list group for comparison. The therapy was conducted in six group sessions of 120 minutes each, followed by an examination 3 months later. The results were not conclusive, but, conservatively interpreted, it can
be said that all treatments produced a significant improvement in behaviour. Mattick and Peters17set out their findings of a follow-up study in which 51 patients of the control group on the waiting list were offered a treatment consisting of guided exposure with or without cognitive restructuring. This was also carried out in groups, with 2 hours of therapy per week over a period of 6 weeks. At the end of treatment, the group which had received the combination of therapies was found, on external ratings, to be only slightly better than the group which had received exposure therapy only, and patients’ self-ratings showed no difference at all. In the 3month follow-up, 48% of the ‘exposure’ patients still showed definite ‘evasive’ behaviour, in contrast to 14%of the combination group; and 47% .of the exposure-only patients were in need of additional treatment, whereas 24% of the combination group were in need of further treatment. The efficacy of ‘social skills training’ (SST) was shown in a study by Stravynski et all9 who examined 22 patients. Their therapy comprised 12 individual sessions of 95 minutes each. At the 6-months follow-up, no difference in efficacy was found as compared with patients who had participated in an additional cognitive training project. Mersch et a120 investigated social skills training augmented by additional homework training in 74 patients, and compared the results with another group receiving rational- emotive therapy in 2-hourly sessions. At the end of the study, no substantial difference in efficacy between these two groups was found. In the 2-year follow-up, 44% of .57 patients required further treatment for social phobia, 38% showed an improvement in behaviour, and 28%of the patients relapsed. In a study by Wlazlo et al’l the long-term effectiveness of the following therapy approaches were compared: specific exposure in vivo, either as a group or individually, and social skills training. The duration of treatment was similar (34 versus 37.5 hours); the social skills training was carried out in groups of 6-8 persons twice a week, involving a total of 25 half-hour sessions over a period of 3 months. Of the 167 patients with social phobia, originally diagnosed according to DSM-111 criteria, 20 rejected treatment; 14 dropped out. Thirty patients were excluded from the analysis because of severe comorbidity. Of the remaining 103 patients (62%), 78 were given follow-up examinations after 1 to 5.5 years (average 2.5 years). All three treatments resulted in a clinical and statistically significant improvement in social competence and social anxiety decreased. Scholing and Emmelkamp,22~23 in their studies of 30 and 73 patients respectively, could not find any significant differences in efficacy between exposure therapy and cognitive therapy, either at the time when the treatment was finished or at the 3-month follow-up. In the authors’ main study,” 89 patients were originally found eligible, but 16 refused to be included; 25% of the ‘completers’and 36% of the ‘drop-outs’ were given regular concomitant medica-
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Therapeutic strategies for social phobia
tion, mostly benzodiazepines or beta-blockers. The therapy was carried out by advanced students of clinical psychology, who had received an intensive training lasting up to 100 hours. At the 3-month follow-up, 11 patients needed further attention, and at the 12-month follow-up, 16 patients (27%). Four out of the 14 patients who dropped out gave as their reason, the lack of clinical improvement. The records suggested that the drop-outs had more severe symptoms than the completers. Turner et a124treated 17 patients whose improvement they ascribed to the social effectiveness therapy developed by them. The average age of onset was 13 years, the mean duration of the disorder was 23 years. One-third of the patients also suffered from generalized anxiety or dysthymia; ten patients (58.8%) also had either an evasive personality disorder and/or an obsessive-compulsive neurosis diagnosed by means of the SCID interview; four patients withdrew from the study, leaving only 13 to be examined. When the therapy was finished, eight patients (67%) could be classified as moderately improved and two (17%) as substantially improved. The same authors then initiated a 2-year follow-up study.25 Unfortunately, only eight out of the 13 patients could be contacted, and interviewed by telephone. Those patients whose behaviour had improved during intensive treatment remained stable afterwards. A marked improvement could be seen in terms of self-esteem, severity of symptoms and reduction in generalized anxiety. In summary, the findings of these studies of behaviour therapy give some evidence of the efficacy of social skills training, exposure therapy and cognitive intervention. There are no indications of any specific differences between the therapeutic effectiveness of these methods. Different clinical paths are available for treating patients with social phobia, and whichever seems to be the most fitting can be selected. The study suggests that the duration of treatment required to achieve the desired results is limited to about 40 hours. Though behaviour therapy for social phobics is obviously easy to learn, it requires enormous practice and empathy with the patient to achieve a satisfactory relationship and successful treatment. However, it is wise not to have too high an expectation of the effectiveness of behaviour therapy and the indication for it. The number of cases treated has been decidedly small; and, in particular, comparative studies of different types of treatment have too few participants in the groups to enable guidelines to be established. Another questionable point is the mode of recruitment. It makes a great difference whether patients are assembled through a newspaper advertisement or whether they seek contact of their own accord because they wish to be treated. Even though in most of the studies the DSM-I11 or DSM-IIIR criteria were adhered to, it is perhaps doubtful whether the patients were genuinely ‘disturbed in the clinical sense, or whether they merely stated they suffered from increased
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social fears or social incompetence. Furthermore; there are no details available on the efficacy of behaviour therapy in comorbid patients. The patients in Wlazlo’s study” were excluded from the review, and in Turner’s studyz4 the numbers of comorbid patients were too low to be generalisable to wider practice.
PHARMACOLOGICAL APPROACHES Reviews conducted by Den Boer et allo and by Boerner and Mdllerg have confirmed the efficacy of various compounds, especially reversible and irreversible MA0 inhibitors, but also certain benzodiazepines and selective serotonin reuptake inhibitors (SSRIs). Among the high potency benzodiazepines, clonazepam has been extensively researched. Of the 75 patients examined by Davidson et a1,26 42% showed a marked improvement with ‘acute’ therapy, and another 42% were rated as improved. However, no details are recorded about the results of the follow-up examination after stopping the drug.
SSRls As far as SSRIs are concerned, hardly any results of placebocontrolled studies have been published. In a double-blind, placebo-controlled cross-over study undertaken by Katzelnick et al?’ involving 12 patients, sertraline proved effective in 52% of patients, as against 9% of the patients given placebo. Stein et a128have shown that paroxetine is also effective in the treatment of social phobia. A 12-week study demonstrated that paroxetine was better than placebo from week 2 (Figure 1). Patients on paroxetine achieved better CGI scores (very much improved, much improved) than patients on placebo (Figure 2). The large number of patients (91) in this study is relevant. Thus, paroxetine or other SSRI can be seen as a possible treatment with good results in the short term.
Paroxetine social phobia study (382) LSAS total score (change from baseline; ITT sample; LOCF dataset) Weeks 0 1 2 3 4 5 6 7 8 9 101112
..-- --
i.
--
* - - - _*_- - - - - -
Paroxetine
- - - _ _* _
-40 Baseline scores: paroxtine 78; placebo 83
*p10.01 Figure 1 Patients treated with paroxetine showed improved CCI levels compared with the placebo group; reproducedfrom Stein et a1 (1994)28
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Paroxetine social phobia study (382)
CGI global improvement (In sample; LOCF dataset)
CGI Very much improved 1 I Much improved
2
1
I
J
Minimally improved 3
1
No change Minimallv worse Much worse Very much worse
4
W Paroxetine (n=91)
7
I
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0
I
10
I
I
20 30 Patients (%)
I
1
40
50
Figure 2 [Reproduced from Stein et al (1994)”; see also Figure 21
MA0 INHIBITORS Conversely, evidence as to the therapeutic benefits of MA0 inhibitors is more abundant. In a study with 78 patients, Versiani et alZ9compared phenelzine at a dosage of 3090 mg/day, moclobemide at 200- 600 mg/day and placebo. After 16 weeks, using a ‘combined efficacy’ measuring system, it was found that 91% of the patients had improved with phenelzine, 82% with moclobemide and 43% with placebo. After week 16, 50% of the responders were switched to placebo, which promptly resulted in a relapse; the other 50% of patients who continued with active treatment showed no recurring symptoms. Brofaromine, a reversible MA0 inhibitor, was evaluated by Van Vliet et a130 in a placebo-controlled study involving 30 patients. In week 8, a major difference in efficacy was shown in favour of brofaromine; at the end of the study (week 12) 73% of brofaromine-treated patients had responded whereas the response to placebo was zero. In subsequent trials over another 12 weeks of treatment, brofaramine continued to be proved superior to placebo. Comprehensive research has been made into the efficacy of the reversible MA0 inhibitor, moclobemide.11v31 Nutt and Montgome$’ reported the findings of a study of 578 patients in which 300 - 600 mg/day moclobemide was administered over 12 weeks, and compared to placebo. The average duration of the patients’ disorder was 16.5 years; 70% reported that their social life had deteriorated, and only 50% were fully employed at the time of entering the study. Thirteen percent exhibited generalized anxiety and 49% an ‘evasive personality disorder’.” After 12 weeks, 21% of the patients treated with 600 mg/ day and 12%of those treated with 300 mg/day were found to have improved satisfactorily (CGI=l), as compared with only 7% who had been given placebo. Patients treated with 600 mg/day showed a more significant improvement on the Liebowitz-scale(0.09%);than those treated with 300 mg/day
(0.05%). Moclobemide was particularly effective in the severe and extreme forms of social phobia, with a response rate of 52% (as against 37%) responding to 300 mg/day; only 30%responded to placebo. In patients with mild to moderate Symptoms, the differences were less pronounced: under 600 mg/day, 45% responded, under 300 mg/day 42%, and under placebo 35%. This study also indicates that the response rate of patients with medium- to long-term social phobia was higher with 600 mg/day (52%) than with 300 mg/day (39%) or placebo (28%). Moclobemide was well tolerated by all but 9%of the patients; these discontinued the study on account of the adverse effects, approximately the same rate as for patients allocated to placebo. Of special interest is the long-term study of Versiani et al.32 Their patients had been receiving moclobemide for 2 years (phase l), before medication was suspended for 2 -4 months. Relapsing patients continued to be treated with moclobemide for another 2 years. Of the original 101 patients included in the study, 58.4% completed the first phase, 59.2% of these being responders. After the suspension phase, the responder rate dropped to 8.1%, but the relapse rate was 96.1%. This group of patients was again treated with moclobemide. After 6 months, the responder rate was now 45.5%. The author’s interpretation of the high rate of relapsers is that social phobia must be regarded as a chronic condition requiring long-term pharmacological treatment. In addition, special mention is made of the high degree of comorbidity, including dysthymia (21%), generalized anxiety (26%), previous major depression (13%), alcohol abuse (32%), dependent personality (16%), and evasive personality disorder (72%) which may, however, reduce the pharmacologic efficacy. Schneir et alj3 found, in an 8-week trial, an extremely low response rate (17.5%) for the moclobemide group (maximum 400 mg/day) and 13.5% for placebo-the difference was not significant. Only for 2 of 10 primary outcome measures and 9 of 20 scondary measures does there exist significant group differences. Some limitations in this study were discussed: the dosage, which could be too low, the possibility of a treatment refractory sample and the short duration of the study. The authors argue that it could be possible that moclobemide is not a highly efficacious treatment for social phobia.
COMPARATIVE STUDIES: BEHAVIOUR THERAPY AND PHARMACOTHERAPY At present, there have been four studies comparing behaviour therapy treatment, pharmacological treatment, or combination treatment. Falloon et aP4 examined 16 patients who attended social skills training (SST) in combination with either propanolol or placebo. The SST took place in two 6-hour
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Therapeutic strategies for social phobia
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POSSIBLE DIFFERENTIAL STRATEGIES groups. After completion, no difference between those who had received the medication and those who had received OF TREATMENT placebo could be shown; in the 6-month follow-up study an When considering the treatment of social phobia, the most improvement was seen in both groups. important thing is how best to alleviate the patient’s Gelernter et al,35 in a study involving 65 patients with condition; we need to know which therapies’ effectiveness social phobia over 12 weeks, used four treatment methods: have been proved beyond doubt. In addition, therapists cognitive behaviour therapy, phenelzine, alprazolam and placebo; in each case the patient was instructed about ‘self- should also consider multimodal theories and therapeutic concepts which imply that social phobia has multiple exposure’. Each patient was seen once a week. At the end of causes. the study, 69% had improved with phenekine, 38% with Evaluation of studies of behaviour therapy as compared alprazolam, 24% under cognitive therapy and 20% under with pharmacotherapy, and the short-term and long-term placebo. At the 2-month follow-up, the response with effects, show that behaviour therapy is apparently more phenelzine was significantly higher than with placebo, whereas the alprazolam group had only one relapsing successful. The number of surveys of behaviour therapy for this disorder is much greater than that of reviews of patient. Unfortunately, the authors gave no information on pharmacological treatment, taking into account follow-up the cognitive therapy group. In one of four therapy groups, Clark and A g r a ~ ~data ~ showing that with behaviour therapy the patient’s condition remains stable for a long time. examined the effects of several forms of therapy on 34 On the one hand, many studies of behaviour therapy musicians with social phobia: cognitive behaviour therapy show a statistically significant improvement; on the other plus placebo, cognitive behaviour therapy plus buspirone, hand, many studies give no details about the extent of buspirone alone and placebo alone. Buspirone (50-60 mgl rehabilitation or whether complete and permanent day) plus placebo were given in a double-blind design over recovery, or at least a partial remission, had been 6 weeks. Both cognitive therapy groups were treated in five individual sessions per week. After one month, the follow- achieved. To answer this question, statistically significant up study showed a great improvement in the level of social results relating to before-and-after comparisons with functions: 83% of the patients with cognitive behaviour placebo would be most useful. In their investigations, therapy plus placebo, 50% with cognitive behaviour Mattick and peter^""^ specifically refer to non-responders and point out that some 47% of the patients, intensively therapy plus buspirone, 50% with buspirone alone, but and successfully treated by behaviour therapy, still require zero under placebo. In the study by Turner et a12472 sufferers from social treatment, even during the short interval between treatment and follow-up. phobia were given treatment with assisted exposure Moreover, attention must be drawn to certain selection training, atenolol or placebo. The groups given atenolol criteria for these studies, and the exclusion of very and placebo were treated over 3 months; they were complicated cases, as well as the drop-out rates. Since examined twice a week during the first month, and some of the studies do not specify any particular method of thereafter once a week, for a total of 16 appointments. The recruitment, it is likely that some patients incorporated into exposure group was checked twice a week during the first 2 the investigation were not ill patients, but rather months and once a week thereafter, a total of 20 sessions. individuals with low self-assertiveness. In addition, 31% of the patients had an additional Axis-I On the grounds of the relatively small numbers, it also disorder (generalized anxiety or dysthymia), and 35% an remains unclear which of the elements in behaviour Axis41 disorder (evasive personality or compulsive distherapy should be given priority. At the present time, turbance). exposure training, cognitive training and self-assertiveness Measured by means of a specially designed improvetraining seem to be equally effective. ment index, 89% of the exposure patients could be classed It must also be emphasized that therapist competence is as significantly improved, versus 27% under atenolol and very important, which is why therapists receive extensive 44% under placebo. In the 6-month follow-up those training of up to 100 hours before meeting patients. patients who had already improved during treatment, were Although certain qualifications are required of therapists found to have sustained their improvement. for social phobia, the additional need for experience and Critically viewed, the individual test groups do not specialist training may make the overall care of patients include enough patients, so the results must be regarded suffering from this epidemiologically severe disorder with reservations. This subject needs to be further extremely expensive. researched before definite statements can be made as to Behaviour therapy cannot therefore be recommended the superiority or inferiority of certain modes of treatment unreservedly as the only therapy, or as the treatment of first or concomitant effects of certain pharmaceutical drugs choice. With reference to drug treatment, a variety of taken concurrently with psychotherapeutic procedures. classes, for example the recently marketed M A 0 inhibitors The drugs mainly tested were buspirone, alprazolam and such as moclobemide, have been found to produce good to atenolol, whose efficacy in social phobia could not be excellent response rates in acute treatment. The findings of conclusively or adequately confirmed.
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Table 1 Phased programme for the treatment of social phobia
the few long-term follow-up studies, however, are rather disappointing; for instance, the paper by Versiani et a13’ simply shows the results of a somewhat unsuitably selected random test with moclobemide. Pharmacological treatment is a convincing alternative not only for patients who do not favour behaviour therapy, but also for patients who need acute treatment. Since no studies on differential indications have yet been published, an individual decision must be made in favour of one or the other alternative. The good, longlasting response to behaviour therapy-if available-within a short period of time is strongly in its favour, whereas the prompt availability and quick action of pharmaceutical drugs endorse the use of medication. Independent of any ideological treatment preferences, the decisive factors should be patient-orientated and based on clinical experience. A phased therapy programme has been developed, as shown in Table 1. Psychoeducation can be looked upon as an essential component of therapy, informing the patient about the characteristics of socal phobia, its possible origin and the most encouraging behavioural approaches such as exposure therapy. From the economy and efficiency aspects, too, psychoeducation should be a basic concept of any therapy, as cited in the study by Heimberg et al?’ who claim that psychoeducation is as good as cognitive behaviour therapy. Whether or not treatment is effective, depends largely on the severity of the disorder, and whether or not the patients has comorbid problems. However, it is likely that after 12 weeks of therapy, the patient will have responded and reached a stage of improvement at least 50% of that expected. But if, after this period, the patient’s condition has not improved sufficiently and if no obvious causes for a failure to respond (such as non-compliance, lack of qualification of the therapist, etc) can be seen, then the therapy should be changed over to medication followed by
behaviour therapy, or vice versa. The possible additive or negative effects of the combination of behaviour therapy plus pharmacotherapy have not yet been adequately researched. Such a combination seems to be plausible, if the patient has been informed about the disorder and its treatment. At the present time, such combined therapy should only be given to particular patients: individuals who do not respond adequately to the sequential management of medication and/or behaviour therapy, or individuals who are so badly affected by the disorder and/or comorbidity that neither medication nor behaviour therapy alone would produce an appreciable improvement. Only a very few of the authors mentioned above concern themselves with comorbid social phobia; most discuss only social phobia as a separate disorder. To just* the successful psychoanalytical treatment of social phobia, Bassler” stresses that continued patient care by the same therapist is of vital importance and should be integrated into the therapy programme along with other specific elements of behaviour therapy. These include exposure instruction, familiarizing the patient with the psychophysiological models of anxiety and training in recognising ‘catastrophic’ conditions. Combining this treatment concept with pharmacotherapy may be particularly relevant if the patient’s behaviour is chronically evasive, and extreme symptoms of social anxiety are manifested. For social phobics suffering from major depression, treatment with antidepressants is indicated in any case, since these substances have been proved to be of great therapeutic value in both the disorders?’ Not until there is a reduction of depressive symptoms, together with a lowering of anxiety, can any improvement be expected from the implementation of behaviour therapy strategies and social skills training. It is to be hoped that in future therapeutic studies and systematic clinical experience will be utilized to develop specific forms of treatment, to enable such patients to be treated more widely and effectively.
Therapeutic strategies for social phobia
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