Aims of treatment
The aims of treatment are symptom reduction and improved function. Elimination of all anxiety is unlikely (and unnecessary), and the therapist has a role in helping the patient to set realistic goals for therapy. Psychological and pharmacological treatments are available for social phobia. The treatments for which there is most evidence of efficacy are cognitive and exposure-based treatments, social skills training packages, antidepressant medication and benzodiazepine anxiolytics. In general, outcome is related to severity of symptoms at pretreatment.
Psychological Treatments for Social Phobia
Pharmacological Treatments of Social Phobia
There remain few controlled trials comparing psychological and pharmacological therapies in the treatment of social phobia. All patients showed significant improvements in self-report measures of fear, avoidance and disability in a study where the active treatments of phenelzine, alprazolam or cognitive behavioral group therapy were no more effective than a placebo given with instructions for self-exposure (drug treatment groups were also given self-exposure instructions).
Subjects who completed cognitive behavioral group therapy, with or without buspirone, had a greater reduction in subjective anxiety during musical performance and a greater improvement in quality of performance than those treated with buspirone or placebo alone in a study of musicians with performance anxiety (92 of 99 subjects met criteria for DSM-III-R social phobia, discrete subtype). A comparison of cognitive behavioral group therapy versus clonazepam (up to 4 mg per day) with encouragement to engage in new social interactions revealed no significant posttreatment differences between treatment groups for any clinician- or patient rated variable using the last observation carried forward method.
Dropout rates of 25% for cognitive behavioral group therapy and 40% for clonazepam were reported as not significantly different. Both conditions showed improvement with effect sizes of 0.92 for cognitive behavioral group therapy and 0.99 for clonazepam. Cognitive behavioral group therapy and phenelzine were superior to placebo and an Education + Support control condition, with the phenelzine group showing an earlier improvement and superiority to cognitive behavioral group therapy on some measures. Effect sizes for phenelzine over placebo were of the order of 0.6 to 0.7 and for cognitive behavioral group therapy were more variable, ranging from 0.1 to 0.44.
Limited evidence suggests that individuals treated with both medication and cognitive behavioral therapy do no better than those treated with a single therapeutic modality, or may even do somewhat worse.
To date, studies of discontinuation of pharmacotherapy have resulted in high relapse rates, even, in one case, after active treatment had been administered for up to 2 years. The depression literature has shown that cognitive behavioral therapy results in a reduction in the frequency and severity of relapse. Future research in social phobia must be directed towards establishing whether treatment gains are maintained and whether maintenance of gains requires continued administration of the drug or could be improved with the addition of cognitive behavioral therapy.
The core elements of social phobia are now well defined. Successful treatments have been identified and include cognitive behavioral therapy, Monoamine oxidase inhibitors and selective serotonin re-uptake inhibitors. Functional outcome of cognitive behavioral therapy is related to pretreatment symptom severity. There is reasonable evidence that gains from cognitive behavioral therapy can be maintained in the medium term, with a need for more long-term studies. There is as yet no evidence that gains from drug treatment can be maintained once medication is withdrawn. The specific active ingredients of cognitive behavioral therapy programs remain largely unknown, and there remains a need for more dismantling studies.
In view of the long-term outcome, cognitive behavioral therapy is the treatment of choice for social phobia. When social phobia is complicated by conditions for which there are established and indicated drug treatments, these drugs should be used as appropriate. There is good evidence for reduction of reported levels of social anxiety and self-reported avoidance of nominated social situations after treatment with either antidepressant therapy or cognitive behavioral therapy. It has not been demonstrated that a reduction in measures of social anxiety equates with more functional social interaction in the real world.
The challenge for social phobia outcome research in the twenty-first century is to find and implement measures of functional outcome: how well do our treatments assist individuals to achieve their goals of social function in work, family and community social domains? There is also a need for more studies to assess the long-term outcome of treatment, and to maximize therapeutic effectiveness for the individual.
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