The Treatments of Social Phobia - Their Nature and Effects

10 The Treatments of Social Phobia:
Their Nature and Effects
If ‘‘epidemiological’’ studies are to be believed, estimated rates of
prevalence of social phobia at the present are generally lower than
those over the ‘‘lifetime.’’ Natural social processes (e.g. meeting an
enterprising admirer, a sympathetic but demanding teacher) leading
to remission would account for the difference. Little evidence of such
benign processes can be seen however in the lives of patients seeking
help, perhaps because these are for the most part little capable of taking
advantage of naturally occurring social opportunities. Social phobia
typically crystallizes as a pattern in the face of the increasingly insistent
social and interpersonal demands of adulthood made on adolescents,
and remains among the most chronic problems seen in the clinic
(see chapter 5). Help is often sought long after the onset of problems.
What of proven value can be offered such patients?
An attempt at the valuation of treatments of social phobia requires
establishing boundaries as to what claims to consider and which to
dismiss outright or ignore. What are the possibilities? One end of a
continuum of strictness might be defined as an indulgent approach
relying on the self-valuation of the proponents of various treatments.
The other end might be designated as a discerning approach demanding
relatively high quality of evidence. Immoderately, I shall opt for the
latter for it seems to me that the most meaningful answer will arise
from the careful selection of the best available studies, methodologically
speaking. This provides as much guarantee as can be had for the relative
soundness of the results, but not necessarily of the conclusions drawn
from them. These must be judged on their own merits.
Studies included in this review had to satisfy the following
requirements:
1. The sample had to admit only social phobic participants; in the inter-
est of clarity, mixed samples were excluded. As the onset of social

phobia is typically in late adolescence, all studies concern adult
patients.
289
2. Clinical status had to be determined by publicly recognized defining
criteria e.g. DSM-IV.
3. The assessment battery had to use multiple measures of outcome;
given that the psychometric characteristics of individual measures
often leave much to be desired, a convergence of outcome of all or
most measures enhances confidence in the validity of the results.
4. The study design had to involve more than one experimental
condition (and therefore random assignment of patients to them).
Consequently, this survey was limited to ‘‘controlled’’ studies that
contrast the experimental treatment with either a well-established
treatment of known outcome or an experimental condition that
simulates a treatment without offering its substance (e.g. ‘‘placebo’’).
Placebo (from the Latin placere, literally, I shall be pleasing) controls
are desirable because dealings between individuals recognized as
healers and cure-seeking sufferers are known to stimulate self-healing
and might therefore constitute a confound. Such simulation of treat-
ment, to have an effect, must be culturally sanctioned in the terms
of reference of the patient (see Moerman, 2002). Shamanic rituals
aiming to appease offended spirits (incantations, amulets, potions)
for example, would be meaningless to the western patient. This,
on the other hand, responds powerfully to medical authority and
hopefully to its healing rituals (establishing diagnosis, prescrib-
ing pills, performing surgery), embedded in a shared outlook
(‘‘science’’), construing the living organism as a machine and
inadequate functioning as its breakdown (in this case, of the brain
or the mind).
Three potential strands of outcome were considered:

1. Reduction in subjective distress in and avoidance of anxiety-evoking
situations; this was taken as the main measure of improvement
owing to its adoption as such by most studies. It is the natural
upshot of the commonly held view that social phobia is a ‘‘disorder’’
of social anxiety. This aspect of outcome will be summarized
throughout.
2. Improvement in social functioning (i.e. the manner in which
the patient participates in social life, assumes roles, and fits in;
see Beattie & Stevenson, 1984). Relatively few studies measured
this effect of treatment although impaired social functioning is
at the heart of social phobia and one of the defining criteria
in DSM-IV. Consequently, it will be summarized only when
available.
290 What Helps Social Phobic Individuals?
3. Improvement in clinical status (i.e. remission). As the best result
possible it sets an absolute standard. Improvements in social anxiety
and social functioning, by contrast, are relative to pretreatment levels.
Although ostensibly ‘‘significant’’ by statistical standards, such gains
might be modest from the point of view of the difference they make
to patients’ lives. Rates of remission will be reported only when
available.
Current Contents, Medline, and PsychInfo electronic databases
were systematically searched in order to increase the likelihood of
including all relevant publications. The selected studies broadly fell
into 3 categories of treatments: the purely psychological, the purely
pharmacological, and the combination or comparison of both.
Psychological Treatments
Two broad strategies have emerged in the psychological treatment
of social phobia: anxiety reduction and improvement in social
functioning.

Anxiety Reduction
Exposure and cognitive restructuring are the main tactics used within
the broad anxiety-reduction strategy.
In principle, exposure is the therapeutic application of the well-
demonstrated fact (Marks, 1987, pp. 457À494) that repeated and
prolonged exposure to the anxiety-evoking social setting results in
significant reduction in anxiety. It is arguably the methodical application
of the principle of habituation, documented in various studies
(e.g. Mauss, Wilhelm, & Gross, 2003). Exposure is particularly useful
when a strong tendency to avoid is manifest. Practically, a graded
hierarchy of increasingly difficult situations might be devised. Starting
at the lower end of the hierarchy, the patient will be induced to face up
to the feared situation (perhaps simulated) in the clinic and remain in
it until distress subsides. Later on (or immediately) exposure will be
extended to real-life situations among others by means of self-exposure
assignments to be performed in-between sessions.
In theory, cognitive restructuring (a generic term for different models of
cognitive modification) rests on the assumption that erroneous thinking,
fed by mistaken beliefs, generates social anxiety. The clinician practicing
this sort of therapy first identifies presumed systematic errors in
thinking (i.e. irrational inference drawing; e.g. exaggerating, ignoring
The Treatments 291
counter-evidence) as inferred from the narrative of the patient. Second,
in addition to these, putative underlying organizing broad beliefs
(‘‘schemas’’) expressing a whole outlook (e.g. being above reproach
guarantees safety), similarly inferred, are challenged. Between sessions,
patients are sent to confront anxiety-evoking encounters and asked to
identify their anxiety-generating thoughts as they arise and rebut them
using methods taught during sessions. Although cognitive restructuring
might be used as a technique in an otherwise behavioral treatment, it is

typically the organizing principle of a therapy relying on (exposure-like)
graduated social tasks, construed as experiments in putting patients’
assumptions to a test. Such a regimen is known as cognitive behavior
therapy (CBT).
The evaluation of anxiety reduction by means of either exposure
or cognitive restructuring as a general orientation to the treatment of
social phobia has generated most research. It is the natural outgrowth
of the construal of social phobia as a ‘‘disorder’’ of anxiety. Anxiety
in turn is conceived of intra-personally (i.e. as an enduring quality
of the individual generated from within; see chapter 3 for a detailed
discussion of the term). In addition to this primary effort, a good
proportion of the research attempted to gauge the relative effects of
exposure and cognitive restructuring. The backdrop to this line of
research is a theoretical clash between two rival outlooks: behaviorism
and cognitivism.
The design and outcome of the studies assessing exposure and
cognitive restructuring are displayed in Table 10.1.
Overall exposure and CBT are of value for both single- (usually
public-speaking) and multi-situation (generalized) social phobia,
yielding clinical improvement in distress and avoidance either in a
group or individual format. Statistically significant improvements from
pretreatment levels are achieved in between 8 to 12 sessions with up to
15% dropping out. These gains do not obtain in control conditions, and
tend to be maintained at 6À18 month follow-up, with one report of
gains maintained till 5À6 years follow-up.
Although it is widely assumed that reduced (presumably more
manageable) levels of social anxiety lead automatically to meaningfully
improved social functioning, there is little evidence to support this.
Better-focused research is needed to clarify this important point.
Conversely, the addition of social skills training to CBT enhanced

its effects in terms of anxiety reduction and improved social
functioning (Herbert, Gaudiano, Rheingold, Myers, Dalrymple, &
Nolan, 2005).
292 What Helps Social Phobic Individuals?
Table 10.1. Comparative outcome of psychological approaches À anxiety reduction
Study Treatment conditions
Outcome
Comments
Social
Avoidance
Subjective
Distress
Social
Functioning Follow-up
Exposure alone vs. waiting list
Mattick et al.
(1989)
6 sessions  2 h Exposure improved
only at follow-up.
1. CR (G); n ¼ 11 (1 ¼ 2 ¼ 3) 4 4
2 not improved
(1 ¼ 2 ¼ 3) 4 4
2 not improved
____
2. EXP (G); n ¼ 11
3. EXP þ CR (G);
n ¼ 11
Improvement stable at
3 months for other
conditions.

4. WL; n ¼ 10
Scholing &
Emmelkamp
(1993a)
8 sessions  1h
(4 weeks)
1. EXP (I); n ¼ 10 1 ¼ 2 ¼ 3 ¼ 4
(all improved)
_____ _____
2. CR (I); n ¼ 10
3. EXP þ CR (I);
n ¼ 10
4. WL
Newman et al.
(1994)
8 sessions  2h Exposure superior on
some measures.
1. EXP (G); n ¼ 18 _____ 1 ¼ 2 _____ _____
2. WL; n ¼ 18 (no improvement)
Hope et al.
(1995a)
12 sessions  2 h Improvement stable at
6 months (1 ¼ 2).
Responders
1. EXP (G); n ¼ 11 1 ¼ 2 4 314 2, 3 _____ 1. 70%
2. EXP þ CR (G);
n ¼ 18
2. 36%
3. WL; n ¼ 11 3. 0%
1 ¼ 2 4 3

Table 10.1. (cont.)
Study Treatment conditions
Outcome
Comments
Social
Avoidance
Subjective
Distress
Social
Functioning Follow-up
Mersch (1995) 14 sessions  1h
1. EXP (I) (1 ¼ 2) 4 3 (1 ¼ 2) 4 3 (1 ¼ 2) 4 3 _____
2. CR H SST H EXP (I)
1 þ 2; n ¼ 17
3. WL; n ¼ 17
Salaberria &
Echeburua
(1998)
8 sessions  2.5 h
1. EXP (G); n ¼ 24 _____ (1 ¼ 2) 4 3 _____ _____
2. EXP þ CR (G);
n ¼ 24
3. WL; n ¼ 23
Cognitive restructuring alone vs. waiting list
Mattick et al.
(1989)
6 sessions  2h
1. CR (G); n ¼ 11 (1 ¼ 2 ¼ 3) 4 4 (1 ¼ 2 ¼ 3) 4 4 _____ _____
2. EXP (G); n ¼ 11 2 not improved 2 not improved
3. EXP þ CR (G);

n ¼ 11
4. WL; n ¼ 10
Scholing &
Emmelkamp
(1993a)
8 sessions  1h
(4 weeks)
1. EXP (I); n ¼ 10 1 ¼ 2 ¼ 3 ¼ 4 _____ _____ _____
2. CR (I); n ¼ 10 (all improved)
3. EXP þ CR (I);
n ¼ 10
4. WL
Taylor et al.
(1997)
8 sessions  1.5 h
1. CR (I); n ¼ 32 1 4 214 2 _____ _____
2. NSP (control) (I);
n ¼ 28
Cottraux et al.
(2000)
6 weeks Responders
1. CR (I) (8 Â 1 h);
n ¼ 31
1 4 21¼ 2 (?) _____ _____ 1. 14%
2. NSP (control) (I)
(3 Â 30 min); n ¼ 32
2. 7%
1 ¼ 2
Stangier et al.
(2003)

15 weeks Improvement stable
at 6 months.
Remitters
1. CR (G: 15 Â 2 h);
n ¼ 26
_____ 1 ¼ 2 4 3 _____ 1. 14%
2. CR (I: 15 Â 1 h);
n ¼ 24
Further significant
reductions for the
individual modality.
2. 50%
2 4 1
3. WL; n ¼ 21 Significant results
obtained only on one
of six measures.
Exposure vs. cognitive restructuring
Emmelkamp
et al. (1985)
6 sessions  2.5 h Improvement stable at
1 month.
Patients were on various
medications.
1. EXP (G) 1 ¼ 2 ¼ 31¼ 2 ¼ 3 _____
2. CR (self-
instruction
variant) (G)
3 not improved (all improved) Exposure showed
further improvement
on the avoidance and

anxiety measures.
3. CR (rational-
emotive variant)
(G)
n ¼ 38
Table 10.1. (cont.)
Study Treatment conditions
Outcome
Comments
Social
Avoidance
Subjective
Distress
Social
Functioning Follow-up
Mattick et al.
(1989)
6 sessions  2 h Exposure improved
only at follow-up.
1. CR (G); n ¼ 11 (1 ¼ 2 ¼ 3) 4 4(1 ¼ 2 ¼ 3) 4 4 _____
2. EXP (G); n ¼ 11 2 not improved 2 not improved Improvement stable at
3 months for other
conditions.
3. EXP þ CR (G);
n ¼ 11
4. WL; n ¼ 10
Scholing &
Emmelkamp
(1993a)
8 sessions  1h

(4 weeks)
____
1. EXP (I); n ¼ 10 1 ¼ 2 ¼ 3 ¼ 4 _____ _____
2. CR (I); n ¼ 10 (all improved)
3. EXP þ CR (I);
n ¼ 10
4. WL
Exposure vs. exposure combined with other ingredients
Butler et al.
(1984)
7 sessions  1 h At 6 months, a
significant difference
appeared on the
avoidance measure
(1 4 2)
Although anxiety
management made
some contribution to
outcome, it was not
meaningful
1. EXP þ AM (I);
n ¼ 15
1 ¼ 2 4 3 1 4 2 ¼ 3 1 ¼ 2 ¼ 3
3 not improved
2. EXP þ NSP
(control) (I);
n ¼ 15
3. WL; n ¼ 15
Mattick &
Peters

(1988)
6 sessions  2 h Improvement stable
at 3 months
The combined group
was superior to
exposure alone on
some measures of
avoidance
1. EXP (G); n ¼ 26 1 ¼ 2 (both
improved)
1 ¼ 2 (both
improved)
_____
2. EXP þ CR (G);
n ¼ 25
Mattick et al.
(1989)
6 sessions  2 h Exposure improved
only at follow-up
Improvement stable at
3 months for other
conditions
1. CR (G); n ¼ 11 (1 ¼ 2 ¼ 3) 4 4(1¼ 2 ¼ 3) 4 4 _____
2. EXP (G); n ¼ 11 2 not improved 2 not improved
3. EXP þ CR (G);
n ¼ 11
4. WL; n ¼ 10
Scholing &
Emmelkamp
(1993a)

8 sessions  1h
(4 weeks)
1. EXP (I); n ¼ 10 1 ¼ 2 ¼ 3 ¼ 4 _____ _____ _____
2. CR (I); n ¼ 10 (all improved)
3. EXP þ CR (I);
n ¼ 10
4. WL
Hope et al.
(1995a)
12 sessions  2 h Improvement stable
at 6 months
Responders
1. 70%
1. EXP (G); n ¼ 11
2. EXP þ CR (G);
n ¼ 18
1 ¼ 2 4 3 1 4 2, 3 _____
(1 ¼ 2) 2. 36%
3. 0%
3. WL; n ¼ 11 1 ¼ 2 4 3
Mersch (1995) 14 sessions  1 h Improvement stable at
18 months (1 ¼ 2)
Further improvement
on the avoidance
measure from
3 months
Avoidant personality
disorder patients
responded equally
well to all treatments,

but functioned less
well at 3 months
follow-up
1. EXP (I) (1 ¼ 2) 4 3(1 ¼ 2) 4 3(1 ¼ 2) 4 3
2. CR H SST H
EXP (I)
1 þ 2; n ¼ 17
3. WL; n ¼ 17
Table 10.1. (cont.)
Study Treatment conditions
Outcome
Comments
Social
Avoidance
Subjective
Distress
Social
Functioning Follow-up
Salaberria &
Echeburua
(1998)
8 sessions  2.5 h Improvement stable at
12 months
The distribution of a
self-help manual has
not contributed to
outcome
1. EXP (G); n ¼ 24 _____ (1 ¼ 2) 4 3 _____
2. EXP þ CR (G);
n ¼ 24

(1 ¼ 2)
Further improvement
for both groups
between post-test
and 6 months
follow-up
3. WL; n ¼ 23 Remitters
Post-test 1. 44%
2. 44%: (1 ¼ 2)
12 months 1. 66%
2. 61%: (1 ¼ 2)
Note: AM: Anxiety management; CR: Cognitive restructuring; EXP: Exposure in vivo; G: Group modality; I: Individual modality; NSP: Non specific
psychotherapy; SST: Social skills training; WL: Waiting list; þ: combined with; H: followed by; Highlighted areas ¼ treatments compared.
Clinically and practically, exposure, cognitive restructuring, and
their combination as CBT produced equivalent effects. Theoretically,
however, the fact that cognitive restructuring or therapy do not affect
cognitive processes more or differently than exposure is of greater
moment. This point is discussed in great detail in chapter 7.
Improving Social Functioning
Two approaches towards improving social functioning have been devel-
oped. Although often using rather similar methods of inducing behavior
change, the two differ radically in the manner of construing the content
of treatment.
The first À I shall name it structural À attempts to improve social
functioning somewhat indirectly, by means of correcting deficient
social skills or problems in the structure of the social behavior of
social phobic patients, deemed necessary for proper social function-
ing. The structural deficiencies could be located at the molecular
(e.g. averted gaze, poor timing) or molar (e.g. assertion) levels of
behavior.

Social anxiety might be regarded in such a theoretical framework as a
realistic recognition of inadequacy on the part of the patients foreseeing
failure in achieving their social aims.
The second approach by contrast, de-emphasizes the formal/struc-
tural aspects of the proper performance of social behavior. Instead,
it lays stress on the function of social behaviors or patterns of behavior.
Practically, it attempts to train the fearfully self-protective social phobic
patients to develop non-defensive interpersonal ways of dealing with
their real-life social circumstances, and to use them in situations very
much a part of their daily lives. The emphasis in therapy is on finding
ways of behaving that will enable patients, for example, better fitting in,
participating in various social activities, and enacting social roles within
the social context of their community. For instance, patients are trained
and encouraged to admit to being flustered or wrong, while making
requests, initiating contact, and being firm or in charge, or assuming
the role of an educator while presenting. Such a functional approach
takes the view that there are many ways of achieving social goals
(e.g. speaking in public or approaching a relative stranger) each poten-
tially useful. Setbacks are not necessarily fatal; another one better suited
for the circumstances can replace a behavior proven unsatisfactory.
Conversely, even a flawless execution of certain behaviors would not
have the intended effect under certain circumstances (e.g. when the
goals of the participants are not aligned).
The Treatments 299
Ultimately, this approach to therapy seeks to erode the overall pattern
of fearful self-protective and defensive tactics that constitute social
phobia and turning it around. Positively stated, that means enhancing
the participation of the individual in the social life of the commu-
nity of which he or she is a member in the pursuit of personal goals.
Such therapy construes social anxiety relationally, as arising from

the defensive interpersonal pattern of which it is a facet, evoked
by social transactions characterized by insufficiency of social power
(see chapter 3). In therapy, social anxiety is therefore likely to subside
hand in hand with the dissolution of a defensive overall pattern and the
gradual emergence of a participatory one, allowing the patient to pursue
desired social goals more effectively.
Whereas the structural approach tends towards a generic view of
social skills applicable to all, the functional approach views social
behavior as idiosyncratic and firmly embedded in a specific social
context. It attempts to devise appropriate behaviors for the achieve-
ment of specific social goals of definite individuals living in concrete
social circumstances, and relentlessly encourages them to put these
to use.
The structural approach uses social skills training to effect behavior
change in treatment. Conceptually, ‘‘social skills training’’ is com-
plementary to the notion of ‘‘social skills deficits’’ that it is meant
to redress. Practically, it is a sequence of behavior-change techniques
usually including modeling, role-play, and feedback, used during train-
ing and homework assignments to be carried out in-between sessions.
The functional approach might use a similar sequence of behav-
ior change techniques during training sessions. These however are nei-
ther conceptually nor practically necessary. The functional approach
yields similar results with or without modeling, role-play, and feedback
(Stravynski et al., 2000a). The practice of targeted behaviors between
sessions, however, is indispensable (Stravynski et al., 1989).
Such therapy approaches social phobia (in DSM terms) as a disorder
of personality and anxiety rolled in one. This follows the logic of
construing social anxiety interpersonally (see chapter 3) as having a
dual locus: self-protective interpersonal maneuvering in threatening
circumstances and a somatic state of alert in its support.

The treatment of social phobia envisaged as an improvement in social
functioning is a less common approach. The design and outcome of the
studies assessing the two variants of regimens seeking to improve social
functioning are described in Table 10.2.
Overall, improving-social-functioning approaches yielded results
superior to waiting lists. Moreover, a smaller number of studies
300 What Helps Social Phobic Individuals?
Table 10.2. Comparative outcome of psychological approaches À improving social functioning
Study Treatment conditions
Outcome
CommentsSocial Avoidance
Subjective
Distress
Social
Functioning Follow-up
Improvement in social functioning (functional) vs. waiting list
Stravynski et al.
(2000a)
12 sessions  2 h Improvement
stable at
12 months
Remitters
1. ISF (G); n ¼ 36 1 ¼ 2 4 31¼ 2 4 31¼ 2 4 3 Post-test 1. 25% 2. 32%
2. ISF þ SST (G);
n ¼ 32
3. WL Follow-up 1. 62% 2. 61%
Stravynski et al.
(2006)
12 sessions Improvement
stable at

12 months
Remitters
1. Discussion þ home-
work (G: 2 h); n ¼ 38
1 ¼ 2 ¼ 3 4 41¼ 2 ¼ 3 4 41¼ 2 ¼ 3 4 4 Post-test 1. 9% 2. 22%
3. 29%: 1 ¼ 2 ¼ 3
2. ISF þ SST þ homework
(G: 2 h); n ¼ 35
Follow-up 1. 43% 2. 52%
3. 67%: 1 ¼ 2 ¼ 3
3. Review/assign
homework (I: 20 min);
n ¼ 29
There was a significant
drop in the number of
patients still considered
socially phobic between
the end of treatment and
12 months follow-up for
all treatment conditions
4. WL
Table 10.2. (cont.)
Study Treatment conditions
Outcome
CommentsSocial Avoidance
Subjective
Distress
Social
Functioning Follow-up
Improvement in social functioning (structural) vs. anxiety reduction

Mersh et al.
(1989)
8 sessions  2.5 h
Mersch et al.
(1991)
1. CR (G); n ¼ 37 1 ¼ 2 (no
meaningful
improvement)
1 ¼ 2 (both
improved)
1 ¼ 2 (no
meaningful
improvement)
Improvement
stable at
14 months
(1 ¼ 2)
A match between type of
patient (e.g. cognitive or
behavioral responders)
and type of treatment
(e.g. CR or SST) did not
result in better outcome
2. SST (G); n ¼ 37
Wlazlo et al.
(1990)
1. SST (G); n ¼ 54: 37.5 h 1 ¼ 2 ¼ 3 (all
improved)
1 ¼ 2 ¼ 3 (all
improved)

_____ Improvement
stable at
3 months
No advantage in matching
types of problem (e.g.
phobic or deficit) and
corresponding treatment
(e.g. anxiety reduction or
SST). ‘‘Skill-deficient’’
patients did less well
2. EXP (I); n ¼ 41: 12 h
3. EXP (G); n ¼ 52: 34 h
Further
improvement
after 2.5 yr
(range 1À5.5
yr) on social
anxiety and
avoidance
Group and individual
exposure were equivalent
van
Dam-Baggen
& Kraimaat
(2000)
17 sessions  1.5 h Improvement
stable at
3 months
Social anxiety and social
skills scores of the SST

group at follow-up
reached the level of a
normal reference group;
this was not the case for
the CR participants
1. SST (G); n ¼ 24 1 4 214 2 _____
2. CR (G); n ¼ 24
Improvement in social functioning (functional) with or without other treatment modalities
Stravynski et al.
(1982b)
12 sessions  2 h Improvement
stable at
6 months
CR did not enhance SST;
only treated interper-
sonal behaviors changed.
1. ISF; (I: n ¼ 4)
(G: n ¼ 7)
1 ¼ 2 (both
improved)
1 ¼ 2 (both
improved)
1 ¼ 2 (both
improved)
2. ISF þ CR;
(I: n ¼ 4) (G: n ¼ 7)
Stravynski et al.
(2000a)
12 sessions  2 h Improvement
stable at

12 months
Remitters
1. ISF (G); n ¼ 36 1 ¼ 2 4 3 1 ¼ 2 4 3 1 ¼ 2 4 3 Post-test 1. 25% 2. 32%
2. ISF þ SST (G);
n ¼ 32
Follow-up 1. 62% 2. 61%
3. WL
Stravynski et al.
(2006)
12 sessions Remitters
1. Discussion þ home-
work (G: 2 h); n ¼ 38
1 ¼ 2 ¼ 3 4 4 1 ¼ 2 ¼ 3 4 4 1 ¼ 2 ¼ 3 4 4 Improvement
stable at
12 months
Post-test 1.9%2. 22%
3. 29%: 1 ¼ 2 ¼ 3
2. ISF þ SST þ home-
work (G: 2 h); n ¼ 35
Follow-up 1. 43% 2. 52%
3. 67%: 1 ¼ 2 ¼ 3
3. Review/assign homework
(I: 20 min); n ¼ 29
4. WL
Note: CR: Cognitive restructuring; EXP: Exposure in vivo; G: Group modality; I: Individual modality; ISF: Improving social functioning; SST: Social
skills training; WL: Waiting list; þ: combined with; Highlighted areas ¼ treatments compared.
has found this strategy to be as effective as exposure and cognitive
restructuring in reducing anxiety and avoidance with both specific and
generalized social phobia/avoidant personality disorder. In one study,
SST resulted in significantly better improvement (van Dam-Baggen

& Kraimaat, 2000). Three studies applying the functional variant
(Stravynski, Arbel, Chenier, Lachance, Lamontagne, Sidoun, &
Todorov, 2006; Stravynski et al., 1982b, 2000a) have shown such treat-
ment to lead to significant improvements in social functioning.
Outstandingly, Stravynski et al. (2000a) reported a remission rate of
60% in the patients who completed therapy at 1-year follow-up.
Equivalent results are reported in Stravynski et al. (2006).
Treatment was usually administered in small groups (5À7) and
tended to last 12À25 sessions for up to 37 hours. The efficiency
gained through group treatment was somewhat offset by a higher drop-
out rate (20À25%). Gains have been shown to maintain up to 2.5 years.
Psycho-Pharmacological Treatments
Whereas individuals devising psychological therapies are driven mostly
by theoretical concerns (and doubtless personal ambition), psycho-
pharmacological treatments have different origins altogether. These
need to be elucidated and put in proper context.
Practically, pharmacological treatments are made possible by the
availability of new compounds, created typically by the pharmaceutical
industry. Psychotropic compounds commonly have a broad impact on
the brain and, correspondingly, an exceedingly wide range of effects
(Janicak, 1999). None of the effects are self-evidently therapeutic;
these need to be singled out with a certain potential application in
mind. In consequence of such choices, some of the effects become
desirable; many others À although unwanted À occur all the same.
None is inherently primary or secondary.
It is a commercial decision, made by marketing departments, that
creates a new drug as ‘‘an antidepressant rather than an anxiolytic or
a treatment for premature ejaculation’’ (Healy & Thase, 2003, p. 388).
A similarly commercial decision designates a medication previously
established as an ‘‘anti-depressant’’ or as ‘‘anti-convulsant’’ as one that

will become ‘‘indicated’’ for social phobia. Furthermore, marketing
departments orchestrate and fund the many activities, not least clinical
trials, analysis and publication of the results, that create the necessary
evidence in support of a certain use of the drug (2003, p. 388). Equipped
with these considerations, we shall now turn to the studies themselves.
304 What Helps Social Phobic Individuals?
Overall, 4 different classes of pharmaceutical agents with different
molecular targets have been extensively evaluated for their anxiety-
reducing properties in the treatment of social phobia. These are:
1. Monoamine oxidase inhibitors (MAOI); these block the metabolism
of the catecholamines and serotonin through inactivation of their
catabolic enzyme, monoamine oxidase. A refinement within the
same class concerns the reversible inhibitors of monoamine oxidase
(RIMAs). Both target the catabolic enzyme; while the MAOIs bind
permanently, the RIMAs do so reversibly. Practically, this broadens
the restrictive diet required under the MAOIs. A typical use for this
type of medication (e.g. moclobemide) is for the treatment of
depression.
2. Selective serotonin reuptake inhibitors (SSRIs); these inhibit
the transport of serotonin back into the neuron where it is subse-
quently metabolized, thus increasing the synaptic concentration of
this neurotransmitter. Today this type of medication is considered
first-choice treatment for depression and most of the anxiety
disorders.
3. Other regulators of monoaminergic synaptic activity (e.g. buspirone).
This type of medication is used occasionally as an anxiolytic;
olanzapine however is primarily used as an anti-psychotic.
4. Suppressants of neural excitability that regulate gabaergic
transmission:
a. agonists of aminobutyric acid (GABA) receptors (e.g. benzo-

diazepines). This type of medication is commonly used for the
treatment of anxiety and insomnia.
b. stimulators of GABA release (e.g. gabapentin). This type of med-
ication is used as an anti-convulsant and more recently as a mood
stabilizer.
The design and outcome of the studies within each class of
medication are summarized in Table 10.3.
Overall, to date the above classes of psycho-pharmacological medica-
tions have been shown to yield effects that supersede placebo. All
the same, in 5 studies medication within these categories (the SSRI
fluoxetine, the RIMA moclobemide, the monoaminergic modulators À
buspirone, olanzapine and St John’s Wort) did not produce effects
that exceeded placebo.
Although not all possible comparisons have been performed, as can
be seen in Table 10.4, overall the various classes of medication appear to
result in similar outcomes, with phenelzine showing a slight advantage
The Treatments 305
over moclobemide and a significant superiority over the beta-blocker
atenolol.
Although the bulk of samples included generalized social phobic
patients, similar results also obtain with specific (i.e. usually public-
speaking) socially phobic patients. While the reduction of subjective
anxiety and the tendency to avoid was worthwhile, the medications
also induce adverse effects, the nature and the extent of which vary.
The main ones are typically selected in relevant publications by the
following combined standards: having been reported by at least
10% of the patients on medication, while simultaneously being at least
twice the rates reported by patients receiving placebo. The latter stan-
dard seems arbitrarily high and results in a narrowing of reported
adverse effects. However that may be, these are summarized in

Table 10.5. Related or not, the rates of patients on medication dropping
out of treatment varied between 0% to 74%.
As can be seen in Table 10.3, the response to the placebo pill
prescribed by authoritative figures (i.e. specialist physicians) operating
in an awe-inspiring medical setting À although varying in degree À is
powerful. In Stein, Pollack, Bystritsky, Kelsey, & Mangano (2005) for
example, 33% of the patients on placebo (vs. 58% on venlafaxine) were
considered improved or much improved. Moreover, 16% of patients
on placebo were in remission (vs. 31% of patients on medication)
after the end of treatment. Considering this, the effect of medication
is overvalued. If the net effect of a medication were to be estimated,
the placebo effect ought to be subtracted from the overall response.
The link between becoming less anxious and less handicapped and
being more and better socially active remains uncertain. Similarly,
no studies to date have systematically observed the relapse rate on and
after stopping medication. In an approximation, 36% of the patients
relapsed after 20 weeks of sertraline followed by placebo (Walker
et al., 2000).
Many social phobic patients respond powerfully to placebo; the rates
of much-improved patients on it vary from 0% to 66%.
Psychological Treatments Combined/Compared
with Psycho-pharmacology
As both psychological and pharmacological treatments have been
shown to be beneficial, some studies sought to compare them singly
or in combination. The design and outcome of these studies are
summarized in Table 10.6.
306 What Helps Social Phobic Individuals?