Cognitive Behavioural Therapies for Social Anxiety Disorder

96 Pages·2013·0.93 MB·English

Cognitive Behavioural Therapies for Social Anxiety Disorder
(SAnD) (Review)
y
McKenna IM, Hunot V, Bailey A, Parker AG, Churchill R
l
n
O

w
e
i
v
e
r
P

r
o
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
F
2013,Issue9
http://www.thecochranelibrary.com
CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review)
Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 3
y
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . .l. . . . . . . . . . . 6
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . .n. . . . . . . . . . . . 9
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure3. . . . . . . . . . . . . . . . . . . . . . . O. . . . . . . . . . . . . . . 15
Figure4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
w
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis1.1.Comparison1CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList,Outcome1Clinical
ResponseatPost-Treatment. . . . . . . . e. . . . . . . . . . . . . . . . . . . . . . 52
Analysis1.2. Comparison 1Cognitive Behavioural TherapiesversusTreatmentasUsual/Waiting List,Outcome2
ReductioninSocialAnxietySymptomsatPost-Treatment. . . . . . . . . . . . . . . . . . . 53
Analysis1.3.Comparison1CognitiveBehaviourialTherapiesversusTreatmentasUsual/WaitingList,Outcome3Attrition
atPost-Treatment. . . . . . . . v. . . . . . . . . . . . . . . . . . . . . . . . . 54
Analysis1.4. Comparison 1Cognitive Behavioural TherapiesversusTreatmentasUsual/Waiting List,Outcome4
ReductioninDepressionSymptomsatPost-Treatment. . . . . . . . . . . . . . . . . . . . 55
e
Analysis1.5.Comparison1CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList,Outcome5Clinical
GlobalImpressionImprovementScaleatPost-Treatment. . . . . . . . . . . . . . . . . . . . 56
Analysis1.6.Comparison1CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList,Outcome6Quality
r
ofLifeatPost-Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Analysis1.7. Comparison 1CPognitive Behavioural TherapiesversusTreatmentasUsual/Waiting List,Outcome7
ReductioninSocialAnxietySymptomsatFollow-Up. . . . . . . . . . . . . . . . . . . . . 58
Analysis1.8. Comparison 1Cognitive Behavioural TherapiesversusTreatmentasUsual/Waiting List,Outcome8
ReductioninDepressionSymptomsatFollow-Up. . . . . . . . . . . . . . . . . . . . . . 58

Analysis1.9.Comparison1CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList,Outcome9Quality
ofLifeatFollrow-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Analysis2.1.Comparison2CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalyses
o
(IndividualversusGroupTreatments),Outcome1ReductioninSocialAnxietySymptomsatPost-Treatment. 60
Analysis2.2.Comparison2CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalyses
(IndividualversusGroupTreatments),Outcome2AttritionatPost-Treatment. . . . . . . . . . . . 61
F
Analysis2.3.Comparison2CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalyses
(IndividualversusGroupTreatments),Outcome3ReductioninDepressionSymptomsatPost-Treatment. . . 62
Analysis3.1.Comparison3CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalyses
-SAnDDiagnosis(<80%GeneralisedSAnDversus>80%GeneralisedSAnDSamples),Outcome1Reductionin
SocialAnxietySymptomsatPost-Treatment. . . . . . . . . . . . . . . . . . . . . . . . 64
Analysis3.2.Comparison3CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalyses-
SAnDDiagnosis(<80%GeneralisedSAnDversus>80%GeneralisedSAnDSamples),Outcome2AttritionatPost-
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Analysis4.1.Comparison4CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalysis-
CommonMentalHealthComorbidity(<50%intheSampleversus>50%intheSample),Outcome1Attrition. 66
ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) i
Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
y
l
n
O

w
e
i
v
e
r
P

r
o
F
CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) ii
Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Cognitive Behavioural Therapies for Social Anxiety Disorder
(SAnD)
y
IanMMcKenna1,VivienHunot2,AlanBailey3,AlexandraGParker3,RachelChurchill2 l
n
1ClinicalPsychology,UniversityofExeter,Exeter,UK.2CentreforMentalHealth,AddictionandSuicideResearch,SchoolofSocial
andCommunityMedicine,UniversityofBristol,Bristol,UK.3CentreofExcellenceinYouthMentalHealth,OrygenYouthHealth
ResearchCentre,CentreforYouthMentalHealth,UniversityofMelbourne,MelbOourne,Australia
Contactaddress:IanMMcKenna,WashingtonSingerLaboratories,Psychology,CollegeofLifeandEnvironmentalSciences,University
ofExeter,Exeter,EX44QG,[email protected].

Editorialgroup:CochraneDepression,AnxietyandNeurosisGroup.
w
Publicationstatusanddate:New,publishedinIssue9,2013.
Reviewcontentassessedasup-to-date: .
Citation: McKennaIM,HunotV,BaileyA,ParkerAG,CheurchillR.CognitiveBehaviouralTherapiesforSocialAnxietyDisorder
(SAnD).CochraneDatabaseofSystematicReviews2013,Issue9.Art.No.:CDXXXXXX.DOI:10.1002/14651858.CDXXXXXX.
Copyright©2013TheCochraneCollaboration.PubilishedbyJohnWiley&Sons,Ltd.
v
e ABSTRACT
Background
r
Social anxiety disorder (SAnD)isahighlyprevalentcondition, characterisedby anintense fear of social or performancesituations
whereindividualsworryaboutbeinPgnegativelyevaluatedbyothers.Anuptodatesystematicreviewoftheeffectivenessofcognitive
behaviouraltherapiesforSAnDisrequiredtoguidepractice.
Objectives

Toassesstheefficacyandacceptabilityofcognitivebehaviouraltherapy(CBT)comparedwithtreatmentasusual/waitinglist(TAU/
r
WL)forindividualswithSAnD.
Searchmethods o
WesearchedtheCochraneDepression,AnxietyandNeurosisGroup(CCDAN)ControlledTrialsRegisterandconductedsupplementary
searchesofMFEDLINE,PsycInfo,EMBASE,andinternationaltrialregisters(ICTRP;ClinicalTrials.gov)inOctober2011andCINAHL
inOctober2012.Wealsosearchedreferencelistsofretrievedarticles,andcontactedtrialauthorsforinformationonongoing/completed
trials.
Selectioncriteria
Randomisedandquasi-randomisedcontrolledtrialsundertakeninout-patientsettings,involvingadultsaged18-75yearswithaprimary
diagnosisofSAnD,assignedeithertoCBTorTAU/WL.
Datacollectionandanalysis
Dataonpatients,interventionsandoutcomeswereextractedbytworeviewauthorsindependently,andtheRiskofbiasineachstudy
wasassessed.Theprimaryoutcomesweresocialanxietyreduction(basedonrelativerisk(RR)ofclinicalresponseandmeandifference
insymptomreduction),andtreatmentacceptability(basedonRRofattrition).
CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) 1
Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mainresults
Thirteen studies (715 participants) were included in the review, of which 11 studies (599 participants) contributed data to meta-
analyses.Basedonfourstudies,CBTwasmoreeffectivethanTAU/WLinachievingclinicalresponseatpost-treatment(RR3.60,95%
CI1.35to9.57),andonelevenstudies(599participants)itwasmoreeffectivethanTAU/WLinreducingsymptomsofsocialanxiety.
NosignificantdifferencewasfoundbetweenCBTandTAU/WLforattrition.Nosignificantdiyfferencewasdemonstratedforsocial
anxietyatfollow-upandnostudiesexaminedfollow-updataforclinicalresponseorattrition.
Authors’conclusions l
n
Theavailableevidencesuggeststhatcognitivebehaviouraltherapymightbeeffectiveinreducinganxietysymptomsfortheshort-term
treatmentofSAnD.However,thebodyofevidencecomparingCBTwithTAU/WLissmallandheterogeneous.
O

w
e
i
v
e
r
P

r
o
F
CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) 2
Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
y
l
n
O

CoCo SUMMARY OF FINDINGS FORwTHE MAIN COMPARISON [Explanation]
pg
yn
rightitive
©B
2eh e
0a Cognitivebehaviouraltherapycomparedwithtreatmentasusual/waitinglistforadultswithsocialanxietydisorder
1v
3io
Tu
heral Patientorpopulation:Adultswithsocialanxietydisorder
CT i
ochraherap SInetettrinvegns:tioPnri:mCaoryg,nsiteivceobndehaaryvicoaurrealotrhceroampymvunitysettings
neies Comparison:Treatmentasusual/Waitinglist
Collaboration.PforSocialAnxie Outcomes Illurstrativeecomparativerisks*(95%CI) R(9e5la%tivCeI)effect N(sotuodfiePsa)rticipants Q(GuRaAlitDyEo)ftheevidence Comments
ublishedtyDisord PATrsesautmmeedntriskas usual/ CCoorgrneistipvoendinbgehriasvkioural
be
yr Waitinglist therapy
Jo(S
hnAn
WileyD)(Re Cpolisnti-ctarelatmreesnptronse at Mediumriskpopulation RR3.60(1.35to9.57) 2(464studies) ⊕low⊕(cid:13)1,2(cid:13), (cid:13)
&v
Soniew) LDoSsMs-IVofdiosaogcnioaslisphuosibniga
s
,
L structured diagnostic in-
td
. terviFew(i.e.theADIS-IV)
Higherscoresindicateim-
provement (i.e. loss of 112per1000 403per1000
SAnDdiagnosis) (151to1072)
Reductioninsocialanx- The mean social anxi- The mean social anxiety 599 ⊕⊕(cid:13)(cid:13) Scores are based on
ietysymptoms etyrangedacrosscontrol intheinterventiongroups (11studies) Low3,4 a back-conversation of
Socialanxietysymptoms groupsfrom(22.9to37. was16lower SMD (-1.18 95%, CI -1.
measured on the Social 25) (-22.44 lower to -9.32 66,-0.69)toBDI-I
Interaction Anxiety Scale lower)(seecomments)
(SIAS). Scale from 0 to
100. (Follow-up: 4 to 12
months)
Lower scores indicate im-
provement (reduction in
socialanxietysymptoms)
3
y
l
n
O

CC w
oo
pg
yn
right©itiveB Treatment acceptability Mediumriskpopulation RR1.09(0.51to2.32) 574(10studies) ⊕⊕(cid:13)(cid:13)
2eh (attrition), measured by e Low3,4
0a
1v
3io theoverallnumberofpeo-
Tu
heral pledroppingoutofpost-
CoTh randomisation and over i
chraneerapies tHheigchoerursescoorfetshetirniadliscate 24per1000 v26per1000
CollabforSo moreattrition e (12.2to55.7)
oration.PcialAnxie Rsmyeemdnuptctotimonsiantdpeopsrte-tsrseiaotn- Tscyohmnertprotomlgmerasonurpansgdfreeodpmraec(s2rso.i5os7ns Tstiyohmnepgtromomuepassninwthadseei7pnrtleeosrwvseeionrn- 3(782studies) ⊕Lo⊕w(cid:13)4,(cid:13)5 SaScMobDraec(s-k0-c.a8or5ne,v9ebr5sa%astei(odCnI-o1onf.
ublishedtyDisord Btoercyk(BDDeI-pIr)e.sSsciaolnefIrnovmen0-Pto8.39) l(o1w0.e4r5)(sleoewceormtome2n.ts8)08 34to-0.36)toBDI-I
be to63
yr
Jo(S (Follow-up: 4 to 12
hnWAnD months)
ile)(R Lower score inrdicate im-
ye
&v provement (reduction in
Soniew) depressionsoymptoms)
s
,
L
td *Thebasisfor theassumedrisk(e.g.themediancontrol groupriskacross studies) isprovidedinfootnotes. Thecorresponding risk(andits95%confidence interval) isbasedonthe
. F
assumedriskinthecomparisongroupandtherelativeeffectoftheintervention(andits95%CI).
CI:Confidenceinterval;RR:RiskRatio.
1Riskofbiasissues:highrateofattrition(>20%)andasignificantdifferenceinattritionrateamongthegroupsin1/4studies
2Thereweresmallsamplesizes(<21participants)in2/4studies
3Allocationconcealmentwasnotreportedfor4/11studies
4Therewereconsiderableamountsofstatisticalheterogeneityindicated
5Allocationconcealmentwasnotreportedfor2/7studies
4
BACKGROUND SAnD was demonstrated in a previous Cochrane review (Stein
2004).TreatmentguidelinesrecommendSSRIsandtheserotonin-
noradrenaline reuptakeinhibitor (SNRI)venlafaxineXRasfirst
line pharmacological interventions for SAnD (Swinson 2006),
Descriptionofthecondition
andhighpotencybenzodiazepinessuchasclonazepam(Davidson
y
Social anxiety disorder (SAnD; or social phobia) islistedin the 1993)andbeta-blockers(Gorman1987)assecond-linepharma-
Diagnostic and Statistical Manual of Mental Disorders (DSM- cologicalinterventions.
IV-TR)(APA2000)andtheInternationalClassificationofDis- Psychologicaltherapieslareanimportantalternativetreatmentop-
eases10(ICD-10) (WHO 1992)alongside otheranxiety disor- tionforSAnDfortnworeasons: (1)patients’concernsabout the
ders(e.g.panicdisorder).SAnDischaracterisedbyanintensefear sideeffectsanddependencyofpharmacologicaltreatmentsresults
ofsocialorperformancesituations wheretheindividual worries intheirlowadherencerates(Hunot2007),and(2)researchcon-
aboutbeingnegativelyevaluatedbyothers(APA2000).Physical sistently repoOrts patients’ preference for psychological interven-
symptomsoftenaccompanyingSAnDincludesweating,shaking, tions compared to antidepressants as a treatment for common
blushing,palpitations,nauseaanddiarrhoea,andcandevelopinto mental disorders (Churchill 2000; Riedel-Heller2005). A wide
apanicattack(APA2000).AccordingtotheDSM-IV-TRAPA range of psychological therapies are now used to treat SAnD:
2000symptomsmaybegeneralised(apersistentfearofmostsocial (1) cognitive and behavioural therapy approaches (CBT; Beck
situations) which can lead to increased social isolation, or non- 1979;Ellis1962)comprising anumber of strategies, invivo or
w
generalised(afearofspecificsocialcontexts;e.g.publicspeaking). imaginal exposure to feared social situations (Butler 1985), ap-
However,recentevidencefromtheDSM-VAnxiety,Obsessive- pliedrelaxation(Öst1987),socialskillstraining(Stopa1993)and
CompulsiveSpectrum,Posttraumatic,andDissociativeDisorders cognitiverestructuring(Ponniah2008;Rowa2005),othertech-
WorkGroupamongothersindicatesthatthereisinsufficientesup- niquesincludevideotapefeedback(Smits2006)andattentional
portforthecurrentcategorical specifier,generalisedsocial anxi- training(McEvoy2009);clinicalpracticeguidelinesrecommend
ety(Aderka2012;Bögels2010).Theauthorsconcludethatsocial CBTasafirst-linetreatmentforSAnD(Swinson2006);(2)be-
anxiety exists along a continuum, the larger the numiber of so- haviouraltreatments(Skinner1953;Watson1924);(3)psycho-
cialfearsthegreatertheseverity,withoutadistinctdviscrimination dynamictreatments(Freud1949)includingbriefpsychodynamic
point(Aderka2012;Bögels2010).Nevertheless,theyfoundev- models (Mann 1973); (4) integrative treatments such as inter-
idenceindicatingthatindividualswithperformanceanxiety(e.g. personaltherapy(Klerman1984)andcognitiveanalytictherapy
e
speakingorperforminginpublic)werequalitativelydistinctfrom (Ryle2002);(5)humanistictreatments,Rogerianperson-centred
individuals with SAnD (Bögels 2010). The specifiers of perfor- therapy(Rogers1951)andGestalttherapy(Perls1976);and(6)
manceSAnDandSAnDareproposedforDSM-V(APAinpress) “third-wave”CBTinterventionsforSAnDacceptanceandcom-
r
to replace the current DSM-IV-TR generalised and non-gener- mitmenttherapy(Hayes2004),andmindfulness-basedstresscog-
alisedSAnDspecifiers(Bögels201P0). nitive therapy(Segal 2002). However,to date no systematic re-
SAnDisthethirdmostcommonpsychologicaldisorder(Kessler viewsormeta-analysesarereportedforpsychodynamic,humanis-
2005)afterdepressionandalcoholdependency(Magee1996).It tic,integrative,orthird-waveCBTtherapiesforSAnD;theover-
hasalifetimeprevalenceofbetween3and13%(Kessler2005), whelmingmajorityoftheevidenceforpsychologicalinterventions

more common in women than in men (ratio of 3 to 2) (Fehm usedtotreatSAnDisforcognitiveandbehaviouralinterventions
2008;Kessler2005),anrdhasatypicalonsetinearlyadolescence (Acurturk2009).
(Wittchen2003).IfleftuntreatedSAnDseemstohaveanendur-
ing,unremittingproognosisfrequentlyleadingtootherpsycholog-
icaldisorders(e.g.depression)(Stein2002).Previouslyviewedas Howtheinterventionmightwork
aneglecteddisorderithasbecomethefocusofincreasedresearch
overthelast2F5years(Liebowitz1985).SAnDisnowunderstood Behaviouraltherapysuchasexposuretherapyisbasedonlearning
tobe ahighlyprevalentdisorder (Kessler2003)associated with theory(Rachman1977).Learningtheoryproposesthatfears(e.g.
significant impairments in social and occupational functioning, socialanxiety)developthroughnegativelearningexperiencesand
psychologicaldifficulties,reducedqualityoflife(Stein2000)and aremaintainedthroughtheavoidance ofthefearedsocial situa-
substantialeconomiccosts(Smits2006). tions(Rachman1977).Treatmentinvolvesrepeatedandsystem-
aticinvivoexposuretoahierarchyofincreasinglyfearedsocialsit-
uations,remainingineachsituationuntilanxietylevelsdiminish.
Cognitive therapy (CT)aims torestructure theindividual’s un-
Descriptionoftheintervention
helpfulappraisals of life eventsthrough understanding therela-
The efficacy of pharmacological treatments (selective serotonin tionshipbetweenthoughts,feelingsandbehaviour.Clark1995ar-
reuptake inhibitors; SSRIs), (monoamine oxidase inhibitors; guesthatSAnDismaintainedbyincreasedself-focusedattention,
MAOIs) and (reversible inhibitors of monamine; RIMAs) for utilisation of maladaptive safety behaviours intended to reduce
CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) 5
Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
theprobabilityofnegativeevaluationfromothers,andengaging Banderlow2009;Fedoroff2001;Feske1995;Gould1997;Taylor
innegativelybiasedpost-eventprocessing.Rapee1997purports 1996).Moreover,thereviewsbyFedoroff2001andFeske1995
thatSAnDisalsomaintainedthroughatendencytomakeneg- includeduncontrolledtrialsintheirmeta-analysis,thusintroduc-
ativepredictionsaboutone’santicipatedperformanceinasocial ing potential methodological heterogeneity (Higgins 2011) and
situation.Aviciouscycleiscreatedwherebydysfunctionalbeliefs statisticalheterogeneitywasnotinvestigatedintwoofthesixre-
y
abouttheselfandtheexpectednormsofconductinsocialsitua- views(Taylor1996;Banderlow2009).Thevariabilityacrossstud-
tions,increasedself-focus,andtheutilisationofsafetybehaviours ies included in the above reviews has the potential to shift the
paradoxically increasesthelikelihoodofthefearedeventsinso- estimateoftheirintervlentioneffectsizesreducingthevalidityof
cialsituations (Beck1985).Cognitive behaviouraltherapiesfre- theirfindings(Higgnins2011).
quentlycombinecognitiverestructuringwithexposuretherapyto Todate,therehasbeennowell-conductedhighqualityCochrane
treatSAnD,andisbasedonthepremisethatSAnDarisesfromthe systematicreviewoftheeffectsofallcognitivebehaviouralther-
existenceofdysfunctional beliefsthatanindividual holdsabout apiesforSAnOD.Inviewofpatients’reportedpreferenceforpsy-
themselves,andhowtheyshouldconductthemselvesinsocialsit- chological therapies, thelackof pharmacological side-effectsas-
uations (Beck 1985), resulting in negatively biased information sociatedwiththeseinterventions(Churchill2000;Riedel-Heller
processing.The therapist and client co-construct more adaptive 2005), and the clinical, methodological, and statistical hetero-
waystoperceivesocialsituations,engageinexternalfocusedpro- gene ityissueswithpreviousreviewsandmeta-analyses,anupto
cessing, alleviate safety behaviours and test anticipated negative date and comprehensive summary of the evidence of cognitive
w
predictions,withtheobjectiveofachievingmorerealisticbeliefs behaviouraltherapiesforSAnDisrequired.Thefindingsofthis
abouttheselfandsocialsituations,includinganacceptancethat reviewwillguide healthcareaswellassupportingpatient/clini-
negativefearedeventsmaysometimeshappeninsocialsituations. ciantreatmentdecision-making aroundthemanagementofthis
Third-waveCBTtherapy(e.g.acceptanceandcommitmentteher- disorder.
apy;Hayes2004)positsthatSAnDresultsfromattemptstocon-
trol anxiety and an “unwillingness” to tolerate unwanted and
distressing thoughts when exposed to difficult socialisituations
(Dalrymple2007).Therapyaimstoincreaseanindvividual’s“psy-
OBJECTIVES
chologicalflexibility”viapsychological“acceptance”,their“will-
ingness”toexperiencedifficultpsychologicalevents“mindfully”, To assess the efficacy and acceptability of cognitive behavioural
e
whilealsobehavingconsistentlywithoneschosen“values”(Hayes therapycomparedwithtreatmentasusual/waitinglistforindivid-
2004).Treatmentalsoutilisestraditionalbehaviourtherapytech- ualswithSAnD.
niques such as role-plays, exposure, and social skills training
r
(Dalrymple2007).
P METHODS
Whyitisimportanttodothisreview
Criteriaforconsideringstudiesforthisreview
Socialanxietydisorderiscurrentlyrecognisedasahighlyprevalent,
r
disabling disorder with significant economic costs, and the evi-
dencebaseonintervoentionsforSAnDhasexpandedconsiderably. Typesofstudies
Overthelast15yearstheefficacyofpsychologicalinterventions Randomisedtrialsdefinedasfollows:
(i.e.cognitiveandbehaviouraltherapies)forSAnDwereassessed 1.Randomisedcontrolledtrials
inseveralsysFtematicreviewsandmeta-analyses(Acurturk2009; 2. Quasi-randomised controlled trials, if they utilise treatment
Feske1995;Taylor1996).Cognitivebehavioural therapieswere assignmentssuchasalternatedaysoftheweek
comparedwithpharmacologicaltreatmentsinanumberofmeta- 3.Trialsthatemployacross-overdesign,usingdatafromthefirst
analyses (Banderlow 2009; Fedoroff 2001; Gould1997). These activetreatmentstageonly
reviews indicatedthatCBTcan beeffectiveinthetreatmentof 4.ClusterRCTswerealsoeligible
SAnD, and that it can be as effective as pharmacological treat- Nolanguageorpublicationrestrictionswereimposed.
ments(Banderlow2009;Gould1997).Importantly,theconclu-
sionsofpreviousreviewsandmeta-analysesarelimitedduetoa
number of clinical and methodological difficulties. Allprevious Typesofparticipants
reviewsinvolvedclinicalheterogeneousgroupsandmostdonot
providesufficientdetailsabouttheseverityandnatureofSAnD
Patientcharacteristicsandsetting
symptomsorcomorbidAxis-I/Axis-IIdisorders(Acurturk2009;
CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) 6
Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Thereviewincludedmaleandfemaleadults,aged18to75years, thestudywereprescribedthesamepharmacological/placeboin-
treatedinaprimary,secondarycareorcommunitysettings. terventions.Combinationtreatmentscomparedagainstapharma-
cologicalorpsychologicaltreatmentalonewereoutsidethescope
ofthisreview.
Diagnosis
y
Comparators
Inclusioncriteria
l
Thecomparatorwastreatmentasusual(TAU).Thiscomparator
Participantshadaprimarydiagnosisofsocialanxietydisorder(so- includedstandardcanre,usualcare,notreatment,andwaitinglist
cial phobia), based on DSM-IV, DSM-IV-TR non-generalised/
(WL).Ineachstudy,thedescriptionofaTAUconditionwasscru-
specificsocialanxietydisorder(excludingperformanceSAnDsee
tinisedtoensurethatitdidnotinvolveanactivesupportivether-
below)andgeneralisedsocialanxietydisordercriteriarespectively O
apytreatment.StudiesthatallowedparticipantsintheTAUarmto
(APA1994;APA2000),oronICDcriteria(WHO1992).Di-
receiveappropriatemedicalcaredeemednecessarybytheclinician
agnosismusthavebeenmadebyatrainedpsychiatricassessorus-
duringthecourseofthestudy(includingpharmacotherapyand/
ingeitherastandardisedinterviewsuchastheAnxietyDisorders
orpsychologicaltherapy)wereincluded.Additionaltreatment(s)
InterviewScheduleforDSM-IV(DiNardo1994)ortheStruc-
receivedby participants in both thecontrol andactive compar-
turedClinicalInterviewforDSM(SCID)(First1996;First2002;
iwsonsforeachincludedstudywerecarefullydocumented.
Spitzer1990).Comorbidpsychologicalorphysicaldisorderswere
includedifparticipantshadaprimarydiagnosisofSAnD.
Exclusioncriteria Typesofoutcomemeasures
RCTsincludingmorethan80%participantswithaprimaryedi-
agnosisofSAnDwereincluded.
Trials involving participants with the following diagnoses were
Primaryoutcomes
excluded: i
Theprimaryoutcomeswerereductioninsocialanxietyandtreat-
1.PerformanceSAnD(e.g.publicspeakinganxietyv)
mentacceptability,asfollows:
2.Sub-clinicalsocialanxiety(e.g.shyness)
1.Treatmentresponse,comprisedtheproportionofparticipants
3.Specificsocialanxieties(e.g.testanxiety)
e showingabsenceversuspresenceofsymptomsorclinicallysignif-
4.Avoidantpersonalitydisorder
icantchange,accordingDSM-IVandDSM-IV-TR(APA1994;
5. Comorbid substance related disorder, schizophrenia or psy-
APA2000)orICD-10(WHO1992)diagnosticcriteriaforsocial
choticdisorderdiagnoses
r anxietydisorder/socialphobia,orthroughadefinedcut-offona
validatedsocialanxietymeasuresuchastheLiebowitzSocialAnx-
P
Typesofinterventions ietyScale(Liebowitz1987)oracompositeofvalidatedmeasures
accordingtothetrialist’sdefinition.
2.Reductioninsocialanxiety symptomsmeasuredusingavali-
Experimentalinterventio ns datedcontinuousscale,suchastheLiebowitzSocialAnxietyScale
StudieswereincludedinthereviewiftheyevaluatedaCBT,in- (Liebowitz1987).
r
cludingthefollowing:cognitivetherapy(CT;Beck1979),ratio- 3. Treatment acceptability (attrition), measured by the overall
nalemotivebehavioouraltherapy(REBT;Ellis1962),multimodal numberofpeopledroppingoutpost-randomisationandoverthe
behaviour therapy (Lazarus 1971), rational behaviour therapy courseofthetrials.
(Maultsby1984),andstressinoculationtraining(Meichenbaum
1985),andtFhird-waveCBTinterventions,acceptanceandcom-
Secondaryoutcomes
mitmenttherapy(Hayes2004),andmindfulness-basedstresscog-
nitivetherapy(Segal2002). 1.Reductionindepressionsymptoms,usingvalidatedobserver-
rated scales (e.g. the Hamilton Rating Scale for Depression) (
Hamilton 1960) or self-report scales (e.g. the Beck Depression
Modalityoftherapies
Inventory)(Beck1987)
Psychologicalinterventionsdeliveredfacetofacebetweenthepa- 2.ClinicalGlobalImpressions-Improvementscale(CGI)(Guy
tientandtherapistandpsychologicaltherapiesconductedineither 1976)
individualorgroupformatswereincluded.However,psychologi- 3. Quality of life, using validated measures (e.g. SF-36) (Ware
caltherapiescomprisingcouplestherapyandfamilytherapywere 1993)
excluded.Comparisonsofdualmodalitytreatmentswereeligible 4.Negativeeffectsoftherapy,assessedbycollatingthenumberof
for inclusion only if thetwo psychological modelscomparedin participantsreportinganynegativeeffectsoftherapy
CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) 7
Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.