literature review current theories and research
TRANSCRIPT
LITERATURE REVIEW
1
Literature Review
Title:
Cognitive Behavioural Therapies for Social Anxiety Disorder: A Systematic Review of
Current Theories and Research
Submitted as part fulfilment of the requirements of the qualification of the Doctorate in
Clinical Psychology from the School of Psychology, University of Exeter
Name: Ian McKenna
Supervisor: Dr. Rachel Churchill
Research supervisor, Academic Unit of Psychiatry
University of Bristol
Regulations: Written to University guidelines
Word Count: 4,000
(Excluding references)
LITERATURE REVIEW
2
Cognitive Behavioural Therapies for Social Anxiety Disorder: A Systematic Review
1.0 Introduction
Social anxiety disorder (SAnD/social phobia) is listed in the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR; APA, 2000) and the International Classification
of Diseases 10 (ICD-10; WHO, 1992) alongside other anxiety disorders (e.g., panic disorder).
SAnD is characterised by an intense fear of social or performance situations where the
individual worries about being humiliated, embarrassed or scrutinised by others (APA, 2000).
Once viewed as a neglected disorder it has become increasingly research over the last 25
years (Liebowitz, Gorman, Fyer, & Klein, 1985). SAnD is now understood to be a highly
prevalent disorder (Kessler, 2003) associated with significant impairments in social,
psychological, and occupational functioning (Smit, Powers, Buxkamper, & Telch, 2006).
Patients' report a preference for psychological therapies for SAnD compared with
pharmacological therapies due to adherence rate problems, side effects, possible dependency
(Hunot, 2007) and frequent relapse of symptoms when medications are discontinued (Riedel-
Heller, 2005; Churchill, 2005).
Psychological therapies for SAnD could fall under one of five broad categories,
cognitive and behavioural approaches (Beck, Emery, & Green, 1985; Butler, 1985; Clark &
Wells, 1995; Rapee & Heimberg, 1997; Rachmann, 1977; Skinner, 1953),
psychoanalytic/dynamic (Klein, 1960; Leichsenring et al., 2009a), humanistic (Perls, 1976;
Rogers, 1951), integrative (Lipsitz, Markowitz, & Cherry, 1997) and third-wave cognitive
behavioural therapies (CBT) (Gilbert, 2005; Hayes, 2004; Teasdale, 2000; Wells, 2000).
Given the considerable literature in this area, and because the findings from single
trials are less reliable and are likely to be underpowered to observe the true effects of
treatments it was decided to review the meta-analyses which summarised the current
evidence for the efficacy of psychological therapies for SAnD.
LITERATURE REVIEW
3
Several meta-analyses assessed the efficacy of psychological interventions (i.e. either
cognitive behavioural therapy and behavioural therapy) for SAnD: Acarturk, Cuijpers, van
Straten and Graaf (2009), Feske and Chambless (1995), and Taylor (1996), as well as
compared psychological therapies with pharmacological treatments, Banderlow, Seidler-
Brandler, Becker, Wedekind and Ruther (2009), Federoff and Taylor (2001), and Gould,
Buckminster, Pollack, and Otto (1997). However, no systematic reviews or meta-analyses
were found for humanistic, psychodynamic, integrative, or third-wave CBT therapies for
SAnD. In short, these CBT reviews postulate that cognitive behavioural and behavioural
therapies are effective treatments for SAnD, as effective as pharmacological treatments
(Banderlow et al., 2009; Gould et al., 1997). However, the finding from these reviews and
meta-analyses must be held tentatively given a number of salient clinical and methodological
flaws which constrain the validity and generalizability of their findings. In addition, these
reviews were conducted in 2009 therefore need updating.
To date, no well-conducted high quality Cochrane systematic review of the effects of
cognitive behavioural therapies for SAnD has been conducted. Therefore, an up to date
comprehensive summary of the evidence on cognitive behavioural therapies for SAnD which
accounts for the clinical and methodological heterogeneity flaws in previous reviews is
required. The findings of this review will guide health care as well as supporting treatment
decision-making around the management of this disorder. In summary, the aim of this review
is to critically appraise meta-analyses relevant to the effectiveness of cognitive behavioural
treatments for social anxiety disorder.
2. 0 Outline of the Review
The review will first provide a definition of SAnD, along with the diagnostic criteria,
and any epidemiological data on its prevalence. The main psychological theories that
LITERATURE REVIEW
4
account for the development and maintenance of SAnD will be considered next. Then an
outline of the search methods used to gather systematic reviews and meta-analyses on the
effectiveness of psychological interventions for SAnD will be given. A summary of the
evidence from these reviews and meta-analyses, and a summary of the quality of this
evidence will be provided. A critical appraisal of the research methodologies will be
undertaken and the clinical implications of this assessment will be outlined, and finally
conclusions will be based on the evidence.
3.0 SAnD Conceptual and Definitional Problems
3.1 The definition of SAnD. Social anxiety disorder or formerly known as “social
phobia” was originally recognised as a distinct disorder during the 1960s (Marks & Gelder,
1965). SAnD is characterised by an intense fear of one or more social or performance
situations where the individual fears being humiliated, embarrassed or scrutinised by others
for not behaving in a manner consistent with the individual’s perceived social norms (APA,
2000). Individuals with SAnD recognise that this fear is excessive or unreasonable
nevertheless, it interferes significantly with their social and occupational functioning (APA,
2000).
SAnD is defined and diagnosed using either the DSM-IV-TR (APA, 2000) criteria
(See Table 1) or the ICD-10 (WHO, 1992). Feared social situations fall under three
categories, interaction (e.g. communicating socially), performance (e.g. public speaking), and
observation (working while being observed). SAnD (DSM-IV-TR, APA 2000) has two
subtypes: SAnD, and performance-SAnD (e.g. speaking or performing in public) which is a
qualitatively distinct category (Bögels 2010). SAnD has a stronger familial aetiology, an
earlier age of onset and a more chronic course than performance-SAnD (Bögels 2010).
LITERATURE REVIEW
5
3.2 The prevalence of SAnD. SAnD is the third most common psychological
disorder (Kessler, Berglund, Demler, Jin, Merikangas & Walters, 2005) with a lifetime
prevalence of between 3 and 13% in North America (Kessler et al., 2005). It is more common
in women than in men (ratio of 3 to 2) (Fehm, Pellissolo, Firmark, & Wittchen, 2005), has a
typical onset in early adolescences (Wittchen & Fehm, 2003). If left untreated SAnD has an
enduring, unremitting prognosis frequently leading to other psychological disorders (e.g.,
depression) (Stein, Jang, & Livesley, 2002). The psychological theories accounting for SAnD
will be now be described.
Table 1.
Social Anxiety Disorder Definition and Diagnostic DSM-IV-TR Criteria (APA, 2000) (all
criteria are necessary for a diagnosis).
a) A marked and persistent fear of one or more social or performance situation in which a
person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears
being embarrassed, humiliated or scrutinised by others.
b) Exposure to feared social situation or anticipation of it provokes anxiety (e.g. situational
panic attack).
c) Recognition that fear is excessive or unreasonable.
d) The feared situation is avoided or endured with distress.
e) Avoidance, anticipation or the actual feared situation causes significant distress and
impairment in social or performance functioning.
f) Duration of at least six months for individuals under 18 years.
g) The fear or avoidance cannot be accounted for by another medical or mental disorder.
h) Specify, “generalised” if the fear encompasses most social situations.
i) Typically associated with other symptoms: palpitations, tremulousness, blushing and
LITERATURE REVIEW
6
sweating
4.0 Psychological Theories for the Development and Maintenance of Social Anxiety
Disorder (SAnD)
Theories fall into four categories: (a) cognitive theories (Beck, Emery & Greenbergs,
1985; Clark & Wells, 1995; Rapee & Heimberg, 1997) and behavioural theories (Rachman,
1977, (b) integrative theories (Lipsitz et al., 1997), and (c) psychodynamic theories
(Leichsenring et al., 2009a)
4.1 Beck, Emery and Greenberg’s (1985) cognitive model of social anxiety
disorder. Beck, Emery and Greenberg argued that SAnD results from the existence of
dysfunctional beliefs that an individual holds about themselves and how they should conduct
themselves in social situations (Musa & Lepine, 2000). Three classes of dysfunctional beliefs
are held by the individual: excessively high standards of social conduct (e.g., “I must not
show any signs of incompetence”); assumption beliefs about social evaluation (e.g., “If I
make a mistake others will think I’m incompetent”); and stable beliefs about the self (e.g., “I
am incompetent”). Once activated by a social situation these cognitive process interact to
maintained SAnD (Musa et al., 2000). Thus, an individual with SAnD interprets the
physiological symptoms of anxiety (e.g. heart racing) produced in social situations as
evidence of their incompetence. This increases their self-focus on internal experiences and
interferes with their capacity to interpret and respond appropriately to external social cues.
The net effect is that it changes others behaviour towards them, confirming their worst fears
(Musa et al., 2000). Moreover, in the absence of such an outcome, cognitive interpretive
biases and threat biases make the individual more susceptible to misinterpret their behaviour
and that of others as being negatively socially evaluated (Musa et al., 2000).
LITERATURE REVIEW
7
4.2 Clark and Wells’ (1995) cognitive model of social anxiety disorder. Clark and
Wells’ model highlighted the salient effects of an attention shift from the external
environment to internal experiences during a social situation for individuals with SAnD. This
shift increases the individual’s awareness of their feared responses and negatively impacts on
their processing of the situation and subsequently others change their behaviour towards
them. Clark and Wells also describe behaviours known as “safety” and “avoidance”
behaviours that individuals with SAnD use to reduce the risk of negative evaluation from
others. Ironically, these behaviours act like a double edged sword, increasing the likelihood
of the feared outcome happening (i.e. the “safety behaviour” of wearing a jacket indoors to
prevent others seeing you perspire causes you to perspire more). Furthermore, when these
individuals use “safety” and “avoidance” behaviours and the feared outcome does not occur,
they attribute the non-occurrence to the behaviours and not the fact that their beliefs were
erroneous.
4.3 Rapee and Heimberg’s (1997) cognitive model of social anxiety disorder.
Rapee and Heimberg (1997) proposed model shares many of the characteristics of Clark and
Wells (1995) model. However, the key difference is that Rapee and Heimberg postulated that
when an individual anticipates or enters a social situation they form a mental representation
of themselves as seen by the others. This representation is influenced by factors such as
memory, physical symptoms, and social feedback. A comparison is then made between the
mental representation of the self (as seen by others) and the perceived norm others would
expect for the social situation (Musa & Lepine, 2000). The larger the difference between the
two, the higher the chance of negative evaluation from others. This predicted negative
evaluation results in anxiety in the social situation thus, further negatively influencing the
individual’s representation of themselves and their subsequent behaviour, maintaining the
process (Musa et al., 2000).
LITERATURE REVIEW
8
4.4 Learning models of social anxiety disorder. In 1977, Rachman proposed three
ways that fears (e.g., social anxiety) could develop through negative learning experiences.
They include: (a) direct conditioning, when a stimulus subsequently produces a fear response
because it was associated with a traumatic event; (b) vicarious acquisition, induced through
witnessing someone else have a traumatic fearful social experience; and (c) information
pathways, learning that particular social contexts are aversive by information transmission
(verbal, visual etc.) by others.
4.5 An integrative model of social anxiety disorder. Lipsitz and Markowitz tailored
interpersonal therapy for the treatment of social anxiety disorder in 1997. The authors posit
that SAnD is precipitated and perpetuated by an interaction between childhood temperament
and negative early life and later life experiences. They argue that SAnD in maintained by the
individual’s negative perception of their difficulties (e.g. I am weak), specific interpersonal
problems (e.g. role transitions, role disputes, and grief), and a paucity of close and trusting
relationships (Lipsitz et al., 1997).
4.6 A psychodynamic model of social anxiety disorder. Leichsenring and
colleagues in 2009 argued that the symptoms of SAnD arise from unconscious core
relationship conflicts rooted in early childhood experiences. The authors suggest that three
core conflictual relationship themes (CCRT) exist for SAnD, (1) a wish to be affirmed by
others, (2) a predicted response from others (e.g. ’Others will humiliate me’), and (3) a
response from the self (e.g. ‘I am afraid of exposing myself’) (NICE, 2013). The
psychological treatments for SAnD will be given next.
5.0 Psychological Treatments for SAnD
5.1 Cognitive behavioural therapies for social anxiety disorder (SAnD). There are
a number of psychological treatments for SAnD that fall under the rubric of cognitive
LITERATURE REVIEW
9
behavioural therapy (CBT). Initially termed cognitive therapy by Beck in 1979, CBT now
also includes a range of techniques including behavioural strategies, cognitive restructuring,
exposure therapy, cognitive therapy + exposure, social skills training, relaxation, and video
tape feedback (Antony & Rowa, 2008). More recently third-wave CBT was developed,
acceptance and commitment therapy (Hayes, 2004), mindfulness based cognitive therapy
(Teasdale, 2000), compassion focused training (Gilbert, 2005), and meta-cognitive therapy
(Wells, 2000). Cognitive behavioural therapy generally involves between 8 and 16 weekly 1-
hour sessions in either individual or group formats (Anthony & Rowa, 2008).
5.2 Interpersonal therapy for social anxiety disorder (SAnD). Lipsitz et al. in
1997 highlight three stages in the treatment for SAnD, (1) shifting the individual’s perception
of SAnD as a difficulty to be coped with rather than an inherent character weakness, (2) using
role plays to encourage emotional expression and accurate communication to alleviate
specific interpersonal problems (e.g. role transitions, role disputes, and grief), and (3)
encouraging the development of a network of close trusting relationships (Lipsitz et al., 1997;
NICE, 2013).
5.3 Psychodynamic therapy for social anxiety disorder (SAnD). The purpose of
the intervention is to develop conscious awareness in the individual between their current
symptoms and unconscious core conflictual relationship theme (CCRT) via the therapeutic
relationship (Leichsenring et al., 2009a). Details on the search methods conducted to
evidence systematic reviews and meta-analyses will follow.
6.0 Search Methods for Identification of Evidence
In order to understand what previous systematic reviews and meta-analyses were
conducted a review was conducted using a structured search strategy. The inclusion criteria
were published systematic reviews and meta-analyses on the effectiveness of psychological
LITERATURE REVIEW
10
therapies for SAnD. The exclusion criteria was narrative reviews. The databases Medline
(FirstSearch) and PsycINFO were searched refined by abstract using the terms: social phobia,
social anxiety, systematic review, and meta-analysis in August 2011 (see Appendix 1 for the
further details on the search strategy). The reference lists of relevant retrieved papers were
also searched. The searches yielded 254 studies of which six meet inclusion in the review
7.0 Evidence for the Effectiveness of Psychological Therapies for Social Anxiety
Disorder (SAnD)
7.1 Cognitive behavioural therapies. The first systematic review and meta-analysis
conducted by Feske & Chambless (1995) compared CBT to exposure for the treatment of
SAnD. The efficacy of CBT versus waiting list controls was assessed in twelve trials and
exposure therapy compared to waiting list in nine trials (Feske et al., 1995). Participants met
DSM-III or DSM III-R (APA, 1980; APA, 1987) criteria for social phobia. The results found
that cognitive therapy + exposure yielded similar effect sizes to exposure alone at pre/post
and pre/follow-up on social phobia self-report measures. In conclusion, exposure with or
without cognitive restructuring seemed to be equally effective treatments for SAnD.
In 1996, Taylor conducted a meta-analysis to examine the effectiveness of CBT
treatments for SAnD. The study aimed to assess whether CBT was better than waiting list and
placebo; whether there were benefits to adding cognitive therapy to exposure; and were
improvement maintained at follow-up? Twenty-four studies were included in the meta-
analysis. Participants met DSM-III to DSM-IV criteria (APA, 1980; APA, 1987; APA, 1994)
for SAnD. At post-treatment, the effects for all CBT therapies were larger than for waiting
list controls. However, only cognitive therapy + exposure (M = 1.06, SD = 0.34) was larger
than placebo (M = 0.48, SD = 0.26). All outcomes increased from post-treatment to follow-up
LITERATURE REVIEW
11
for all treatments with no significant differences among them. In summary, cognitive therapy
+ exposure was the most effective treatment from SAnD.
Acarturk, Cuijpers, van Straten and Graaf (2009) conducted the most recent review
and meta-analysis on psychological interventions for SAnD. The aim of their study was to
investigate whether the results of the previous meta-analyses remained positive when
restricted only to randomised control trials and when all new studies in the area where
included. Twenty-nine studies were included. All participants met DSM-III to DSM-IV
(APA, 1980; APA, 1987; APA, 1994) criteria or were above cut-off on a self-report or
clinician-rated SAnD scale (Acarturk et al., 2009). The conditions compared were: CBT;
cognitive therapy; social skills training; exposure; relaxation; waiting list; placebo; and
treatment as usual.
The overall effect size for all the psychological therapies was large (M = 0.70, 95%,
CI, 0.56-0.83) with no differences reported among the treatments (i.e. CBT versus exposure)
(Acarturk at al., 2009). Subgroup analysis reported that studies which compared against
placebo or treatment as usual had significantly smaller effect sizes relative to those that
compared against waiting list controls. Furthermore, studies that included participants who
met DSM diagnosis criteria reported significantly lower effect sizes than those that used
different criteria (Acarturk at al., 2009). In summary, given these findings all CBT
psychological treatments were posited as effective treatments for adults with SAnD.
7.2 Humanistic therapies. No systematic reviews or meta-analysis were found for
humanistic therapies.
7.3 Psychodynamic therapies. No systematic reviews or meta-analysis were found
for psychodynamic therapies.
LITERATURE REVIEW
12
7.4 Integrative therapies. No systematic reviews or meta-analysis were found for
integrative therapies.
7.5 Third-wave cognitive behavioural therapies. No systematic reviews or meta-
analysis were found for third-wave CBT therapies.
7.6 Cognitive behavioural therapies versus pharmacological treatments. The first
review and meta-analysis to compare psychological and pharmacological treatments for
SAnD was produced by Gould, Buckminster, Pollack, Otto, and Yap, in 1997. The meta-
analysis evaluated the effectiveness of CBTs (e.g., cognitive therapy + exposure, exposure)
versus pharmacological therapies (e.g., SSRIs, MAOIs). A total of 24 studies with 40
separate treatments were compared with controls (e.g., waiting list, placebo, treatment as
usual). Participants met SAnD criteria, DSM-III, to DSM-IV (APA, 1980; 1987; 1994;) or
would have if these criteria were applied.
For the psychological interventions, exposure resulted in the largest effect size,
followed by CBT + exposure. SSRIs and benzodiazepines resulted in the largest effects for
pharmacological interventions. All the CBT interventions combined and all the
pharmacological treatments combined were similarly effective, and the combinations of the
two were similarly effective. Slight therapeutic gains were reported for all psychological
interventions at follow-up but not for the pharmacological interventions. This was the first
evidence to suggest that CBT and pharmacological interventions are equally effective
treatments for SAnD.
Federoff and Taylor (2001) undertook a review and meta-analysis of the effectiveness
of psychological and pharmacological therapies for SAnD. They included 108 trials
comparing (e.g., waiting list, pill placebo, attention placebo, benzodiazepines, SSIRs,
LITERATURE REVIEW
13
MAOIs, exposure, cognitive therapy, cognitive therapy + exposure). Participants met DSM-
III, to DSM-IV SAnD criteria (APA, 1980; 1987; 1994).
All psychological therapies reported moderate effects but only cognitive + exposure
was significantly better than waiting list and attention placebo but not pill placebo.
Benzodiazepines demonstrated significantly larger effects that psychological treatments but
only in the short-term. Similar effect sizes were reported for SSRIs, MAOIs and cognitive
therapy + exposure. Psychological treatment effects continued at follow-up. The findings
from the review/meta-analysis suggested that benzodiazepine, SSRIs, MAOIs and cognitive
therapy + exposure were effective treatments for SAnD.
A review and meta-analysis by Banderlow, Seidler-Brandler, Becker, Wedekind and
Ruther (2009) compared the effectiveness of psychological and pharmacological treatments
for SAnD; the authors only reviewed studies that also included a combined pharmacological
and psychological treatment condition (Bandelow et al., 2009). Six trials were reviewed. All
participants had SAnD diagnoses (DSM-III, DSM. III-R, or DSM-IV; APA, 1980; 1987;
1994). Comparison conditions were: drugs; CBT; drugs + CBT; CBT + pill placebo; drugs +
pill placebo; and pill placebo.
Among the six trials only one reported a significant difference between treatments
(i.e., between CBT + drugs and CBT + pill placebo). Pre-post effect sizes were large for both
psychological and pharmacological interventions with no differences between any of the
treatment conditions. Due to the small number of studies, it was not possible to draw
conclusions about the effectiveness of combined psychological and pharmacological
treatments.
LITERATURE REVIEW
14
8.0 Quality of the Evidence
The quality of the systematic reviews and meta-analysis above were determined by
examining their internal validity (e.g. including uncontrolled studies, or completing
heterogeneity testing) and external validity (e.g. SAnD diagnosis and comorbidity details)
(see Appendix 2 for the Quality Grading of Evidence Table).
8.1 Quality of the cognitive behavioural therapy evidence for SAnD. There are a
number of major weaknesses in all three CBT reviews and meta-analyses (Fesk et al., 1995;
Taylor 1996; Acurturk et al., 2009): (a) they all included participants with both generalised
and specific (performance) SAnD and avoidant personality disorder (APD), and did not
provide sufficient details on the aforementioned disorders or other comorbid Axis I or Axis II
disorders in their reviews. This clinical heterogeneity will interfere with the validity of the
intervention effect size estimates of these reviews (Higgins & Green, 2011). Evidence
indicates that generalised SAnD is less responsive to treatment than specific SAnD (Brown,
Heimberg & Juster, 1995), as is APD (Feske, Perry, Chambless, Renneberg, & Goldstein,
1996). Furthermore, comorbidity interferes with treatment effects (Gould et al., 1997). Feske
et al., (1995) and Taylor, (1996) included studies without control conditions thus, introducing
methodological heterogeneity which potentially biases their effect estimates. Statistical tests
of heterogeneity were conducted in only one study (Acurturk et al., 2009). In short, the
internal and external validity and therefore the generalisability of effects of these reviews
would seem to be biased.
8.2 Quality of the cognitive behavioural therapy versus pharmacological
evidence for SAnD. An important caveat which seriously reduces the validity of these
reviews (Gould et al., 1997; Federoff et al., 2001; Banderlow et al., 2009) is their clinical
heterogeneity problems: (a) details concerning generalised and specific SAnD were omitted
LITERATURE REVIEW
15
from two reviews (Banderlow et al., 2009; Gould et al., 1997); and (b) information regarding
comorbid Axis-I and Axis-II disorders were omitted from two reviews (Banderlow et al.,
2009; Federoff et al., 2001) while the Gould et al., 1997 review contained studies with APD
comorbidity issues. These clinical internal and external validity problems bias the treatment
effects and reduced the generalisability of their findings (Higgins et al., 2011).
In summary, given the tentative nature of the findings for CBT for SAnD, and for
CBT versus pharmacological therapies for SAnD, coupled with the fact that the most recent
reviews were conducted in 2009, a more internally and externally valid and up to date review
of the evidence is required.
8.0 Methodologies Available to Research the Topic
Randomised controlled trials (RCT) are considered to the gold standard research
design for demonstrating a cause-and-effect relationship between intervention and an
outcome, for this reason they are the research method of choice for meta-analysis (instead of
observation studies or single case studies) (Stommell & Wells, 2004). The main strengths of
RCTs as a research design are the methodological safeguards they lend which increase
experimental control, these are outlined in Table 2. However, problems in RCT design or
reporting of the RCTs may carry through into meta-analyses negatively influencing their
results (See Table 3).
Table 2
Research Strengths of Randomised Controlled Trials
(a) Randomisation (i.e., randomly allocating participants to treatment and control conditions;
Salmon, 2008). Thus, making both groups as demographically similar as possible and ruling
out other possible causes for the treatments effect. Concealment of allocation is an additional
LITERATURE REVIEW
16
protective measure conducted during randomization. It prevents investigators from assigning
participants to treatment and control conditions in a subjective or biases fashion (Salmon,
2002). Evidence indicates that non-randomised studies tend to over and underestimate
treatment effect sizes (Salmon, 2002).
(b) Blinding. Blinding is a process whereby the participants, investigators and treatment
teams are oblivious to the treatments that have been received/administrated/assessed until
after the study in order reduce differential treatment or biased assessment.
Systematic reviews and meta-analyses, if done well, can be a powerful way to
summarise information from a number of independent studies examining the effectiveness of
psychological therapies for SAnD. However, the outputs from a meta-analysis may still be
biased if they are not based on a review that has been conducted systematically (garbage in
garbage out). The clinical implications of the findings in this review will be provided next.
Table 3
The Main Methodological Problems in the Design and Conduct of Randomised Control
Trials that can Affect Meta-Analyses (Flather, Farkouth, Pogue, & Yusif, 1997).
a) Flawed methods of randomisation
b) Non-blinding of trial treatments
c) Treatment compliance problems
d) Badly described treatment conditions
e) Use of unreliable and non-validated outcome measures
f) Incomplete reporting of outcome measures
g) Studies with low power (small sample sizes)
LITERATURE REVIEW
17
h) Not analysing non-compliant/non-completing participants within the groups they were
originally assigned
9.0 Clinical Implications
Research consistently reports patients' preference for psychological therapies over that
of antidepressants as a treatment options for mental disorders (Riedel-Heller, 2005; Churchill
2000). Typically, adherence rates for antidepressants are very low, due to patients' concerns
about side effects and potential dependency (Hunot, 2007) and symptom relapse when they
are discontinued. Psychological therapies comprising cognitive therapy + exposure; cognitive
therapy; social skill training and exposure alone have been shown to be effective treatments
for SAnD (as effective as pharmacological treatments) by a number of meta-analyses (Fiske
et al., 1995; Taylor, 1996; Gould et al., 1997; Federoff, et al., 2001; Banderlow et al., 2009)
and are recommended as a first-line intervention for SAnD in clinical practice guidelines
(Swinson, 2006).
10. 0 Conclusions and Future Directions
Research indicates SAnD has become a highly prevalent and disabling disorder. A
number of systematic reviews and meta-analyses have been published to summarise the
prevailing evidence on psychological interventions for SAnD. Cognitive therapy + exposure,
cognitive therapy; social skill training and exposure alone have consistently been
demonstrated as effective as pharmacological treatments for SAnD. Nevertheless, these
studies have important limitations which reduce the validity and generalisability of their
findings: (a) failing to report levels of generalised or specific SAnD, or comorbid Axis-I or
Axis-II disorders, not testing for heterogeneity (i.e., clinical heterogeneity); and (b) including
controlled and uncontrolled RCTs in their meta-analyses (methodological heterogeneity).
LITERATURE REVIEW
18
Given patients' reported preference for psychological therapies, coupled with adherence rate
difficulties for pharmacological treatments, an up to date and comprehensive summary of the
evidence on CBT for SAnD, using Cochrane systematic review methodology, is now timely.
These findings are intended to guide health care policy and patient/clinician decision-making
in the management of this disorder.
LITERATURE REVIEW
19
References
Acarturk, C., Cuijpers, P., van Straten, A., & de Graaf, R. (2009). Psychological treatment of
social anxiety disorder: A meta-analysis. Psychological medicine, 39(2), 241-54.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental
disorders: DSM-III (3rd
Ed.). Washington, DC: American Psychiatric Association.
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental
disorders: DSM-III-R (3rd
Ed. revised). Washington, DC: American Psychiatric
Association.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders: DSM-IV (4rd
Ed.). Washington, DC: American Psychiatric Association.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders: DSM-IV-TR (4rd
Ed. text-revision). Washington, DC: American
Psychiatric Association.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders: DSM-IV-TR (5th
Ed.). Washington, DC: American Psychiatric
Association.
Balint, M., Ornstein, P. O., & Balint, E. (1972). Focal psychotherapy. London: Tavistock.
Bandelow, B., Zohar, J., Hollander, E., Kasper, S., Möller, H.-J., Allgulander, C.,…Ayuso-
Gutierrez, J. (2008). World federation of societies of biological psychiatry (WFSBP)
guidelines for the pharmacological treatment of anxiety, obsessive- compulsive and
post-traumatic stress disorders - first revision. The World Journal of Biological
LITERATURE REVIEW
20
psychiatry: The official journal of the World Federation of Societies of Biological
Psychiatry, 9(4), 248-312.
Basco, M. R., Bostic, J. Q., Davies, D. (2000). Methods to improve diagnostic accuracy in a
community mental health setting. American Journal Psychiatry, 157, 1599-1605.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1987). Cognitive therapy of depression.
New York: Guildford Press.
Berne, E. (1961). Transactional analysis in psychotherapy. New York: Grove Press.
Barrett-Lennard, G. T. (1986). The relationship inventory now: Issues and advances in
theory, method and use. In: Greenberg, L. S. & Pinsof, W. (Eds.). The
Psychotherapeutic Process: A Research Handbook. New York: Guildford Press.
Butler, G. (1985). Exposure as a treatment for social phobia: Some instructive difficulties.
Behaviour Research and Therapy, 23, 651–657.
Pinsof, W. (1986). The psychotherapeutic process: A research handbook. New York:
Guildford Press.
Churchill. R., Khaira. M., Gretton, V., Chilvers, C., Dewey, M., & Duggan, C. (2000).
Treating depression in general practice: Factors affecting patients' treatment
preferences. Journal of General Practice, 50, 905-6.
Clark, D. M., & Wells, A. A. (1995). Cognitive model of social phobia. In R. G. Heimberg,
M. R. Liebowitz, S. A. Hope, F. R. Schneier, (Eds.), Social Phobia: Diagnosis,
Assessment and Treatment. New York: Guildford Press.
Di Nardo, P. A., Brown . T. A., Barlow, D. H. (1994). Anxiety disorders interview schedule
for DSM-IV (ADIS-IV). San Antonio, Texas: Psychological Corporation.
LITERATURE REVIEW
21
Fedoroff, I. C., & Taylor, S. (2001). Psychological and pharmacological treatments of social
phobia: A meta-analysis. Journal of Clinical Psychopharmacology, 21(3), 311-24.
Feske, U., & Chambless, D. L. (1995). Cognitive behavioural versus exposure only treatment
for social phobia: A meta-analysis. Behavior Therapy, 26(4), 695-720.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). Structured clinical
interview for DSM-IV Axis 1 disorders - patient edition (SCID-I/P, version 2.0).
New York: New York State Psychiatric Institute, Biometrics Research
Department.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B.W. (2002). Structured clinical
interview for DSM-IV-TR Axis I disorders, research version, patient edition.
(SCID-I/P) New York: Biometrics Research, New York State Psychiatric Institute.
Gilbert. P., & Irons, C. (2005). Focused therapies and compassionate mind training for shame
and self-attacking. In Gilbert P. (Eds.), Compassion: Conceptualisations, research
and rse in Psychotherapy. Hove: Routledge.
Gould, R. A., Buckminster, S., Pollack, M. H., Otto, M. W., & Yap, L. (1997). Cognitive-
behavioural and pharmacological treatment for social phobia: A meta-analysis.
Clinical Psychology: Science and Practice, 4, 291-306.
Guy, W. (1976). ECDEU Assessment manual for psychopharmacology-revised (p. 218-212).
NIMH Psychopharmacology Research Branch: Division of Extramural Research
Programs.
Hamilton, M. A. (1960). Rating scale for depression. Journal of Neurology, Neurosurgery
and Psychiatry, 23, 56-62.
LITERATURE REVIEW
22
Hayes, S. (2004). Acceptance and commitment therapy, relational frame theory, and the third
wave of behavioral and cognitive therapies. Behavior Therapy,35, 639-665.
Higgins, J. P. T., & Green, S. (2011). Cochrane handbook for systematic reviews of
interventions version 5.1.0 [updated March 2011]. The Cochrane Collaboration,
Available from www.cochrane-handbook.org.
Higgins, J. T., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003). Measuring
inconsistency in meta-analyses. British Medical Journal, 327, 557-60.
Kessler, R.C. (2003). The impairments caused by social phobia in the general population:
implications for intervention. Acta Psychiatry Scandinavia Supplement, 108, 19-27.
Klein, M. (1960). Our adult world and its roots in infancy. London: Tavistock.
Klerman, G. L., Weissman, M. M., Rousaville, B. J., & Chevron, E. S. (1984). Interpersonal
psychotherapy for depression. New York: Basic Books.
Law, J., Garrett, Z., Nye, C. (2003). Speech and language therapy interventions for children
with primary speech and language delay or disorder: Cochrane Database of
Systematic Reviews. Issue 3, Art. No.: CD004110. DOI:
10.1002/14651858.CD004110.
Leichsenring, F., Hoyer, J., Beutel, M, Herpertz, S., Hiller, W., Irle E.,… Leibing E. (2009a).
The social phobia psychotherapy research network - The first multi-centre
randomized controlled trial of psychotherapy for social phobia: Rationale, methods
and patient characteristics. Psychotherapy and Psychosomatics, 78, 35-41.
Liebowitz, M. R., Gorman, J. M., Fyer, A. J., & Klein, D. F. (1985). Social phobia: Review
of a neglected anxiety disorder. Archives of General Psychiatry, 42, 729-36.
LITERATURE REVIEW
23
Mann, J. (1973). Time-limited psychotherapy. Cambridge, Massachusetts: Harvard University
Press.
Marks, I. M., & Gelder, M. G. (1965). A controlled retrospective study of behaviour therapy
in phobic patients. The British journal of Psychiatry,111, 561-73.
Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50, 270-96.
May, R. (1961). Existential psychology. New York: Random House.
National Institute of Clinical Excellence. (2013). Social Anxiety disorder: Recognition,
assessment and treatments. NICE Clinical Guideline 159. London: The British
Psychological Society and The Royal College of Psychiatrists.
Perls, F. (1976). The Gestalt approach and eye witness to therapy. New York: Bantam
Books.
Ponniah, K., & Hollon, S. D. (2008). Empirically supported psychological interventions for
social phobia in adults: A qualitative review of randomized controlled trials.
Psychological medicine, 38(1), 3-14.
Riedel-Heller, S. G., Matschinger. H., Angermeyer, M. C. (2006). Mental disorders: Who and
what might help? Help-seeking and treatment preferences of the lay public. Social
Psychiatry and Psychiatric Epidemiology, 40, 167-74.
Rogers, C. (1951). Client-centred therapy. Boston, Massachusetts: Houghton Mifflin.
Sifneos, P. E. (1992). Short-term anxiety-provoking psychotherapy: A treatment manual.
New York: Plenum.
Skinner, B. F. (1953). Science and human behaviour. New York: Free Press.
LITERATURE REVIEW
24
Smits. J. A. J., Powers, M. B., Buxkamper. R., & Telch, M. J. (2006). The efficacy of
videotape feedback for enhancing the effects of exposure-based treatment for social
anxiety disorder: A controlled investigation. Behaviour Research and Therapy, 44,
1773–1785.
Spitzer, Robert. L., Williams, J. B. W., Gibbon M., & First M. B. (1990). Structured clinical
interview for DSM-III-R, patient edition/non-patient edition (SCID-P/SCID-NP),
Washington, D.C.: American Psychiatric Press, Incorporated.
Stein, M. B., & Kean, Y. M. (2000). Disability and quality of life in social phobia:
Epidemiological findings. American Journal of Psychiatry, 157, 1606–1613.
Taylor, S. (1996). Meta-analysis of cognitive-behavioral treatments for social phobia. Journal
of Behavior Therapy and Experimental Psychiatry, 27, 1–9.
Teasdale, J. D., Seal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M, & Lau, M.
A. (2000). Prevention of relapse/occurrence in major depression by mindfulness-
based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615-623.
Turner, S.M., Beidel, D.C., Dancu, C.V., & Stanley, M.A. (1989). An empirically derived
inventory to measure social fears and anxiety: The social phobia and anxiety
inventory. Psychological Assessment, 1, 35-40.
Ware, J. E, Snow, K. K., & Kosinski, G. B. (1993). SF-36 Health Survey: Manual and 1993
interpretation guide. Boston. Massachusetts: New Psychological therapies for social
anxiety disorder, England Medical Center, Health Institute.
Watson, J. B. (1924). Behaviorism. New York: Norton.
LITERATURE REVIEW
25
Wells, A. (2000). Emotional disorders and metacognition: Innovative cognitive therapy.
Chichester, UK: Wiley.
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Johannesburg, South Africa:
Stanford University Press.
World Health Organization. (1992). International statistical classification of diseases and
health related problems. Geneva: World Health Organization.
Zanarini, M. C, Skodol, A. E., Bender, D., Dolan R, Sanislow. C., & Schaefer, E. (2000). The
collaborative longitudinal personality disorders study: Reliability of axis I and axis
II diagnoses. Journal Personality Disorder, 14(4) 291-9.
LITERATURE REVIEW
26
Appendix 1
Combination of Search Terms and Results for Each Database
Search Terms Number of results
Medline PsycINFO
Social phobia AND Meta
analysis
19 references 35 references
Social anxiety disorder AND
Meta analysis
43 references 40 references
Social phobia AND
Systematic review
22 references 13 references
Social anxiety disorder AND
Systematic review
60 references 22 references
Totals 144 110
Overall Total 254
LITERATURE REVIEW
27
Appendix 2
Quality Grading of Evidence
Criteria
Feske &
Chambless
(1995)
Taylor
(1996)
Acarturk,
Cuijpers,
van Straten
and Graaf
(2009)
Gould,
Buck-
minster,
Pollack,
Otto, and
Yap,
(1997)
Federoff
and
Taylor
(2001)
Banderlow
, Seidler-
Brandler,
Becker,
Wedekind
and
Ruther
(2009)
External
validity:
Participants
DSM social
anxiety
disorder
(SAnD)
diagnoses
DSM-III and
DSM III-R
DSM-III to
DSM-IV
DSM-III to
DSM-IV
DSM-III,
to DSM-
IV
DSM-III,
to DSM-
IV
DSM-III,
to DSM-
IV
Reported full
details on
participants
SAnD
diagnoses
Not provided -
“heterogeneous
generalised and
specific SAnD
sample” p21,
Not
provided
Not
provided
Some but
not all
details
provided
Yes Not
provided
Included
studies with
specific
(performance)
SAnD
Yes Yes Yes Yes No unclear
Reported full
details on
Axis I and
Axis II
comorbidity
(especially
APD)
Not provided
- included
participants
with APD
comorbidity
Not
provided-
included
participants
with APD
comorbidity
Not
provided-
included
participants
with APD
comorbidity
Yes Not
provided
Not
provided
Internal
validity:
Included
uncontrolled
studies
Yes Yes No No Yes No
Heterogeneity
analyses
Yes No Yes Yes No No