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Franklin R. Schneier, Brigette A. Erwin, Richard G. Heimberg, Randall D. Marshall, Lisa A. Mellman: Chapter 30. Social

Anxiety Disorder and Specific Phobias, in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition. Edited by Glen O.

Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585622986.258250.

Printed 5/10/2009 from www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part VI. Anxiety Disorders, Dissociative Disorders, and Adjustment

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Chapter 30. Social Anxiety Disorder and Specific Phobias

INTRODUCTION

Social anxiety disorder and specific phobias are two of the most common mental disorders, and

knowledge about their treatments has grown rapidly in recent years. A stimulus to research into

specific treatments has been the recognition that phobias are a heterogeneous entity, as reflected

in the Diagnostic and Statistical Manual of Psychiatric Disorders, Third Edition (DSM-III; American

Psychiatric Association 1980) and subsequent editions. Distinctions between social anxiety

disorder, specific phobias, and agoraphobia have been validated by differential course of illness;

familial, environmental, and genetic factors; and psychological and biological characteristics. There

has been a corresponding recognition that particular types of phobias may respond best to specific

psychotherapeutic and pharmacological treatments. In this chapter, we review the treatment of

social anxiety disorder and specific phobias.

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)

Social anxiety disorder, also known as social phobia, encompasses fear and avoidance of social or

performance situations, with prominent fear of embarrassment or humiliation. The disorder is very

common, typically has onset by teenage years, and is often chronic. DSM-IV-TR (American

Psychiatric Association 2000) recognizes a generalized subtype of social anxiety disorder in which

most social situations are feared. The remainder of persons with social anxiety disorder may be

considered to have a nongeneralized type, most commonly focused on fear of specific public

situations such as public speaking or performing on stage.

Persons with social anxiety disorder may be generally self-conscious, fearful of negative evaluation,

and unassertive. Panic attacks limited to social situations are sometimes present. Patients often

present many years after the onset of social anxiety disorder, sometimes after the occurrence of

comorbid major depression. Assessment requires a systematic inquiry into the scope of the

situations feared because patients may initially underreport the range of their avoidance. Rating

instruments such as the Brief Fear of Negative Evaluation Scale (Rodebaugh et al. 2004b) and the

Liebowitz Social Anxiety Scale (see Mennin et al. 2002) may be useful clinically for assessing

severity and treatment response.

Cognitive-Behavioral Therapies

Cognitive-behavioral treatments—specifically those that employ exposure either alone or combined

with cognitive restructuring, social skills training, and relaxation training—have received the most

attention of any psychotherapeutic approaches in the empirical literature. Exposure-based

cognitive-behavioral treatments have been categorized by the International Consensus Group on

Depression and Anxiety as having good evidence for efficacy (Ballenger et al. 1998). Thorough

reviews of psychotherapy for social anxiety disorder have been conducted by Turk et al. (2002) and

Rodebaugh et al. (2004a).

Exposure

Exposure requires individuals to imagine (imaginal exposure) or directly confront (in vivo

exposure) feared stimuli. In vivo exposure can be directed toward actual or simulated situations in

treatment sessions or toward real-life situations in between-session homework assignments.

Exposure requires patients to confront progressively more anxiety-provoking situations, beginningPrint: Chapter 30. Social Anxiety Disorder and Specific Phobias http://www.psychiatryonline.com/popup.aspx?aID=258254&print=yes…

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with ones that elicit a moderate amount of fear. Before exposure to the next most feared situation

is initiated, exposure to each situation is repeated a sufficient number of times so that it no longer

elicits a distressing amount of fear. It appears likely that the mechanism underlying exposure

involves the acquisition of new learning that does not replace the original fear response but rather

results in the assimilation of both the original fear response and new information derived from

exposure experiences (Bouton 2002).

Imaginal exposure for social anxiety disorder has not been examined sufficiently. In vivo exposure

techniques have demonstrated short- and long-term efficacy in both self-directed and

therapist-directed formats (for a review, see Rodebaugh et al. 2004a). As a sole treatment for

social anxiety disorder, exposure has resulted in greater anxiety reduction than progressive muscle

relaxation training, pill placebo, and delayed treatment. Methodological problems in some studies

suggest the need for replication. However, exposure is rarely administered in the absence of other

techniques and is not the most comprehensive approach. It does not appear to systematically or

adequately challenge dysfunctional beliefs (Turk et al. 2002) and information processing biases,

which appear to maintain social anxiety disorder (D. M. Clark and Wells 1995; Rapee and Heimberg

1997).

Exposure Combined With Cognitive Restructuring Techniques

Treatments combining exposure with cognitive restructuring techniques are the best-studied

psychosocial interventions for social anxiety disorder. Cognitive restructuring seeks to help persons

with social anxiety disorder test out alternative ways of thinking about themselves and others in

social and performance situations. Techniques employed include monitoring of automatic, negative,

and irrational thoughts that occur during anxiety-provoking situations (e.g., “I won’t know what to

say” or “She’ll think I’m boring”), identifying errors of logic present in those thoughts (e.g., the

tendency to predict negative future outcomes without evidence or to act as if one knows what the

other person is thinking), and developing rational alternatives (e.g., to tell yourself on the basis of

questioning your automatic thoughts that you have been able to come up with appropriate

conversational topics in most social interactions in the past). When combined with exposure

exercises, cognitive restructuring may be employed before, during, and after exposures. In this

context, exposure is utilized as a means of both facilitating habituation and challenging patients’

irrational thoughts and beliefs (Rodebaugh et al. 2004a).

The four meta-analyses that have investigated components of cognitive-behavioral interventions

(i.e., exposure alone, cognitive restructuring alone, exposure plus cognitive restructuring) and

compared them to other cognitive-behavioral interventions (e.g., social skills training, applied

relaxation) found effect sizes for all interventions superior to those for delayed treatment (Fedoroff

and Taylor 2001; Feske and Chambless 1995; Gould et al. 1997; Taylor 1996); only the combination

of cognitive techniques and exposure yielded effect sizes greater than those for placebo treatments

(Taylor 1996). Effect sizes for all of these interventions increase from posttreatment to follow-up

assessments, suggesting continuing improvement over follow-up intervals averaging 3 months

(Taylor 1996).

Empirical studies have been equivocal regarding the relative efficacy of exposure alone and

exposure plus cognitive restructuring, with some studies demonstrating equivalent outcomes and

others finding the combination to be superior and to provide additional gains during the follow-up

period (for a review, see Rodebaugh et al. 2004a). There has been a modest tendency for patients

treated with exposure alone to show some loss of gains after discontinuation of treatment,

suggesting that additional treatment components may be necessary to maximize durability of

improvements. Cognitive techniques may enhance the efficacy of exposure as they appear to

reduce the amount of exposure necessary to achieve typically similar positive outcomes (Turk et al.

2002).

One of the most thoroughly investigated cognitive-behavioral treatments for social anxiety disorder

is the cognitive-behavioral group therapy (CBGT) package developed by Heimberg and Becker

(2002). CBGT integrates in-session exposure to simulated anxiety-provoking situations, cognitivePrint: Chapter 30. Social Anxiety Disorder and Specific Phobias http://www.psychiatryonline.com/popup.aspx?aID=258254&print=yes…

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restructuring, and homework for both self-directed in vivo exposure and cognitive restructuring.

(See Heimberg and Becker 2002 for further discussion of the techniques of CBGT.) In the first

controlled study of this package (Heimberg et al. 1990), CBGT patients were more improved after

12 weeks on clinician ratings of distress and impairment and reported less anxiety during a

behavioral test than patients who received a credible placebo treatment. Assessors classified 75%

of CBGT patients as responders, compared to only 40% of control participants. Gains were

maintained in a subset of the original sample at 4.5- to 6.25-year follow-up (Heimberg et al. 1993).

Several studies have investigated factors influencing response to CBGT (see Rodebaugh et al.

2004a for a review). Patients with social anxiety disorder complicated by additional mood disorders

improved in response to CBGT at the same rate as patients with uncomplicated social anxiety

disorder and patients with additional anxiety disorders but were more impaired and symptomatic

before treatment and remained so after treatment and at 12-month follow-up (Erwin et al. 2002).

Other factors that have been shown to predict poor treatment outcome include generalized subtype

of social anxiety disorder, poor compliance with exposure and cognitive-restructuring homework,

and low expectations for treatment outcome.

Studies of the adaptability of CBGT to individual sessions suggest that individual

cognitive-behavioral therapy (CBT) for social anxiety disorder is feasible and practical. An

individual CBT approach developed by Hope et al. (2000) was more efficacious than delayed

treatment. Stangier et al. (2003) found that among individuals with generalized social anxiety

disorder, individual CBT based on the model of D. M. Clark and Wells (1995) was superior at

posttreatment and 6-month follow-up to a group CBT based on the same model.

Social Skills Training

Social skills training (SST) is based on the assumption that social anxiety is related to a lack of

social skills, which provokes negative reactions from others and leads to poor interpersonal

outcomes and distress. SST programs typically provide education for patients about appropriate

social behavior, often in the form of instruction and modeling of target social skills (e.g., eye

contact, voice volume, posture). Patients then rehearse each social skill until it is performed

adequately, receiving praise from the therapist for successively better approximations of the

desired behavior. Newly acquired social skills are then practiced in real-life situations. It is unclear

whether individuals with social anxiety disorder actually demonstrate impairment in the quality of

their social behavior. However, it is clear that persons with social anxiety disorder underestimate

their behavioral competence in social situations.

Research into the effectiveness of SST is the least advanced and methodologically sophisticated in

the behavioral therapy literature. No study has demonstrated that SST alone is more effective than

a control condition. However, in an uncontrolled study, Turner et al. (1994) reported that social

effectiveness therapy (SET), which combines SST with education and exposure, was effective in the

treatment of patients with generalized social anxiety disorder and that these gains were maintained

2 years after the end of treatment (Turner et al. 1995). Because SST necessarily involves exposure

to anxiety-provoking situations, it appears impossible to separate the effects of such training from

those of in vivo exposure.

Relaxation Strategies

Applied relaxation combines training in relaxation techniques with instructions to employ these

skills first in non-anxiety-provoking situations and subsequently through gradual exposure to

anxiety-provoking situations. This combination of relaxation and exposure techniques may be

effective in the treatment of social anxiety disorder (e.g., Öst et al. 1981). However, no study to

date has compared applied relaxation with exposure alone to determine whether the inclusion of

relaxation enhances treatment efficacy. There is no evidence to suggest that relaxation without the

applied component is useful as a sole intervention for social anxiety disorder.

Psychodynamic and Interpersonal PsychotherapiesPrint: Chapter 30. Social Anxiety Disorder and Specific Phobias http://www.psychiatryonline.com/popup.aspx?aID=258254&print=yes…

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Psychodynamic psychotherapy, although not well studied for patients with social anxiety disorder,

can potentially address several aspects of the disorder. Affects of shame and fear, and inhibitions in

interpersonal relationships, are key features of social anxiety disorder and traditional foci of

dynamic treatment. In an uncontrolled 52-week study of supportive-expressive therapy for

avoidant personality disorder, a condition known to greatly overlap social anxiety disorder, 60% of

patients no longer met diagnostic criteria (Barber et al. 1997).

In psychodynamic therapies, the personal meaning of social fears is defined within the life story of

relationships. Some patients have internalized representations of parents, siblings, and caregivers

who criticized, shamed, or abandoned them (Gabbard 2005). Such expectations are projected onto

others and produce a powerful urge to avoid potentially threatening situations. Most socially phobic

patients are exquisitely sensitive to potential conflict with others. Exploration of these fears,

expectations, and assumptions about others and underlying wishes can be therapeutic. Some

patients confuse assertion with aggression and are greatly inhibited by guilty worries about being

too socially aggressive.

During treatment, exploration of the transference to a critical (Barber et al. 1997), overprotective

and rejecting (Lieb et al. 2000), or anxious (Rosenbaum et al. 1992) parental or other authority

figure, if such a history is present, may be especially productive. Expectations and fantasies about

such figures may elucidate the factors that continue to reinforce the patient’s avoidance.

Ultimately, treatment should result in internalization of more benign and accepting object relations

with associated symptomatic improvement. Many intelligent individuals, however, can develop a

psychodynamically rich therapy without significant change in symptoms or behavior. It is usually

necessary for patients to confront their feared situations, and traditionally trained therapists will

need to grapple with common countertransference inhibitions to being so directive. Group therapy,

from a psychodynamic, systems theory, or other perspective, offers a supportive setting in which

the patient can engage in and explore a range of real interactions that can be instructive and

corrective.

A single open trial of interpersonal psychotherapy (IPT) for social anxiety disorder found that

symptoms were reduced 78% in the overall sample (Lipsitz et al. 1999). The goal of IPT for social

anxiety disorder is to help the patient understand the connection between the phobic symptoms

and current interpersonal problems and to use this understanding to improve both. In the first

phase of IPT, social anxiety disorder symptoms are identified as a treatable disorder, and an

interpersonal problem is agreed upon as the primary focus. In the middle phase, this focus is

elaborated and explored, and interpersonal assumptions are questioned. In the termination phase,

the therapist reviews progress and attempts to consolidate gains.

Medication and Other Biological Therapies

There now exists a substantial body of evidence demonstrating efficacy of several classes of

medications in social anxiety disorder. Well-controlled trials include studies of irreversible and

reversible monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs),

serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, beta-adrenergic blockers,

gabapentin, and pregabalin. Tricyclic antidepressants do not appear to be clinically effective

(Simpson et al. 1998a). Medication treatment of social anxiety disorder has been the subject of

recent meta-analytic reviews of randomized clinical trials (Blanco et al. 2003; D. J. Stein et al.

2005). Most patients in these clinical trials have had the generalized subtype of social anxiety

disorder, so the relevance of these findings for nongeneralized social anxiety disorder is unclear.

Selective Serotonin Reuptake Inhibitors and Venlafaxine

SSRIs and the SNRI venlafaxine have emerged as the first-line medication treatment for the

generalized subtype of social anxiety disorder, based on more than a dozen randomized

placebo-controlled trials. Paroxetine, sertraline, and venlafaxine have each received U.S. Food and

Drug Administration (FDA) approval in the United States for the indication of social anxiety

disorder, and fluoxetine, fluvoxamine, citalopram, and escitalopram have also been studied inPrint: Chapter 30. Social Anxiety Disorder and Specific Phobias http://www.psychiatryonline.com/popup.aspx?aID=258254&print=yes…

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randomized clinical trials. In short-term (8- to 12-week) clinical trials of these medications,

response rates, based on clinical global impression of much improved or very much improved, have

typically ranged from 40% to 70% (e.g., M. B. Stein et al. 1998). These rates are generally

20%–30% greater than corresponding placebo response rates. Treatment dosages are similar to

those used for depression (i.e.,. median effective paroxetine dose 20 mg/day, although range of

optimal dosing may vary from 10 to 80 mg/day). Time course of acute response may be slower than

that seen in depression, with most responses occurring by the eighth week of treatment, but some

further response occurring at least up to the twelfth week (D. J. Stein et al. 2002). No single drug in

this class has been demonstrated to be superior to another in direct comparisons, although two

negative placebo-controlled studies of fluoxetine raise questions as to that agent’s efficacy in social

anxiety disorder (D. M. Clark et al. 2003; Kobak et al. 2002).

SSRIs and the SNRI venlafaxine offer advantages of a relatively mild adverse-effect profile, safety

in overdose or with concurrent use of alcohol, and a broad spectrum of efficacy for comorbid

anxiety and affective disorders. Drawbacks include delayed response and common adverse effects

that may exacerbate some problems already common in social anxiety disorder, such as increased

sweating or sexual dysfunction, as well as lack of evidence for efficacy in the nongeneralized

subtype of social anxiety disorder.

Social anxiety disorder patients who respond to initial SSRI treatment are commonly treated for

6–12 months or longer. Responders after a year of treatment may show further improvement after

a second year of treatment (D. J. Stein et al. 2003). Relapse prevention studies show that following

acute response, maintenance treatments of 6 months or greater significantly decrease chance of

relapse, although in some studies more than 50% of treatment responders have been able to

maintain response after drug discontinuation (e.g., D. J. Stein et al. 2002).

Benzodiazepines

Among the benzodiazepines, clonazepam has the most evidence for efficacy in social anxiety

disorder. Davidson et al. (1993) completed a double-blind, placebo-controlled study of clonazepam

in 75 patients. After 10 weeks of treatment, 78% of those on clonazepam (mean dosage 2.4

mg/day) and 20% of those on placebo were rated as at least moderately improved. In another

randomized clinical trial, clonazepam and CBGT were equally effective after 12 weeks of treatment

(Otto et al. 2000). In a placebo-controlled discontinuation trial among social anxiety disorder

patients effectively treated with clonazepam, 79% were able to tolerate slow taper (0.25-mg

reduction every 2 weeks) and discontinuation without relapse in the short term (Connor et al.

1998). Similar efficacy was reported for bromazepam. Alprazolam, however, did not differ from

placebo on most measures in one trial, and at 2-month follow-up most patients had lost most of

their gains (Gelernter et al. 1991). Although benzodiazepines have not been systematically studied

in nongeneralized social anxiety disorder, they are often used clinically on an as-needed basis for

performance anxiety, and they represent an alternative to beta-adrenergic blockers for these

patients.

Benzodiazepines offer advantages of rapid onset and good tolerability. Disadvantages include lack

of efficacy for comorbid depression, relative contraindication in the presence of comorbid substance

abuse, risk of abuse in vulnerable patients, and routine development of physiological dependence

requiring slow taper to discontinuation. A small study of coadministration of clonazepam with an

SSRI demonstrated a trend for the combination to be superior to an SSRI alone (Seedat and Stein

2004), which is consistent with clinical experience with the utility of clonazepam and as

augmentation for partial responders to SSRIs.

Clonazepam appears most effective when given on a twice-a-day or three-times-a-day

standing-dose basis, typically at a total dose of 2–4 mg per day. Dosage should be initiated at 0.5

once daily at bedtime and gradually increased on a twice-a-day or three-times-a day schedule. The

most common adverse effect is sedation, which usually abates within several days after a dosage

increase. Patients should be warned against abrupt discontinuation due to risk of withdrawal

symptoms.Print: Chapter 30. Social Anxiety Disorder and Specific Phobias http://www.psychiatryonline.com/popup.aspx?aID=258254&print=yes…

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Monoamine Oxidase Inhibitors

MAOIs were the first class of medications to be extensively studied for social anxiety disorder. The

efficacy of phenelzine, an irreversible MAOI, has been established in four double-blind,

placebo-controlled studies. The most recent study compared two treatments of known

efficacy—phenelzine and CBGT—with placebo and with a psychosocial control group that provided

education and support but not exposure exercises (Heimberg et al. 1998). Both phenelzine and

CBGT were superior to the control conditions, and phenelzine was superior to CBGT on some

measures after both 6 and 12 weeks of treatment. In a prior study, Liebowitz et al. 1992) compared

phenelzine and atenolol in outpatients, most of whom had the generalized subtype of social anxiety

disorder (n = 74). After 8 weeks of treatment, 64% of the patients on phenelzine were much

improved, significantly more than the 23% of those on placebo and the 30% of those on atenolol.

Open trials have reported response rates of 79% for tranylcypromine, another irreversible MAOI

(Versiani et al. 1988), but in another study (Simpson et al. 1998b), selegiline, at a low dose ( 10

1. mg) that limits its function to MAO-B inhibition, was ineffective for most patients.

Although the irreversible MAOIs appear to be at least as effective as the SSRIs for social anxiety

disorder, they remain a second- or third-line treatment due to dietary restrictions and a relatively

high rate of adverse effects. The low-tyramine diet prohibits most cheeses, and a variety of other

foods, beer and red wines, and sympathomimetic medications must also be avoided. SSRIs must be

allowed to “wash out” for 2 weeks (5 weeks for fluoxetine) before initiating an MAOI due to the

risk of serotonin syndrome. Common adverse effects at effective doses (usually 45–90 mg/day) of

phenelzine include postural hypotension, sedation, sexual dysfunction, and weight gain.

Nevertheless, patients who find their response to phenelzine to be superior to their response to

other treatments are often more than willing to put up with its drawbacks.

Two reversible inhibitors of monoamine oxidase (RIMAs), brofaromine and moclobemide, are

selective for its A isoenzyme. These medications have fewer side effects, a much lower risk of

hypertensive crisis, and consequently less restrictive dietary precautions. Brofaromine has been

shown to be effective for social anxiety in three controlled trials, but it has never been marketed.

Moclobemide, which has been widely marketed outside of the United States, has appeared

moderately efficacious in three out of five placebo-controlled trials (Bonnet 2003). Meta-analyses

have found that moclobemide is significantly less efficacious than the SSRIs and the irreversible

MAOIs (Blanco et al. 2003).

Beta-Adrenergic Blockers

Beta-blockers, although appearing effective for performance anxiety in numerous nonpatient

samples, have not proven superior to placebo in several controlled trials in patients with primarily

the generalized subtype of social anxiety disorder (e.g., Liebowitz et al. 1992). Despite these

findings, beta-blockers such as propranolol appear to be clinically effective when used in single

doses (10–40 mg for propranolol) as needed for performance anxiety. It is possible that their utility

is greatest in nongeneralized social anxiety disorder, where autonomic arousal symptoms are most

prominent, and for this reason did not emerge in studies including mainly persons with generalized

social anxiety disorder.

Propranolol is typically given in a 10- to 40-mg dose 1 hour prior to the performance situation, and

effects typically last a few hours. Patients may be encouraged to first take a test dose at home to

allay any fears about tolerability and to test whether dosage is adequate to block an

exercise-induced increase in heart rate.

Buspirone

Buspirone has appeared ineffective at low dosages ( 30 mg/day) in controlled trials for social

anxiety disorder (Van Vliet et al. 1997) and for musicians with performance anxiety and

predominantly nongeneralized social anxiety disorder (D. B. Clark and Agras 1991). Open trial data

(Schneier et al. 1993) suggest that buspirone may be more effective at dosages greater than or

equal to 45 mg/day or as augmentation of partial responders to SSRIs.Print: Chapter 30. Social Anxiety Disorder and Specific Phobias http://www.psychiatryonline.com/popup.aspx?aID=258254&print=yes…

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Gabapentin and Pregabalin

The anticonvulsant gabapentin and its analogue pregabalin have each appeared efficacious in a

single controlled trial. Although gabapentin response was superior to placebo, only 32% of patients

randomized to gabapentin were judged responders (Pande et al. 1999), suggesting that

gabapentin’s efficacy may be modest.

Other Agents

More limited data from open trials or very small controlled trials suggest possible efficacy for

several other medications, including the antidepressants nefazodone, mirtazapine, and bupropion;

the anticonvulsants topiramate and valproate; and the antipsychotic olanzapine. St. John’s wort did

not appear to be effective in a single controlled trial.

Treatment-Refractory Patients and Augmentation Strategies

Strategies for medication treatment of nonresponders to an initial agent have been little studied in

social anxiety disorder. Patients not responding to an initial trial of an SSRI may benefit from a

longer duration of treatment (D. J. Stein et al. 2003), particularly if comorbid major depression is

present (Schneier et al. 2003). Partial responders to SSRIs are commonly augmented with

benzodiazepines, buspirone, or gabapentin. Nonresponders to an SSRI trial may be switched to

another SSRI, venlafaxine, a benzodiazepine, gabapentin, or an MAOI (after an appropriate

washout period).

Topical and Surgical Treatments of Physical Symptoms

Several reports have suggested that direct treatment of embarrassing physical symptoms may be

helpful in patients with social anxiety disorder with prominent sweating (hyperhidrosis) or

blushing. Social anxiety disorder with prominent hyperhidrosis has been reported to benefit from

topical application of 20% aluminum chloride in 93% anhydrous ethyl alcohol to affected skin area

for 3 consecutive nights followed by weekly maintenance applications (Bohn and Sternbach 1996).

A surgical approach to hyperhidrosis and pathological blushing, endoscopic thoracic

sympathicotomy, has been reported to benefit treatment-refractory social anxiety disorder in an

open case series (Telaranta 1998), but compensatory sweating (gustatory or lower extremity)

sometimes occurs, and long-term outcome has not been well studied.

Comparison and Integration of Medication and Cognitive-Behavioral

Therapies

Meta-analyses suggest that pharmacological treatments produce equivalent (Gould et al. 1997) to

superior (Fedoroff and Taylor 2001) effects at posttreatment relative to cognitive-behavioral

treatments for social anxiety disorder. Heimberg et al. (1998) compared CBGT with the MAOI

phenelzine and two control conditions. After 12 weeks, CBGT and phenelzine produced equivalent

response rates (CBGT, 75%; phenelzine, 77%), which were superior to those of control conditions.

Although phenelzine produced more immediate gains and greater effects on some measures, CBGT

patients (17%) were less likely than phenelzine patients (50%) to relapse over the course of 6

months of maintenance treatment and 6 months of follow-up (Liebowitz et al. 1999). D. M. Clark et

1. (2003) found that among individuals with generalized social anxiety disorder, individual CBT

based on the model proposed by D. M. Clark and Wells (1995) was superior at posttreatment and

1-year follow-up to fluoxetine plus instructions for self-directed exposure and placebo plus

instructions for self-directed exposure. There were no differences between the fluoxetine and

placebo conditions in this study.

The utility of combining CBGT and pharmacological treatment has been evaluated in several

investigations. Heimberg et al. (1998) conducted a multisite study comparing phenelzine, CBGT,

their combination, and pill placebo. Preliminary results suggested that the combination of

phenelzine and CBGT was more likely to be superior to placebo than either phenelzine or CBGT

alone (Heimberg 2002). Davidson et al. (2004) conducted a similarly designed study using the SSRI

fluoxetine and found all treatments superior to placebo and no advantage to combining fluoxetinePrint: Chapter 30. Social Anxiety Disorder and Specific Phobias http://www.psychiatryonline.com/popup.aspx?aID=258254&print=yes…

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and cognitive-behavioral treatment. Finally, Blomhoff et al. (2001) reported that the SSRI

sertraline, exposure treatment, and their combination were superior to placebo at posttreatment,

but that only the combination of sertraline and exposure was significantly better than placebo after

24 weeks. One-year follow-up suggested that only patients who received exposure alone continued

to improve, whereas patients who received sertraline with or without exposure tended to give up a

portion of their gains (Haug et al. 2003). In light of findings reported by Liebowitz et al. (1999)

that patients receiving CBGT evidenced lower relapse rates than patients receiving phenelzine, our

research team currently is investigating whether cognitive-behavioral treatment provided upon

discontinuation of paroxetine will reduce relapse rates further.

Treatment Selection

Investigations into the management of social anxiety disorder have provided several useful points

for approaching treatment selection. CBT has the advantage of producing more enduring

improvement than medication therapies (an important consideration in this highly chronic

condition), and it has safety advantages, especially in women who are considering pregnancy or

breast-feeding, and in medically ill patients.

Medication may be the preferred first-line treatment option for social anxiety disorder under

conditions that compromise a patient’s ability to participate in CBT (unavailability of a CBT-trained

clinician, patient preference for medication, very severe social anxiety disorder, or social anxiety

disorder comorbid with severe depression), situations demanding more rapid response, or history

of nonresponse to adequate CBT. For those persons whose feared situations are encountered only

infrequently (e.g., giving a toast at a wedding), a medication that can be taken as needed may be

the most efficient treatment.

Combined medication and CBT treatment may yield synergistic benefits for some patients, although

further study is needed to delineate how best to combine treatments and which patients will

benefit. Combination of psychodynamic or interpersonal approaches with CBT has not been studied.

Its hypothetical benefit of addressing social anxiety problems at multiple levels must be weighed

against the difficulty patients may experience trying to integrate these very different

conceptualizations. Given the limited evidence for superiority of combined approaches, initiating

treatment with a single modality seems prudent in general.

SPECIFIC PHOBIAS

The specific phobias, formerly known as simple phobias, remain a heterogeneous grouping, linked

by excessive or unreasonable fear of circumscribed objects or situations that is unrelated to fear of

unexpected panic attacks or fear of embarrassment. Specific phobias often accompany other more

severe psychiatric diagnoses in individuals who present for treatment. The clinician should make

certain that the presenting symptomatology is in fact best categorized as a specific phobia rather

than as panic disorder or another diagnosis. For example, many agoraphobic patients also avoid

specific phobic situations, such as elevators or heights, out of fear that they will have a panic

attack, in which case the more clinically meaningful diagnosis would be panic disorder.

Cognitive-Behavioral Therapies

Cognitive-behavioral approaches, particularly in vivo exposure, have demonstrated greater efficacy

than any other treatment approaches for specific phobias.

Exposure Treatments

In vivo exposure is by far the most studied and effective treatment for specific phobias, and it

should be considered the first-line treatment. Much of the research literature has focused on the

identification of elements of exposure that lead to the fastest and most effective treatment for

specific phobias.

Modeling in the form of observing another patient receive treatment prior to the patient’s own in

vivo exposure has been shown to enhance the effects of in vivo exposure and increase the speedPrint: Chapter 30. Social Anxiety Disorder and Specific Phobias http://www.psychiatryonline.com/popup.aspx?aID=258254&print=yes…

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with which positive outcomes are attained (Gotestam and Berntzen 1997). Therapist-directed in

vivo exposure is generally more effective than self-directed manual-based exposure (Öst et al.

1991), with treatment gains enduring at 1 year follow-up (e.g., Öst et al. 1991) and 8-year

follow-ups (Gotestam and Berntzen 1997). Addition of self-directed in vivo exposure homework to

therapist-directed in vivo exposure treatment may increase the likelihood, speed, and durability of

treatment gains.

Several investigations have attempted to determine the minimum number of sessions necessary to

produce treatment gains. Multiple exposure sessions are generally considered more effective than a

single exposure session and may produce greater treatment effects immediately following

treatment (Hellström et al. 1996). However, single-session in vivo exposure has produced favorable

outcomes at posttreatment and 1-year follow-up for persons with spider phobia, blood–injury

phobia, injection phobia, claustrophobia, flying phobia, and small animal phobia (see Öst 1997 for a

review). Maintenance programs may improve treatment gains and durability of one-session

treatments (Hellström et al. 1996). A related question is the spacing of exposure sessions.

Chambless (1990) compared the effects of 10 daily and 10 weekly in vivo exposure sessions for

specific phobias and found no differences at posttreatment or 6-month follow-up on outcome or

attrition.

Immersive computer-generated virtual reality exposure (VRE) involves the three-dimensional

simulation of feared situations. The salience of virtual environments can be augmented by

instructing patients to touch real objects (e.g., toy spiders) that correspond with the virtual

environment (see Rothbaum et al. 2000). Rothbaum et al. (1995) conducted the first randomized

controlled trial comparing VRE with a wait-list control condition for acrophobia and, despite a small

sample size (n = 17), demonstrated positive effects. Rothbaum et al. (2000) more recently

compared anxiety management training plus VRE, anxiety management training plus in vivo

exposure, and a wait-list control condition for fear of flying. VRE and in vivo exposure resulted in

equivalent gains, which were maintained at 6-month follow-up (n = 45) and 12-month follow-up

(n = 24) (Rothbaum et al. 2002). Maltby et al. (2002) compared VRE with an attention group

therapy control condition for fear of flying and reported that VRE produced gains that were superior

to the control condition on measures of flight anxiety and on rates of clinically significant change.

These gains were not maintained at 6-month follow-up.

Applied Relaxation

In a controlled study of the application of applied relaxation to specific phobias (Öst et al. 1982),

applied relaxation was as effective as in vivo exposure and superior to delayed treatment for

claustrophobia. Persons with claustrophobia who demonstrated higher levels of physiological

reactivity than behavioral avoidance responded more favorably to applied relaxation than to in vivo

exposure.

Applied Tension

Applied tension was designed specifically to treat the parasympathetic arousal (i.e., dilation of

blood vessels, drop in blood pressure, slowed heart rate, constricted airways) that is unique to

blood–injection–injury phobia. Applied tension requires patients to tense muscles in the presence

of phobic stimuli in order to elevate blood pressure and thus contains an exposure component. In

an uncontrolled study, persons with phobias for blood, wounds, and injuries responded equally well

to applied tension, applied relaxation, and their combination at posttreatment and at 6-month

follow-up (Öst et al. 1989), although the effects of applied tension were achieved in half the

number of sessions. Dismantling studies have attempted to parse the effects of muscle tension from

those of the exposure component of applied tension (Hellström et al. 1996). Persons treated with

applied tension and tension only evidenced similar gains at posttreatment and 1-year follow-up,

and these gains were superior to those produced by in vivo exposure. Moreover, the effects of

applied tension and tension only may be achieved in one session (Hellström et al. 1996).

Cognitive RestructuringPrint: Chapter 30. Social Anxiety Disorder and Specific Phobias http://www.psychiatryonline.com/popup.aspx?aID=258254&print=yes…

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The cognitive model of specific phobia posits that irrational thoughts are responsible for the

development of the phobias, maintain avoidance behavior, and contribute to physiological

symptoms. A number of studies have provided evidence suggesting that persons with specific

phobias have phobia-specific irrational beliefs (e.g., Thorpe and Salkovskis 1995). When combined

with exposure to feared stimuli, cognitive restructuring may be useful. However, there are

relatively few studies of cognitive treatments for specific phobias.

Psychodynamic and Other Psychotherapies

Although behavioral therapies are considered the treatment of choice for specific phobias, there is

some evidence for efficacy of other psychotherapies. Klein et al. (1983) found psychodynamic

supportive psychotherapy to be as effective as systematic hierarchical desensitization in the

treatment of specific phobias over 26 weeks of once-weekly treatment. Because 80% of the

patients in each group showed moderate to marked improvement, the investigators concluded that

psychodynamic psychotherapy served as an instigator for self-exposure, leading to specific

improvement in phobic symptoms. A few controlled studies that examined hypnotic suggestion

alone or in combination with behavioral techniques found some evidence for its effectiveness for

hypnotizable subjects (Stanley et al. 1990). Uncontrolled and controlled studies of eye movement

desensitization and reprocessing (EMDR) for specific phobias demonstrated some improvement in

phobic symptoms, although EMDR was less effective than behavior therapy in two comparative

trials (as reviewed by De Jongh et al. 1999).

Despite a paucity of controlled studies, a variety of psychotherapeutic techniques, including

psychoeducation, psychodynamic interpretation, supportive persuasion, and hypnosis, may diminish

fear and anxiety, instill hope and a sense of self-efficacy, and facilitate exposure to avoided

situations. Exploring the specific phobia as a possible expression of and defense against other

unrecognized, more diffuse fears may serve to relieve anxiety, diminish fear of the actual phobic

object, and thereby facilitate self-exposure (Gabbard 2005). Specific phobias usually date to

childhood and may be connected to other developmental issues. When the patient can recall a

traumatic event associated with the onset of the phobia, reframing the phobia as an understandable

yet maladaptive reaction to the event may facilitate treatment.

Medication and Combined Therapies

Only a handful of studies have investigated medication treatments for persons with a specific

phobia. Most of these medication studies have investigated whether drug treatment can enhance

the efficacy of exposure therapy. Beta-blockers reduce sympathetic arousal in anticipation of and

during exposure, but they do not appear either to diminish subjective fear or to facilitate approach

(e.g., Campos et al. 1984). Imipramine treatment combined with behavioral or supportive dynamic

psychotherapy did not contribute significantly to the efficacy of either (Zitrin et al. 1983).

Benzodiazepines, on the other hand, may have a modest role in treatment of specific phobias.

Several studies have shown that diazepam facilitates approach to the phobic situation and possibly

enhances the therapeutic effects of exposure. Marks et al. (1972), for example, found that a waning

dose of diazepam (0.1 mg/kg, given 4 hours before a 2-hour exposure) was more effective than

placebo in acutely reducing both fear and avoidance. Higher doses may retard the desensitization

process, however, by dissociating the learned experience from the drug-free state. In all studies,

the therapeutic effect of exposure itself was much larger than drug–placebo differences.

A novel experimental strategy employed the medication D-cycloserine to facilitate extinction of

acrophobia in patients undergoing behavioral exposure therapy (Ressler et al. 2004). This

medication is a partial agonist at the N-methyl-D-aspartate receptor, and it has previously been

shown to improve extinction of fear in rodents. Administered prior to each of two exposure

sessions, D-cycloserine was significantly superior to placebo in reducing acrophobia symptoms, and

these gains were maintained at 3-month follow-up. Attempts to replicate this approach are under

way.Print: Chapter 30. Social Anxiety Disorder and Specific Phobias http://www.psychiatryonline.com/popup.aspx?aID=258254&print=yes…

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Medications are most commonly useful on an as-needed basis for specific phobias that occur

predictably, such as a phobia of flying in airplanes. Short-acting benzodiazepines such as

alprazolam or lorazepam are commonly used in single or repeated doses for anticipatory anxiety

and during exposure to the feared situation. Dosage should be individualized to minimize sedation

while achieving sufficient relief of anxiety symptoms. Patients should be educated about the risk of

more regular use evolving into physical dependence, and small amounts of medication should be

dispensed at a time. For regularly occurring phobic situations, patients should be encouraged to

pursue preventive strategies, such as behavior therapy. Patients engaged in behavior therapy

should consider the possibility that concomitant benzodiazepines may interfere with full

effectiveness of exposure.

CONCLUSION

Recent studies have established the efficacy of several treatment techniques for both social anxiety

disorder and specific phobias. For treatment of social anxiety disorder, the best-established

approaches include CBT, SSRI medications, the MAOI phenelzine, and the benzodiazepine

clonazepam. Other medications and a variety of other psychotherapies, including social skills

training, psychodynamic, and interpersonal psychotherapies, may be beneficial but require further

study. Beta-adrenergic blockers appear to be clinically useful for nongeneralized social anxiety

disorder.

For specific phobias, behavioral therapies using exposure have established efficacy and are

generally the treatment of choice. Medications, in particular the benzodiazepines, may also be

helpful in certain cases but require further study. Other psychotherapies have also been reported to

be effective, largely on an anecdotal basis.

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