Individuals with social phobia fear one or more social or performance situations because of a concern of being humiliated or embarrassed by performing poorly or displaying visible anxiety symptoms in front of others (APA, 2000). The social phobia may be generalized, in which the individual fears a multitude of social and performance situations, or it may be nongeneralized, in which only one or two social or performance situations are feared. The prevalence rate for social phobia has been found to be 13% (Kessler et al., 1994). The age of onset of social phobia is usually in the midteens, with a mean age of onset of approximately 16 (Barlow, 2002; Ost, 1987). Social phobia is typically more prevalent in women than in men, with the female-to-male ratio being approximately 3:2 (Den Boer, 2000; Kessler et al., 1994).
Several treatments for social phobia have been found to be effective, including exposure, cognitive restructuring, social skills training, and psychopharmacology. Al-Kubaisy et al. (1992) found clinician-accompanied exposure and self-exposure to be superior to self-relaxation with no exposure. In a comparison of cognitive therapy and social skills training to supportive therapy, cognitive therapy with social skills training was found to be superior to supportive therapy (Cottraux et al., 2000).
A combined treatment, cognitive behavior group therapy (CBGT), has shown promising results (Gelernter et al., 1991; Heimberg et al., 1990). CBGT has three primary components: exposure to feared social situations in session, cognitive restructuring, and homework assignments for in vivo exposure and associated cognitive resturcturing (Turk, Heimberg, & Hope, 2001). The group is designed to meet for 12 weekly 2--hour sessions. In a study conducted by Heimberg et al. (1990), CBGT was compared to an educational-supportive treatment. Results indicate that individuals receiving CBGT were less impaired, reported less anxiety, showed increases in positive cognitions, and showed decreases in negative cognitions. These improvements were also maintained at 6-month follow-up.
Several studies have also examined the effectiveness of medication for social phobia. Gelernter et al. (1991) compared CBGT, alprazolam, phenelzine, and placebo plus self-directed exposure. Results found no differences between groups on self-report measures of social avoidance, distress, fear of negative evaluation, and positive and negative self-statements, with all groups showing clinically significant improvements. When comparing the medication groups, the alprazolam- and phenelzine-treated patients were significantly less impaired, at posttest than the placebo-treated group. However, at the 2-month follow-up, after discontinuation of the medicine, only the phenelzine-treated group remained less impaired, while the alprazolam-treated group was no different than the placebo-treated group. In contrast, the CBGT-treated group showed clinically significant improvement at posttest and even greater improvement among the CBGT-treated group, while the alprazolam group showed initial improvement at follow-up. Thus, CBGT and phenelzine show maintenance of the therapeutic gains at follow-up, with even greater improvement among the CBGT-treated group, while the alprazolam shows initial improvement at posttest but demonstrates a relapse response at follow-up.
Another study compared the effectiveness of cognitive therapy with fluoxetine (Clark et al., 2003). There were three treatment conditions: cognitive therapy, fluoxetine plus self-exposure, and placebo plus self-exposure. The components of cognitive therapy included role-playing, addressing dysfunctional assumptions, video feedback, and in vivo exposure. Results indicate that all groups showed substantial improvement, but the cognitive therapy condition was superior to the fluoxetine plus self-exposure and to the placebo plus self-exposure conditions. The fluoxetine and placebo groups did not differ. Further, cognitive therapy remained superior to the fluoxetine plus self-exposure group at 12-month follow-up. Thus, cognitive therapy was shown to be effective in reducing fear and avoidance in social phobics at posttest and after
1 year. Fluoxetine itself was not found to be any more effective than placebo in the treatment of social phobia.
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