Treatment for Social Phobia

By | January 9, 2015


Effective pharmacological and psychological treatments of social phobia are available. At present, phenelzine is the pharmacological treatment of choice, and cognitive-behavioral group treatment is the psychological treatment of choice for the generalized subtype (). These treatments appear to be about equally effective and, when combined, may work better than either treatment alone. Evidence favoring such combined treatment is presently lacking so that clinical judgment, treatment availability, and patient preference must be considered. Medication may, by reducing anxiety, improve patient adherence to psychological treatment; psychological treatment may, on the other hand, improve the stability of treatment gains over the long run.

Treatment must take the individual characteristics of the social phobic and available treatment resources into account. Discrete phobics (e.g., public speaking, musical performing) who encounter phobic situations only occasionally may benefit from single doses of a beta-blocking drug (e.g., propranolol 40 mg) or a benzodiazepine (e.g., alprazolam 0.5 mg) taken an hour or more before their performance. They should then be encouraged to expose themselves to public speaking (e.g., toastmasters club) or performance situations and, as their comfort increases, to phase out medication (). Discrete social phobics also respond to exposure-based therapy.

Generalized social phobics or those with avoidant personality traits are more apt to benefit from medication taken on a regular basis. While phenelzine has established efficacy, the dietary restrictions (i.e., tyramine-free diet) and the risk of hypertensive crises are difficult for some patients to tolerate. Tricyclic antidepressants appear to lack efficacy and benzodiazepines have dependence potential (). Patients who take benzodiazepines before social encounters to increase their comfort may develop psychological dependence. The daily dose of phenelzine is similar to that used for depression but the dose of serotonin reuptake inhibitors may be higher than that for depression (e.g., fluoxetine 40-80 mg). The latter are well tolerated but often associated with sexual dysfunction.

Cognitive-behavioral therapy should be started at the same time medication is begun. Conducting this treatment in groups appears to be ideal because the group provides controlled exposure to a social situation in which feared activities can be rehearsed (e.g., conversation with someone of the opposite sex) and negative cognitions examined. This therapy combines exposure and cognitive restructuring, techniques that interact to give a superior result. Because of the unpredictable nature of social interactions, graded exposure (i.e., gradually increasing intensity) may be difficult to arrange, and patients may avoid cues in social situations. Consequently, patient effort and therapist guidance are especially important in this treatment endeavor.

Pharmacological treatment for Social Phobia

Beta-blocking drugs

The sympathetic activation that occurs in performance and competitive situations is mediated by beta-adrenergic receptors, and their peripheral manifestations (e.g., dry mouth, palpitations, sweating, blushing, tremor) may be reversed by beta-blocking drugs. For example, the cardiovascular reaction to public speaking, including tachycardia and increased systolic blood pressure, may be blocked by these agents (). On account of this, beta-adrenergic antagonists have been tried in situations where excessive physiological arousal might have a detrimental effect on performance (). Most studies compared the effect of single doses of drug or placebo on ratings of subjective distress and objective performance. Some found drug superior to placebo but others did not. In several studies, musicians reported feeling less anxious while performing on a beta-blocking drug (). Performance on stringed instruments, as assessed by blind raters, was superior on drug in some studies but this advantage tended to disappear after the first session. The widespread use of beta-blocking drugs among professional musicians suggests efficacy. In one survey 27% of musicians reported occasional use ().

Trials of beta-blocking drugs in social phobics have been disappointing. Falloon et al. (1981) found propranolol no better than placebo in a small number of social phobics who were also receiving social skills training. Although an open trial with atenolol was promising, the drug failed to show superiority in a placebo-controlled trial (). Nevertheless, social phobics of the discrete subtype (e.g., speaking or performing in public) may benefit from 20-80 mg propranolol taken an hour before speaking or performing. A fall in resting heart rate is an indicator of peripheral beta-blockade that correlates with relief of anxiety.

Benzodiazepines and azapirones

Open trials with high-potency benzodiazepines – alprazolam and clonazepamin social phobic patients were promising and led to controlled trials. The first of these, by Gelernter et al. (1991), showed alprazolam (mean 4.2 mg daily) to be more effective than placebo. Alprazolam was as beneficial as cognitive-behavioral therapy but less effective than phenelzine; however, when the drugs were discontinued, most patients on alprazolam relapsed whereas those on phenelzine maintained their improvement.

Convincing evidence for the efficacy of clonazepam came from a placebo-controlled trial by Davidson et al. (1993). In this study, 75 social phobics received clonazepam (mean 2.4 mg daily) or placebo. Response rates were 78% for clonazepam and 20% for placebo. Statistically significant effects were found as early as the first week on a global improvement measure and the second week using the Brief Social Phobia Scale (). As a group, patients on clonazepam were improved to the point that their mean social phobia score was close to that for the normal population. Clonazepam was said to be well tolerated, the most frequent side-effects being unsteadiness 30%, dizziness 29%, lack of orgasm 23%, bad taste 14%, and blurred vision 12%. When clonazepam was rapidly tapered (over 2 weeks) and discontinued, 74% of subjects relapsed.

Open trials of buspirone, an azapirone, show that this drug has modest efficacy in social phobia (). Munjack et al. (1991) reported that nine of 17 patients experienced at least moderate improvement after 8 weeks, and Schneier et al. (1993) found eight of 17 patients much improved after 12 weeks on a mean of 46 mg daily. A higher proportion of patients able to tolerate 45 mg or more daily (67%) were much improved.

Monoamine oxidase inhibitors

Studies in which phenelzine, a monoamine oxidase inhibitor, proved beneficial for mixed phobic and atypical depressives led to its trial in social phobia (). Three controlled studies have shown phenelzine to be superior to placebo (). In one of these, the overall response rate (among those who completed the trial) was 64% for patients receiving phenelzine compared to 23% for those on placebo. As a group, patients showed substantial reductions not only in fear but in avoidance of social activities. The mean dose of phenelzine was 76 mg daily with a range of 45-90 mg. As the number of subjects was small, the response of those with the discrete subtype could not be examined separately. When six patients, who had responded to phenelzine, were blindly switched to placebo after 16 weeks, two relapsed but four maintained their response.

Versiani et al. (1992) compared the response to phenelzine, moclobemide, and placebo in a 16 week trial. Moclobemide is a reversible inhibitor of monoamine oxidase that causes little potentiation of the presser response to tyramine. Consequently, dietary restrictions and the risk of hypertensive crises are less than with phenelzine or tranylcypromine. After 8 weeks, both active drugs were more effective than placebo, and patients on phenelzine were somewhat better than those receiving moclobemide. By 16 weeks further improvement had occurred in the moclobemide group, and by that time, 73% of subjects on phenelzine and 54% on moclobemide were much improved compared to 12% on placebo. Responders who were switched to placebo tended to relapse. Controlled trials of brofaromine, another reversible monoamine oxidase inhibitor, have also shown positive results ().

These favorable results, combined with the clear benefits from cognitive-behavioral treatment of social phobia, prompted an important well-designed study comparing these modes of treatment. This study was conducted in two sites, one which emphasizes pharmacological treatment and the other psychological treatment. Patients at both sites were randomized to pharmacological treatment (i.e., drug versus placebo) or psychological treatment (i.e., cognitive behavioral treatment versus education, supportive treatment). Preliminary results indicate that the active treatments were about equally effective with a slight edge going to phenelzine on some measures ().

Serotonin reuptake inhibitors

Open trials indicate that the serotonin reuptake inhibitors, fluoxetine and sertraline, may be useful for social phobia (). Ten of 16 patients treated with fluoxetine (mean 54 mg daily) responded to the drug (). Similarly, 16 of 22 social phobics given sertraline (mean 148 mg daily) responded. The most common adverse effects were gastrointestinal distress followed by increased nervousness and insomnia. In a controlled trial, van Vliet et al. (1994) found fluvoxamine, in a daily dose of 150mg, superior to placebo. Given the opportunity to continue medication after the trial, 14 of 16 elected to do so.

Psychological treatment for Social Phobia

A number of psychological treatments have been employed for social phobia, and some have proven more effective than others. The literature is growing rapidly in this area, and a number of reviews are available (). Although many important questions remain and more research needs to be done, cognitive-behavioral group treatment has emerged as the treatment of choice (); however, other approaches have application and should be considered in overall treatment planning.

Social skills training

Some social phobics have adequate skills for interacting but anxiety interferes. Others lack skills and become anxious in situations where their awkwardness is exposed (). To correct such deficits, social skills training was developed. Such training takes an educational approach. Targeted behaviors (e.g., conversing with others) are introduced, modeled by the therapist, then rehearsed by the patient. The therapist provides feedback and reinforcement, and the patient practices until he or she becomes skillful. Although a number of studies suggest benefit, they have mostly lacked controlled comparisons (). Also, attempts to show that skills training preferentially helped those with skills deficits have only been partly successful ().

Exposure in vivo

Freud observed that therapy for phobias makes little progress until the patient exposes him or herself to phobic situations. Exposure is now a well-established treatment for phobic disorders. It involves making a list of feared situations and establishing a hierarchy of the most feared to the least. Then, under the support and guidance of the therapist, a patient exposes himself to the least feared situation until he becomes comfortable before moving to the next. The patient is encouraged to remain in each situation until his or her anxiety declines, and in so doing, he or she learns to confront the situation without discomfort. In this way, negative reinforcement that maintains the disorder (i.e., relief of anxiety on leaving situations) is removed and anxiety extinguished. Application of this technique to social phobia has been recent, but a series of studies have shown exposure to be superior to relaxation training or information plus self-exposure instructions ().

Butler et al. (1984) compared exposure alone, exposure plus anxiety management (i.e., relaxation training, distraction techniques, rational self-talk), and wait-list condition in social phobics. Patients met with a therapist weekly for 7 weeks after which both exposure groups were significantly improved. After 6 months, the exposure plus anxiety management patients were doing better than those who had received exposure alone, which suggests that exposure by itself might not be the most effective approach. In doing this research, Butler (1985) observed several difficulties in carrying out exposure in social phobics. She noted that, because social situations are variable and unpredictable, it may be hard to arrange repetition of situations that have gradually increasing difficulty. In addition, she observed that many social encounters are brief and do not allow the required length of exposure. Finally, socially phobic individuals are preoccupied with the presumed negative evaluation of others but receive little feedback with which to correct misperceptions ().

Exposure plus cognitive restructuring

Treatments designed to modify maladaptive cognitions were shown to have a beneficial effect in social phobics, and this led to trials in which exposure and cognitive restructuring were combined (). Mattick & Peters (1988) compared exposure to exposure plus cognitive restructuring which they integrated with exposure procedures. Although patients who received exposure improved, those receiving the combined treatment did better. At follow-up, only 14% of patients who received the combined treatment reported avoidance of the target phobia, compared to 48% of the exposure only patients. In a second study, Mattick et al. (1989) again showed the advantage of combining exposure and cognitive restructuring over either treatment alone. Patients who received the combination showed significant reductions not only in phobic avoidance but also in negative self-evaluation and maladaptive beliefs.

Heimberg et al. (1990) developed a cognitive-behavioral group treatment. In groups, patients receive exposure to social situations in a controlled manner. Their cognitive-behavioral group treatment is administered in 12 weekly, two-and-a-half hour sessions in groups of six (). In the course of the treatment patients are taught the cognitive-behavioral model and shown how cognitive restructuring is achieved. They learn how to identify negative cognitions, how to challenge the logic behind these cognitions, and how to replace them with rational alternatives. Patients then confront feared situations, first as they are simulated in the group and then as homework assignments. While completing behavioral tasks (e.g., conversing with someone, giving a talk), patients are asked to monitor their anxiety and cognitions. At the same time they are encouraged to practice remaining in feared situations and using newly-formulated positive cognitions. Detailed descriptions of this technique are available ().

The results of cognitive-behavioral group treatment have been quite favorable (). For example, in a study comparing this treatment with group therapy that provided only education and support, 75% of the cognitive-behaviorally treated patients were clinically improved compared to 40% of patients receiving the control treatment. At 5 year follow-up, similar proportions of patients continued to show improvement and, on average, the cognitive-behaviorally treated patients showed few remaining symptoms while the control group treated patients were rated as requiring further treatment. Thus, exposure appears to be most effective when combined with cognitive restructuring, as in this group treatment ().

Pharmacological versus psychological and combined treatments

Several studies have compared the efficacy of pharmacological and cognitive-behavioral interventions or a combination of the two (). In reviewing four of these, Heimberg (1993) noted that little could be concluded except that cognitive-behavioral treatment appears to be as effective as pharmacological therapy. With two exceptions, these studies used drugs (i.e., propranolol, atenolol and buspirone) that were less effective than phenelzine. The two studies that examined combined psychological and pharmacological interventions did not show added effectiveness (). Here too, both employed relatively ineffective drugs and treated small samples.

The most recent study comparing phenelzine, placebo, cognitive-behavioral treatment, and psychological placebo therapy (i.e., education and group support) is nearing completion. As previously described this large study was conducted in two sites known for their expertise and research in pharmacological and psychological therapies. Over 130 patients were enrolled in this study which lasted 12 weeks. Patients who responded to acute treatment were followed for 6 months on maintenance treatment, then for 6 months maintenance free (i.e., no treatment). Preliminary results indicate that the active treatments were about equally effective at the end of the acute phase.

Enormous progress has been made in the diagnosis and treatment of social phobia since its first appearance in the official classification less than two decades ago. The development of effective treatment for such a widespread and disabling condition is a great triumph.

Selections from the book: “The anxiety disorders” (1998)