Social phobia. Longitudinal course and long-term outcome of cognitive-behavioral treatment

Interest in social phobia has increased dramatically in the past decade, and our knowledge of this previously understudied disorder has increased as well. We now know that social phobia is a chronic condition and that patients with this disorder are unlikely to experience significant improvement without intervention. It is also a highly prevalent condition affecting as many as 13% of the adult population of the Unites States. Although our understanding of the causes of social phobia remains limited, we do know that it is associated with serious impairment and disability in multiple spheres. Thus, the development of treatments with proven long-term efficacy is an important research goal. In this article, we have reviewed studies that examined either exposure, cognitive restructuring, social skills training, or some combination of these treatments. Here, we summarize the major findings of this review. Exposure has fared well as a treatment for social phobia and, in every case, within-group analyses show that patients have improved after treatment. Methodologic problems in some studies, however, limit the conclusions that can be drawn about the comparative efficacy of exposure, social skills training, and relaxation therapy. Conceptual models of social phobia have stressed the importance of cognitive processes in the development and maintenance of social phobia and much attention has been directed at the long-term efficacy of cognitive-behavioral techniques. It has been hypothesized that exposure plus cognitive restructuring would be a particularly effective combination and several methodologically sound studies have examined this combination. These studies have demonstrated consistently clinically significant within-group changes and superiority to control conditions. Heimberg's CBGT is probably the most widely studied of these treatments. CBGT has been shown to be more effective than an equally credible attention-placebo group. Patients receiving CBGT have maintained their advantage over patients in the attention-placebo group, even 5 years after treatment although flaws in that follow-up study limit generalizability of its results. Generalized and nongeneralized social phobic patients respond equivalently to this highly integrated treatment, and it has been applied effectively by researchers outside the center where it was developed. Despite the successes of combined exposure and cognitive restructuring treatments, it remains unclear as to what the effective component(s) of these and similar treatments are and, therefore, whether or not the integration of therapy components is really necessary. A number of the studies reviewed addressed this question with mixed results. Three studies showed that the combination therapy was superior to either treatment alone. There is also evidence that patients treated with exposure only may show some deterioration during follow-up whereas patients treated with cognitive restructuring and exposure may continue to improve. Still, other studies found no differences in long-term outcome among exposure alone, RET, or the combined treatment. Hope et al found that exposure alone was as effective as an integrated treatment combining exposure and cognitive restructuring (CBGT), and Taylor and colleagues (submitted for publication, 1995) reported that exposure was not enhanced by initial treatment with cognitive restructuring. These results are disappointing in light of all that has been written about the likely benefits of combining cognitive and behavioral therapy in the treatment of social phobia. For example, it has been hypothesized that fear of negative evaluation is a key factor in social phobia and that change in this construct should be the goal of treatment. There is some research that supports this claim and other evidence that suggests that exposure alone is not particularly effective in producing those changes. Butler concluded that the treatment of social phobia is made more difficult whe