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Psychological Medicine (2008), 38, 3–14. f2007CambridgeUniversity Press INVITEDREVIEW
doi:10.1017/S0033291707000918 Printed in the United Kingdom
Empirically supported psychological interventions
for social phobia in adults: a qualitative review
of randomized controlled trials
1 2
K. Ponniah * and S. D. Hollon
1 New York State Psychiatric Institute, New York and Department of Psychiatry, Columbia University, New York, NY, USA
2 Department of Psychology, Vanderbilt University, Nashville, TN, USA
Background. Social phobia is a chronic disorder that results in substantial impairment. We conducted a qualitative
review of randomized controlled trials (RCTs) of psychological interventions for social phobia.
Method. Articles were identified through searches of electronic databases and manual searches of reference lists. They
were classified by psychological interventions evaluated. Data regarding treatment, participants and results were then
extracted and tabulated. We identified which psychological interventions are empirically supported, using the scheme
proposed by Chambless & Hollon (Journal of Consulting and Clinical Psychology 1998, 66, 7–18).
Results. Thirty studies evaluating the efficacy of social skills training (SST), exposure therapy and/or cognitive treat-
mentswereidentified.Cognitivebehaviortherapy(CBT),involvingcognitiverestructuringandexposuretofearedand
avoided social situations or behavioral experiments, was found to be an efficacious and specific treatment for social
phobia. Exposure therapy was found to be an efficacious treatment since most of the evidence of its efficacy was from
comparisonswithnotreatment.ThereweremixedfindingsregardingtherelativeefficacyofCBTandinvivoexposure.
Somestudiesreported that the interventions were equivalent, while others found that patients treated with CBT had a
better outcome. There was little evidence to support the use of SST.
Conclusions. CBT is the psychological intervention of choice for social phobia. The findings of this review are com-
pared to those of other major reviews and limitations are discussed.
Received 25 July 2006; Revised 26 April 2007; Accepted 1 May 2007; First published online 20 July 2007
Keywords: Empiricallysupportedpsychologicalinterventions,qualitativereview,randomizedcontrolledtrials,social
phobia.
Introduction generalized social phobia and co-morbid avoidant
Social phobia is characterized by a marked and personality disorder (Kessler, 2003).
persistent fear of social or performance situations The efficacy of psychological treatments for social
in which the person may be scrutinized by others phobia has been addressed in several reviews (e.g.
and fears coming across in way that would be embar- Chambless et al. 1998; DeRubeis & Crits-Christoph,
rassing or humiliating (APA, 1994). It is a chronic 1998; Chambless & Ollendick, 2001; Roth & Fonagy,
disorder, which usually begins in early adolescence 2005). Nonetheless, differing opinions exist as to what
and results in considerable impairment that increases constitutes sufficient evidence to consider a practice
overanindividualslifespan(Wittchen&Fehm,2003). evidence-based. Roth&Fonagy(2005,p.480)required
A lifetime prevalence ranging from 3% to 13% has replicated demonstration of superiority to a control
been reported by epidemiological and community condition or another treatment condition, or a single,
studies (APA, 1994). Effects on role functioning and high-quality randomized control trial (RCT), in ad-
quality of life are most severe for people with dition to other criteria. In contrast, Chambless &
Hollon (1998) differentiated efficacious and specific,
efficacious, and possibly efficacious therapies. Ac-
cording to these criteria, for a designation of effi-
* Address for correspondence: Dr K. Ponniah, Redhill Reigate & cacious and specific, the therapy must have been
Horley Primary Care Mental Health Team, Surrey and Borders shown to be statistically significantly superior to pill
Partnership NHS Trust, Shaws Corner, Blackborough Road, Reigate,
Surrey, RH2 7DG, UK. or psychological placebo or to an alternative bona
(Email: kathrynbetts@hotmail.com) fide treatment in at least two independent research
4 K. Ponniah and S. D. Hollon
settings (p. 18). If the therapy proved more beneficial Results
than no treatment in at least two settings, it would be Thirty studies were identified that met our inclusion
considered efficacious. If there was only one study criteria. These studies evaluated the efficacy of social
supporting the therapys efficacy, or all the research skills training (SST) (n=2), exposure therapy (n=
has been conducted in one setting, the therapy would 15), and cognitive treatment (n=25) for social
be considered possibly efficacious, pending repli- phobia (see Fig. 1). A number of trials investigated
cation. DeRubeis & Crits-Christoph (1998) used these more than one intervention. There were no trials
criteria. involving more traditional dynamic or humanistic
In this article, we review studies of psychological approaches.
interventionsforsocialphobiainadultsandprovidean
updateonwhichonesareempiricallysupported,using
the scheme proposed by Chambless & Hollon (1998). SST
This is a qualitative review, not a meta-analysis. The skills deficit model proposes that some forms of
psychiatric disorder are caused or worsened by lack of
Method social competence,andcanbetreatedthroughtraining
in social skills (Trower et al. 1978). SST for social pho-
A literature search for trials of psychological inter- bia involves identifying, discussing, and practicing
ventions for social phobia published up to the end of feared situations. Behavioral modification techniques
2005 was conducted. Articles were identified through include the provision of instructions, modeling, role-
electronic searches of the PsycINFO and PubMed rehearsal and feedback (Stravynski et al. 1982, 2000).
databases. A search strategy containing the following Patients are encouraged to practice the skills they have
key words and combinations was used: (SOCIALPHOBIA learned in natural settings between sessions (Ost et al.
or SOCIAL ANXIETY DISORDER) and (RANDOM, RANDOMLY, 1981).
RANDOMISE, RANDOMIZE, RANDOMISED,orRANDOMIZED). The In RCTs, SST has been compared to behavioral
PubMed database was also searched for RCTs that treatment without training in social skills and SST
contained the terms SOCIAL PHOBIA or SOCIAL ANXIETY with cognitive modification. An overview of these
DISORDER. Manual searches of the reference lists of studies is presented in Table 1. In these trials, SST was
articles and chapters were also conducted. The first conducted over a mean of 13 sessions (range 12–14).
author completed the literature search. Stravynski et al. (2000) reported that the rates of
Studies were included if they satisfied the following patients in remission following an intervention fo-
criteria: (1) evaluated the treatment of adult patients cused on improving interpersonal relationships with
with a diagnosis of social phobia; (2) randomly allo- SSTwereequivalenttothosefollowinganintervention
cated patients to psychological treatment or a no focused on improving interpersonal relationships
treatment, placebo or alternative treatment condition; without SST. SST may produce improvement in
(3) provided a clear description of the treatment social phobia because of the opportunity it provides
method;and(4)werewritteninEnglish.Studieswere for practice of previously avoided social responses
excluded if they satisfied any of the following criteria: in a non-threatening environment (Spence, 1994,
(1) evaluated the efficacy of psychological treatment p. 266).
in a mixed sample of patients without examining
diagnostic groups separately; (2) selected patients on Exposure therapy
the basis of them being suitable for a particular
intervention; and (3) compared patients on the basis Learning theory postulates that the origin of neuroses
of them being a particular type of responder (e.g. can be dated back to a particular occasion of immense
behavioral) in a test. distress or the repeated arousal of anxiety in a recur-
Articles were obtained, read and classified on ring situation, and stimuli comparable to those in the
the basis of which psychological interventions were precipitating situations can later evoke phobic reac-
evaluated. Data regarding treatment, participants and tions (Wolpe, 1973). Extinction is the progressive
results were then extracted and tabulated. Studies weakening of a habit though the repeated evocation
werereviewedwithaparticularfocusoncomparisons without reinforcement of the responses that manifest
betweenpsychologicalinterventions and notreatment it (p. 19). The paradigm of experimental extinction
or minimal treatment, psychological or pill placebo, generated exposure techniques. Exposure treatment
and pharmacological or other psychological treat- for social phobia involves constructing and then
ments. Finally, we identified which psychological working through a hierarchy of feared social and per-
interventions are empirically supported, using the formance situations, starting with the least anxiety-
scheme proposed by Chambless & Hollon (1998). provoking situation and remaining in it until fear has
Psychological interventions for social phobia 5
Psychological
treatments for
social phobia
Social skills Exposure Cognitive
training therapy treatment
Social skills Exposure with Rational Self- Exposure in Symptom Rational emotive Cognitive therapy
training plus anxiety emotive instructional combination with prescription with therapy, social including
cognitive management therapy training cognitive reframing skills training and behavioral
modification restructuring exposure experiments
Fig. 1. Classification of psychological treatments for social phobia in randomized controlled trials.
decreased before moving on to the next situation. in assessment and exposure therapy for social
Flooding is the intensive application of exposure. phobia provided the treatment (Haug et al. 2000).
In RCTs, exposure therapy for social phobia has Markedly more sertraline- than non-sertraline-treated
been evaluated against the effects of no treatment, patients responded but no marked difference was
relaxation training, pill placebo, pharmacological observed between exposure- and non-exposure-
treatment, and cognitive therapy (CT). An overview of treated patients (Blomhoff et al. 2001). Nevertheless,
thesestudiesispresentedinTable1.Exposuretherapy quality of implementation was not measured. From
in these trials was conducted over a mean of 12 the end of treatment to 6-month follow-up, however,
sessions (range 6–20). patients who had been treated with exposure therapy
Exposure to feared social and performance situ- plus placebo showed further improvement, whereas
ations has been showntoproducesignificantlygreater patients who had been treated with exposure therapy
improvements in social phobia symptoms than a combined with sertraline or sertraline plus general
waiting-list control condition (Butler et al. 1984; Hope medical care showed a tendency to deteriorate (Haug
et al. 1995; Mersch, 1995; Salaberria & Echeburua, et al. 2003).
1998;Hofmann,2004;Hofmannetal.2004).Follow-up
assessments up to 18 months after treatment have Cognitive treatment
shownthat the gains patients make in exposure treat-
ment are largely maintained (Butler et al. 1984; Hope According to cognitive theory, exaggerated fear of
et al. 1995; Mersch, 1995; Salaberria & Echeburua, being the focus of attention, of having ones weak-
1998). Not only do fear and avoidance decrease over nesses exposed, and as a result being judged nega-
the course of treatment, but in some studies there is tively by others leads to social anxiety (Beck et al.
evidence of cognitive change over exposure treatment 1985). A vicious cycle is created whereby the antici-
too (Mersch, 1995; Salaberria & Echeburua, 1998; pation of an absolute, extreme, irreversible outcome
Hofmann, 2004). tends to make a person more fearful, defensive, and
In one trial, flooding was shown to be superior to inhibited when entering the situation (p. 151).
pill placebo on self-reported social avoidance and In RCTs, the efficacy of cognitive interventions has
distress, whereas atenolol, a beta-blocker, was not been evaluated against the effects of no treatment,
(Turner et al. 1994). Independent evaluators judged supportivetherapy,relaxationtraining, SST, symptom
flooding patients, but not atenolol patients, to be prescription, exposure therapy, pill placebo and
markedly more improved, have less symptomatology pharmacological treatments. An overview of these
and avoid less social interactions than placebo studiesispresentedinTable1.Cognitiveinterventions
patients. Onanimpromptuspeechtask,patientsinthe in these trials were conducted over a mean of 12
flooding group reported significantly more improve- sessions (range 3–20).
mentindistress and positive and negative thoughts at Some studies have examined the benefit of adding
theendoftreatmentthanthoseintheotherconditions. cognitive techniques to behavioral treatments. SST,
Blomhoff et al. (2001) examined the efficacy of alone or in combination with cognitive modification
sertraline, exposure therapy and combined treatment has been evaluated in patients with diffuse social
in generalized social phobia. General practitioners phobia and avoidant personality disorder (Stravynski
whohadreceived approximately 30 hours of training et al. 1982). Both interventions produced significant
6
K.
a Ponniah
Table 1. Psychological treatments for social phobia
Study Treatment/s Results and
Stravynski et al. (1982) Social skills training (SST) or SST plus cognitive modification (SST-CM) SST and SST-CM patients improved to a similar extent S.
Butler et al. (1984) Exposure with anxiety management (E-AM) or E with associative E-AMandEwerebetterthanWL,andE-AMwassuperiortoE D.
therapy (E) Hollon
Emmelkampetal. (1985) Exposure (E) or rational-emotive therapy (RET) or self-instructional RETwassuperiortoSITonphobicanxiety
training (SIT)
Mattick & Peters (1988) Exposure (E) or E and cognitive restructuring (E-CR) End-state functioning significantly better in E-CR than E
Clark & Agras (1991) Cognitive behavior therapy with placebo (CBT-P) or CBT with buspirone Subjective anxiety during a musical performance and a speech reduced
(CBT-B) or buspirone (B) significantly more in CBT with B or P than B or P only
Gelernter et al. (1991) Cognitive-behavioraltherapy(CBT)orphenelzineandself-exposure(P-SE) All groups improved comparably on self-report measures with one
or alprazolam and SE (A-SE) exception – P-SE patients had less trait anxiety at post-treatment and
follow-up than other groups
Al-Kubaisy et al. (1992) Clinician-accompanied exposure plus self-exposure (CAE-SE) For social phobia, CAE-SE was better than SE on some fear measures
or self-exposure (SE)
Scholing & Emmelkamp Exposurefollowedbycognitivetherapy(E-CT)orCTfollowedbyE(CT-E) Nomarkeddifferences in outcome between different treatment packages
(1993a) or integrated cognitive behavioral treatment (CBT)
Scholing & Emmelkamp Exposure (E), cognitive therapy followed by E (CT-E) or integrated At the end of both blocks of treatment and at 3-month follow-up no
(1993b) cognitive behavioral treatment (CBT) markeddifferences in outcome between treatment packages
Newmanetal.(1994) Behavioral treatment for public speaking anxiety (BT) Fear of negative evaluation and behavioral anxiety improved
significantly more in BT than WL
Turner et al. (1994) Flooding (F) or atenolol (A) At post-treatment, F was better than P, while A was not. F was better
than A on some behavioral measures
Akillas & Efran (1995) Symptomprescription with or without reframing (SP-R or SP) SP-R better than SP or WL on self-reported social anxiety and fear of
negative evaluation
Hopeetal. (1995) Cognitive behavioral treatment (CBT) or exposure (E) CBTandEimprovedsignificantlymorethanWL.CBTandEimproved
similarly
Mersch (1995) Exposure (E) or an integrated treatment (I) Treatment better than WL. E and I did not differ significantly
Scholing & Emmelkamp See Scholing & Emmelkamp (1993a) for details Nosignificant differences between treatment packages at 18-month
(1996a) follow-up
Scholing & Emmelkamp See Scholing & Emmelkamp (1993b) for details Nomaineffectdetected for treatment package
(1996b)
Taylor et al. (1997) Cognitiverestructuringfollowedbyexposure(CR-E)orassociativetherapy CRwassignificantly more efficacious than AT but did not improve
followed by E (AT-E) outcome in later E
Heimberg et al. (1998) Cognitive behavioral therapy (CBT) or phenelzine therapy (PT) CBTandPThadsignificantlyhigherresponserates than EST and
P–CBTandPTwerecomparable
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