Recent advances in the psychosocial treatment of social anxiety disorder

Neural evidence of face processing in social anxiety disorder: A systematic review with meta-analysis

Numerous previous studies have used event-related potentials (ERPs) to examine facial processing deficits in individuals with social anxiety disorder (SAD). However, researchers still need to determine whether the deficits are general or specific and what the dominant factors are behind different cognitive stages. Meta-analysis was performed to quantitatively identify face processing deficits in individuals with SAD. Ninety-seven results in 27 publications involving 1032 subjects were calculated using Hedges' g. The results suggest that the face itself elicits enlarged P1 amplitudes, threat-related facial expressions induce larger P2 amplitudes, and negative facial expressions lead to enhanced P3/LPP amplitudes in SAD individuals compared with controls. That is, there is face perception attentional bias in the early phase (P1), threat attentional bias in the mid-term phase (P2), and negative emotion attentional bias in the late phase (P3/LPP), which can be summarized into a three-phase SAD face processing deficit model. These findings provide an essential theoretical basis for cognitive behavioral therapy and have significant application value for the initial screening, intervention, and treatment of social anxiety.

Therapeutic strategies for social anxiety disorder: where are we now?

Introduction: Classical well-established treatments of social anxiety disorder (SAD) are now complemented by more recent therapeutic strategies. This review aims to summarize available therapies for SAD and discuss recent evidence-based findings on the management of this disorder.Areas covered: Recent guidelines recommend psychotherapy, particularly cognitive-behavioral therapy (CBT), and pharmacotherapy, as first-line treatments of patients with SAD, without a clear superiority of one option over the other. CBT includes classical approaches such as in vivo exposure to social situations and cognitive therapy, but new modalities and techniques have been recently developed: third-wave approaches, internet-delivered therapy, virtual reality exposure, and cognitive bias modification. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors have been also extensively studied and shown to be effective in SAD. Two alternative strategies have been developed to treat SAD with disappointing results: cognitive bias modification, and pharmacological augmentation of psychotherapy using D-cycloserine during exposure sessions.Expert opinion: Personalized treatments for SAD patients are now available. Innovative strategies such as online psychotherapy and virtual reality exposure are useful alternatives to CBT and SSRIs. Future developments and optimization of attention bias modification and of pharmacological augmentation of psychotherapy can be promising.

Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized-controlled trials

Group psychotherapy for social anxiety disorder (SAD) is an established treatment supported by findings from primary studies and earlier meta-analyses. However, a comprehensive summary of the recent evidence is still pending. This meta-analysis investigates the efficacy of group psychotherapy for adult patients with SAD. A literature search identified 36 randomized-controlled trials examining 2171 patients. Available studies used mainly cognitive-behavioral group therapies (CBGT); therefore, quantitative analyses were done for CBGT. Medium to large positive effects emerged for wait list-controlled trials for specific symptomatology: g=0.84, 95% CI [0.72; 0.97] and general psychopathology: g=0.62, 95% CI [0.36; 0.89]. Group psychotherapy was also superior to common factor control conditions in alleviating symptoms of SAD, but not in improving general psychopathology. No differences appeared for direct comparisons of group psychotherapy and individual psychotherapy or pharmacotherapy. Hence, group psychotherapy for SAD is an efficacious treatment, equivalent to other treatment formats.

Generalized social anxiety disorder: A still-neglected anxiety disorder 3 decades since Liebowitz's review

In the 3 decades since Liebowitz's review of 'a neglected anxiety disorder,' controversy and challenges have remained in the study of social anxiety disorder (SAD). This review examines evidence around the classification and subtyping of SAD, focusing on generalized SAD. Substantial discrepancies and variation in definition, epidemiology, assessment, and treatment of generalized SAD exist as the international literature on it has grown. In East Asian cultures in particular, study of taijin kyofusho has been important to a broadened conceptualization of SAD into generalized SAD. Despite important progress with biological and other studies, many challenges in the understanding of generalized SAD will remain in the years to come.

The impact of social skills training for social anxiety disorder: a randomized controlled trial

OBJECTIVE

Social anxiety disorder (SAD) impacts social, occupational and academic functioning. Although many interventions report change in social distress, improvement in social behavior remains under-addressed. This investigation examined the additive impact of social skills training (SST) for the treatment of SAD.

METHOD

Using a sample of 106 adults who endorsed SAD across numerous social settings, participants were randomized to exposure therapy (imaginal and in vivo) alone, a combination of SST and exposure therapy known as Social Effectiveness Therapy (SET), or a wait list control. The assessment strategy included self-report measures, blinded clinical ratings and blinded assessment of social behavior.

RESULTS

Both interventions significantly reduced distress in comparison to the wait list control and at post-treatment, 67% of patients treated with SET and 54% of patients treated with exposure therapy alone no longer met diagnostic criteria for SAD, a difference that was not statistically significant. When compared to exposure therapy alone, SET produced superior outcomes (p<.05) on measures of social skill and general clinical status. In addition to statistical significance, participants treated with SET or exposure reported clinically significant decreases on two measures of self-reported social anxiety and several measures of observed social behavior (all ps<.05).

CONCLUSIONS

Both interventions produced efficacious treatment outcome, although SET may provide additional benefit on measures of social distress and social behavior.

Culturally Competent CBT

A 21-year-old Korean, single, and immigrant male presented to therapy with significant symptoms of social anxiety disorder (SAD) for treatment at a university training clinic. At the time of intake, he was experiencing intense distress and remarkable adaptations in his life to accommodate rather chronic physiological symptoms related to social interactions. He immigrated to the United States 5 years prior to treatment from Seoul, Korea. He endured social anxiety for 6 years preceding treatment. The case was conceptualized and treated from a cognitive-behavioral framework. Treatment gains were measured using behavioral markers and a reliable change index using standardized outcome measures. This case illustrates the ability to adhere to a cognitive-behavioral treatment model for SAD while considering pertinent cultural factors. Furthermore, it highlights the generalizability of a specific treatment model when working with Korean immigrants. The authors discuss the need for future research, and treatment implications of this case are described.