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Cognitive Behavioural Therapies for Social Anxiety Disorder (SAnD) (Review) y McKenna IM, Hunot V, Bailey A, Parker AG, Churchill R l n O w e i v e r P r o ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary F 2013,Issue9 http://www.thecochranelibrary.com CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd. TABLE OF CONTENTS HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 3 y BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . .l. . . . . . . . . . . 6 Figure1. . . . . . . . . . . . . . . . . . . . . . . . . .n. . . . . . . . . . . . 9 RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Figure3. . . . . . . . . . . . . . . . . . . . . . . O. . . . . . . . . . . . . . . 15 Figure4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 w CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Analysis1.1.Comparison1CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList,Outcome1Clinical ResponseatPost-Treatment. . . . . . . . e. . . . . . . . . . . . . . . . . . . . . . 52 Analysis1.2. Comparison 1Cognitive Behavioural TherapiesversusTreatmentasUsual/Waiting List,Outcome2 ReductioninSocialAnxietySymptomsatPost-Treatment. . . . . . . . . . . . . . . . . . . 53 Analysis1.3.Comparison1CognitiveBehaviourialTherapiesversusTreatmentasUsual/WaitingList,Outcome3Attrition atPost-Treatment. . . . . . . . v. . . . . . . . . . . . . . . . . . . . . . . . . 54 Analysis1.4. Comparison 1Cognitive Behavioural TherapiesversusTreatmentasUsual/Waiting List,Outcome4 ReductioninDepressionSymptomsatPost-Treatment. . . . . . . . . . . . . . . . . . . . 55 e Analysis1.5.Comparison1CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList,Outcome5Clinical GlobalImpressionImprovementScaleatPost-Treatment. . . . . . . . . . . . . . . . . . . . 56 Analysis1.6.Comparison1CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList,Outcome6Quality r ofLifeatPost-Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Analysis1.7. Comparison 1CPognitive Behavioural TherapiesversusTreatmentasUsual/Waiting List,Outcome7 ReductioninSocialAnxietySymptomsatFollow-Up. . . . . . . . . . . . . . . . . . . . . 58 Analysis1.8. Comparison 1Cognitive Behavioural TherapiesversusTreatmentasUsual/Waiting List,Outcome8 ReductioninDepressionSymptomsatFollow-Up. . . . . . . . . . . . . . . . . . . . . . 58 Analysis1.9.Comparison1CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList,Outcome9Quality ofLifeatFollrow-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Analysis2.1.Comparison2CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalyses o (IndividualversusGroupTreatments),Outcome1ReductioninSocialAnxietySymptomsatPost-Treatment. 60 Analysis2.2.Comparison2CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalyses (IndividualversusGroupTreatments),Outcome2AttritionatPost-Treatment. . . . . . . . . . . . 61 F Analysis2.3.Comparison2CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalyses (IndividualversusGroupTreatments),Outcome3ReductioninDepressionSymptomsatPost-Treatment. . . 62 Analysis3.1.Comparison3CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalyses -SAnDDiagnosis(<80%GeneralisedSAnDversus>80%GeneralisedSAnDSamples),Outcome1Reductionin SocialAnxietySymptomsatPost-Treatment. . . . . . . . . . . . . . . . . . . . . . . . 64 Analysis3.2.Comparison3CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalyses- SAnDDiagnosis(<80%GeneralisedSAnDversus>80%GeneralisedSAnDSamples),Outcome2AttritionatPost- Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Analysis4.1.Comparison4CognitiveBehaviouralTherapiesversusTreatmentasUsual/WaitingList:SubgroupAnalysis- CommonMentalHealthComorbidity(<50%intheSampleversus>50%intheSample),Outcome1Attrition. 66 ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) i Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd. CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 y l n O w e i v e r P r o F CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) ii Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd. [InterventionReview] Cognitive Behavioural Therapies for Social Anxiety Disorder (SAnD) y IanMMcKenna1,VivienHunot2,AlanBailey3,AlexandraGParker3,RachelChurchill2 l n 1ClinicalPsychology,UniversityofExeter,Exeter,UK.2CentreforMentalHealth,AddictionandSuicideResearch,SchoolofSocial andCommunityMedicine,UniversityofBristol,Bristol,UK.3CentreofExcellenceinYouthMentalHealth,OrygenYouthHealth ResearchCentre,CentreforYouthMentalHealth,UniversityofMelbourne,MelbOourne,Australia Contactaddress:IanMMcKenna,WashingtonSingerLaboratories,Psychology,CollegeofLifeandEnvironmentalSciences,University ofExeter,Exeter,EX44QG,[email protected]. Editorialgroup:CochraneDepression,AnxietyandNeurosisGroup. w Publicationstatusanddate:New,publishedinIssue9,2013. Reviewcontentassessedasup-to-date: . Citation: McKennaIM,HunotV,BaileyA,ParkerAG,CheurchillR.CognitiveBehaviouralTherapiesforSocialAnxietyDisorder (SAnD).CochraneDatabaseofSystematicReviews2013,Issue9.Art.No.:CDXXXXXX.DOI:10.1002/14651858.CDXXXXXX. Copyright©2013TheCochraneCollaboration.PubilishedbyJohnWiley&Sons,Ltd. v e ABSTRACT Background r Social anxiety disorder (SAnD)isahighlyprevalentcondition, characterisedby anintense fear of social or performancesituations whereindividualsworryaboutbeinPgnegativelyevaluatedbyothers.Anuptodatesystematicreviewoftheeffectivenessofcognitive behaviouraltherapiesforSAnDisrequiredtoguidepractice. Objectives Toassesstheefficacyandacceptabilityofcognitivebehaviouraltherapy(CBT)comparedwithtreatmentasusual/waitinglist(TAU/ r WL)forindividualswithSAnD. Searchmethods o WesearchedtheCochraneDepression,AnxietyandNeurosisGroup(CCDAN)ControlledTrialsRegisterandconductedsupplementary searchesofMFEDLINE,PsycInfo,EMBASE,andinternationaltrialregisters(ICTRP;ClinicalTrials.gov)inOctober2011andCINAHL inOctober2012.Wealsosearchedreferencelistsofretrievedarticles,andcontactedtrialauthorsforinformationonongoing/completed trials. Selectioncriteria Randomisedandquasi-randomisedcontrolledtrialsundertakeninout-patientsettings,involvingadultsaged18-75yearswithaprimary diagnosisofSAnD,assignedeithertoCBTorTAU/WL. Datacollectionandanalysis Dataonpatients,interventionsandoutcomeswereextractedbytworeviewauthorsindependently,andtheRiskofbiasineachstudy wasassessed.Theprimaryoutcomesweresocialanxietyreduction(basedonrelativerisk(RR)ofclinicalresponseandmeandifference insymptomreduction),andtreatmentacceptability(basedonRRofattrition). CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) 1 Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd. Mainresults Thirteen studies (715 participants) were included in the review, of which 11 studies (599 participants) contributed data to meta- analyses.Basedonfourstudies,CBTwasmoreeffectivethanTAU/WLinachievingclinicalresponseatpost-treatment(RR3.60,95% CI1.35to9.57),andonelevenstudies(599participants)itwasmoreeffectivethanTAU/WLinreducingsymptomsofsocialanxiety. NosignificantdifferencewasfoundbetweenCBTandTAU/WLforattrition.Nosignificantdiyfferencewasdemonstratedforsocial anxietyatfollow-upandnostudiesexaminedfollow-updataforclinicalresponseorattrition. Authors’conclusions l n Theavailableevidencesuggeststhatcognitivebehaviouraltherapymightbeeffectiveinreducinganxietysymptomsfortheshort-term treatmentofSAnD.However,thebodyofevidencecomparingCBTwithTAU/WLissmallandheterogeneous. O w e i v e r P r o F CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) 2 Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd. y l n O CoCo SUMMARY OF FINDINGS FORwTHE MAIN COMPARISON [Explanation] pg yn rightitive ©B 2eh e 0a Cognitivebehaviouraltherapycomparedwithtreatmentasusual/waitinglistforadultswithsocialanxietydisorder 1v 3io Tu heral Patientorpopulation:Adultswithsocialanxietydisorder CT i ochraherap SInetettrinvegns:tioPnri:mCaoryg,nsiteivceobndehaaryvicoaurrealotrhceroampymvunitysettings neies Comparison:Treatmentasusual/Waitinglist Collaboration.PforSocialAnxie Outcomes Illurstrativeecomparativerisks*(95%CI) R(9e5la%tivCeI)effect N(sotuodfiePsa)rticipants Q(GuRaAlitDyEo)ftheevidence Comments ublishedtyDisord PATrsesautmmeedntriskas usual/ CCoorgrneistipvoendinbgehriasvkioural be yr Waitinglist therapy Jo(S hnAn WileyD)(Re Cpolisnti-ctarelatmreesnptronse at Mediumriskpopulation RR3.60(1.35to9.57) 2(464studies) ⊕low⊕(cid:13)1,2(cid:13), (cid:13) &v Soniew) LDoSsMs-IVofdiosaogcnioaslisphuosibniga s , L structured diagnostic in- td . terviFew(i.e.theADIS-IV) Higherscoresindicateim- provement (i.e. loss of 112per1000 403per1000 SAnDdiagnosis) (151to1072) Reductioninsocialanx- The mean social anxi- The mean social anxiety 599 ⊕⊕(cid:13)(cid:13) Scores are based on ietysymptoms etyrangedacrosscontrol intheinterventiongroups (11studies) Low3,4 a back-conversation of Socialanxietysymptoms groupsfrom(22.9to37. was16lower SMD (-1.18 95%, CI -1. measured on the Social 25) (-22.44 lower to -9.32 66,-0.69)toBDI-I Interaction Anxiety Scale lower)(seecomments) (SIAS). Scale from 0 to 100. (Follow-up: 4 to 12 months) Lower scores indicate im- provement (reduction in socialanxietysymptoms) 3 y l n O CC w oo pg yn right©itiveB Treatment acceptability Mediumriskpopulation RR1.09(0.51to2.32) 574(10studies) ⊕⊕(cid:13)(cid:13) 2eh (attrition), measured by e Low3,4 0a 1v 3io theoverallnumberofpeo- Tu heral pledroppingoutofpost- CoTh randomisation and over i chraneerapies tHheigchoerursescoorfetshetirniadliscate 24per1000 v26per1000 CollabforSo moreattrition e (12.2to55.7) oration.PcialAnxie Rsmyeemdnuptctotimonsiantdpeopsrte-tsrseiaotn- Tscyohmnertprotomlgmerasonurpansgdfreeodpmraec(s2rso.i5os7ns Tstiyohmnepgtromomuepassninwthadseei7pnrtleeosrwvseeionrn- 3(782studies) ⊕Lo⊕w(cid:13)4,(cid:13)5 SaScMobDraec(s-k0-c.a8or5ne,v9ebr5sa%astei(odCnI-o1onf. ublishedtyDisord Btoercyk(BDDeI-pIr)e.sSsciaolnefIrnovmen0-Pto8.39) l(o1w0.e4r5)(sleoewceormtome2n.ts8)08 34to-0.36)toBDI-I be to63 yr Jo(S (Follow-up: 4 to 12 hnWAnD months) ile)(R Lower score inrdicate im- ye &v provement (reduction in Soniew) depressionsoymptoms) s , L td *Thebasisfor theassumedrisk(e.g.themediancontrol groupriskacross studies) isprovidedinfootnotes. Thecorresponding risk(andits95%confidence interval) isbasedonthe . F assumedriskinthecomparisongroupandtherelativeeffectoftheintervention(andits95%CI). CI:Confidenceinterval;RR:RiskRatio. 1Riskofbiasissues:highrateofattrition(>20%)andasignificantdifferenceinattritionrateamongthegroupsin1/4studies 2Thereweresmallsamplesizes(<21participants)in2/4studies 3Allocationconcealmentwasnotreportedfor4/11studies 4Therewereconsiderableamountsofstatisticalheterogeneityindicated 5Allocationconcealmentwasnotreportedfor2/7studies 4 BACKGROUND SAnD was demonstrated in a previous Cochrane review (Stein 2004).TreatmentguidelinesrecommendSSRIsandtheserotonin- noradrenaline reuptakeinhibitor (SNRI)venlafaxineXRasfirst line pharmacological interventions for SAnD (Swinson 2006), Descriptionofthecondition andhighpotencybenzodiazepinessuchasclonazepam(Davidson y Social anxiety disorder (SAnD; or social phobia) islistedin the 1993)andbeta-blockers(Gorman1987)assecond-linepharma- Diagnostic and Statistical Manual of Mental Disorders (DSM- cologicalinterventions. IV-TR)(APA2000)andtheInternationalClassificationofDis- Psychologicaltherapieslareanimportantalternativetreatmentop- eases10(ICD-10) (WHO 1992)alongside otheranxiety disor- tionforSAnDfortnworeasons: (1)patients’concernsabout the ders(e.g.panicdisorder).SAnDischaracterisedbyanintensefear sideeffectsanddependencyofpharmacologicaltreatmentsresults ofsocialorperformancesituations wheretheindividual worries intheirlowadherencerates(Hunot2007),and(2)researchcon- aboutbeingnegativelyevaluatedbyothers(APA2000).Physical sistently repoOrts patients’ preference for psychological interven- symptomsoftenaccompanyingSAnDincludesweating,shaking, tions compared to antidepressants as a treatment for common blushing,palpitations,nauseaanddiarrhoea,andcandevelopinto mental disorders (Churchill 2000; Riedel-Heller2005). A wide apanicattack(APA2000).AccordingtotheDSM-IV-TRAPA range of psychological therapies are now used to treat SAnD: 2000symptomsmaybegeneralised(apersistentfearofmostsocial (1) cognitive and behavioural therapy approaches (CBT; Beck situations) which can lead to increased social isolation, or non- 1979;Ellis1962)comprising anumber of strategies, invivo or w generalised(afearofspecificsocialcontexts;e.g.publicspeaking). imaginal exposure to feared social situations (Butler 1985), ap- However,recentevidencefromtheDSM-VAnxiety,Obsessive- pliedrelaxation(Öst1987),socialskillstraining(Stopa1993)and CompulsiveSpectrum,Posttraumatic,andDissociativeDisorders cognitiverestructuring(Ponniah2008;Rowa2005),othertech- WorkGroupamongothersindicatesthatthereisinsufficientesup- niquesincludevideotapefeedback(Smits2006)andattentional portforthecurrentcategorical specifier,generalisedsocial anxi- training(McEvoy2009);clinicalpracticeguidelinesrecommend ety(Aderka2012;Bögels2010).Theauthorsconcludethatsocial CBTasafirst-linetreatmentforSAnD(Swinson2006);(2)be- anxiety exists along a continuum, the larger the numiber of so- haviouraltreatments(Skinner1953;Watson1924);(3)psycho- cialfearsthegreatertheseverity,withoutadistinctdviscrimination dynamictreatments(Freud1949)includingbriefpsychodynamic point(Aderka2012;Bögels2010).Nevertheless,theyfoundev- models (Mann 1973); (4) integrative treatments such as inter- idenceindicatingthatindividualswithperformanceanxiety(e.g. personaltherapy(Klerman1984)andcognitiveanalytictherapy e speakingorperforminginpublic)werequalitativelydistinctfrom (Ryle2002);(5)humanistictreatments,Rogerianperson-centred individuals with SAnD (Bögels 2010). The specifiers of perfor- therapy(Rogers1951)andGestalttherapy(Perls1976);and(6) manceSAnDandSAnDareproposedforDSM-V(APAinpress) “third-wave”CBTinterventionsforSAnDacceptanceandcom- r to replace the current DSM-IV-TR generalised and non-gener- mitmenttherapy(Hayes2004),andmindfulness-basedstresscog- alisedSAnDspecifiers(Bögels201P0). nitive therapy(Segal 2002). However,to date no systematic re- SAnDisthethirdmostcommonpsychologicaldisorder(Kessler viewsormeta-analysesarereportedforpsychodynamic,humanis- 2005)afterdepressionandalcoholdependency(Magee1996).It tic,integrative,orthird-waveCBTtherapiesforSAnD;theover- hasalifetimeprevalenceofbetween3and13%(Kessler2005), whelmingmajorityoftheevidenceforpsychologicalinterventions more common in women than in men (ratio of 3 to 2) (Fehm usedtotreatSAnDisforcognitiveandbehaviouralinterventions 2008;Kessler2005),anrdhasatypicalonsetinearlyadolescence (Acurturk2009). (Wittchen2003).IfleftuntreatedSAnDseemstohaveanendur- ing,unremittingproognosisfrequentlyleadingtootherpsycholog- icaldisorders(e.g.depression)(Stein2002).Previouslyviewedas Howtheinterventionmightwork aneglecteddisorderithasbecomethefocusofincreasedresearch overthelast2F5years(Liebowitz1985).SAnDisnowunderstood Behaviouraltherapysuchasexposuretherapyisbasedonlearning tobe ahighlyprevalentdisorder (Kessler2003)associated with theory(Rachman1977).Learningtheoryproposesthatfears(e.g. significant impairments in social and occupational functioning, socialanxiety)developthroughnegativelearningexperiencesand psychologicaldifficulties,reducedqualityoflife(Stein2000)and aremaintainedthroughtheavoidance ofthefearedsocial situa- substantialeconomiccosts(Smits2006). tions(Rachman1977).Treatmentinvolvesrepeatedandsystem- aticinvivoexposuretoahierarchyofincreasinglyfearedsocialsit- uations,remainingineachsituationuntilanxietylevelsdiminish. Cognitive therapy (CT)aims torestructure theindividual’s un- Descriptionoftheintervention helpfulappraisals of life eventsthrough understanding therela- The efficacy of pharmacological treatments (selective serotonin tionshipbetweenthoughts,feelingsandbehaviour.Clark1995ar- reuptake inhibitors; SSRIs), (monoamine oxidase inhibitors; guesthatSAnDismaintainedbyincreasedself-focusedattention, MAOIs) and (reversible inhibitors of monamine; RIMAs) for utilisation of maladaptive safety behaviours intended to reduce CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) 5 Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd. theprobabilityofnegativeevaluationfromothers,andengaging Banderlow2009;Fedoroff2001;Feske1995;Gould1997;Taylor innegativelybiasedpost-eventprocessing.Rapee1997purports 1996).Moreover,thereviewsbyFedoroff2001andFeske1995 thatSAnDisalsomaintainedthroughatendencytomakeneg- includeduncontrolledtrialsintheirmeta-analysis,thusintroduc- ativepredictionsaboutone’santicipatedperformanceinasocial ing potential methodological heterogeneity (Higgins 2011) and situation.Aviciouscycleiscreatedwherebydysfunctionalbeliefs statisticalheterogeneitywasnotinvestigatedintwoofthesixre- y abouttheselfandtheexpectednormsofconductinsocialsitua- views(Taylor1996;Banderlow2009).Thevariabilityacrossstud- tions,increasedself-focus,andtheutilisationofsafetybehaviours ies included in the above reviews has the potential to shift the paradoxically increasesthelikelihoodofthefearedeventsinso- estimateoftheirintervlentioneffectsizesreducingthevalidityof cialsituations (Beck1985).Cognitive behaviouraltherapiesfre- theirfindings(Higgnins2011). quentlycombinecognitiverestructuringwithexposuretherapyto Todate,therehasbeennowell-conductedhighqualityCochrane treatSAnD,andisbasedonthepremisethatSAnDarisesfromthe systematicreviewoftheeffectsofallcognitivebehaviouralther- existenceofdysfunctional beliefsthatanindividual holdsabout apiesforSAnOD.Inviewofpatients’reportedpreferenceforpsy- themselves,andhowtheyshouldconductthemselvesinsocialsit- chological therapies, thelackof pharmacological side-effectsas- uations (Beck 1985), resulting in negatively biased information sociatedwiththeseinterventions(Churchill2000;Riedel-Heller processing.The therapist and client co-construct more adaptive 2005), and the clinical, methodological, and statistical hetero- waystoperceivesocialsituations,engageinexternalfocusedpro- gene ityissueswithpreviousreviewsandmeta-analyses,anupto cessing, alleviate safety behaviours and test anticipated negative date and comprehensive summary of the evidence of cognitive w predictions,withtheobjectiveofachievingmorerealisticbeliefs behaviouraltherapiesforSAnDisrequired.Thefindingsofthis abouttheselfandsocialsituations,includinganacceptancethat reviewwillguide healthcareaswellassupportingpatient/clini- negativefearedeventsmaysometimeshappeninsocialsituations. ciantreatmentdecision-making aroundthemanagementofthis Third-waveCBTtherapy(e.g.acceptanceandcommitmentteher- disorder. apy;Hayes2004)positsthatSAnDresultsfromattemptstocon- trol anxiety and an “unwillingness” to tolerate unwanted and distressing thoughts when exposed to difficult socialisituations (Dalrymple2007).Therapyaimstoincreaseanindvividual’s“psy- OBJECTIVES chologicalflexibility”viapsychological“acceptance”,their“will- ingness”toexperiencedifficultpsychologicalevents“mindfully”, To assess the efficacy and acceptability of cognitive behavioural e whilealsobehavingconsistentlywithoneschosen“values”(Hayes therapycomparedwithtreatmentasusual/waitinglistforindivid- 2004).Treatmentalsoutilisestraditionalbehaviourtherapytech- ualswithSAnD. niques such as role-plays, exposure, and social skills training r (Dalrymple2007). P METHODS Whyitisimportanttodothisreview Criteriaforconsideringstudiesforthisreview Socialanxietydisorderiscurrentlyrecognisedasahighlyprevalent, r disabling disorder with significant economic costs, and the evi- dencebaseonintervoentionsforSAnDhasexpandedconsiderably. Typesofstudies Overthelast15yearstheefficacyofpsychologicalinterventions Randomisedtrialsdefinedasfollows: (i.e.cognitiveandbehaviouraltherapies)forSAnDwereassessed 1.Randomisedcontrolledtrials inseveralsysFtematicreviewsandmeta-analyses(Acurturk2009; 2. Quasi-randomised controlled trials, if they utilise treatment Feske1995;Taylor1996).Cognitivebehavioural therapieswere assignmentssuchasalternatedaysoftheweek comparedwithpharmacologicaltreatmentsinanumberofmeta- 3.Trialsthatemployacross-overdesign,usingdatafromthefirst analyses (Banderlow 2009; Fedoroff 2001; Gould1997). These activetreatmentstageonly reviews indicatedthatCBTcan beeffectiveinthetreatmentof 4.ClusterRCTswerealsoeligible SAnD, and that it can be as effective as pharmacological treat- Nolanguageorpublicationrestrictionswereimposed. ments(Banderlow2009;Gould1997).Importantly,theconclu- sionsofpreviousreviewsandmeta-analysesarelimitedduetoa number of clinical and methodological difficulties. Allprevious Typesofparticipants reviewsinvolvedclinicalheterogeneousgroupsandmostdonot providesufficientdetailsabouttheseverityandnatureofSAnD Patientcharacteristicsandsetting symptomsorcomorbidAxis-I/Axis-IIdisorders(Acurturk2009; CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) 6 Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd. Thereviewincludedmaleandfemaleadults,aged18to75years, thestudywereprescribedthesamepharmacological/placeboin- treatedinaprimary,secondarycareorcommunitysettings. terventions.Combinationtreatmentscomparedagainstapharma- cologicalorpsychologicaltreatmentalonewereoutsidethescope ofthisreview. Diagnosis y Comparators Inclusioncriteria l Thecomparatorwastreatmentasusual(TAU).Thiscomparator Participantshadaprimarydiagnosisofsocialanxietydisorder(so- includedstandardcanre,usualcare,notreatment,andwaitinglist cial phobia), based on DSM-IV, DSM-IV-TR non-generalised/ (WL).Ineachstudy,thedescriptionofaTAUconditionwasscru- specificsocialanxietydisorder(excludingperformanceSAnDsee tinisedtoensurethatitdidnotinvolveanactivesupportivether- below)andgeneralisedsocialanxietydisordercriteriarespectively O apytreatment.StudiesthatallowedparticipantsintheTAUarmto (APA1994;APA2000),oronICDcriteria(WHO1992).Di- receiveappropriatemedicalcaredeemednecessarybytheclinician agnosismusthavebeenmadebyatrainedpsychiatricassessorus- duringthecourseofthestudy(includingpharmacotherapyand/ ingeitherastandardisedinterviewsuchastheAnxietyDisorders orpsychologicaltherapy)wereincluded.Additionaltreatment(s) InterviewScheduleforDSM-IV(DiNardo1994)ortheStruc- receivedby participants in both thecontrol andactive compar- turedClinicalInterviewforDSM(SCID)(First1996;First2002; iwsonsforeachincludedstudywerecarefullydocumented. Spitzer1990).Comorbidpsychologicalorphysicaldisorderswere includedifparticipantshadaprimarydiagnosisofSAnD. Exclusioncriteria Typesofoutcomemeasures RCTsincludingmorethan80%participantswithaprimaryedi- agnosisofSAnDwereincluded. Trials involving participants with the following diagnoses were Primaryoutcomes excluded: i Theprimaryoutcomeswerereductioninsocialanxietyandtreat- 1.PerformanceSAnD(e.g.publicspeakinganxietyv) mentacceptability,asfollows: 2.Sub-clinicalsocialanxiety(e.g.shyness) 1.Treatmentresponse,comprisedtheproportionofparticipants 3.Specificsocialanxieties(e.g.testanxiety) e showingabsenceversuspresenceofsymptomsorclinicallysignif- 4.Avoidantpersonalitydisorder icantchange,accordingDSM-IVandDSM-IV-TR(APA1994; 5. Comorbid substance related disorder, schizophrenia or psy- APA2000)orICD-10(WHO1992)diagnosticcriteriaforsocial choticdisorderdiagnoses r anxietydisorder/socialphobia,orthroughadefinedcut-offona validatedsocialanxietymeasuresuchastheLiebowitzSocialAnx- P Typesofinterventions ietyScale(Liebowitz1987)oracompositeofvalidatedmeasures accordingtothetrialist’sdefinition. 2.Reductioninsocialanxiety symptomsmeasuredusingavali- Experimentalinterventio ns datedcontinuousscale,suchastheLiebowitzSocialAnxietyScale StudieswereincludedinthereviewiftheyevaluatedaCBT,in- (Liebowitz1987). r cludingthefollowing:cognitivetherapy(CT;Beck1979),ratio- 3. Treatment acceptability (attrition), measured by the overall nalemotivebehavioouraltherapy(REBT;Ellis1962),multimodal numberofpeopledroppingoutpost-randomisationandoverthe behaviour therapy (Lazarus 1971), rational behaviour therapy courseofthetrials. (Maultsby1984),andstressinoculationtraining(Meichenbaum 1985),andtFhird-waveCBTinterventions,acceptanceandcom- Secondaryoutcomes mitmenttherapy(Hayes2004),andmindfulness-basedstresscog- nitivetherapy(Segal2002). 1.Reductionindepressionsymptoms,usingvalidatedobserver- rated scales (e.g. the Hamilton Rating Scale for Depression) ( Hamilton 1960) or self-report scales (e.g. the Beck Depression Modalityoftherapies Inventory)(Beck1987) Psychologicalinterventionsdeliveredfacetofacebetweenthepa- 2.ClinicalGlobalImpressions-Improvementscale(CGI)(Guy tientandtherapistandpsychologicaltherapiesconductedineither 1976) individualorgroupformatswereincluded.However,psychologi- 3. Quality of life, using validated measures (e.g. SF-36) (Ware caltherapiescomprisingcouplestherapyandfamilytherapywere 1993) excluded.Comparisonsofdualmodalitytreatmentswereeligible 4.Negativeeffectsoftherapy,assessedbycollatingthenumberof for inclusion only if thetwo psychological modelscomparedin participantsreportinganynegativeeffectsoftherapy CognitiveBehaviouralTherapiesforSocialAnxietyDisorder(SAnD)(Review) 7 Copyright©2013TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.

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Reduction in Social Anxiety Symptoms at Post-Treatment. Comparison 2 Cognitive Behavioural Therapies versus Treatment as Usual/Waiting List: Subgroup Analyses .. “third-wave” CBT interventions for SAnD acceptance and com- mitment therapy (Hayes 2004), and mindfulness-based stress cog-.
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