Interpersonal subtypes in social phobia: diagnostic and treatment implications

Interpersonal assessment may provide a clinically useful way to identify subtypes of social phobia. In this study, we examined evidence for interpersonal subtypes in a sample of 77 socially phobic outpatients. A cluster analysis based on the dimensions of dominance and love on the Inventory of Interpersonal Problems-Circumplex Scales (Alden, Wiggins, & Pincus, 1990) found 2 interpersonal subtypes of socially phobic patients. These subtypes did not differ on pretreatment global symptom severity as measured by the Brief Symptom Inventory (Derogatis, 1993) or diagnostic comorbidity but did exhibit differential responses to outpatient psychotherapy. Overall, friendly-submissive social phobia patients had significantly lower scores on measures of social anxiety and significantly higher scores on measures of well-being and satisfaction at posttreatment than cold-submissive social phobia patients. We discuss the results in terms of interpersonal theory and the clinical relevance of assessment of interpersonal functioning prior to beginning psychotherapy with socially phobic patients.     

School phobia: An overview

This article discusses general features of school phobia and specific clinical and familial traits and characteristics. Included are overviews of theoretical explanations, types of school phobia, suggested methods of treatment, and their efficacy.     

Exposure as a treatment for social phobia: Some instructive difficulties

The main rules guiding the application of exposure to the treatment of simple phobias and agoraphobia are described, together with the four principal difficulties that came to attention when these rules were applied to the treatment of social phobia. These difficulties were: (i) specifying graduated and repeatable tasks; (ii) prolonging exposure; (iii) securing adequate engagement during exposure; and (iv) dealing with the cognitive aspects of social phobia. Solutions to these difficulties are described and illustrated from case material collected during the treatment of 45 socially-phobic out-patients. The discussion considers the implications of these solutions both for the treatment of other conditions and for understanding the processes involved in exposure.     

Shaping approach responses as intervention for specific phobia in a child with autism

We evaluated contact desensitization (reinforcing approach responses) as intervention for specific phobia with a child diagnosed with autism. During hospital-based intervention, the boy was able to encounter previously avoided stimuli. Parental report suggested that results were maintained postdischarge.     

Social skills and social phobia: An investigation of DSM-IV subtypes

Social phobia is characterized as pervasive social timidity in social settings. Although much is known about this disorder, aspects of its clinical presentation remain unexplored, in particular characteristics that distinguish the generalized and non-generalized subtypes. For example, it remains unclear whether patients with the non-generalized subtype display social skills deficits in social interactions, and if so, are these deficits clinically, as well as statistically, significant? In this study, adults with either the non-generalized (NGSP; n = 60) or generalized (GSP; n = 119) subtype of social phobia and adults with no psychological disorder (n = 200) completed an extensive behavioral assessment of social skill and social anxiety. As expected, adults with NGSP and GSP reported equal distress and displayed similar rates of avoidance during an Impromptu Speech Task when compared to adults with no disorder. In contrast, the three groups were distinctly different when interacting with another person in various social situations. Adults with NGSP displayed social skill deficits when compared to individuals with no disorder, but they had fewer deficits than the GSP subtype. However, the identified skill deficits were clinically as well as statistically significant only for the GSP subtype. The results are discussed in terms of the contribution of skill deficits to the conceptualization and treatment of social phobia.     

Optimizing treatment in social phobia: a review of treatment resistance

Over the last 25 years, there has been a rapid expansion of our knowledge base of social phobia (SP). Although there are a number of well-validated treatment modalities, including pharmacotherapy and cognitive-behavioral therapy, significant gaps remain in our ability to achieve full remission in most patients. Despite advances in the neurobiology of SP, the etiology has yet to be determined. Investigations examining potential predictors of response have provided little guidance in selecting an appropriate treatment modality. These gaps in our knowledge have pushed us to examine issues related to treatment resistance. This paper presents a review of the current literature and issues related to treatment-resistant SP, including a discussion of the functional impairment associated with SP, definitions of treatment response and remission, as well as outcome measures that have been used in clinical investigations of SP. In addition, criteria for a standard treatment trial, predictors of treatment response, a review of treatment resistance studies, and potential directions for future research are examined. The most promising strategies to attain remission, will likely involve augmenting selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors with agents such as anticonvulsants, benzodiazepines, and antipsychotics as well as combining pharmacotherapy with cognitive-behavioral therapy. Our current treatment target of simply attaining a response needs to be refocused, so that an asymptomatic state and high end state functioning become the final goal of treatment.     

Social phobia: a comparison of specific and generalized subtypes and avoidant personality disorder.

The validity of the social phobia subtype distinction was examined in a large sample of carefully diagnosed social phobics (N = 89). Generalized and specific subtypes were diagnosed reliably, and the generalized subtype showed a consistent pattern of greater symptom severity than did the specific subtype. In addition, generalized social phobics with and without avoidant personality disorder were compared, and a difference was found for only 1 of 4 parameters. The results are discussed in terms of the validity of subtyping in social phobia and the diagnostic boundary between social phobia and avoidant personality disorder.     

Prediction of treatment outcome in social phobia: a cross-validation.

This study was a replication of a study on the prediction of treatment outcome in social phobic patients [Chambless, D. L., Tran, G. Q. Glass, C.R. (1997). Predictors of response to cognitive-behavioral group therapy for social phobia. Journal of Anxiety Disorders, 11 221-240]. Results at the posttest and the 18-months follow-up were analyzed for DSM-III-R social phobic patients, with either a generalized social phobia (n = 50) or a nongeneralized fear, i.e. fear of blushing, trembling or sweating in social situations (n = 26). Predictors were pretreatment depression, personality disorder traits, clinician rated severity of impairment and frequency of negative self-statements during social interactions. The criterium variable was (the residual gain score of) self-reported avoidance of social situations. In line with Chambless et al., pretreatment depression showed some predictive value, but smaller and only at the posttest. Change in the frequency of negative self-statements paralleled, but did not predict, change in social phobia symptoms. In contrast with Chambless et al., clinician rated severity was (slightly) predictive for treatment outcome, whereas avoidant personality traits had reverse correlations with outcome in both subgroups. The results are discussed and directions for further research are given.     

Virtual reality in the treatment of spider phobia: a controlled study

This study explored whether virtual reality (VR) exposure therapy was effective in the treatment of spider phobia. We compared a treatment condition vs. a waiting list condition in a between group design with 23 participants. Participants in the VR treatment group received an average of four one-hour exposure therapy sessions. VR exposure was effective in treating spider phobia compared to a control condition as measured with a Fear of Spiders questionnaire, a Behavioural Avoidance Test (BAT), and severity ratings made by the clinician and an independent assessor. Eighty-three percent of patients in the VR treatment group showed clinically significant improvement compared with 0% in the waiting list group, and no patients dropped out. This study shows that VR exposure can be effective in the treatment of phobias.     

The practice of empathy as a prerequisite for informed consent

The patient-physician relationship, as formulated in the traditional biomedical model of medicine, is inherently flawed. In entering this relationship, most patients seek simply to be delivered from illness back to normal psychosocial functioning. The physician, however, almost invariably responds with a purely biologic approach to diagnosis and treatment that often does not effectively address the patient's needs. This precludes the opportunity for a consensus between them, and may in fact lead to the physician manipulating the patient's decisions about the course of therapy. The relationship should be reshaped within a new scientific model of patient care that combines the biomedical analysis of disease with an empathic understanding of the patient's illness experience. Truly informed consent is viewed as a natural outcome of the application of this more comprehensive framework.     

Intensive cognitive behavioural group treatment for social phobia: a pilot study

The aim of this pilot study was to examine the effectiveness of an intensive form of cognitive behavioural group treatment practised routinely in a psychiatric clinic. A total of 27 outpatients with social phobia of long duration were assigned to a 41-hour treatment administered over 2 periods of 3.5 and 4.5 days, 1 week apart. Four groups, each comprising 6-8 patients, participated in the study. All except 1 patient (26/27) completed the treatment and 20 patients participated in all follow-up sessions after 3, 6 and 12 months. Treatment significantly reduced fear and avoidance of social interaction and performance, anticipatory anxiety and symptoms' influence on daily life. Follow-up assessments indicated maintained or increased improvement from post-test to 1 year and large sensitivity to treatment at both post-test and 1 year. Of the patients in the study, 85% were taking a prescribed drug, and 70% had taken medication for at least 1 year before they entered the treatment. At 1-year follow-up 52% had discontinued medication.     

Using a taped intervention to improve kindergarten students' number identification

A multiple baseline design across students was used to evaluate the effects of a taped numbers (TN) intervention on the number‐identification accuracy of 4 kindergarten students. During TN, students attempted to name the numbers 0 through 9 on randomized lists before each number was provided via a tape player 2 s later. All 4 students showed immediate increases and reached 100% in number‐identification accuracy. One student reached 100% accuracy after TN was supplemented with performance feedback, reinforcement, and overcorrection.     

Social phobia: Relationship to shyness

The characteristics of social phobia and shyness were compared on six dimensions: somatic features, cognitive characteristics, behavioral responses, daily functioning, clinical course, and onset characteristics. The results revealed that shyness and social phobia have a number of similar features. However, as currently conceptualized, the two syndromes differ in a number of important aspects as well. Definitive distinctions are hampered by the lack of empirical studies directing comparing the two conditions and by the heterogeneity of the shy population. Recommendations for clarifying some of the ambiguities are made.     

Role-reversed systematic desensitization in the treatment of a writing phobia

A role-reversal technique was employed to teach cognitive coping skills to a patient with a writing phobia. The patient presented desensitization scenes to the therapist and devised coping strategies for lessening anxiety. Treatment resulted in a reduction of anxiety and an increased ability to write in the presence of other people. A 10-mo. follow-up showed no relapse.     

Social phobia and avoidant personality disorder as related to parental history of social anxiety: a general population study

Using a validated and DSM-IV compatible questionnaire, the present study related family history of excessive social anxiety to social phobia and avoidant personality disorder (APD) in epidemiologically identified probands in the general population. Probands met diagnostic criteria for social phobia with or without APD and APD with or without social phobia. A two- to three-fold increased relative risk of social anxiety was observed for all diagnostic groups. Increasing severity in probands by varying diagnostic criteria did not affect the relative risk. Because familial aggregation of social anxiety was not modulated by Axis I or II diagnosis or diagnostic cut-off levels, data imply that social phobia and APD may represent a dimension of social anxiety rather than separate disorders. Thus, having an affected family member is associated with a two- to three-fold risk increase for both social phobia and APD.