Psychosocial treatments
Nondirective or nonspecific psychotherapies are not as effective for treating SAD as the more directive behavioral therapy and CBT that are specifically targeted toward reducing social fears and avoidance.58 CBT can have several components, including psychoeducation, social skills training, symptom management skills, progressive muscle relaxation, exposure (imaginal and in vivo), and cognitive restructuring.59 CBT focuses on the present rather than the past, and it involves working collaboratively with patients and teaching them cognitive and behavioral skills.
While it is not at all clear yet which component of CBT is the most effective, evidence suggests that it is important to include both exposure and cognitive components.60 A recent qualitative review of 30 randomized controlled trials that evaluated the efficacy of social skills training, exposure therapy, and cognitive treatments for social phobia in adults concluded that CBT was the psychological intervention of choice for SAD.61 The Table provides a brief description of the empirically supported components of CBT for treatment of SAD.
CBT can be conducted in individual or group formats. It typically lasts 16 to 24 sessions. It is considered an appropriate first-line option for treating SAD. However, it requires specialized training, which limits its availability. The evidence that supports the efficacy of various components of CBT interventions for treatment of SAD is quite extensive, and results suggest that as many as 75% of patients can benefit from it.60-62 There are also emerging data for its efficacy in older children and adolescents.63,64
The treatment gains from CBT are generally more enduring over the long term than those from pharmacotherapy. Also, relapse rates after discontinuation of CBT are significantly lower.65,66
Regarding efficacy, randomized studies that compared the use of medications with CBT have not demonstrated superiority of one treatment over the other.67,68 However, the onset of symptom response tends to be faster with pharmacotherapy, while CBT appears to result in a more durable response.67
Treatment selection
The empirical evidence reviewed above suggests that a variety of effective psychosocial and pharmacological options are available to treat SAD. In this respect, the field has advanced significantly since the diagnosis of SAD (social phobia) was introduced. However, we still do not have a very clear understanding about:
• Which treatments work best for which individuals
• What factors lead to better treatment outcomes
• The best clinical approach for those who do not respond to treatment
Patients with SAD often need sensitive clinical management. Many have had the disorder for years and tend to have a history of varied, ineffective, and failed treatments. Patients should be educated about the disorder and reassured of a realistic hope for recovery. A therapeutic alliance with patients is an important part of any selected treatment and includes establishing a relationship that provides respectful attention to the patient’s concerns and worries, realistic reassurance and instillation of hope, and a willingness to be available in case of unexpected problems. It includes exploring and discussing the patient’s concerns about medications and explaining treatment options.
Treatment planning begins by discussing the benefits and risks of treatment options. Both clinician and patient must consider several factors that go beyond acute treatment success rates when selecting an approach. These decisions involve weighing the advantages and disadvantages of each treatment to see how well it matches a patient’s presentation, severity of symptoms, degree of functional impairment, psychiatric and substance-related comorbidities, personal and financial resources, and preferences.
There is no empirically derived algorithm for treating SAD, although global options include pharmacotherapy, CBT, or both. As mentioned earlier, studies suggest that pharmacological treatment may result in faster response than CBT, while the effects of CBT may last longer. Even when formal CBT is not used, to facilitate long-term gains, some form of gradual reentry into feared situations should be a part of every treatment plan for SAD.
