Introduction

Anxiety disorders are the most widespread class of mental disorders in which twelve-month prevalence in the community was estimated as 18.1% (Kessler, Chiu, Demler, & Walters, 2005). Among those, social anxiety disorder (SAD) also described as social phobia is a condition comprising remarkable anxiety about performance and social situations in which there exists fear and avoidance of oneself under scrutiny of others (Stein & Stein, 2008) and it occurs with a lifetime rate of 12% and the 12-month prevalence is 7% of the population (Leichsenring et al., 2014). Individuals may have concerns in such situations and their behaviour may result in embarrassment and humiliation. As a result of too pronounced concerns, individuals avoid interpersonal encounters or bear these situations with severe discomfort (Stein & Stein, 2008). Individuals with social anxiety disorder have an underlying thought that other people have a negative evaluation of them. Because of this core maladaptive belief, they have some difficulties while interacting a range of social activations such as eating or writing in a crowded place, beginning or keeping conversations, attend parties, dating, meeting strangers, or communicating with authority figures (Hofmann & Otto, 2017).  As a result, their functionality in everyday life is affected negatively and their behaviour in social environment is restricted. With the publication of DSM-V (American Psychiatric Association, 2013), a few changes have been made in the definition of SAD. Individuals with SAD typically have multiple social fears and social impairments albeit some individuals may have only fear in speaking or performing in public. In addition to humiliation and embarrassment, other consequences such as rejection by others in social environment is occurred in SAD.

Epidemiological surveys have shown that SAD is commonly comorbid with other psychiatric disorders, for instance, depression, substance abuse, and other anxiety disorders (Grant et al., 2005; Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992). In addition, SAD’s earlier onset in comparison to many other mental disorders (Kessler et al., 2005) and its association with anxiety risk factors such as behavioural inhibition (Hayward, Killen, Kraemer, & Taylor, 1998) demonstrate that it is an important condition which requires treatment.

Risk Factors in the Development and Course of Social Anxiety Disorder

Several risk factors including familial factors, conditioning events, temperamental factor and cognitive factors were associated in the development and course of SAD.

Familial Factors

Familial studies have demonstrated that first-degree relatives of patients with SAD are affected three times as likely as relatives of control subjects (Fyer, Mannuzza, Chapman, Martin, & Klein, 1995; Mannuzza et al., 1995; Reich & Yates, 1988). Mannuzza et al. (1995) evaluated first-degree relatives of 129 patients with SAD by applying interviews and family history methodologies. Their findings indicated that relatives of patients with generalized SAD had three times more rates in comparison to patients with nongeneralized subtype. In parallel to this results, relatives of patients with SAD were significantly higher than the familiality of other anxiety disorders. On the other hand, Stein et al., (1998) evaluated 106 first-degree relatives of 23 patients with generalized SAD by applying direct interview methodology. In this study risk ratio for generalized SAD in the relatives of patients in comparison to control subjects was 9.7 but no significant differences were found in nongeneralized SAD. Although all these studies confirm the familial background in the occurrences of SAD, the differences in the risk ratios may arise due to methodological distinctions such as differing assessment methods. Larger studies are needed using more standardized methodologies.

When parental practices are taken into account, higher parental rejection and higher parental overprotection were shown to increase rates of SAD in offspring. In the case of parents have psychopathology, the relationship between parental rejection and occurrences of SAD in adolescents were greater (Lieb et al., 2000). In addition, Bruch (1989) speculated that children who experienced criticism and rejection are more likely to have SAD in further life through fear of negative evaluation and avoidance of social scrutiny.

Family environment may also influence adolescents’ perceptions and promote social anxiety. Caster, Inderbitzen and Hope (1999) found that adolescents who reported higher level social anxiety have different perceptions in their family environment than adolescents who have lower social anxiety levels. Nevertheless, parents of adolescents who experiencing higher social anxiety did not perceive their family of environment differently than parents of adolescents who have lower social anxiety.  Moreover, high social anxiety group perceived their parents more socially isolating and less socially active in comparison to low social anxiety group.

Conditioning Events

Traumatic social conditioning experiences and shyness were shown to be a risk factor in the genesis of SAD (Stemberger, Turner, Beidel, & Calhoun, 1995). The repetitive and cumulative experiences such as rejection by peers may result in development of fear in social interactions or scrutiny (Beidel, Turner, & Association, 2007). Moreover, studies demonstrated that shy adolescent and avoidant adults have displeasing experiences with peers (Ishiyama, 1984) and neglected children by their peers also showed higher SAD and fear of negative evaluation (La Greca, Dandes, Wick, Shaw, & Stone, 1988) as well as self-isolation and behavioural inhibition. As a result, both neglect or displeasing experiences with peers may have reciprocal interactive relationship in the occurrence of SAD.

Temperamental Factors

“Behavioural inhibition to unfamiliar” (BI) is a hypothesis which indicates that behavioural reactions to unfamiliarity, threat or challenge are occurred due to the tonic differences in the threshold reactivity in the amygdala and the hypothalamus which are parts of the limbic lobe (Kagan, Reznick, & Snidman, 1987). Children with different ages have distinct physiologic reactions to unfamiliarity. For instance, increased urinary 3-methoxy-4-hydroxy phenylglycol at the age between 4 and 5.5 years and increased baseline morning salivary cortisol at the age between 5.5 and 7.5 years were observed in children and these events were regulated by limbic-hypothalamic arousal (Kagan, Reznick, & Snidman, 1988). Furthermore, Calkins, Fox and Marshall (1996) studied physiological and behavioural antecedents of uninhibited and inhibited behaviour in infants with 9-10 months of age. Their findings showed that there were pattern of frontal activation and asymmetry in cerebral activation in high-reactive and inhibited infants. Distinctions in frontal activation in infants have previously been shown to exhibit distress after brief maternal separation. In parallel to these data, hypoactivation in the left frontal region increased the development of SAD and depression in adults and similar differences were found in the brain of those individuals (Davidson, 1994). On the other hand, several studies linked BI occurring in children to the development of SAD. For instance, maternal reported early BI was shown to affect approximately four times increased chance of a lifetime SAD occurrences during adolescence (Chronis-Tuscano et al., 2009). In a meta-analytic study, BI was shown to associate more than seven times higher occurrences of SAD and largest single risk factors in SAD development  (Clauss & Blackford, 2012). These results suggest that BI has association with the development of SAD in children, adolescence and adults.

Cognitive Factors

Several research proposed cognitive model in relate to self-perception which is an important maintaining factor in SAD (Clark, Crozier, & Alden, 2005; Clark & Wells, 1995; Rapee & Heimberg, 1997). For instance, people with SAD may be preoccupied by their projected self-image in performance and social situations. Moreover, studies showed that people with SAD creates negative self-image based not on their personal view but on the view of their potential evaluators (Rapee & Heimberg, 1997; Wells, Clark, & Ahmad, 1998). In other words, in social situations, people with SAD take observer perspective in which they view themselves from the external point. This views are generally negative and play a key role in the development and course of SAD (Hook & Valentiner, 2002) and changes in negative self-perception is an important factor in the treatment procedures.

Cognitive Behavioural Therapy in the Treatment of Social Anxiety Disorder

Cognitive behavioural therapy (CBT) is the most extensively investigated nonpharmacological and psychosocial approach in the treatment of SAD and its effectiveness has been proved in a wide range of research. CBT is present-oriented psychotherapy strategy in which patients are taught the behavioural and cognitive skills that are required for their normal functioning of intrapersonal and interpersonal worlds (Hofmann & Otto, 2017). In CBT, the evaluations are primarily based on cognitive and behavioural observations, nevertheless other factors in relate to patient such as biological, interpersonal and so on were also taken into account (Wright, 2006). ). At the same time, CBT focuses on the present time rather than the past, also “here and now” and it commences with psychoeducation. The client and the therapist cooperate to overcome the problem. Namely, collaboration is very crucial in this process. Thus, CBT examines maladaptive thoughts and tries to replace them with more adaptive ones (Craske, 2010).

On the other hand, there has been several investigations in which CBT is useful for individuals with SAD. Olatunji, Cisler, and Deacon (2010) claim that CBT generally provides cognitive restructuring and in vivo exposure therapy to the feared event for SAD. In this way, individuals having social phobia can reappraisal and change their dysfunctional thoughts about the possibility of living negative social situations and results. Thus, patients’ everyday life actions can be facilitated and functional improvement can be ensured through CBT.

The Forms of Cognitive Behavioural Therapy in the Treatment of Social Anxiety Disorder

The varieties of CBT which have been applied for the treatment of SAD are exposure, relaxation training, cognitive restructuring, social skills training and mindfulness based cognitive behavioural therapy.

Exposure

Exposure methods are designed to assist patients in facing the conditions that they fear despite distress. Patients who faced fear stay physiologically engaged in and as a result of natural conditioning process reduction in the fear can be observed. Although there has been debates in the mechanisms explaining the effects of exposure, according to Bouton (2002), exposure does not lead and replace to the patient’s unlearning fear responses, instead it creates more ambiguous and new learning that compete with the original fear response. The exposure process begins with developing a rank-ordered list of anxiety provoking situation between patient and therapist in which patient brainstorms a list of situations that creates fear. During exposure, therapist instruct patient to engage and imagine in feared situation. As a result of patient’s exposure of feared situation in sufficient length leads to a new learning or habituation and anxiety is being reduced (Heimberg & Becker, 2002). In addition, exposures begin with lower-ranked situations and they were gradually moved up to more feared situations so that keeping situations manageable. On the other hand, in order for exposure methods be most effective, patients are required to fully engaged in and concentrated to the situation. If socially anxious individual cannot fully concentrate and can find it difficult to do, they may face with distraction and avoid paying full attention in detail to the feared situation. The previous data indicates that given instructions to maintain and increase the patient’s focus on the feared situation increases the effectiveness of exposure methods (Wells & Papageorgiou, 1998). Therefore, clinicians should be alerted in which patient’s subtle avoidance can reduce efficacy of exposure. A similar form of avoidance occurring in the patients that negatively affects exposure technique is safety behaviours. For instance, SAD patient who fears in public speaking may hold their hands behind their backs so that they would like to escape shaking hands with others. Although patients with SAD may use safety behaviours for their success, that kind of patients may be perceived as not component in front of audiences due to a lack of expressiveness. The previous data showed that ceasing safety behaviours increases the effectiveness of exposure method (Wells et al., 1995).

Relaxation Training

Progressive muscle relaxation training (Bernstein & Borkovec, 1973) has been developed for patients to learn controlling physiological arousal when feared situation was anticipated. However, relaxation training exhibited minimal effects on SAD (Alström, Nordlund, Persson, Harding, & Ljungqvist, 1984) and using its alone is not sufficient in the SAD treatment. On the other hand, applied relaxation which is a form of progressive muscle relaxation training technique initially treats patient with muscle relaxation and then through instructed practices, patients are sufficiently skilled while confronting feared situations. As a result of applied relaxation, general techniques in relaxation training in adapted and combined, and then patients are gradually exposed to feared situations so that new coping strategies are developed (Öst, 1987). Finally, patients are able to apply relaxation skills in anxiety-provoking situations.

Cognitive Restructuring

Cognitive behavioural models suggest that incorrect beliefs about the prospective dangers posed by social situations and negative predictions about the results of such circumstances may occur in patients with SAD (Clark & Wells, 1995; Rapee & Heimberg, 1997). The cognitive restructuring consider individuals’ thoughts about the social situations which create anxiety rather than only focusing on situations (Beck, Emery, & Greenberg, 2005). In cognitive restructuring, the patient and therapist collaboratively work on identifying negative automatic thoughts that provokes anxiety before, during or after the situation. And then, Socratic questioning or behavioural experiments assess accuracy of patient’s thoughts. Finally, rational alternative thoughts are derived from data gathered from the assessment (Heimberg & Becker, 2002).

Social Skills Training

Based on the behavioural deficiencies (e.g., poor eye contact) occurring in people with SAD, social skills training focused on solving anxiety problems arises from inadequate social interaction skills. Studies have some contradictory results for finding evidence regarding social skill deficiencies in people with high versus low social anxiety group. For instance, Stopa and Clark (1993) found deficiencies in social skills in people with SAD, however, no significant differences were found on observers’ ratings of public speaking performance in social phobics and control group (Rapee & Lim, 1992). But, in both of research people with SAD underestimated the adequacy of their behavioural performance (Rapee & Lim, 1992; Stopa & Clark, 1993).

Social skills training methods comprise therapist modelling, corrective feed-back, homework assignments and social reinforcement. Benefits arise from social skills training due to its training aspects such as repetitive practices of feared situations and exposure aspects including confrontation of feared events or its cognitive elements. In addition, social skills training can also be combined with other CBT techniques such as exposure and cognitive restructuring. Moreover, exposure and social skills training was combined with education as a multicomponent treatment for social phobia and increased treatment outcome was observed in patients with SAD (Turner, Beidel, Cooley, Woody, & Messer, 1994).

Mindfulness-Based Cognitive Behavioural Therapy (MCBT)

Mindfulness has been previously defined as “bringing one’s complete attention to the present experience on a moment‐to‐moment basis”  (Marlatt & Kristeller, 1999) and it is a kind of attentional training intervention which had marked impact on CBT. MCBT comprises elements of cognitive therapy that leads to decentred views of individuals’ thoughts by proposing statements such as “I am not my thoughts” and “thoughts are not facts”. With the high degree of overlap in mindfulness-based stress reduction (MSBR) (Kabat-Zinn & Hanh, 2009),  both MCBT and MSBR focused on systematically train mind and thoughts. Furthermore, results from those interventions have significantly reduced stress, anxiety and depression symptomologies in a wide range of non-clinical and clinical populations (Brown, Ryan, & Creswell, 2007). It is well-reasonable that MCBT might have an increased affect to reduce SAD symptomology by training patients to pay attentional control and increase their tolerance to negative symptomologies of SAD, therefore reducing worry, rumination and negative self-perception (Brown et al., 2007; Segal, Williams, & Teasdale, 2002).

Pharmacological Treatments for Social Anxiety Disorder

Although earlier studies in the treatment of patients with SAD using medications provided equivocal support for the effectiveness of drug treatments due to poorly done diagnostic criteria  and methodological flaws (see Blanco, Antia, & Liebowitz, 2002), a lot of studies empirically demonstrated wide range of medications can be effective in the treatment of SAD (Liebowitz et al., 1992; Stein, Liebowitz, et al., 1998; Van Ameringen et al., 2001). While earlier treatments utilized monoamine oxidase inhibitors (MAOI) in the treatment of SAD (Blanco et al., 2002), selective serotonin reuptake inhibitors (SSRIs) were also used with enhanced frequency. Especially sertraline and paroxetine and norepinephrine-serotonin reuptake inhibitor venlafaxine have been effectively used in SAD treatment. Other type of medications used in the treatment of SAD were benzodiazepines and beta-blockers (Blanco et al., 2002). On the other hand, a meta-analytic review demonstrated that largest effect size (ES=1.02) for phenelzine in the treatment of SAD in comparison to other medications such as benzodiazepine clonazepam (ES=.097), gabapentin (anti-convulsant) (ES=.78), brofaromine (MAOI) (ES=.66) and SSRIs (ES=.65) (Blanco et al., 2003). Authors suggested to use SSRIs as first line treatment strategy since they were safer than other type of medications especially benzodiazepine clonazepam since it may create concerns such as excessive sedation, potential withdrawal symptoms and dependency (Blanco et al., 2003).

Psychodynamic Therapy in the Treatment of Social Anxiety Disorder

Psychodynamic or psychoanalytic therapy (PDT) investigate aspects of self that are not fully known and focused on exploration and discussion of a patient’s emotions, threatening feelings or feelings that patient may not be able to recognize. In addition, it has developmental focus in which it was built on recognition of early experiences (e.g., early attachment figures) that was impact on present. As a result, psychodynamic therapists investigate the relation of early experiences with present while focusing not only on past but also how patient’s past shapes current psychological difficulties. The main aim is here to decentre patients from the bonds of past so as to live them more fully in the present state.  Moreover, PDT focuses on interpersonal relationships in which problematic interpersonal relationship of a patient was also considered. Patients’ thoughts naturally occurring in many areas of mental life such as desires, fantasies, daydreams and dreams are encouraged to talk in the therapy sessions so that therapists can find rich source of information about the patients’ inner world, views and interprets (Shedler, 2010). PDT has been shown to be efficacious in the treatment of SAD in both short and long term period of time (Bögels, Wijts, Oort, & Sallaerts, 2014; Leichsenring et al., 2013, 2014).

Critical Review

Research on Psychodynamic Therapy versus Cognitive Behavioural Therapy

            Leichsenring et al., (2013) investigated the effectiveness of CBT and PDT in SAD in a multicentre randomized trial. 495 patients with SAD from outpatient clinics at the universities of Bochum, Dresden, Göttingen, Jena, and Mainz were attended to experiment, albeit in total of 1450 patients were screened. Inclusion criteria for this study comprised participants aged between 18-70 years, participants who diagnosed with SAD according to the German-language edition of the Structured Clinical Interview for DSM-IV, participants who have a score greater than 30 in Liebowitz Social Anxiety Scale and participants primarily diagnosed on Anxiety Disorders Interview Schedule were included. In addition, participants with psychotic and acute substance-related disorders, personality disorders, organic mental disorders, heavy medical conditions and participants under psychotherapeutic and psychopharmacological treatment were excluded. Participant allocation was randomly held by computerized system and patients were assigned PDT, CBT and waiting list in 3:3:1 ratio.

            CBT treatment approach comprised several methods such as role-play based behavioural experiments, improving external attentional focus and cognitive restructuring (e.g., restricting deteriorated self-image by behavioural experiments or video feed-back). In addition, therapists also investigated safety behaviours by asking specific questions in relate to them. On the other hand, to make comparable CBT to PDT, a specific manual guided PDT which consisted of supportive and extensive interventions was adapted to treat SAD in the current research (Leichsenring et al., 2013). This manual focused on past and present relationships of patients. For both PDT and CBT treatments 50 minutes sessions up to 25 individuals were completed. While sessions in CBT was conducted on weekly basis, in PDT sessions were also weekly with the exception of the middle part of treatment in which two sessions in a week were also conducted to strengthen the therapy at that middle part. In addition, a preparatory session was also done before starting experiment to cover diagnostic and administrative health issues. As a result, minimum duration for CBT and PBT was more than 6 months. On the other hand, the assessments were videotaped to ensure treatment integrity. In terms of assessing treatment integrity the Penn Adherence and Competence Scale for Supportive-Expressive Therapy and the Cognitive Therapy Competence Scale for Social Phobia were used. Assessments at the baseline, at weeks 8 and 15 were done. Moreover, video interviews were also conducted for analysing interrater reliability. Response rates for remission and self-report instruments such as such as the Social Phobia and Anxiety Inventory, the Beck Depression Inventory, and the Inventory of Interpersonal Problems were used as an outcome measure. During the trial, adverse and serious adverse events as well as continuous monitoring of patients were done for safety reasons. No significance tests were applied in further analysis due to small number of adverse and serious adverse events.

This research has several findings: (1) While remission rates were observed as 36%, 26% and 9% for CBT, PDT and waiting list groups respectively, corresponding response rates were observed as 60%, 52% and 15%. These findings suggest that CBT and PDT have superiority to waiting list subjects in terms of response and remission rates. On the other hand, logistic regression models revealed that CBT was more effective in comparison to PDT in remission but not for response rates. (2) The completer analysis which included the patients who complete the treatment showed remission rates as 42% and 30% for CBT and PDT, respectively and corresponding response rates were 66% and 56%. Therefore, the pattern of results was similar. (3) The CBT and PDT technique used in this research had significant influence on the outcome of rating on the Social Phobia and Anxiety Inventory and the Inventory of Interpersonal Problem. Moreover, results suggest that CBT is superior to PDT.

            This research has several strengths: (1) the results of this study are in parallel to previous report in which this study confirms the previous findings (Stangier, Schramm, Heidenreich, Berger, & Clark, 2011). (2) large sample size used in this study increases its significance, (3) adapted manuals especially for PDT also increases significance of results, (4) using multiple centres and large number of therapists also supports generalizability of findings. On the other hand, there are some limitations as well. As authors discussed, this study did not include pharmacotherapy or combined therapies. In addition, as many patients with SAD generally use pharmacotherapy, authors excluded those sample from this study (Leichsenring et al., 2013). This situation may limit generalization of data. Further multi-disciplinary research on genetics and neuroimaging may be required so as to confirm findings of this research. On the other hand, Leichsenring et al., (2014) were performed follow-up evaluation of their previous study (Leichsenring et al., 2013) at 6, 12, and 24 months after treatment process to investigate the long term impact of the CBT and PDT. The purpose of the present study was to observe these participants’ improvements for 24 months. Results of this study revealed that both CBT and PDT sessions were effective in terms of long-term and short-term for SAD. In this study, the response rate was 70% and the remission rate was 40%. There were statistically significant but small differences in favour of CBT in the short-term were observed. On the other hand, at the end of the treatment, both remission and response rates were not significantly differed and they were similar. Therefore, considering previous research data (Leichsenring et al., 2013) in CBT and PDT, results suggest that application of CBT over PDT in the treatment of SAD actually did not prove superiority of CBT over PDT in follow-up period. Since there were small differences in CBT and PDT data, the differences between patients who benefit in one treatment condition over the other should be considered. Finally, authors recommend that further research on unified protocols needs to be done because evidence has not yet been established that it is more effective than disorder-specific treatments (Leichsenring et al., 2014).

            Bögels et al., (2014) investigated short- and long- term effects and effectiveness of PDT and CBT on SAD. Although in total of 80 participants were screened, 49 participants were found to be eligible for this study. People with SAD (1) who have previously treated with CBT and/or PBT in the last 2 years, (2) who have substance abuse and dependence, (3) psychotic disorder and (4) suicidal behaviour were excluded from this research. Diagnostic interviews were held to include subjects to study and diagnostic criteria for SAD was also considered. Random assignment of participants to CBT and PDT groups were done with tossing a coin at the clinical staff meeting. Sessions for CBT and PDT took up to 36 weeks of period. Then, patients were revaluated at weeks 12 and 24 only if they received longer treatment, at post-treatment, at 3 months and 12 months after treatment. Social anxiety measurements were done with following instruments: The Social Phobia and Anxiety Inventory (SPAI)–Social Phobia

Subscale, the subscales Main Phobia and Social Phobia of the Fear Questionnaire (FQ) and the subscale Social Anxiety of the Self-Consciousness Scale (SCS). In addition, other instruments (e.g., the SPAI subscale Agoraphobia) and behaviour assessments were also used in terms of analysing different factors. On the other hand, authors also investigated social anxiety related factors such as social skills deficits, self-focused attention and negative social beliefs for CBT and defence mechanisms for PDT. Further, PDT and CBT were carried out in patients with SAD. While in PDT, basically patients are exposed to exploration, clarification, and interpretation, and occasionally, supportive-expressive interventions, CBT techniques included social skills training, applied relaxation, cognitive restructuring and task concentration training (Bögels et al., 2014).

            This research has several findings: (1) Pre-test and post-test analysis showed that both PDT and CBT was highly and equally effective in terms of reducing social anxiety. (2) At post-test 64% and 63% of changes in patients with SAD for CBT and PBT were observed. This situation was also reliable at 3 months (58% CBT and 50% PDT) and 12 months follow-ups (65% CBT and 75% PDT). (3) No interactions with treatment conditions or any other variable were observed at any time of point. Personality disorders have no impact on treatment conditions. (4) Defence mechanisms in CBT and PDT did not differ when outcome of both therapies was considered.

            This research has several strengths: (1) The remission rates found in Bögels et al., (2014) study was 54% and 47% for CBT and PDT respectively. In parallel to these results, Leichsenring et al., (2013) found remission rates as 36% and 26% for CBT and PDT. (2) The unique contribution of this study to existing literature is that Bögels et al., (2014) applied flexible and structured treatments based on case formulations rather than it was manually guided. Therefore, two therapeutic interventions (CBT and PDT) can be validly compared without existing bias. There also some limitations exist: (1) Relatively small sample size was used in this study in comparison to study of Leichsenring et al., (2013). This may have negative impact on the significance of data or generalization of findings. (2) No placebo control was used in this study. Finally, authors recommend different choices of treatment based on family history or patient background. But therapist should also consider cost-effectiveness of CBT over PDT since CBT took shorter training sessions, while from patient’s perspective, CBT homework requires times, effort and attention (Bögels et al., 2014).

Research on Mindfulness-Based Cognitive Therapy and Group Cognitive Behavioural Therapy

            Piet, Hougaard, Hecksher and Rosenberg, (2010) studied the effectiveness of MCBT alone and in combination with group cognitive behavioural therapy (GCBT). The experiment included 26 participants aged 18-25 years who have diagnosed with SAD according to DSM-IV criteria, albeit initial screening was done with 43 patients. Exclusion criteria were determined as psychosis, severe depression, substance dependence, cluster A and B personality disorders, bipolar disorder and current psychological and pharmacological treatment. Diagnostic interviews were carried out with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders and the Anxiety Disorders Interview Schedule for DSM-IV. In the experimental approach, crossover design was used in which subjects were randomly allocated each of the treatment conditions. Outcome measures were collected prior to therapy, after first treatment, after second treatment, after 6 months and 12 months. Total duration of study was 19 months due to some breaks occurring between treatments (Piet et al., 2010).

            GCBT consisted of treatment elements such as psycho-education SAD, case formulations, cognitive restructuring and behavioural experiments in relate to feared situations. The GCBT manual given to participants also included homework assignments. Group therapy was initially done with 12 weekly 2-hour sessions and then 2 weekly 2-hour sessions of individual therapy was applied. On the other hand, MCBT consisted of content about psycho-education. Mindfulness medication methods (e.g., body scan, yoga exercises) were also utilized in daily basis in which participants spent 30-40 minutes. Total duration of MCBT comprised 8 weekly 2-hour sessions.

            Treatment outcomes in relate to social anxiety and its components were measured using the Liebowitz Social Anxiety Scale, the Social Phobia Scale, the Social Interaction Scale, the Symptom Checklist-90-Revised, the Beck Anxiety Inventory, the Inventory of Interpersonal Problems, the Fear of Negative Evaluation and Shehan Disability Scale.

            This study has several findings: (1) MCBT and GCBT groups did not differ on any of the baseline variables, (2) Between group comparisons revealed no significant differences between MCBT and GCBT groups after the first treatment, however most outcome variables in relate social anxiety and its components were in favour of GCBT group, (3) there were no significant differences after second treatment, and all follow-ups (after 6 months and 12 months treatments), (4) Within group changes revealed that both MCBT and GCBT group have significant improvements in relate to SAD symptomology after 6 months, (5) No significant differences were found in participant satisfaction between two groups. Results of this study suggested that although MCBT produces significant improvements in terms of reducing SAD symptomology in young adults, it has numerically smaller number than GCBT and no statistical differences were observed between two groups (Piet et al., 2010).

            In a previous study, Koszycki, Benger, Shlik and Bradwejn (2007) studied how well MBSR and GCBT for SAD, decreasing key SAD symptoms and enhancing mood, functionality and standard of living. They expected that both treatments would provide important and clinically valid changes, but they anticipate GCBT would ensure more remission on SAD symptoms. Their results indicated that response and recruitment levels with GCBT were also considerably higher than MBSR, with the response rate for GCBT being similar to other cognitive-behavioural SAD treatments. On the other hand, there are some limitations in their study. For example, there is not a control comparison in this study, so in these patients may occur probability of spontaneous remission. In addition to this, evaluations were made only at the beginning and end of the study and were not conducted weekly. Even though they have a significant rate of participants getting better, 12 weeks of GCBT and 8 weeks of MBSR could not provide full remission because of insufficient time. The results of Piet et al., (2010) did not show significant differences between mindfulness based therapies over GCBT but Koszycki et al., (2007) found the superiority of GCBT over MSBR. This distinction may arise due to sample size affect in which Piet et al., (2010) used smaller sample size (N=26) in comparison to study of  Koszycki et al., (2007) (N=53). This should be considered as limitation in the mentioned research. In addition, no placebo or wait list were used as control condition and high degree of drop-out in the second treatment were also considered limitations. This study has some strength as well: The highly achieved effect sizes for GCBT is in parallel to previous meta-analytic reports (Norton & Price, 2007). In conclusion, MCBT might be a low-cost and useful strategy in the treatment of SAD but GCBT might be more effective than MCBT in treating social anxiety related symptomology. 

            Kocovski, Fleming, Hawley, Huta and Antony (2013) studied effectiveness of mindfulness and acceptance-based group therapy (MAGT) and GCBT for SAD. 137 participants (mean age is 34) were recruited for recruited for this study. In order to be eligible, SAD assessment was done based on using the Structured Clinical Interview for DSM-IV. Patients who have substance and alcohol abuse or dependence, major depressive disorder, psychosis, mania, suicidal intent and past treatment with acceptance-commitment therapy and CBT for SAD. On the other hand, psychotropic medicine use was allowed in the case of using stable doses from 3 months prior to and during the experiment. Treatment outcomes were measured at baseline, at 6 weeks (mid-treatment), at 12 weeks (post-treatment) in all groups. Primary treatment outcomes in relate to SAD were assessed using the Social Phobia Inventory. Clinician administered measures included Liebowitz Social Anxiety Scale in which social anxiety related symptomologies were assessed at baseline, post-treatment and follow-up (at 3 months).  The Clinical Global Impression scale was used to assess treatment efficacy.  The Reappraisal subscale of the Emotion Regulation Questionnaire was used to evaluate cognitive reappraisal and the Freiburg Mindfulness Inventory was used to evaluate mindfulness in patients with SAD. On the other hand, Social Anxiety-Acceptance and Action Questionnaire was used to evaluate acceptance specific to social anxiety and Rumination subscale of the Rumination Reflection Questionnaire was used to evaluate rumination. Each therapy was comprised 12 weekly 2-hour sessions. While GCBT included cognitive restructuring, MAGT included mindfulness exercises such as body scan and mountain meditation (Kocovski et al., 2013).

            This research has several findings: (1) The outcomes of MAGT and CGBT at the post treatment did not significantly differ from each other with a few exceptions but significantly differed from wait list group. When mindfulness and reappraisal outcome considered, MABT scored significantly higher than wait list group but mindfulness in GCBT and wait list groups did not differ significantly between each other. (2) The secondary outcome measures were significantly improved in patients with SAD both for GCBT and MABT group but not in the wait list. (3) GCBT and MABT demonstrated significantly faster rate of improvement in over time in comparison to wait list and GCBT and MABT did not significantly differ between each other in terms of improvement rates. (4) Participants in GCBT group (47.2%) and MABT group (37.7%) showed clinically reliable improvement. Overall, in both groups 32.1% of patients have demonstrated clinically significant change. For completers, the clinically significant changes were higher for GCBT (43.8%) and MABT (43.2%) groups. (5) 3-months follow-up data demonstrated that similar pattern for the improvement rates in patients with SAD for both MABT and GCBT groups.

            This study has several strengths: (1) Results gathered from this research supported previous findings (Piet et al., 2010), (2) Large sample size was used. On the other hand, there are some limitations as well: (1) The follow-up data may have been affected by attrition bias due to significant attrition rates were observed in patients with SAD (40% for GCBT and 30% for MABT). Therefore, the rates of participants who discontinue to this treatment should also be considered when data were taken into account. (2) Since therapist competence was not assessed in this study, the differences may exist between MABT and GCBT group in terms of competence and enthusiasm. This may negatively affect the superiority of one intervention over another and multiple therapists and multisite design with more sample size might provide better and more transparent results. In conclusion, finding of authors suggested that MAGT and GCBT are effective treatments in the treatment of SAD.

Research on Internet-Based Cognitive Behavioural Therapy and Group Cognitive Behavioural Therapy

            Hedman et al. (2011) investigated the therapeutic outcomes of conventional GCBT and internet-based cognitive behavioural therapy (i-CBT) in patients with SAD in a randomized controlled non-inferiority trial. 230 patients were initially screened and 126 patients with SAD who meets eligibility criteria were included to study (i-CBT, N=64 and GCBT, N=62). Patients who meets with DSM-IV criteria for SAD were evaluated using the Structured Clinical Interview for DSM-IV axis I disorders. In addition, patients who have not previously undergone CBT treatment and who have used medications in constant dosage 2 months before the experiment agreed on keeping dosage stable during study were included in the experiment. Patients with substance abuse, psychosis or bipolar disorder, suicide ideation and personality disorder cluster A and B were not included in study due to there might be some interferences in the therapeutic stages in CBT. Inclusion was made based on using several initial assessment questionnaires about SAD (e.g., the Social Phobia Screening Questionnaire) and interviews held by expert psychiatrists. Outcome measures evaluated social anxiety through Liebowitz Social Anxiety Scale, the Social Phobia Scale and the Social Interaction Anxiety Scale. In addition, anxiety sensitivity, general anxiety, quality of life and depression were also measured. Assessments in relate to treatment were performed before and immediately after treatment and 6 months after treatment. 1:1 ratio was used in random allocation for i-CBT and GCBT.

            15 weeks i-CBT treatment included internet-based self-help text modules (time duration spent was less than 10 minutes per week) which covers distinct CBT theme (e.g., cognitive restructuring, exposure). On the other hand, GCBT comprised of 1-week initial group treatment session followed by 14 weeks sessions (2.5 hours for each session followed by 10 minutes break). In GCBT’s sessions (2-3), participants are taught about anxiety and deal with negative automatic thoughts. Further sessions (4-14) focused on combination of cognitive restructuring and exposure methods to reduce fear in relate to social anxiety. Sessions 14-15 included to evaluate progress of participants and their set goals for future. Expert psychologists and psychotherapists directed therapies in both groups.

            This research has several findings: (1) Post-treatment results demonstrated that 55% of participants in i-CBT group and 34% of participants in GCBT group were positively responded to mentioned therapies. At 6-months follow-up period corresponding numbers were 64% and 45% for i-CBT and GCBT. In addition, significant improvement in relate to social anxiety symptomology were seen people with SAD in both treatment groups. In pre-, post- and after treatments. (2) Clinician administered measures of improvement demonstrated that 66% of participants for i-CBT and 55% of participants in GCBT was very much or much improved according to the Clinical Global Impression Improvement Scale. Wilcoxon analysis (pre-post-tests) showed that follow-up improvements were significant at i-CBT but not in GCBT group. But the improvements were not at statistically significance level for post-treatment in i-CBT and GCBT groups indicating that immediately after treatment both i-CBT and GCBT were almost similar affect on reducing SAD symptomology.

            This research has several strengths: (1) It was the first study in the literature which demonstrated the effectiveness of i-CBT in comparison to GCBT. (2) Authors used large sample size and those large number of populations gathered higher improvement rates both at post-treatment and follow-up. There are some limitations in this study as well: (1) No randomization using placebo condition were done which may result in misinterpretation of findings. (2) In this study, patients willingly choice which treatment they should receive. This may also create a limitation in data. (3) In addition, although this study included short-term follow-up, no long-term follow-up experiments were performed to understand the effectiveness of i-CBT and GCBT. In conclusion, this study has demonstrated that i-CBT is as effective as conventional GCBT in the treatment of SAD. Using i-CBT method may also create effective treatment in terms of reducing SAD symptoms.