Abstract

Objective: Evaluation of the effectiveness of cognitive behavioural therapy over other therapies on social anxiety disorder

Methods: A literature search was performed in the Google Scholar online databases (https://scholar.google.co.uk/) for research papers published between 2010-2019. Following keywords were used in the search: “social anxiety disorder” and/or “cognitive behavioural therapy” or “psychodynamic therapy” or “mindfulness based cognitive therapy” or “pharmacotherapy” or “internet-based cognitive therapy”. Nine studies were selected in terms of analysing effectiveness of aforementioned interventions on social anxiety disorder.

Results: Studies demonstrated that cognitive behavioural therapy and its different forms such as mindfulness based cognitive therapy, group cognitive behavioural therapy and internet based cognitive therapy are highly effective in the treatment of social anxiety disorder. Moreover, psychodynamic therapy and cognitive behavioural therapy were equally effective in terms of reducing social anxiety symptomologies. However, medication plus group cognitive behavioural therapy was shown to be superior in the treatment of social anxiety disorder.

Conclusion: This review was provided important information about the effectiveness of cognitive behavioural therapy and treatment of social anxiety disorder. Although it is hard to generalize superiority of one study over another, combined treatments seem to be most effective methods in the treatment of SAD. Individual-specific treatment strategies and limitations of current literature were discussed.

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 generalised SAD had three times more rates in comparison to patients with nongeneralised 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 generalised SAD by applying direct interview methodology. In this study risk ratio for generalised SAD in the relatives of patients in comparison to control subjects was 9.7 but no significant differences were found in nongeneralised 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 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.

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.

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).

Internet-Based Cognitive Behavioural Therapy (i-CBT)

Printed self-help CBT manuals have been developed to treat SAD. However, these manuals generally apply conventional CBT approaches by means of guided therapists. On the other hand, internet-based cognitive behavioural therapy (i-CBT) is a computerized version of CBT used in psychological treatments (Proudfoot, 2004). Computerized systems (e.g., i-CBT) minimizes patient-therapist interaction (Marks, Shaw, & Parkin, 1998). Research groups have developed cost-effective internet based interventions for several psychologic conditions (Ritterband et al., 2003) and i-CBT applications were also used in the treatment of anxiety disorders (Andersson, Bergström, Carlbring, & Lindefors, 2005). The all different varieties of CBT can be applied to i-CBT with minimal therapist-patient interaction. In addition, i-CBT is less costly than conventional CBT and was shown to be as equally effective as CBT (Titov et al., 2009). Several reports proved the effectiveness of i-CBT on reducing SAD symptomology (Hedman, Andersson, Ljótsson, Andersson, Rück, & Lindefors, 2011; Hedman, Andersson, Ljótsson, Andersson, Rück, Mörtberg, et al., 2011; Hedman, Furmark, et al., 2011).

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) investigates 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

A literature search was performed in the Google Scholar online databases (https://scholar.google.co.uk/) for research papers published between 2010-2019. Following keywords were used in the search: “social anxiety disorder” and/or “cognitive behavioural therapy” or “psychodynamic therapy” or “mindfulness based cognitive therapy” or “pharmacotherapy” or “internet-based cognitive therapy”. Inclusion criteria for selected studies were: (1) studies empirically analysing cognitive behavioural therapy versus psychodynamic therapy, (2) studies empirically analysing mindfulness-based cognitive therapy and group cognitive behavioural therapy, (3) studies empirically analysing internet-based cognitive behavioural therapy and group cognitive behavioural therapy, (4) studies empirically analysing pharmacological therapy and group cognitive behavioural therapy, (5) studies published between 2010 and 2019.

Research on Psychodynamic Therapy versus Cognitive Behavioural Therapy

            Leichsenring et al., (2013) investigated the effectiveness of CBT and PDT on 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, in order to make an accurate comparison in CBT and 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 due to added preparatory session. 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 inter-rater reliability. Response rates for remission and self-report instruments 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 in terms of reducing SAD symptomology.

            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 generalisation 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 in response to 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 durations 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 different 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 PDT 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 were 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, 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 interventions were 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 PDT 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 generalisation 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 about 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 groups 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 strengths 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 overtime 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 effect 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.

            Hedman, Furmark, et al., (2011) investigated the long-term effects of i-CBT for SAD in a randomized controlled trial. 80 participants were included in this study in which randomization was equally conducted between waiting list (N=40) and i-CBT group (N=40) albeit 144 of them were interviewed. Following treatment and post-treatment, respondents in the waiting list group were also underwent i-CBT in 1-year follow-up. However, because of the fact that two groups had underwent i-CBT treatment in different time points, the outcomes were reported separately. Therefore, one group only received i-CBT (group 1) and the other group at the waiting list received i-CBT in the follow up (group 2). Total follow-up duration consisted of 5 years.

In order to be eligible for this study, participants met the criteria for SAD according to the Structural Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders DSM-IV Axis-I disorders. In addition, participants who received pharmacological medications for anxiety or depression were also included only if they keep constant dosage in their medications and no other psychological treatments were allowed during the experiment. On the other hand, participants who did not have internet access, or serious psychotic disorder (e.g., schizophrenia) were excluded.

            Fear and avoidance were measured as primary outcome using the Liebowitz Social Anxiety Scale. In addition, the Social Interaction Anxiety Scale, the Social Phobia Screening Questionnaire and the Social Phobia Scale were used to measure social anxiety. On the other hand, depressive symptomology and generalised anxiety levels were also assessed as a secondary outcome. Clinical assessment interviews were done to confirm that participants’ eligibility for SAD criteria at 5-year follow-up. i-CBT treatment included computer-based self-help text delivered with internet which encompasses specific themes in relate to forms of CBT (e.g., exposure, cognitive restructuring). In addition, modules in i-CBT also focused on educational homework assignments and some behavioural trainings to reduce SAD related symptomology. Moreover, after participants received i-CBT, they were able to give feed-back and have a chance to anonymously talk with each other in online discussion forum (Hedman, Furmark, et al., 2011).

            This study has several findings: (1) Participants who received i-CBT treatment in both groups showed significant improvements at baseline, 1-year and 5-year follow-ups in all social anxiety measures. The improvement on the Liebowitz Social Anxiety Scale between 1-year and 5-year did not significantly change. However, group 2 (wait list-i-CBT) showed significant improvement on the Social Interaction Anxiety Scale at the 5-year follow-up in comparison to 1-year follow-up. (2) All participants showed significant improvement on the depressive symptomology and generalised anxiety levels at the baseline to 1-year and 5-year follow-up. (3)  Clinical assessment interviews revealed very much and much improvement (60% for group 1 and 67% for group 2) at 5-year follow-up. On the other hand, 48% of respondents in both groups were no longer showed SAD symptoms after 5-year follow-up (Hedman, Furmark, et al., 2011).

            This research has several strengths: (1) The effect sizes found in this study are parallel to those found in other studies which exhibited long-term efficacy of CBT on SAD (Heimberg, Salzman, Holt, & Blendell, 1993; Hunt & Andrews, 1998). In addition, previous research on 30-months follow-up i-CBT for social phobia also demonstrated similar effect sizes (Carlbring, Nordgren, Furmark, & Andersson, 2009) (2) This study also had very low attrition rates increasing the generalizability of data. (3) Results gathered from this study have some clinical implications. First, since the effectiveness of i-CBT over a long period of time (e.g.,5 years) was proven, it is a cost-effective treatment which minimizes face-to-face contact between therapist and patient. Secondly, the satisfaction rates of patients were very high (94% in this study).

            This study has some limitations as well: (1) no control condition was existed, therefore data did not demonstrate the differences between i-CBT and control group after 5-years follow-up. (2) This study analysed 1-year and 5-year follow-up but not the intervals between follow-ups. Therefore, symptom levels occurring in the year 2, 3 and 4 were disregarded. This situation creates uncertainty in diagnostic status of patients when SAD was considered. Apart from those limitations, this study proved that applying i-CBT in the treatment of SAD might be an important strategy in treating target population.

            Månsson et al., (2015) investigated neural predictors of long-term clinical response in patients with SAD who received i-CBT using functional magnetic resonance imaging (fMRI) and support vector machine learning. This novel study utilized supervised pattern recognition methods named support vector machine (SVM) which is clinical neuroimaging method that successfully separates SAD from healthy subjects and panic disorder patients. As a brief background information, SAD patients had multivariate pattern of blood oxygen level dependent (BOLD) response in the amygdala, anterior cingulate cortex (ACC), hippocampus and insula which are dysfunctional fear networks in the brain. CBT assists prefrontal-limbic interactions so that impaired cognitive control was restored. This study aimed to analyse 1-year outcome of received i-CBT and internet delivered attention bias modification (ABM) and used SVM classification in the assessment of neural predictors. In order to this, disorder-relevant fMRI paradigm was used and BOLD responses were entered to sentences for self-referential criticism. 26 right-handed participants who had SAD were attended to this experiment. Participants who have no somatic or neurological disorder, no ongoing psychological treatment and suicidal ideation were included in this study. Initial screenings were done based on the structured clinical interview for the 4th version of Diagnostic and Statistical Manual of Mental Disorders axis 1. The Clinical Global Impression-Improvement Interview Scale (CGI-IS) was used to assess treatment response at 1-year follow-up and long-term clinical improvement was evaluated using Liebowitz Social Anxiety Scale. In the treatment, cross-over design was used in which participants received ABM and i-CBT treatment in 1:1 ratio. I-CBT protocol included self-help text about homework assignments, cognitive restructuring and exercises and intervention lasted 9 weeks. On the other hand, ABM which is internet-delivered computerized flash program that targets distorted attentional process in patients with SAD. ABM lasted 4 weeks and exercises were conducted twice a week.

            BOLD responses to self-referential criticism were assessed using developed experimental task. In this task, 216 sentences were split into three categories based on valences (negative, neutral or positive). Next, by matching sentences on the number of letter and words, participants are told to read the sentences and to press the button with their right hand after sentences were read. Total duration for this stimulus took 17 minutes and 20 seconds and each sentence was shown at most 2500 milliseconds duration. Structural images within the desired brain regions (fear network regions of interest) were collected before the experiment. BOLD contrast images were also acquired in every 2000 milliseconds. Structural images and functional images were co-registered and different computer programs were used in data processing. Later, SVM analysis was done using appropriate software. For every interested region in the fear network, dot-product kernel matrix approach was used by summarizing pre-treatment contrast images of self-referential criticism. And then, SVM data were trained (machine learning) to separate the CGII-S responders from non-responders.

            This research has several findings: (1) The responders were 52% at 1-year follow-up in response to CGII-S clinical interview measure. Participants also improved in social anxiety symptomology from pre-treatment to 1-year follow-up. On the other hand, the treatment efficacy between post-treatment and 1-year follow-up did not differ significantly. (2) SVM analysis for BOLD response to self-referential found that the information in the anterior cingulate cortex (ACC) was highly accurate (balanced accuracy was 91.7%) 1-year after treatment in terms of classifying CGI-IS responders from non-responders. Further SVM data revealed that dorsal ACC alone and dorsal ACC interaction together with amygdala but not ventral ACC predicted 1-year clinical outcome. (4) The initial responses measured in those regions (e.g., ACC and amygdala -a part of fear network region of interest) were significantly lower in respondents than non-responders indicating the improvement in response to i-CBT in patients with SAD. Taken together, fMRI approach and BOLD response to self-referential criticism in the dorsal ACC and amygdala predicted 1-year response to i-CBT in patients with SAD.

            This study has several strengths: (1) The results found in this study are in parallel to those found in a previous study in relate to ACC-dependent self-referential processing (Pizzagalli, 2011). In addition, it is also consistent with the study which demonstrated therapeutic success of CBT for SAD in the brain’s cognitive and emotion processing areas (Klumpp, Fitzgerald, & Phan, 2013). (2) This study provides novel personalized treatment strategies in terms of using neuroimaging biomarkers for patients with SAD.

            This research has some limitations as well: (1) The sample size is small which makes the generalisation and interpretation of data difficult. (2) The reliability assessment for CGI-IS were not done. In conclusion, this study demonstrated dorsal ACC-amygdala interaction in i-CBT treatment using BOLD response to self-referential criticism and lowering this response in the fear network of brain regions has association in symptoms improvement (Månsson et al., 2015).

Research on Pharmacological Therapy and Group Cognitive Behavioural Therapy

            Blanco et al., (2010) investigated the effectiveness of GCBT and medication (phenelzine) combination over to each monotherapy in the treatment of SAD in a randomized, double blind and placebo controlled multi-centre trial. 726 patients were screened for eligibility and in total of 128 sample were include this study. Inclusion criteria comprised primary DSM-IV diagnosis for SAD in participants aged 18-65 years. Participants who have comorbid anxiety disorders, history of bipolar disorder, and schizophrenia, major depressive disorder, substance abuse or alcohol dependency, previous failure in CBT, phenelzine or other MAOIs treatment, were excluded. 4 groups were randomly assigned which are (1) GCBT (N=40), (2) phenelzine (N=45), (3) combined treatment (GCBT plus phenelzine, N=42) and (4) placebo group (N=39). After withdraws, 128 of participants involved in experiment. Phenelzine sulfate group consisted of 35, placebo group consisted of 27, GCBT group consisted of 34 and combined treatment group consisted of 32 individuals. Groups of 4 to 6 participants were received GCBT treatment in 12 and 2.5-hour sessions. GCBT focused on cognitive restructuring and behavioural tasks. Pharmacological therapy included phenelzine sulfate treatment at the dose of 15mg/day for 3 weeks, then 30mg/day for 4 days, 45mg/day for week 2 and 60 mg/day for weeks 3 and 4. The dosage was increased to 75mg/day for week 5 and 90mg/day for weeks 6 to 12, if there is an improvement and no adverse effects. Control group took placebo pills with matching dosages corresponding to phenelzine treated group. On the other hand, GCBT plus phenelzine group were received combination of CBT and phenelzine sulfate as described in the previous paragraphs. Assessments were done at baseline, at weeks 6, 12 and 24. Clinician administered measures included the Liebowitz Social Anxiety

Scale, the Anxiety Disorders Interview Schedule for DSM-IV Clinician’s Severity Rating and the Hamilton Rating Scale for Depression. Patient-rated self-report measures included the Fear Questionnaire Social Phobia Subscale, the Social Interaction Anxiety Scale, the Social Phobia Scale and the Sheehan Disability Scale. Moreover, adverse effects were evaluated for GCBT, phenelzine, GCBT plus phenelzine groups.

            This research has several findings: (1) Participants who received combined treatment (GCBT plus phenelzine) showed lower baseline values in all patient rated-self report measures in comparison to phenelzine alone, GCBT alone and placebo control groups. (2) Changes in the scores of the Liebowitz Social Anxiety Scale were significantly higher in combined treatment and phenelzine groups than placebo control condition. Nevertheless, no significant differences were observed in the slopes of GCBT and placebo groups. In parallel to these results, combined treatment and phenelzine were shown to significantly superior to placebo condition on reducing the symptomologies in the Liebowitz Social Anxiety Scale, the Social Interaction Anxiety Scale and the Fear Questionnaire Social Phobia Subscale. There were no significant differences observed in all outcome measures between GCBT and placebo groups. (3) Although, probability of response did not differ significantly in GCBT alone, phenelzine alone and placebo conditions, responders comprised combined treatment group. This situation was also similar for remitters.

            This research has some strengths: (1) This study found that phenelzine treatment is superior to placebo condition in which this data is in line with a previous study (Heimberg et al., 1998). On the other hand, Heimberg et al., (1998) also showed good response rates in GCBT, but this study showed lower efficacy in GCBT treatment. Sample differences may have impact on this condition. (2) In addition, sample size was large in this study and patients were recruited from two different centres. On the other hand, this study has some limitations as well: (1) GCBT plus placebo condition did not exist in this study. As a result, non-specific effects of phenelzine in the combined treatment cannot be eliminated. (2) This study only investigated effect of one MAOIs (phenelzine), therefore the findings cannot be generalised for SSRIs or selective noradrenergic reuptake inhibitors. Empirically spotted trials are required to conclude superiority of pharmacotherapy over GCBT in comparison to placebo in the treatment of SAD. In conclusion, this study demonstrated superiority of combined therapy over medication, CBT and placebo, respectively in the treatment of SAD.

Table 1: Selected characteristics of the studies and different interventions in the treatment of SAD.

Discussion

            This review introduced the effectiveness of CBT and its various forms on SAD and made some critical evaluation based on previous studies. Nine empirical studies were selected for this purpose and the efficacy of distinct treatment strategies (e.g., CBT over psychodynamic therapy, pharmacological therapy) on SAD were evaluated. SAD has been previously shown to be effectively treated using psychodynamic therapy (e.g., Bögels et al., 2014), pharmacological therapy (see review of Blanco et al., 2010), and CBT and its various forms such as MBCT, i-CB and GCBT (Hedman, Andersson, Ljótsson, Andersson, Rück, & Lindefors, 2011; Hedman, Andersson, Ljótsson, Andersson, Rück, Mörtberg, et al., 2011; Hedman, Furmark, et al., 2011; Kocovski et al., 2013; Månsson et al., 2015; Piet et al., 2010). But superiority of one treatment condition over another result in distinct findings in short- and long-term investigations.

            Regarding to effectiveness of CBT and psychodynamic therapy in the treatment of SAD, the superiority of CBT over PDT was found in terms of reducing SAD symptomology and remission rates (Leichsenring et al., 2013). However, in the follow-up period, both of the treatment strategy became equally effective (Leichsenring et al., 2014). These findings indicated that while superior effectiveness of CBT over PDT occurs in a short-term period, this affect disappears in the long-term follow up period. On the other hand, Bögels et al., (2014) come up with a data stating that PDT and CBT was highly and equally effective in the treatment of SAD in short- and long- term period. However, this study was used relatively sample size in comparison to Leichsenring et al., (2013) study. Therefore, it might be possible to see that the greater efficacy in CBT treatment over PDT in short term while in a long term both of the treatments become equally effective.

            Regarding to effectiveness of MBCT and GCBT in the treatment of SAD, both of the treatments were found to be equally effective in terms of improvement and reducing SAD symptomology (Kocovski et al., 2013; Piet et al., 2010). In contrast to these findings, the superiority of GCBT over MSBR were demonstrated in another study (Koszycki et al., 2007). Although this study used relatively larger sample size, the evaluations were done at baseline and at the end of the study. No-follow-ups were investigated. As studies of Piet et al., (2010) and Kocovski et al., (2013) included in long term follow-up data, it might be seem that their results are more consistent and both MCBT and GCBT were equally effective in the treatment SAD.

            Regarding to effectiveness of i-CBT and GCBT in the treatment of SAD, both of the treatments were found to be equally effective in terms of improvement and reducing SAD symptomology (Hedman, Andersson, Ljótsson, Andersson, Rück, Mörtberg, et al., 2011). Moreover, significant long-term effects of i-CBT in the treatment of SAD after 5-year follow-up were also demonstrated (Hedman, Furmark, et al., 2011). Since i-CBT and GCBT were found to be as equally effective as conventional GCBT, cost-effectiveness might be considered when clinicians intend to treat patients with SAD. Moreover, i-CBT minimizes patient-therapy interaction and improves deteriorated negative thoughts through computerized CBT. As a result, it is cheaper and easier method than conventional GCBT. On the other hand, more recent research revealed that how i-CBT reduce SAD symptomology in responders versus non-responders using fMRI and SVM machine learning principles (Månsson et al., 2015). As a result, BOLD responses to self-referential criticism through ACC-amygdala interactions (part of the fear network regions in human brain) leads to lowering fear responses after i-CBT treatment. This study is especially important which demonstrates i-CBT mechanism of action in the treatment of patients with SAD (Månsson et al., 2015).

            Regarding to effectiveness of pharmacological therapy and GCBT in the treatment of SAD, the superiority of  combined treatment (GCBT plus phenelzine) over phenelzine and GCBT was proved in a randomized controlled multi-centre trial (Blanco et al., 2010). In addition, phenelzine but not GCBT alone was more effective in comparison to placebo condition. On the other hand, this study worked with MAOI but not other type of medications (e.g SSRIs) which hardens generalisation of results for pharmacotherapy treatment. Therefore, more research is needed to investigate the effects of other type of medications.    

            There are some gaps and limitations in the literature that needs to be investigated more potentially. For instance, more genetics and neuroimaging research are needed to understand mode of action of PDT and CBT for SAD treatment. Neuroimaging studies leads to understand how treatments influence on mechanisms that affect the regions within human brain. Furthermore, most of the trials have  (1) small sample sizes which make it difficult to generalise the data (Månsson et al., 2015; Pfeiffer, Heisler, Piette, Rogers, & Valenstein, 2011) and (2) lack of placebo condition that leads to inaccurate comparisons (Bögels et al., 2014). (3) higher drop-out rates (Piet et al., 2010) and (4) lack of follow-up data after intervention should be considered as limitations in the current literature. In addition, different therapies have distinct impacts on SAD, therefore implicating findings from the studies are somehow difficult since lack of standardization across manuals (e.g., different manuals used in CBT and PDT) and experiments occurred in distinct experiments.

            The empirical evidences of current studies have suggested that efficacious psychosocial and pharmacological interventions exist for SAD treatment. However, as mentioned above, choices of which treatment over another for which individuals and somehow lack of understanding the factors that leads effective treatments is needed to be analysed in detail. Furthermore, responders and non-responders should be considered and patient-specific treatments should be applied while treating SAD. When the effectiveness of available interventions considered in the treatment of SAD, some clinical recommendations might be helpful in the improvement of patients: (1) Therapists should consider cost-effectiveness of the therapy for patients. For instance, while CBT, MBCT and i-CBT are more cost-effective in comparison to PDT since training periods are shorter and therapist costs are lower. However, since CBT comprised of several homework assignments in comparison to PDT, this requires effort, time and attention for patient. (2) Therapists should consider responders versus non-responders and select individual-specific treatment. For instance, individual factors exist in response and remission after specific intervention. As a result, therapists should observe patient in detail and determine the superiority of one treatment over another, since there should be no response to most efficacious treatment. (3) Although combined treatments were shown to be the most efficacious in the treatment of SAD, medications could cause adverse and serious adverse events in patients. This could create ineffectiveness and reduction in the rate of response in the treatment of SAD., relapses after discontinuation of medication should also be considered.

            Future research should focus on more comprehensive analysis utilizing most of the interventions. In addition, we still require more neuroimaging studies to better understand about the nature of SAD.

Conclusion

            Selected characteristics of the studies and different interventions in the treatment of SAD were summarised in Table 1. As can be clearly seen in the comparison table, CBT and its varieties (e.g., MABT, MBT, i-CBT and GCBT) are highly effective intervention strategies in terms of reducing SAD symptomology. CBT directly targets negative thoughts, self-image and fears and trains individuals so that they learn how to deal with distress conditions. Other intervention methods such as PDT is also shown to be as equally effective as CBT. While PDT focused on past and present, CBT is present-oriented psychotherapy strategy. Therapists should consider personal aspects of treatment since one therapy might be effective in one individual but not in the another. On the other hand, although the most effective treatment option is combined therapy (GCBT plus medication), one should also consider potential side effects of medication and relapse rates after discontinuation. On the other hand, among CBTs, i-CBT is very cheap and easy method in which patient is only required to computer to be trained. Therefore, clinicians and therapist should take into account pros and cons of all varieties of interventions and should select the best fit therapy for the treatment of patient with SAD.

References

Alström, J. E., Nordlund, C. L., Persson, G., Harding, M., & Ljungqvist, C. (1984). Effects of four treatment methods on social phobic patients not suitable for insight‐oriented psychotherapy. Acta Psychiatrica Scandinavica, 70(2), 97–110.

Andersson, G., Bergström, J., Carlbring, P., & Lindefors, N. (2005). The use of the Internet in the treatment of anxiety disorders. Current Opinion in Psychiatry, 18(1), 73–77.

Association, A. P. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Beck, A. T., Emery, G., & Greenberg, R. L. (2005). Anxiety disorders and phobias: A cognitive perspective. Basic Books.

Beidel, D. C., Turner, S. M., & Association, A. P. (2007). Shy children, phobic adults: Nature and treatment of social anxiety disorder. American Psychological Association Washington, DC.

Bernstein, D. A., & Borkovec, T. D. (1973). Progressive relaxation training: A manual for the helping professions.

Blanco, C., Antia, S. X., & Liebowitz, M. R. (2002). Pharmacotherapy of social anxiety disorder. Biological Psychiatry, 51(1), 109–120.

Blanco, C., Heimberg, R. G., Schneier, F. R., Fresco, D. M., Chen, H., Turk, C. L., … Juster, H. R. (2010). A placebo-controlled trial of phenelzine, cognitive behavioral group therapy, and their combination for social anxiety disorder. Archives of General Psychiatry, 67(3), 286–295.

Blanco, C., Schneier, F. R., Schmidt, A., Blanco‐Jerez, C., Marshall, R. D., Sánchez‐Lacay, A., & Liebowitz, M. R. (2003). Pharmacological treatment of social anxiety disorder: A meta‐analysis. Depression and Anxiety, 18(1), 29–40.

Bögels, S. M., Wijts, P., Oort, F. J., & Sallaerts, S. J. M. (2014). Psychodynamic psychotherapy versus cognitive behavior therapy for social anxiety disorder: an efficacy and partial effectiveness trial. Depression and Anxiety, 31(5), 363–373.

Bouton, M. E. (2002). Context, ambiguity, and unlearning: sources of relapse after behavioral extinction. Biological Psychiatry, 52(10), 976–986.

Brown, K. W., Ryan, R. M., & Creswell, J. D. (2007). Mindfulness: Theoretical foundations and evidence for its salutary effects. Psychological Inquiry, 18(4), 211–237.

Bruch, M. A. (1989). Familial and developmental antecedents of social phobia: Issues and findings. Clinical Psychology Review, 9(1), 37–47.

Calkins, S. D., Fox, N. A., & Marshall, T. R. (1996). Behavioral and physiological antecedents of inhibited and uninhibited behavior. Child Development, 67(2), 523–540.

Carlbring, P., Nordgren, L. B., Furmark, T., & Andersson, G. (2009). Long-term outcome of internet-delivered cognitive–behavioural therapy for social phobia: A 30-month follow-up. Behaviour Research and Therapy, 47(10), 848–850.

Caster, J. B., Inderbitzen, H. M., & Hope, D. (1999). Relationship between youth and parent perceptions of family environment and social anxiety. Journal of Anxiety Disorders, 13(3), 237–251.

Chronis-Tuscano, A., Degnan, K. A., Pine, D. S., Perez-Edgar, K., Henderson, H. A., Diaz, Y., … Fox, N. A. (2009). Stable early maternal report of behavioral inhibition predicts lifetime social anxiety disorder in adolescence. Journal of the American Academy of Child & Adolescent Psychiatry, 48(9), 928–935.

Clark, D. M., Crozier, W. R., & Alden, L. E. (2005). A cognitive perspective on social phobia. The Essential Handbook of Social Anxiety for Clinicians, 193–218.

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. Social Phobia: Diagnosis, Assessment, and Treatment, 41(68), 22–23.

Clauss, J. A., & Blackford, J. U. (2012). Behavioral inhibition and risk for developing social anxiety disorder: a meta-analytic study. Journal of the American Academy of Child & Adolescent Psychiatry, 51(10), 1066–1075.

Craske, M. G. (2010). Cognitive–behavioral therapy. American Psychological Association.

Davidson, R. J. (1994). Asymmetric brain function, affective style, and psychopathology: The role of early experience and plasticity. Development and Psychopathology, 6(4), 741–758.

Fyer, A. J., Mannuzza, S., Chapman, T. F., Martin, L. Y., & Klein, D. F. (1995). Specificity in familial aggregation of phobic disorders. Archives of General Psychiatry, 52(7), 564–573.

Grant, B. F., Hasin, D. S., Blanco, C., Stinson, F. S., Chou, S. P., Goldstein, R. B., … Huang, B. (2005). The epidemiology of social anxiety disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of Clinical Psychiatry.

Hayward, C., Killen, J. D., Kraemer, H. C., & Taylor, C. B. (1998). Linking self-reported childhood behavioral inhibition to adolescent social phobia. Journal of the American Academy of Child & Adolescent Psychiatry, 37(12), 1308–1316.

Hedman, E., Andersson, E., Ljótsson, B., Andersson, G., Rück, C., & Lindefors, N. (2011). Cost-effectiveness of Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: results from a randomized controlled trial. Behaviour Research and Therapy, 49(11), 729–736.

Hedman, E., Andersson, G., Ljótsson, B., Andersson, E., Rück, C., Mörtberg, E., & Lindefors, N. (2011). Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: a randomized controlled non-inferiority trial. PloS One, 6(3), e18001.

Hedman, E., Furmark, T., Carlbring, P., Ljótsson, B., Rück, C., Lindefors, N., & Andersson, G. (2011). A 5-year follow-up of internet-based cognitive behavior therapy for social anxiety disorder. Journal of Medical Internet Research, 13(2), e39.

Heimberg, R. G., & Becker, R. E. (2002). Cognitive-behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. Guilford Press.

Heimberg, R. G., Liebowitz, M. R., Hope, D. A., Schneier, F. R., Holt, C. S., Welkowitz, L. A., … Cloitre, M. (1998). Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome. Archives of General Psychiatry, 55(12), 1133–1141.

Heimberg, R. G., Salzman, D. G., Holt, C. S., & Blendell, K. A. (1993). Cognitive—behavioral group treatment for social phobia: Effectiveness at five-year followup. Cognitive Therapy and Research, 17(4), 325–339.

Hofmann, S. G., & Otto, M. W. (2017). Cognitive behavioral therapy for social anxiety disorder: Evidence-based and disorder specific treatment techniques. Routledge.

Hook, J. N., & Valentiner, D. P. (2002). Are specific and generalized social phobias qualitatively distinct? Clinical Psychology: Science and Practice, 9(4), 379–395.

Hunt, C., & Andrews, G. (1998). Long-term outcome of panic disorder and social phobia. Journal of Anxiety Disorders, 12(4), 395–406.

Ishiyama, F. I. (1984). Shyness: Anxious social sensitivity and self-isolating tendency. Adolescence, 19(76), 903.

Kabat-Zinn, J., & Hanh, T. N. (2009). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. Delta.

Kagan, J., Reznick, J. S., & Snidman, N. (1987). The physiology and psychology of behavioral inhibition in children. Child Development, 1459–1473.

Kagan, J., Reznick, J. S., & Snidman, N. (1988). Biological bases of childhood shyness. Science, 240(4849), 167–171.

Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627.

Klumpp, H., Fitzgerald, D. A., & Phan, K. L. (2013). Neural predictors and mechanisms of cognitive behavioral therapy on threat processing in social anxiety disorder. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 45, 83–91.

Kocovski, N. L., Fleming, J. E., Hawley, L. L., Huta, V., & Antony, M. M. (2013). Mindfulness and acceptance-based group therapy versus traditional cognitive behavioral group therapy for social anxiety disorder: A randomized controlled trial. Behaviour Research and Therapy, 51(12), 889–898.

Koszycki, D., Benger, M., Shlik, J., & Bradwejn, J. (2007). Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behaviour Research and Therapy, 45(10), 2518–2526.

La Greca, A. M., Dandes, S. K., Wick, P., Shaw, K., & Stone, W. L. (1988). Development of the Social Anxiety Scale for Children: Reliability and concurrent validity. Journal of Clinical Child Psychology, 17(1), 84–91.

Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S., Hiller, W., Hoyer, J., … Poehlmann, K. (2013). Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: a multicenter randomized controlled trial. American Journal of Psychiatry, 170(7), 759–767.

Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S., Hiller, W., Hoyer, J., … Poehlmann, K. (2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. American Journal of Psychiatry, 171(10), 1074–1082.

Lieb, R., Wittchen, H.-U., Höfler, M., Fuetsch, M., Stein, M. B., & Merikangas, K. R. (2000). Parental psychopathology, parenting styles, and the risk of social phobia in offspring: a prospective-longitudinal community study. Archives of General Psychiatry, 57(9), 859–866.

Liebowitz, M. R., Schneier, F., Campeas, R., Hollander, E., Hatterer, J., Fyer, A., … Gully, R. (1992). Phenelzine vs atenolol in social phobia: a placebo-controlled comparison. Archives of General Psychiatry, 49(4), 290–300.

Mannuzza, S., Schneier, F. R., Chapman, T. F., Liebowitz, M. R., Klein, D. F., & Fyer, A. J. (1995). Generalized social phobia: Reliability and validity. Archives of General Psychiatry, 52(3), 230–237.

Månsson, K. N. T., Frick, A., Boraxbekk, C.-J., Marquand, A. F., Williams, S. C. R., Carlbring, P., … Furmark, T. (2015). Predicting long-term outcome of Internet-delivered cognitive behavior therapy for social anxiety disorder using fMRI and support vector machine learning. Translational Psychiatry, 5(3), e530.

Marks, I., Shaw, S., & Parkin, R. (1998). Computer‐aided treatments of mental health problems. Clinical Psychology: Science and Practice, 5(2), 151–170.

Marlatt, G. A., & Kristeller, J. L. (1999). Mindfulness and meditation.

Norton, P. J., & Price, E. C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. The Journal of Nervous and Mental Disease, 195(6), 521–531.

Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010). Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings. Psychiatric Clinics, 33(3), 557–577.

Öst, L.-G. (1987). Applied relaxation: description of a coping technique and review of controlled studies. Behaviour Research and Therapy, 25(5), 397–409.

Pfeiffer, P. N., Heisler, M., Piette, J. D., Rogers, M. A. M., & Valenstein, M. (2011). Efficacy of peer support interventions for depression: a meta-analysis. General Hospital Psychiatry, 33(1), 29–36.

Piet, J., Hougaard, E., Hecksher, M. S., & Rosenberg, N. K. (2010). A randomized pilot study of mindfulness‐based cognitive therapy and group cognitive‐behavioral therapy for young adults with social phobia. Scandinavian Journal of Psychology, 51(5), 403–410.

Pizzagalli, D. A. (2011). Frontocingulate dysfunction in depression: toward biomarkers of treatment response. Neuropsychopharmacology, 36(1), 183.

Proudfoot, J. G. (2004). Computer-based treatment for anxiety and depression: is it feasible? Is it effective? Neuroscience & Biobehavioral Reviews, 28(3), 353–363.

Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35(8), 741–756.

Rapee, R. M., & Lim, L. (1992). Discrepancy between self-and observer ratings of performance in social phobics. Journal of Abnormal Psychology, 101(4), 728.

Reich, J., & Yates, W. (1988). Family history of psychiatric disorders in social phobia. Comprehensive Psychiatry, 29(1), 72–75.

Ritterband, L. M., Gonder-Frederick, L. A., Cox, D. J., Clifton, A. D., West, R. W., & Borowitz, S. M. (2003). Internet interventions: In review, in use, and into the future. Professional Psychology: Research and Practice, 34(5), 527.

Schneier, F. R., Johnson, J., Hornig, C. D., Liebowitz, M. R., & Weissman, M. M. (1992). Social phobia: comorbidity and morbidity in an epidemiologic sample. Archives of General Psychiatry, 49(4), 282–288.

Segal, Z. V, Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY, US. Guilford Press. http://dx. doi. org/10.1037/e533222009-006.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98.

Stangier, U., Schramm, E., Heidenreich, T., Berger, M., & Clark, D. M. (2011). Cognitive therapy vs interpersonal psychotherapy in social anxiety disorder: a randomized controlled trial. Archives of General Psychiatry, 68(7), 692–700.

Stein, M. B., Chartier, M. J., Hazen, A. L., Kozak, M. V, Tancer, M. E., Lander, S., … Walker, J. R. (1998). A direct-interview family study of generalized social phobia. American Journal of Psychiatry, 155(1), 90–97.

Stein, M. B., Liebowitz, M. R., Lydiard, R. B., Pitts, C. D., Bushnell, W., & Gergel, I. (1998). Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial. Jama, 280(8), 708–713.

Stein, M. B., & Stein, D. J. (2008). Social anxiety disorder. The Lancet, 371(9618), 1115–1125.

Stemberger, R. T., Turner, S. M., Beidel, D. C., & Calhoun, K. S. (1995). Social phobia: an analysis of possible developmental factors. Journal of Abnormal Psychology, 104(3), 526.

Stopa, L., & Clark, D. M. (1993). Cognitive processes in social phobia. Behaviour Research and Therapy, 31(3), 255–267.

Titov, N., Andrews, G., Robinson, E., Schwencke, G., Johnston, L., Solley, K., & Choi, I. (2009). Clinician-assisted Internet-based treatment is effective for generalized anxiety disorder: randomized controlled trial. Australian & New Zealand Journal of Psychiatry, 43(10), 905–912.

Turner, S. M., Beidel, D. C., Cooley, M. R., Woody, S. R., & Messer, S. C. (1994). A multicomponent behavioral treatment for social phobia: Social effectiveness therapy. Behaviour Research and Therapy, 32(4), 381–390.

Van Ameringen, M. A., Lane, R. M., Walker, J. R., Bowen, R. C., Chokka, P. R., Goldner, E. M., … Pecknold, J. C. (2001). Sertraline treatment of generalized social phobia: a 20-week, double-blind, placebo-controlled study. American Journal of Psychiatry, 158(2), 275–281.

Wells, A., Clark, D. M., & Ahmad, S. (1998). How do I look with my minds eye: Perspective taking in social phobic imagery. Behaviour Research and Therapy, 36(6), 631–634.

Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995). Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behavior Therapy, 26(1), 153–161.

Wells, A., & Papageorgiou, C. (1998). Social phobia: Effects of external attention on anxiety, negative beliefs, and perspective taking. Behavior Therapy, 29(3), 357–370.

Wright, J. H. (2006). Cognitive behavior therapy: Basic principles and recent advances. Focus, 4(2), 173–178.