Social phobia: a preliminary cross-national comparison.
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Adult↗
Biomedical subjects
R G Heimberg
Publications and source records attributed to R G Heimberg.
Social phobia and PTSD in Vietnam veterans.
Posttraumatic stress disorder (PTSD) is the most prevalent psychological disorder experienced by Vietnam veterans. However, there are many other disorders and problems of adjustment, like social anxiety and social phobia, that have not been fully investigated in this population. This study examined the prevalence of social phobia and the comorbidity of social phobia and PTSD, and tested out a theory of the etiology of social anxiety in trauma victims. Forty one Vietnam combat veterans were interviewed and completed self-report measures assessing PTSD and social phobia. Adversity of homecoming was also assessed. Using a conservative multi-method assessment approach, 32% of the sample were found to be positive for both social phobia and PTSD. Veterans with PTSD were significantly more likely to carry an additional diagnosis of social phobia as compared to veterans without PTSD. Adversity of homecoming and shame about one's experience in Vietnam were significant predictors of current level of social anxiety over and above the effects of pre-military anxiety and severity of combat exposure. These observations suggest that social anxiety and social phobia may be significant problems among individuals with PTSD. Further, these findings offer preliminary support for the theory that posttrauma environment may impact upon the later development of social anxiety.
Adult↗
A systematic replication of the prescriptive treatment of school refusal behavior in a single subject.
We employed a multiple-baseline design to test the efficacy of a recently developed approach for reducing school refusal behavior. This approach uses a systematic method for conducting a functional analysis for the target behaviors and suggests specific intervention strategies based upon this analysis. To maximize external validity, the intervention was tested using a systematic replication strategy, whereby only the major conceptual elements of the intervention were retained from previous applications. The subject was a 10 year old girl who attended school with great difficulty and resistance and who was assigned DSM-III-R diagnoses of separation anxiety disorder and social phobia prior to treatment. Following 8 weeks of treatment, she showed marked reductions in problem behavior and no longer met criteria for any anxiety disorder diagnoses. The results highlight the importance of the use of functional analytic strategies to effect behavior change.
Anxiety, Separation↗
Issues in the design of trials for the evaluation of psychopharmacological treatments for social phobia.
Social phobia was neglected by psychopharmacologically oriented researchers until the past decade. Benefitting from the experience with other anxiety and other affective disorders, however, and also from unique interdisciplinary collaborative arrangements between psychopharmacological and cognitive behavioral investigators, treatment research in social phobia has made remarkable progress in the past few years. Not only has the field itself advanced, but investigative models have been created that are now being adopted and adapted for other disorders.
Clinical Trials as Topic↗
Issues in the design of trials for the evaluation of psychosocial treatments for social phobia.
Scientific evaluation of the efficacy of treatments for mental disorders is an undertaking of critical importance. However, the design of trials evaluating psychosocial treatments may determine whether or not they will ultimately provide meaningful data that may guide further treatment development. In this paper, we address areas of methodological concern in the evaluation of psychosocial treatments. These are discussed in the context of psychosocial treatments for social phobia, whether they be the sole focus of an outcome trial, compared to other psychosocial or pharmacological treatments, or combined with pharmacotherapies. We address issues of patient representativeness, adequacy of treatment as conducted, selection and design of control conditions, and assessment of change over the course of treatment for social phobia. Most of these issues have implications for the evaluation of pharmacotherapies for social phobia as well.
Behavior Therapy↗
Social phobia: diagnostic issues and review of cognitive behavioral treatment strategies.
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Cognitive Behavioral Therapy↗
Memory bias does not generalize across anxiety disorders.
Individuals with social phobia were compared with normal controls on their memory for socially-related threat words in contrast to positive and neutral words. A memory paradigm used in a previous study of panic disorder patients [Cloitre, M. & Liebowitz, M. R. (1991) Cognitive Therapy and Research, 15, 609-619] was applied to test the generalizability of findings of threat-biased memory in a semantic memory task (free recall) and a perceptual memory task (high-speed recognition) to social phobics. No evidence of threat-related memory bias among social phobics was obtained. Since both the social phobic and control groups showed better memory for affectively valenced (threat and positive) compared to neutral information, it is unlikely that the absence of threat-biased memory among social phobics was the result of insensitive measurement.
Adult↗
Alcohol and caffeine use by social phobics: an initial inquiry into drinking patterns and behavior.
Social phobics are often fearful that their anxiety symptoms will cause them embarrassment and lead to negative evaluation from others. Thus, it was hypothesized that they might attempt to control the intake of substances such as alcohol and caffeine that may affect their anxiety in social situations. The current investigation sought to determine, via a self-report questionnaire, whether the alcohol and caffeine consumption patterns of social phobics differ from those of community controls in terms of typical and greatest weekly quantities and how social phobics differ from controls in alcohol and caffeine use in a variety of socially threatening and nonthreatening situations. Social phobics reported less typical weekly beverage consumption than community subjects. Specifically, social phobics reported less consumption of wine and liqueur than community subjects but did not differ from community subjects in typical weekly consumption of caffeinated beverages. Further, social phobics reported a significantly greater intent to drink alcohol while in social situations involving strangers and significantly less intent to drink caffeinated coffee in meetings than did community subjects. Finally, a number of gender differences were found for both alcohol and caffeine consumption in specific situations, and the implications of these findings are discussed.
Adult↗
Self selection and sample selection in a treatment study of social phobia.
The external validity or generalizability of a treatment outcome study may be influenced by the choices patients make (self-selection) and by study requirements intended to increase internal validity or protect subject welfare (e.g. sample selection). Although these effects are well-known, they have rarely been studied, and little is known about the impact they may have on generalizability of findings. In this study, subjects accepting random assignment to a larger study examining pharmacologic and cognitive-behavioral treatments for social phobia were compared with subjects refusing random assignment (i.e. self-selected) and excluded subjects (i.e. "sample-selected"). "Acceptors" differed from "refusers" on some measures suggesting that they have a lower annual income and may have fewer social supports. Therefore, they may have fewer available resources and might be more willing to accept help wherever it is offered. Despite these differences, acceptors differed from refusers on just one pretreatment measure of clinical functioning. Excluded subjects did not differ from refusers or acceptors on demographic or pretreatment clinical measures. Refusers and excluded subjects were treated with the same cognitive-behavioral treatment used in the comparative outcome study, and their posttreatment data were compared with the subgroup of acceptors who were randomly assigned to that treatment. Again, there were few significant differences. These results suggest that while self-selection and sample selection may have influenced some characteristics of the sample in this comparative outcome study, the three groups of subjects were clinically similar and responded similarly to cognitive-behavioral treatment of social phobia.
Adult↗
Dismantling cognitive-behavioral group therapy for social phobia.
The efficacy of Heimberg's (1991) Cognitive-Behavioral Group Therapy (CBGT) [Unpublished manuscript] for social phobia has been demonstrated in several studies in recent years. However, little is known about the mechanisms underlying the treatment's success. In order to determine whether the cognitive restructuring component of CBGT is essential, this study compared CBGT to an exposure-based treatment without formal cognitive restructuring. A wait-list control was also included. In general, Ss in the active treatment conditions improved and control Ss did not improve on a variety of self-report, clinician, and behavioral measures. Limited evidence indicated that Ss in the non-cognitive treatment may have made somewhat greater gains on some measures. Although CBGT Ss reported more improvement than exposure-alone Ss in subjective anxiety during an individualized behavioral test at posttreatment, this difference disappeared at 6-month follow-up. Surprisingly, CBGT was less effective than in previous controlled trials, and possible reasons for this are discussed. Implications of the results for cognitive theory and cognitive-behavioral therapy for social phobia are addressed.
Adolescent↗
Cognitive-behavioral group treatment for social phobia in adolescents. A preliminary study.
The present study is a preliminary evaluation of the effectiveness of a new cognitive-behavioral group treatment protocol for social phobia in adolescents. Five adolescents with social phobia were treated in a 16-session group treatment program, with parental involvement in selected sessions. Treatment involved skills training (social skills, problem solving, assertiveness), cognitive restructuring, behavioral exposure, and homework. Self-report measures of anxiety and depression, taken throughout treatment, indicated significant improvements over a 1-year follow-up period. Behavior test measures also indicated a decrease in subjective anxiety ratings after treatment which was maintained at follow-up. Structured diagnostic interviews 1 year after treatment confirmed full remission of social phobia for four subjects, with one subject's phobia in partial remission. Overall, the present findings support the continued evaluation of this protocol for social phobic adolescents.
Adolescent↗
Shyness and public self-consciousness: additive or interactive relation with social interaction?
Shy people are characterized as engaging in self-derogatory thinking leading to anxiousness and inhibition, while people who are publicly self-conscious are focused on the impression they create on others. In addition, public self-consciousness has been described as an antecedent of shyness. In the present research, we tested additive versus interactive hypotheses about the association of shyness and public self-consciousness with dysfunctional social interaction. Undergraduate men varying in shyness and public self-consciousness engaged in a conversation with an unfamiliar woman confederate. Following the conversation, subjects completed self-report measures focusing on their responses during the conversation. Only main effects for shyness and public self-consciousness were found, supporting an additive hypothesis. Shyness was related to all dependent variables reflecting a negative self-bias, while public self-consciousness was not. In particular, shyness was inversely related to the balance of subjects' positive and negative thoughts and to reported use of protective as well as avoidance of acquisitive self-presentation responses. Public self-consciousness was positively related to use of protective self-presentation responses but unrelated to acquisitive responses.
Adult↗
Monoamine oxidase inhibitor dietary restrictions: what are we asking patients to give up?
BACKGROUND: Though the list of possible indications for monoamine oxidase inhibitors (MAOIs) continues to expand, many psychiatrists remain hesitant about prescribing MAOIs, citing concerns about dietary prohibitions and hypertensive reactions. Data about psychiatric patients' frequency of consumption of foods, beverages, and medications prohibited during MAOI use are lacking. METHOD: We conducted a survey of 139 psychiatric patients admitted to either an inpatient unit specializing in the treatment of mood disorders or an outpatient anxiety disorders clinic specializing in the treatment of social phobia. At inclusion, patients were not being treated with MAOIs, although they might have received such treatment afterward. All patients completed a self-report questionnaire created for this study to ascertain their consumption of food, beverage, and medication items frequently found on MAOI diet lists. Demographic and diagnostic information was also recorded. RESULTS: The most frequently used high-risk items were the hard cheeses. Ninety percent of patients reported daily or weekly consumption of some food containing cheese, while less than 1% of patients reported never eating hard cheese. Yeast products, dry sausage, corned beef, broad beans, sauerkraut, and beer were used at least monthly by more than 50% of patients. Of the intermediate-risk foods, chocolate was the most frequently consumed, with almost 30% of the patients eating some chocolate daily. Over 40% of patients reported using over-the-counter cold preparations on a monthly basis. CONCLUSION: A wide variety of tyramine-containing foods and contraindicated medications were commonly used by our patients prior to evaluation for possible MAOI pharmacotherapy. The number and diversity of frequently consumed items do not support recommendations to reduce the breadth of restrictions in MAOI diets. Individually targeted dietary assessment and education are recommended to reduce the risks of prescribing MAOIs.
Adult↗
Social phobia. Longitudinal course and long-term outcome of cognitive-behavioral treatment.
Interest in social phobia has increased dramatically in the past decade, and our knowledge of this previously understudied disorder has increased as well. We now know that social phobia is a chronic condition and that patients with this disorder are unlikely to experience significant improvement without intervention. It is also a highly prevalent condition affecting as many as 13% of the adult population of the Unites States. Although our understanding of the causes of social phobia remains limited, we do know that it is associated with serious impairment and disability in multiple spheres. Thus, the development of treatments with proven long-term efficacy is an important research goal. In this article, we have reviewed studies that examined either exposure, cognitive restructuring, social skills training, or some combination of these treatments. Here, we summarize the major findings of this review. Exposure has fared well as a treatment for social phobia and, in every case, within-group analyses show that patients have improved after treatment. Methodologic problems in some studies, however, limit the conclusions that can be drawn about the comparative efficacy of exposure, social skills training, and relaxation therapy. Conceptual models of social phobia have stressed the importance of cognitive processes in the development and maintenance of social phobia and much attention has been directed at the long-term efficacy of cognitive-behavioral techniques. It has been hypothesized that exposure plus cognitive restructuring would be a particularly effective combination and several methodologically sound studies have examined this combination. These studies have demonstrated consistently clinically significant within-group changes and superiority to control conditions. Heimberg's CBGT is probably the most widely studied of these treatments. CBGT has been shown to be more effective than an equally credible attention-placebo group. Patients receiving CBGT have maintained their advantage over patients in the attention-placebo group, even 5 years after treatment although flaws in that follow-up study limit generalizability of its results. Generalized and nongeneralized social phobic patients respond equivalently to this highly integrated treatment, and it has been applied effectively by researchers outside the center where it was developed. Despite the successes of combined exposure and cognitive restructuring treatments, it remains unclear as to what the effective component(s) of these and similar treatments are and, therefore, whether or not the integration of therapy components is really necessary. A number of the studies reviewed addressed this question with mixed results. Three studies showed that the combination therapy was superior to either treatment alone. There is also evidence that patients treated with exposure only may show some deterioration during follow-up whereas patients treated with cognitive restructuring and exposure may continue to improve. Still, other studies found no differences in long-term outcome among exposure alone, RET, or the combined treatment. Hope et al found that exposure alone was as effective as an integrated treatment combining exposure and cognitive restructuring (CBGT), and Taylor and colleagues (submitted for publication, 1995) reported that exposure was not enhanced by initial treatment with cognitive restructuring. These results are disappointing in light of all that has been written about the likely benefits of combining cognitive and behavioral therapy in the treatment of social phobia. For example, it has been hypothesized that fear of negative evaluation is a key factor in social phobia and that change in this construct should be the goal of treatment. There is some research that supports this claim and other evidence that suggests that exposure alone is not particularly effective in producing those changes. Butler concluded that the treatment of social phobia is made more difficult whe
Cognitive Behavioral Therapy↗
Social anxiety and perception of early parenting among American, Chinese American, and social phobic samples.
Emotionally distant and controlling child-rearing attitudes have been reported to characterize the parents of American or western European social phobics in previous research. However, the notion that these parental attitudes may be associated with social anxiety only in some cultures has not been investigated. The present study examined social anxiety among American social phobics and American and Chinese/Chinese American volunteer samples and how it may relate to their parents' child-rearing attitudes. Multivariate analyses of variance revealed overall group differences. Both volunteer samples reported lower levels of anxiety than social phobics. Parents of Chinese/Chinese Americans and social phobics were reported to be similar in their (1) isolation of children from social activities; (2) over-emphasis of others' opinions; and (3) use of shame tactics for discipline (more so than American volunteers' parents). However, parents of nonsocial phobics were more likely to attend family social activities than social phobics' parents. Overall, the association between a reported parenting style emphasizing others' opinions and shame tactics and social anxiety in their adult children was more evident in both American samples than among Chinese/Chinese Americans.
Adult↗
Cognitive assessment strategies and the measurement of outcome of treatment for social phobia.
With the development of cognitive-behavioral theories and treatments for the emotional disorders, there is an increased need for the development and utilization of assessment devices to quantify cognitive constructs. This is especially important in the study and treatment of social phobia, an anxiety disorder that appears to have a significant cognitive component. In this paper, I review and evaluate the use of cognitive assessment strategies in studies of the cognitive-behavioral treatment of social phobia. Although much useful data have been collected, studies that included any form of cognitive assessment relied heavily on questionnaire assessment of fear of negative evaluation or irrational beliefs, with only occasional use of other methods such as thought listing or self-statement questionnaires. In the latter part of the review, I focus on the potential utility of other measures including those derived from the growing literature on the processing of information among persons with social phobia or other anxiety disorders. Studies that have demonstrated differences between social phobics and comparison groups are reviewed, and the potential uses of these information processing techniques are examined. The cognitive assessment of social phobia and its response to cognitive-behavioral interventions remains in its childhood, although the transition to adolescence may be on the horizon.
Cognitive Behavioral Therapy↗
Treatment of social phobia in cognitive-behavioral groups.
Interest in social phobia has increased dramatically since its inclusion in DSM-III, and several approaches to its treatment have been developed. In this paper, we focus on one specific treatment package known as Cognitive-Behavioral Group Treatment for Social Phobia (CBGT), which has been developed at the University at Albany's Center for Stress and Anxiety Disorders over the last several years. An overview of the techniques of CBGT is provided, and empirical studies that provide support for its effectiveness are reviewed. The paper is concluded with the detailed presentation of a patient who was treated with CBGT.
Cognitive Behavioral Therapy↗
The revised Stroop color-naming task in social phobics.
Information processing was examined in a sample of social phobic individuals using a revised version of the Stroop color-naming task. In the first of two experiments, the response latencies of social phobics and matched community controls were compared when color-naming socially threatening words, physically threatening words and color words. Social phobics demonstrated greater response latencies regardless of type of stimulus word and additional interference in color-naming social threat words compared to the control group. The second experiment examined the cognitive structural change that has been hypothesized to accompany successful treatment of individuals with an anxiety disorder. Social phobics who were treated with cognitive-behavioral group therapy, phenelzine or pill placebo were classified as treatment responders or nonresponders, and their latencies to color-naming on the Stroop task were compared. Treatment responders showed a significant reduction in latencies to color-name social threat words (vs matched control words) while nonresponders did not. This effect was not demonstrated with color words or physically threatening words. Clinical implications and future research directions are discussed.
Adult↗