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date: 22 February 2018

Psychological Treatments for Social Anxiety Disorder

Summary and Keywords

Social anxiety disorder (SAD) is characterized by fear of being negatively evaluated by others in social situations. Multiple psychological interventions have been developed to treat SAD. The most widely studied of these interventions stem from cognitive-behavioral, acceptance-based, interpersonal, and psychodynamic conceptualizations of SAD. In cognitive-behavioral therapy (CBT), patients learn to identify and question maladaptive thoughts and engage in exposures to feared situations to test the accuracy of biased beliefs. Mindfulness and acceptance-based approaches to treating SAD focus on mindful awareness and acceptance of distressing internal experiences (i.e., psychological and physiological symptoms) with the ultimate goal of behavior change and living a meaningful life based on identified values. Interpersonal psychotherapy links SAD to interpersonal problem areas and aims to reduce symptoms by targeting interpersonal difficulties. Psychodynamic psychotherapy for SAD focuses on identifying unresolved conflicts that lead to SAD symptoms, fostering insight and expressiveness, and forming a secure helping alliance.

Generally, CBT is the most well-studied of the psychological treatments for SAD, and research demonstrates greater reductions in social anxiety than pill placebo and waitlist controls. Results from randomized controlled trials (RCTs) suggest that mindfulness—and acceptance-based therapies may be as efficacious as CBT, although the body of research remains small; four of five RCTs comparing these approaches to CBT found no differences. RCTs comparing CBT to IPT suggest that CBT is the more efficacious treatment. Two RCTs comparing CBT to psychodynamic psychotherapy suggest that psychodynamic psychotherapy may have efficacy similar to CBT, but that it takes longer to achieve similar outcomes. RCTs examining CBT and pharmacotherapy suggest that the medications phenelzine and clonazepam are as efficacious as CBT for treating SAD and are faster acting, but that patients receiving these medications may be more likely to relapse after treatment is discontinued than patients who received CBT. Research generally does not indicate added benefit of combining psychotherapy with pharmacotherapy above each monotherapy alone, although this body of research is quite variable. Effectiveness studies indicate that CBT is equally effective in community clinics and controlled research trials, but studies of this nature are lacking for other psychological approaches.

Keywords: treatment, social anxiety disorder, therapy, cognitive-behavioral therapy, psychodynamic psychotherapy, interpersonal psychotherapy, acceptance and commitment therapy, mindfulness, cognitive therapy

Introduction

Social anxiety disorder (SAD) is characterized by fear of being negatively evaluated by others in social situations and often leads to impaired functioning in work, school, and interpersonal relationships (American Psychiatric Association [APA], 2013). It is a chronic disorder that often develops in childhood or early adolescence (Wittchen & Fehm, 2003). SAD is the fourth most common psychiatric disorder in the United States in terms of lifetime prevalence (12.1%) and the second most common in terms of 12-month prevalence (7.1%) (Kessler, Chiu, Demler, Merikangas, & Walters, 2005). Thus, a number of psychological interventions have been developed to treat SAD. Many of these interventions stem from cognitive-behavioral theories on the development and maintenance of the disorder. Other psychological treatments have been developed from interpersonal and psychodynamic conceptualizations of SAD. In this article, we present a detailed qualitative review of the published research on psychological treatments for SAD in adults, including cognitive-behavioral therapies (CBTs), acceptance—and mindfulness-based therapies, interpersonal psychotherapy (IPT), and psychodynamic psychotherapy.

We conducted a literature search for randomized controlled trials (RCTs) and effectiveness trials of psychological interventions for SAD up to the end of April 2016. Articles were identified through electronic searches of the PsychINFO and Google Scholar databases, as well as a backward literature search that consisted of scanning references cited in identified articles to evaluate if these references might be relevant to our criteria. A search strategy containing the following keywords and combinations was utilized: (social anxiety disorder or social phobia or social anxiety) and (randomized controlled trial, randomized, or effectiveness) and (cognitive behavioral therapy, CBT, cognitive therapy, exposure, social skills training, acceptance and commitment therapy, mindfulness, cognitive restructuring, interpersonal psychotherapy, IPT, psychodynamic psychotherapy, psychodynamic therapy, medication, pharmacotherapy, SSRI, SNRI, or MAOI). Two additional studies that became known to the authors after the conclusion of the search period were also considered for inclusion.

Studies were included if they (1) evaluated a psychological treatment for adults with SAD; (2) included random assignment of patients to a psychological intervention, a no-treatment condition, a placebo, or an active comparison treatment condition OR were clearly marked as effectiveness trials (3) clearly described the treatment method; and (4) were written in English.

This article is organized the following way: We start with a review of CBTs, followed by acceptance—and mindfulness-based therapies, IPT, and finally, psychodynamic psychotherapy. We then discuss moderators and mediators of psychological treatments for SAD. Following reviews of the psychological treatments, we review RCTs examining psychological interventions in relation to pharmacotherapy. We end this article with a general discussion of the state of the SAD treatment literature. A summary of all trials reviewed in this article is provided in Table 1.

Each psychological treatment section is organized as follows: First, we provide a description of the conceptual basis and core components of the psychological intervention of focus. Then we review single-treatment controlled trials (i.e., RCTs comparing the treatment of focus to a waitlist control, treatment as usual, pill placebo, or an active control condition), if they exist. We found no single-treatment RCTs of acceptance-based therapy, one single-treatment RCT of mindfulness-based therapy, one single-treatment RCT of IPT, and no single-treatment RCTs examining psychodynamic psychotherapy. Most controlled trials to date examining these interventions have compared them to CBT. Thus, after presenting available single-treatment trials, we review multitreatment controlled trials of each intervention. We then review effectiveness trials for CBT only, as we found no such trials for any other class of intervention.

Of note, CBTs comprise a large umbrella of clinical interventions rooted in the goal of behavior change. However, the language, processes, and techniques employed to achieve this aim vary somewhat across specific treatments. In the current article, we survey various elements of CBT that have been used both as stand-alone treatments and in conjunction with each other, including exposure, cognitive restructuring, and social skills training.

Cognitive-Behavioral Therapy

The rationale for CBT for SAD stems from two similar models of the development and maintenance of the disorder, which posit that an interaction between innate behavioral predispositions and early life experiences leads individuals to perceive social situations as dangerous and their ability to navigate them as lacking (D. M. Clark & Wells, 1995; Rapee & Heimberg, 1997). Socially anxious individuals strongly wish for others to form favorable impressions of them but highly doubt their ability to create such impressions (Schlenker & Leary, 1982), which enhances the sense that they will behave ineptly and that such behavior will have catastrophic consequences.

Heimberg, Brozovich, and Rapee’s (2014) update of Rapee and Heimberg’s (1997) cognitive-behavioral model of SAD suggests that in the presence or anticipation of an audience, people with SAD become more vigilant of cues (e.g., environmental cues; their own mental representation of how they appear to others) that indicate the realization of their feared outcomes. They engage in self-protective “safety behaviors” (D. M. Clark & Wells, 1995; Piccirillo, Dryman, & Heimberg, 2016) and other avoidance behaviors, which maintain anxiety by preventing opportunities for disconfirmation of maladaptive beliefs. The result is a vicious cycle in which anxiety informs the mental representation of the self as seen by others, exacerbating anxiety and motivating negative post-event processing, maintaining anxiety in future similar social situations.

CBTs for SAD are based, more or less, on these theoretical formulations and contain various combinations of exposure, cognitive restructuring, and social skills training. The most common and well-studied of these CBTs is exposure combined with cognitive restructuring. Through these combined elements, patients learn to identify and question maladaptive thoughts and engage in exposures to feared situations to test the accuracy of biased beliefs, with the eventual goals of habituating to anxiety and developing more adaptive beliefs about feared situations.

More specifically, exposures allow for patients to engage with feared situations in a planned way, providing a context in which they can gather evidence against negative beliefs about the situation. Exposures may be done imaginally, in session (e.g., through role-play exercises or behavioral experiments), or in vivo, in real life. In optimal exposure conditions, patients discard safety behaviors (Wells et al., 1995) and focus on the task at hand (e.g., having a conversation) rather than their internal experience (Wells & Papageorgiou, 1998). Cognitive restructuring used in conjunction with exposures addresses the cognitive-behavioral theory that biased processing of the situation, rather than the situation itself, underpins anxiety. Patients practice analyzing and modifying their biased beliefs, developing a more realistic and less anxiety-provoking assessment of the situation as a method of coping with anticipatory anxiety and consequently reducing avoidance.

Controlled Trials of Combined Exposure and Cognitive Restructuring

Group Treatment Versus Control

Research investigating exposure and cognitive restructuring for SAD in group settings has provided consistent support for the treatment. Heimberg et al. (1990) randomized patients with SAD according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) 3rd edition (DSM-III; APA, 1980) to either cognitive-behavioral group treatment (CBGT; n = 25) or an attention-placebo control (n = 24), each comprised of twelve 2-hour sessions. CBGT consisted of education on the cognitive-behavioral model of SAD, cognitive restructuring exercises, in-session exposures, and homework involving cognitive restructuring practice and exposures. The control was an educational-supportive psychotherapy group (ES), which involved both a series of lecture-demonstration-discussions on topics relevant to SAD (e.g., perfectionism and the need for acceptance) and a patient-led support group; ES patients were not explicitly instructed to confront feared situations. CBGT and ES were equally credible. Clinically significant improvement was determined by a decrease of at least 2 points on the 0–8 phobic severity rating of the Anxiety Disorders Interview Schedule (ADIS; Di Nardo, O’Brien, Barlow, Waddell, & Blanchard, 1983) and an endpoint phobic severity score of less than 4. Of those who completed CBGT (n = 20) and ES (n = 20), significantly more CBGT than ES patients were rated as improved at posttreatment (75% vs. 40%, respectively) and 6-month follow-up (81% vs. 47%, respectively). Furthermore, CBGT patients reported significantly less anxiety than ES patients before and during a behavioral simulation of a feared situation at posttreatment and 6-month follow-up. Gains realized in CBGT were maintained on average five years later (Heimberg, Salzman, Holt, & Blendell, 1993).

Heimberg et al. (1998) compared CBGT (n = 36) to ES (n = 33) again, within a larger RCT also examining pharmacotherapy for SAD. Patients were considered responders if independent assessors classified them as markedly or moderately improved on a modified version of the Clinical Global Impression Improvement rating (CGI-I; Guy, 1976; Zaider, Heimberg, Fresco, Schneier, & Liebowitz, 2003). In an intent-to-treat (ITT) analysis, a significantly higher proportion of patients were classified as responders to CBGT (58%) than ES (27%).

Mörtberg, Karlsson, Fyring, and Sundin (2006) randomized patients with DSM-IV (APA, 1994) SAD to three weeks of intensive group cognitive therapy (CT) based on D. M. Clark and Wells (1995) (n = 13) or a 6-month waitlist control (WL; n = 13). Intensive group CT consisted of five hours of treatment daily from Monday–Thursday in weeks 1 and 3. During week 2, patients completed homework but returned to their normal routines. At posttreatment, 3-month follow-up, and 6-month follow-up, group CT patients had significantly lower scores on primary social anxiety (SA) measures compared to WL, and they continued to improve at 3-month and 6-month follow-ups. By 6-month follow-up, group CT patients reported significantly lower levels of SA, avoidance, and safety behaviors. WL patients did not improve significantly on SA at any time-point. Within-group effect sizes for improved measures were large at posttreatment and were maintained or increased over time.

Bjornsson et al. (2011) randomized 45 undergraduates with DSM-IV SAD to CBGT or group psychotherapy (GPT), a credible control condition based on that used in Heimberg et al.’s 1990 and 1998 studies. CBGT was an abbreviated version of Heimberg and Becker’s (2002) protocol. Both treatment and control were efficacious, with no differences between groups. One possible explanation for this finding, which conflicts with those of previous studies (e.g., Heimberg et al., 1990, 1998) and the results of meta-analyses (Barkowski et al., 2016), is the abbreviated nature of treatment in the CBGT condition as compared to previous uses of this protocol.

Individual Treatment Versus Control

Ledley et al. (2009) compared individuals with DSM-IV SAD (N = 38) receiving individual CBT to those in a WL condition. CBT was based on a client workbook (Hope, Heimberg, Juster, & Turk, 2000) and completed in 16 sessions within 20 weeks. WL patients received brief biweekly phone calls with a therapist for clinical status checks and support for 20 weeks, at which point they began CBT if indicated. CBT patients demonstrated significant improvements on six of seven outcome variables, with large to very large within-group effect sizes, while WL patients did not improve on any measure. CBT patients had significantly lower scores on the ADIS-IV (Brown, Di Nardo, & Barlow, 1994) clinician’s severity rating (CSR), the Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987), and all other SA measures at posttreatment than WL patients. Significantly more CBT patients (73.3%) were classified as responders on the modified CGI-I (Zaider et al., 2003) than WL patients (6.3%). Gains were maintained at 3-month follow-up. Goldin et al. (2012) compared the same individualized CBT protocol (n = 38) to WL (n = 37) for patients with DSM-IV SAD. CBT resulted in significantly greater SA reductions compared to WL, and this effect was large. Improvements were comparable to those observed in Ledley et al. (2009) and maintained at 1-year follow-up.

Carlbring et al. (2007) examined whether individual exposure and cognitive restructuring treatment could be adapted into an efficacious Internet-based treatment. They compared a 9-week Internet CBT (ICBT; n = 29) to WL (n = 28) in Swedish adults with DSM-IV SAD. Each session module provided information, exercises, an interactive quiz, and essay questions intended to facilitate learning and inform online therapists whether patients understood the material. The treatment also included an online discussion group. Therapists instructed patients about whether to advance to the next module based on their performance and understanding. In brief weekly phone calls, therapists provided feedback and answered questions.

ICBT patients improved significantly more on measures of SA, general anxiety, avoidance, and depression than WL patients, and these results endured at one-year follow-up. In addition, ICBT patients improved significantly from pre- to posttreatment, whereas WL patients did not, and this finding represented a large within-group effect size. In a follow-up study, Carlbring, Bergman Nordgren, Furmark, and Andersson (2009) reported significant improvements from both pretreatment and posttreatment to 30-month follow-up. Of the 66.7% of individuals who completed follow-up, 84.2% no longer met criteria for SAD.

Individual Versus Group Treatment

Stangier, Heidenreich, Peitz, Lauterbach, and Clark (2003) compared an individual cognitive therapy (CT) to group CT and WL in 71 adults with DSM-IV SAD. CT, based on D. M. Clark and Wells’s (1995) model and used in multiple trials in the current review, included the following: developing a personalized cognitive-behavioral model with the patient using her own thoughts/images, attentional biases, safety behaviors, and symptoms; exercises in manipulating self-focused attention and safety behaviors; training in focusing attention outside oneself; restructuring distorted self-imagery using video feedback; collecting evidence disconfirming negative self-beliefs; and behavioral experiments to test negative predictions, during which the patient attempts to forego safety behaviors. Patients in the treatment conditions received up to 15 weekly sessions and were then followed for up to six months; WL patients received no treatment for 10 months, at which point they were offered treatment.

Both individual and group CT led to significant improvement on three measures of SA. Both treatments led to significantly more improvement than WL on one SA measure, but only individual CT was superior to WL on the other SA measures. At posttreatment, non-blind therapist reevaluation indicated that significantly more individual CT patients (50%) than group CT patients (13.6%) no longer met diagnostic criteria for SAD, and further significant improvements were observed in the individual CT condition at follow-up, but not in group CT or WL. Of note, however, group CT in this study was based on D. M. Clark and Wells’s (1995) model but had not been piloted or used previously, raising questions about whether the finding that individual CT is more efficacious than group CT could be generalized to other group CBTs.

Mörtberg, Clark, Sundin, and Åberg Wistedt (2007) compared 16 sessions over three weeks of intensive group CT, 16 shorter sessions over four months of individual CT based on D. M. Clark and Wells’s 1995 model, and up to one year of treatment as usual (TAU) in an RCT with 100 patients with DSM-IV SAD. TAU consisted of a selective serotonin reuptake inhibitor (SSRI) or benzodiazepine, combined with therapy sessions as needed, and did not include exposure instruction or cognitive restructuring. Patients in all treatments showed significant improvement at 4-, 8-, and 12-months, but those in individual CT improved significantly more than those in group CT and TAU. Group CT was superior to TAU on some, but not all, SA measures. In the ITT sample, individual CT yielded significantly greater improvements on measures of SA, depression, and disability than group CT or TAU, which did not differ. Independent assessors using the Structured Clinical Interview for the DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 1995) SAD module found that 75% of individual CT patients no longer met criteria for SAD at 12 months, compared to 66% in group CT and 48% in TAU. Individual CT was superior to TAU according to the SCID, but was not significantly different from group CT. The disparity between the two treatment formats reduced over time, and the shorter length of group CT may have contributed to this outcome.

Mörtberg, Clark, and Bejerot (2011) conducted a 5-year follow-up of this study, in which 72% of the original sample that received group or individual CT participated. At follow-up, there was a nonsignificant trend toward lower SA for individual CT. Patients in both groups demonstrated further improvement on SA and disability measures, and these findings held true even when analyses were restricted to the 75% of patients who had received no additional treatment, suggesting that effects of CT in both group and individual formats can be maintained long term.

Hedman et al. (2011) conducted a randomized controlled noninferiority trial comparing ICBT (n = 64) to CBGT (n = 62) in patients with DSM-IV SAD. ICBT included 15 weekly modules and brief weekly therapist email contact. CBGT (based on Heimberg & Becker, 2002) consisted of fourteen 2.5-hour group sessions over 15 weeks. Both groups significantly improved on SA, with large within-group effect sizes, and there were no differences between groups at posttreatment or 6-month follow-up on scores on the self-report version of the Liebowitz Social Anxiety Scale (LSAS-SR; S. L. Baker, Heinrichs, Kim, & Hofmann, 2002) or response status. Gains were maintained at 4-year follow-up (Hedman et al., 2014), and LSAS-SR scores were well within the noninferiority range. Providing further support of the equivalent efficacy of CBT in group and individual formats, the results of several meta-analyses converge to suggest that there is little difference in efficacy between individual and group CBT (e.g., Barkowski et al., 2016; Mayo-Wilson et al., 2014; Powers, Sigmarsson, & Emmelkamp, 2008).

Controlled Trials Involving an Exposure-Only Condition

Some researchers have questioned whether cognitive restructuring is necessary to the efficacy of CBT and have consequently evaluated exposure as a stand-alone treatment. Butler, Cullington, Munby, Amies, and Gelder (1984) randomly assigned 45 adults with DSM-III SAD to exposure and anxiety management training (EXP/AM), exposure alone (EXP), or WL. EXP focused on graduated exposure to feared and/or avoided situations. The EXP group also included associative therapy as a nonspecific control “filler” treatment to maintain equal amounts of exposure in the two conditions; patients were asked to talk about their background history, letting related memories and thoughts freely come to mind; the therapist showed interest, asked open-ended questions, identified themes, and reflected back. Anxiety management focused on identifying anticipatory and situational anxiety symptoms and targeting them with relaxation, distraction, and rational self-talk (i.e., recognizing negative thoughts and practicing more constructive responses to them).

Both treatments were superior to WL at posttreatment and 6-month follow-up. EXP/AM was superior to EXP on SA at posttreatment and also social avoidance and phobic severity at follow-up. No EXP/AM patients sought further treatment, compared to 40% of EXP patients. These findings suggest that while exposure is an efficacious stand-alone treatment compared to WL, targeting cognitive symptoms results in further treatment gains. However, because anxiety management included relaxation and distraction in addition to rational self-talk, it is unclear whether the further improvement can be specifically attributed to the inclusion of a cognitive component. Additionally, patients rated EXP as significantly less credible than EXP/AM by the fourth treatment session, adding further ambiguity to interpretation of these results.

Mattick and Peters (1988) randomly assigned 51 adults with DSM-III SAD to receive EXP or EXP combined with cognitive restructuring. EXP was systematic and graded and included modeling, the intentional varying of performance, and self-directed exposure homework. Both treatments resulted in significant improvements in SA at posttreatment and 3-month follow-up, but the combined treatment was superior to EXP at posttreatment in functioning, approach behavior, and self-reported avoidance, suggesting an added benefit of cognitive restructuring above the effects of exposure alone.

Mattick, Peters, and Clarke (1989) randomized 43 patients with DSM-III SAD to six 2-hour weekly group sessions of either EXP, cognitive restructuring without exposure (CR-alone), combined cognitive restructuring and EXP, or WL. Patients in CR-alone were cautioned against entering anxiety-provoking situations, and the group setting deemphasized social interaction. A behavioral approach test in which patients entered into feared/avoided situations was conducted at posttreatment and 3-month follow-up.

Patients in the combined and CR-alone conditions improved on both SA and fear of negative evaluation, whereas those in EXP significantly improved on SA only. At posttreatment, both combined treatment and EXP were superior to CR-alone on behavioral approach. However, at 3-month follow-up, patients in the combined treatment demonstrated significantly greater behavioral approach than those in EXP and CR-alone, which were not significantly different. Nevertheless, the combined treatment was superior to EXP on only two of five self-report measures, and there were no significant between-group differences in end-state functioning, suggesting that the added benefit of cognitive restructuring to EXP was not substantial.

D. M. Clark et al. (2006) randomized 62 patients with DSM-IV SAD to CT (D. M. Clark & Wells, 1995), exposure and applied relaxation (EXP + AR), or WL. Patients in both the CT and EXP + AR groups improved significantly more than WL, and both treatments yielded large controlled effect sizes. However, CT resulted in greater improvement in SA than EXP + AR. At posttreatment, 84% of CT patients, 42% of EXP + AR patients, and 0% of waitlist no longer met criteria for SAD. Results held at 1-year follow-up, and EXP + AR patients were more likely to have sought further treatment.

Hofmann (2004) conducted an RCT with 90 patients with DSM-IV SAD comparing 12 weekly sessions of CBGT, exposure group therapy (EGT) without formal cognitive restructuring, and WL. CBGT and EGT did not differ significantly from each other at posttreatment, and both groups were superior to WL. Effect sizes of within-group SA symptom reduction were moderate for both CBGT (d = 0.72) and EGT (d = 0.52). Only patients who received CBGT demonstrated significant further improvement in SA from posttreatment to 6-month follow-up.

Although evidence exists that cognitive restructuring adds some benefit to exposure therapy, this finding is neither strong nor consistent. Furthermore, meta-analyses do not support the benefit of adding cognitive restructuring to exposure. Acaturk et al.’s (2009) meta-analysis of 29 randomized treatment studies found no indication that adding cognitive restructuring to exposure yielded higher effect sizes. Studies in this meta-analysis, however, included inconsistent combinations of these methods, making it difficult to draw strong conclusions on the effects of the individual components. In a meta-analysis comparing 12 CBT and 9 exposure-only studies, Feske and Chambless (1995) found no significant differences between the two variants but found that a greater number of exposure sessions was associated with more improvement at posttreatment. Powers et al.’s (2008) meta-analysis reported similar results; controlled effect sizes for combined exposure and cognitive restructuring did not differ significantly from controlled effect sizes for cognitive restructuring alone or exposure alone at posttreatment or follow-up.

Controlled Trials Involving a Social Skills Training Component

Some CBTs include, as either a core or added component, social skills training (SST). The rationale for SST as a treatment focus is based on research (e.g., S. R. Baker & Edelmann, 2002) suggesting potential social skills deficits in individuals with SAD. Though evidence of social skills deficits in socially anxious individuals is neither pervasive nor consistent in the literature, people often negatively interpret certain behaviors common in individuals with SAD (e.g., lack of eye contact) as indicative of a social skills deficit. SST has been employed as a behavioral intervention aimed at improving verbal and nonverbal interpersonal skills through practice, instruction, modeling, feedback, and reinforcement.

Beidel et al. (2014) conducted an RCT examining the effect of adding SST to EXP. They randomized 106 adults with DSM-IV SAD to receive EXP alone, a combination of SST and EXP known as Social Effectiveness Therapy (SET), or WL. Both treatments consisted of 24 sessions over 12 weeks. SET involved learning basic conversational skills, making new friends, practicing assertiveness, and public speaking. Both treatments resulted in significant improvements in distress and remission compared to WL. In ITT analyses, there was no difference in remission between SET (67%) and EXP (54%) patients. However, significantly more SET (92%) than EXP (75%) patients were classified as responders. In addition, SET patients performed significantly better than EXP patients on measures of social skills and observed social behavior at posttreatment.

Herbert et al. (2005) examined whether SST added to the efficacy of CBGT. Sixty-five adults with DSM-IV generalized SAD received twelve 2-hour sessions of either CBGT (based on Heimberg & Becker, 2002) or CBGT integrated with SST. Social skills practice was fully integrated into exposure assignments to ensure equivalent number of exposures in each treatment. In ITT analyses, patients in the integrated treatment improved significantly more on two of three SA measures than those in CBGT; these findings persisted at 3-month follow-up. More patients in the SST condition (79%) were classified as responders than patients in the non-SST condition (38%); however, this difference was no longer significant at 3-month follow-up.

Bögels and Voncken (2008) examined whether SST was superior to exposure and cognitive restructuring in adults with DSM-III-R (APA, 1987) SAD and primary fears of showing bodily symptoms (i.e., blushing, trembling, or sweating). Fifty-five participants received 12 weekly 2-hour sessions of group SST or CT, both with special emphasis on fear of showing bodily symptoms. Patients in both treatments improved significantly at posttreatment and follow-up, with no differences between groups. Notably, SST utilized role-plays of problem situations, which may indirectly influence distorted beliefs by providing opportunities for disconfirming evidence.

Effectiveness Trials

Though RCTs have provided considerable evidence in favor of CBTs, the generalizability of these studies is limited by the controlled nature of such research, which often calls for strict exclusion criteria and highly structured manualized treatments. These treatments and patient populations may not be representative of typical therapy and patients seen in community clinics. Thus, several benchmarking studies have examined the generalizability and transportability of CBT.

Lincoln et al. (2003) examined the effectiveness of individual CBT in 217 unselected patients with DSM-III-R SAD from four outpatient clinics in Germany. Treatment consisted of an assessment phase (4–6 sessions), a feedback and preparation phase (after which patients were asked to decide whether they wanted to participate), and a high-density exposure phase, consisting of 5–7 full days of intensive exposure and cognitive restructuring, followed by 6 weeks of practicing exposures at home. Patients improved on measures of SA, general anxiety, and depression at posttreatment, and effect sizes were large.

Gaston, Abbott, Rapee, and Neary (2006) conducted a benchmarking study comparing response to CBGT of patients with DSM-IV SAD at a research institution (n = 58) and a private practice (n = 54). Treatment consisted of ten 2.5-hour sessions. Both groups demonstrated significant decreases in SA at posttreatment, with equivalent and large effect sizes. There were no group differences on SA, and gains continued in both groups between posttreatment and 3-month follow-up, with small effect sizes.

McEvoy (2007) conducted a benchmarking study examining the effectiveness of CBGT in a community clinic. Patients with SAD (n = 153) received seven 4-hour weekly sessions of CBGT. ITT analyses showed improvement on SA and depression, with large effect sizes, comparable to those in CBT efficacy trials and meta-analyses. Age, depressive symptoms, psychiatric comorbidity, student status, or problems with alcohol did not affect outcome effect sizes.

McEvoy, Nathan, Rapee, and Campbell (2012) compared treatment outcomes of the same CBGT protocol in a community sample (n = 94) and a research sample (n = 71) of individuals with DSM-IV SAD. Medication use, the presence of comorbid conditions, and higher SA and life interference levels were more common in the community sample. ITT analyses demonstrated significant improvements on SA and life interference, with large effect sizes and no differences between the community and research samples.

Studies examining effectiveness of CBT in Internet-based formats have also been promising. El Alaoui et al. (2015) examined the effectiveness of therapist-guided ICBT for SAD in an outpatient clinic. Patients completed weekly CBT modules and homework and received therapist feedback. ICBT was effective at reducing SA and comorbid depressive symptoms, with large effect sizes on the LSAS-SR at posttreatment and 6-month follow-up. Approximately 20% and 33% of participants were considered in remission at posttreatment and 6-month follow-up, respectively, comparable to face-to-face CBT remission rates.

Conclusions About CBT

Overall, research has provided the most consistent support for exposure combined with cognitive restructuring for SAD. Though research has been mixed regarding the benefit of adding cognitive restructuring to exposure, several studies have found that combined exposure and cognitive restructuring is either equally or slightly more efficacious than exposure alone, although the controlled effect sizes of the combination versus exposure alone are not significantly different. There is some support for SST as a useful addition to exposure and cognitive restructuring. However, SST as a stand-alone treatment lacks support (Ponniah & Hollon, 2008), and meta-analyses (Acaturk et al., 2009) did not find higher effect sizes associated with the inclusion of SST in other psychological interventions for SAD.

Generally, CBT results in greater reductions in SA symptoms than controls. Mayo-Wilson et al.’s (2014) network meta-analysis of 101 randomized trials supports this conclusion; CBTs were superior to waitlist; however, only the combination of cognitive restructuring and exposure was superior to psychological placebos. Finally, CBT appears to be efficacious in individual, group, and Internet-based formats. Though some of the reviewed findings suggest superior outcomes for individual compared to group CBT, meta-analyses (Barkowski et al., 2016; Mayo-Wilson et al., 2014; Powers et al., 2008) found no significant differences between group and individual CBT at posttreatment or follow-up.

Effectiveness studies indicate that CBT is just as effective in community clinics as it is in controlled research trials in individual, group, and Internet-based formats. However, the remission rate in these studies continues to be low, usually with only about 30–50% of patients achieving remission. Furthermore, attrition rates continue to be high. Thus, though CBTs have been shown to be efficacious and effective in a large body of literature, there is much work yet to be done.

Mindfulness and Acceptance-Based Therapies

Broadly speaking, cognitive-behavioral therapies include behavioral interventions and address cognitions. Indeed, mindfulness-based interventions fall under this umbrella, and it has been argued that these therapies are best classified within a CBT approach (Herbert, Gershkovich, & Forman, 2014). It is not the presence of negative cognitions, but rather their role (i.e., negative cognitions as the root of SAD in CBT approaches, versus cognitions as symptoms of SAD in mindfulness and acceptance-based approaches) that differs across CBT and acceptance—and mindfulness-based conceptualizations of the disorder (Herbert et al., 2014).

Herbert and Cardaciotto’s (2005) acceptance-based model of SAD proposes that being less accepting of one’s internal experience (e.g., feeling anxious in a social situation) evokes the use of experiential control strategies, which leads to a vicious cycle of heightened self-focused attention in social situations and greater control efforts, thereby intensifying anxiety-related arousal. Thus, mindfulness and acceptance-based approaches to treating SAD focus on mindful awareness and acceptance of distressing internal experiences (i.e., psychological and physiological symptoms) with the ultimate goal of behavior change and living a meaningful life based on identified values. Mindful awareness involves actively, intentionally, and nonjudgmentally paying attention to the present moment without attempting to avoid or modify one’s internal experience (Kabat-Zinn, 1990). Mindfulness and acceptance-based therapies for SAD include acceptance and commitment therapy (ACT) and two broad mindfulness-based approaches: mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990) and mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002).

ACT (Hayes, Strosahl, & Wilson, 2011) emphasizes historical and current contexts that engender cognitions and focuses on understanding the relationship between thoughts and behaviors. ACT aims to foster the psychological flexibility to react to one’s experiences without judgment while committing to acting based on identified values (Hayes et al., 2011). Core elements include elucidating the problem of a control agenda (i.e., attempts to control one’s negative internal experiences paradoxically exacerbate them), engendering creative hopelessness (i.e., facing the unworkable nature of one’s control strategies), and valued action (i.e., acting according to one’s values). The focus in treatment on acceptance of one’s internal experience inherently de-emphasizes the importance of symptom reduction, though symptom reduction may occur.

Compared to CBT, research on ACT for SAD is in its infancy, and only one RCT has been completed to date. Craske et al. (2014) conducted a trial in which 87 adults with DSM-IV SAD were randomized to 12 sessions of CBT, ACT (manual by Eifert & Forsyth, 2005), or WL. Participants completed self-report measures, public speaking tasks, and clinician ratings. Both groups were superior to WL, and no differences were found between CBT and ACT on any outcome measure. Rates of clinically significant change did not differ between ACT and CBT at posttreatment or 6- or 12-month follow-ups. This was the first methodologically sound controlled trial examining ACT for SAD, and in this study, it appeared to be an efficacious treatment, on par with CBT.

Jazaieri, Goldin, Werner, Ziv, and Gross (2012) compared MBSR (n = 31) to an active control condition, aerobic exercise (AE; n = 25). Participants receiving MBSR completed eight 2.5-hour group sessions, a 1-day meditation retreat, and daily home practice. MBSR aimed to foster nonjudgmental, flexible, and present-focused attention (Kabat-Zinn, 1990) through practices aimed at reducing automatic tendencies to judge and react to one’s internal state. AE was chosen as the active control to match nonspecific MBSR factors without including active MBSR ingredients; participants were given a 2-month gym membership and completed at least one group and two individual AE sessions weekly for eight weeks.

MBSR and AE were both related to significant improvements in SA, depression, and subjective well-being at posttreatment and 3-month follow-up. MBSR patients also showed significant improvements in SA, perceived stress, satisfaction with life, and loneliness compared to an untreated SAD group (which was not part of the initial random assignment). AE demonstrated improvements in SA and self-compassion compared to the untreated group. Overall, MBSR did not perform better than the active control, and effects sizes in MBSR were predominantly medium and smaller than those found in CBT.

Koszycki, Benger, Shlik, and Bradwejn (2007) randomized 53 patients with DSM-IV generalized SAD to eight weeks of MBSR or 12 weeks of CBGT (Heimberg & Becker, 2002). CBGT was superior to MBSR on SA symptoms, severity, and current disability, but not depression or quality of life. ITT response and remission rates as assessed by the CGI-I were significantly higher in CBGT (66.7% and 29.6%, respectively) than MBSR (38.5% and 7.7%, respectively).

Goldin et al. (2016) conducted a trial in which 108 adults with DSM-IV SAD were randomized to 12 weekly 2.5-hours sessions of CBGT (Heimberg & Becker, 2002, with additional material from Hope, Heimberg, & Turk, 2010), MBSR, or WL. Both treatments were significantly better than WL at posttreatment, and the reduction in SA was not significantly different in CBGT versus MBSR. SA improvements were maintained at 1-year follow-up for both treatments. Both treatments also resulted in significant improvements in frequency and self-efficacy of cognitive reappraisal, cognitive distortions, mindfulness, and attention focusing. CBGT resulted in significantly greater reductions in subtle avoidance behaviors.

Piet, Hougaard, Hecksher, and Rosenberg (2010) conducted a randomized cross-over study of MBCT and CBGT in young adults with SAD. Twenty-six patients with DSM-IV SAD were randomized to eight 2-hour sessions of MBCT or twelve 2-hour sessions of CBGT. CBGT combined elements from Heimberg and Becker’s (2002) CBGT protocol and CT based on D. M. Clark and Wells’s (1995) model. MBCT was based on Segal et al.’s (2002) manual, adapted for SAD; it focused on fostering an open and detached reaction to one’s internal experiences and included mindfulness meditation practices. Both groups demonstrated moderate within-group change on most measures after the first phase. MBCT did not differ significantly from CBGT, although improvements were larger in CBGT than MBCT (d = 1.15 and d = 0.78, respectively). Findings suggested that MBCT might be an efficacious treatment for SAD, but perhaps slightly less so than CBGT. However, given the limited sample size and longer treatment length of CBGT compared to MBCT, this conclusion is tentative.

Mindfulness and acceptance-based group therapy (MAGT) for SAD is largely based on ACT and includes enhanced mindfulness techniques from MBCT. In the sole RCT of this treatment (Kocovski, Fleming, Hawley, Huta, & Antony, 2013), 137 adults with DSM-IV SAD were randomized to 12 weekly 2-hour sessions of MAGT (n = 53), CBGT (Heimberg & Becker, 2002; n = 53) or WL (n = 31). Both MAGT and CBGT were superior to WL in terms of improvements in SA, Clinical Global Impression Severity (CGI-S; Guy, 1976; Zaider et al., 2003), depression, mindfulness, experiential avoidance, and quality of life. The two treatments did not differ on any outcome measure. At 3-month follow-up, improvements were maintained.

Interpersonal Psychotherapy

Interpersonal psychotherapy (IPT; Klerman, Weissman, Rounsaville, & Chevron, 1984), originally developed for the treatment of depression, aims to reduce symptoms by targeting interpersonal difficulties. IPT for SAD involves a detailed review of SA symptoms, an interpersonal inventory (i.e., an assessment of past and current relationships), identifying symptoms as part of SAD (i.e., identifying emotional, physical, and cognitive SA symptoms as part of a treatable disorder and giving the patient the “sick role” to remove some of the emotional burden of having interpersonal impairments), and then linking SAD to interpersonal problem area(s) (Lipsitz, 2012).

Lipsitz et al. (2008) compared IPT for SAD (n = 36) to a control condition, supportive therapy (ST; n = 34). Both conditions consisted of 14 weekly sessions. ST was based on Pinsker’s (1997) supportive therapy and emphasized empathy, a relaxed conversational style, encouragement, and helping the patient express emotions. Both treatment and control led to significant improvements in SA, with no significant differences between groups at posttreatment, 6-month, or 12-month follow-ups. This study, however, had limitations that make it difficult to draw conclusions about whether IPT is efficacious for SAD. ST in this study had not been previously demonstrated as a credible control condition and had considerable conceptual overlap with IPT; both conditions emphasized supportive elements and focused on problems within interpersonal relationships. Thus, it is unclear whether IPT failed to outperform the control because it was not efficacious or because the control would have been better conceptualized as an active treatment.

Borge et al. (2008) conducted an RCT in which 80 patients with chronic, highly comorbid, treatment-refractory DSM-IV SAD were randomized to 10 weeks of residential CT or residential IPT. Individual CT (based on D. M. Clark & Wells’s 1995 model) and IPT for SAD protocols were each adapted to create more intensive therapies that integrated group and individual therapy in a residential treatment setting. Residential IPT focused on developing healthy interpersonal behavior, encouraged patient openness about feelings and wishes in daily encounters, and included discussions regarding communication within the group. Both treatments addressed safety behaviors, included exposure and video feedback, and emphasized maintaining factors in patients’ SAD. Both residential CT and IPT groups demonstrated significant improvement at posttreatment, and there were no significant differences between groups. Patients from both groups continued to improve through 1-year follow-up. Notably, residential IPT included several cognitive-behavioral techniques, and it is difficult to determine whether it would yield similar results without these components.

The equivalent efficacy of CT and IPT was not supported in a later trial. Stangier, Schramm, Heidenreich, Berger, and Clark (2011) randomized 117 adults with DSM-IV SAD to receive 16 sessions over 20 weeks and one booster session of CT (based on D. M. Clark & Wells, 1995), IPT, or WL. CT was superior to IPT and WL on the LSAS, and differences between CT and IPT were maintained at 1-year follow-up. At posttreatment in the ITT sample, 65.8% of CT patients were categorized as responders on the CGI-I, compared to 42.1% of IPT patients, and 7.3% of controls. At 1-year follow-up, 68.4% of CT patients were responders, compared to 31.6% of IPT patients. These differences may have been underestimated to a degree as “the rate of patients not receiving an adequate treatment dose was significantly higher for CT than for IPT” at one of the treatment sites (p. 695).

Dagöö et al. (2014) conducted an RCT comparing a mobile (via smartphone, tablet, or computer) CBT intervention (mCBT; n = 27) to a mobile guided self-help IPT intervention (mIPT; n = 25) for patients with DSM-IV SAD. Each treatment consisted of nine weekly sessions, and patients received weekly phone calls for feedback on homework and questions. mCBT involved cognitive restructuring and exposure as well as a social skills component. mIPT included role-playing challenging social situations and focused on interpersonal attachment, role transitions, role disputes, and social skills. Both treatments yielded significant decreases in SA at posttreatment, but significantly more patients were classified as responders in mCBT (55.6%) than mIPT (8.0%).

Psychodynamic Psychotherapy

According to psychodynamic theory (Leichsenring, Beutel, & Leibing, 2007), SAD stems from unresolved conflicts, referred to as the “Core Conflictual Relationship Theme” (CCRT; Luborsky, 1984). Three components comprise the CCRT: a wish (i.e., what the patient desires from other people; e.g., to be affirmed), the anticipated response to the wish from others (e.g., others will reject me), and the response from the self (e.g., I won’t expose my true self to others). Leichsenring et al.’s (2007) psychodynamic psychotherapy manual for SAD, used in the trial described below, is based on supportive-expressive therapy (Luborsky, 1984), which emphasizes the CCRT, therapist supportiveness, expressiveness, and a secure helping alliance. The early phase of this therapy involves establishing goals and a secure therapeutic alliance, identifying the CCRT, and applying it to the patient’s symptoms. The middle phase involves examining how the CCRT comes up in the patient’s relationships, including the patient-therapist relationship. Avoidance of feared situations is viewed as a defense mechanism that leads to self-fulfilling prophecies within the patient’s relationships. Thus, self-exposure is encouraged and discussed as necessary for successful treatment. The therapist summarizes what the patient has learned and how the CCRT relates to symptom resurgence during the termination phase. Booster sessions are used to monitor and support progress, encourage self-exposure, and relate relapse to loss of the therapist and the CCRT (Leichsenring et al., 2007).

Leichsenring et al. (2013) conducted a multicenter controlled noninferiority trial in Germany in which 495 adults with DSM-IV SAD were randomly assigned to receive up to twenty-five 50-minute sessions of CT (D. M. Clark & Wells, 1995; n = 209), psychodynamic therapy (n = 207), or WL (n = 79). Significantly more CT patients (36%) than psychodynamic psychotherapy patients (26%) achieved remission; however, the treatments did not differ in their response rates (60% in CBT vs. 52% in psychodynamic psychotherapy). Both treatments were superior to WL. CBT patients improved significantly more than psychodynamic psychotherapy patients on measures of SA and interpersonal symptoms, but not depression. However, there were no significant differences between treatments at 6-month follow-up. At 2-year follow-up (Leichsenring et al., 2014), response and remission rates for both treatments were approximately 70% and 40%, respectively. Overall, there were small effects indicating the superiority of CBT on some, but not all measures at the end of treatment; however, at follow-up, the treatments appeared to be similarly efficacious. It should be noted that D. M. Clark (2013) raised objections to several aspects of the design of this study, which he suggests diluted the efficacy of CT (see response to Clark by Leichsenring, Salzer, & Leibing, 2013).

Bögels, Wijts, Oort, and Sallaerts (2014) randomized 47 adults with DSM-IV SAD to receive up to 36 sessions of psychodynamic psychotherapy or CBT. Both treatments were efficacious, with large within-subject effect sizes. Rates of clinically significant change in SA (Jacobson & Truax, 1991) for CBT and psychodynamic psychotherapy were 64% and 63% at posttreatment and 65% and 75% at 1-year follow-up, with no significant differences between treatments. Results corroborated Leichsenring et al.’s (2013, 2014) findings regarding no significant differences in remission rates between CBT and psychodynamic psychotherapy. However, CBT required fewer sessions (M = 19.8) than psychodynamic therapy (M = 31.4) to yield similar outcomes.

General Conclusions About Psychotherapy

Research evaluating CBT and comparing it to other psychological treatments provides consistent support for CBT. Results from the studies reviewed also suggest that mindfulness—and acceptance-based therapies may be efficacious. Four of five studies of MBCT, MAGT, ACT, and MBSR (Craske et al., 2014; Goldin et al., 2016; Kocovski et al., 2013; Piet et al., 2010) found no differences between these therapies and CBT at posttreatment or follow-up. Inconsistent with these conclusions, Koszyscki et al. (2007) found CBT to be superior to MBSR. However, the study lacked a control condition, and treatment consisted of eight sessions in MBSR (plus a 1-day meditation retreat) versus 12 sessions in CBT, making it difficult to conclude with confidence that CBT was more efficacious.

Research comparing CBT to IPT suggests that CBT is more efficacious. Stangier et al. (2011) and Dagöö et al. (2014) found that CBT was superior to IPT in typical outpatient treatment and via a mobile application, respectively. In contrast, Borge et al. (2008) found no differences between intensive residential versions of IPT and CBT among treatment-refractory patients with SAD. However, IPT in this study included exposures and video feedback; we cannot conclude that IPT would be as efficacious as CBT without these common components. Although Lipsitz et al. (2008) failed to demonstrate IPT superiority to supportive therapy, it appears that IPT can lead to significant improvements in SA, and that it can be an efficacious treatment for SAD when it includes exposure as part of treatment. In less intensive formats and without the inclusion of exposure, IPT may be less efficacious than CBT for SAD.

Though only two RCTs have compared CBT to psychodynamic psychotherapy, findings suggest that psychodynamic psychotherapy may be similar in efficacy to CBT. Though Leichsenring et al. (2013) found a slight indication of superiority of CBT at posttreatment, there were no differences between the treatments at 6-month or 2-year follow-ups. However, the inclusion of exposure in the psychodynamic psychotherapy protocol makes interpretation of these findings difficult (see also D. M. Clark, 2013). Additionally, Bögels et al. (2014) found no differences between CBT and psychodynamic psychotherapy at posttreatment or 1-year follow-up.

Moderation and Mediation Effects of Psychotherapies on SAD Outcome

Though a full review of studies examining factors that moderate or mediate the effects of psychotherapeutic treatments on SAD outcomes is beyond the scope of this article, we review a few of the more notable studies here (see Schneider, Arch, & Wolitzky-Taylor, 2015, for a systematic review of treatment moderators for anxiety disorders). Most research to date examining outcome of treatment for SAD has focused on cognitive factors as potential mediators and moderators.

Craske et al. (2014) examined moderators of treatment outcome in their RCT comparing ACT, CBT, or WL for SAD (reviewed earlier). Lower baseline psychological flexibility (i.e., the ability to react to one’s experience, regardless of content, in a way that aligns with one’s values) was related to greater improvement at 12-month follow-up in CBT compared to ACT. Fear of negative evaluation also moderated outcomes in this study, with more extreme scores predicting better outcomes for CBT than for ACT.

In the same trial, Niles, Mesri, Burklund, Lieberman, and Craske (2013) tested attentional bias, as measured by the difference in reaction times to threatening and nonthreatening stimuli, as a potential moderator of treatment response in CBT and ACT. Forty-six patients with DSM-IV generalized SAD were assessed at baseline, posttreatment, and 6- and 12-month follow-ups. Attentional bias moderated the relationship between treatment and response status; individuals slower to disengage from threatening stimuli (i.e., with greater attentional bias) exhibited greater reduction in clinician-rated fear and avoidance in CBT than in ACT.

Hedman et al. (2012) examined moderators of treatment outcome in their study comparing ICBT and CBGT (Hedman et al., 2011; reviewed earlier). Comorbid depression and anxiety symptoms moderated treatment outcome; the absence of comorbid depression and lower general anxiety were related to lower SA in ICBT but not in CBGT. Of note, level of depression (in contrast to presence or absence of comorbid depression) did not moderate treatment outcome, although greater baseline depressive symptoms predicted less SA reduction overall across treatments.

Hofmann’s (2004) RCT (reviewed earlier) comparing CBGT to exposure group therapy without formal cognitive restructuring examined estimated social cost, or the participant’s rating of how bad or distressing it would be for various social situations to occur (e.g., having someone leave while you’re talking to several people), as a potential mediator of treatment outcome. Estimated social cost mediated changes in SA from baseline to posttreatment in both CBGT and EGT. CBGT resulted in significantly greater reductions in SA at 6-month follow-up than EGT, suggesting that the inclusion of an explicit cognitive intervention in CBGT led to more lasting effects than a similar treatment without formal cognitive instruction, and this effect was also mediated by changes in estimated social cost. Moscovitch, Hofmann, Suvak, and In-Albon (2005) examined mediators of CBGT outcome in 66 patients from the same trial. They found that decreases in SA mediated 91% of depression symptom reduction from pre- to posttreatment, while depression reduction during treatment accounted for only 6% of SA symptom reduction from pre- to posttreatment.

In Goldin et al.’s (2012) study (reviewed earlier), the authors examined cognitive-reappraisal self-efficacy (CR-SE) as a mediator of CBT and change in SA. CR-SE was measured on a 7-point Likert-type scale, which assessed patients’ belief in their own ability to succeed at cognitive reappraisal (i.e., “How capable are you of using reappraisal when you want to . . .”) in various situations (e.g., “control my emotions by changing the way I think about the situation I’m in”). CBT resulted in greater increases in CR-SE than WL, and CR-SE mediated CBT’s effect on SA. It is possible that the cognitive restructuring portion of CBT increases one’s frequency of utilizing cognitive restructuring and the belief in one’s ability to do so effectively and that the combination of these two components of CR-SE facilitates anxiety reduction (Goldin et al., 2012).

In their study comparing CBGT versus MBSR, Goldin et al. (2016) examined mediators of these treatments and SA symptom reduction. Cognitive reappraisal frequency, attention focusing and shifting, mindfulness skills, and reductions in safety behaviors and cognitive distortions, each mediated the effect of both CBGT and MBSR on SA. Increases in cognitive reappraisal self-efficacy and decreases in safety behaviors mediated the effect of CBGT as compared to MBSR on SA symptoms.

Kocovski, Fleming, Hawley, Ho, and Antony (2015) examined mechanisms of change in their RCT comparing CBGT and MAGT (Kocovski et al., 2013; reviewed earlier). Cognitive reappraisal was associated with subsequent change in SA for both CBGT and MAGT, but this relationship was significantly stronger for CBGT. In addition, mindfulness was associated with subsequent change in SA, and SA was associated with subsequent change in mindfulness, for both CBGT and MAGT.

Niles et al. (2014) examined session-by-session change in negative thoughts as a potential mediator of CBT outcomes and experiential avoidance as a potential mediator of ACT outcomes in the same Craske et al. (2014) study reviewed earlier. The slope of negative thoughts at the start of treatment predicted lower posttreatment SA and depression symptoms for both ACT and CBT. The slope of experiential avoidance during treatment significantly mediated the relationship between treatment group and posttreatment SA and depression, such that a steeper decline of experiential avoidance at the start of treatment predicted fewer SA and depression symptoms post-ACT, but not post-CBT.

Taking these findings together, it seems that cognitive and behavioral factors (i.e., lower psychological flexibility, greater experiential avoidance, and greater attentional bias toward threat) moderate treatment outcome, such that they are associated with greater improvements in CBT compared to ACT. In addition, comorbid depression was related to poorer treatment outcome in Internet-based compared to in-person CBT.

Cognitive and behavioral factors also appear to mediate SAD treatment outcome. Changes in estimated social cost and cognitive reappraisal self-efficacy and decreases in safety behaviors mediated treatment outcome in CBT. Decreases in negative automatic thoughts earlier in treatment mediated SA reduction in both CBT and ACT, and greater reduction of experiential avoidance early in treatment mediated SA reduction in ACT.

CBT Versus Medication

Gelernter et al. (1991) randomized 65 patients with DSM-III-R SAD to receive CBGT, the benzodiazepine alprazolam, the monoamine oxidase inhibitor (MAOI) phenelzine, or pill placebo. Medications were administered double-blind. Each condition consisted of 12 weekly sessions. CBGT sessions were 2-hours long, and medication sessions involved 12–30 minute meetings with a psychiatrist who encouraged self-exposure. All four conditions resulted in significant changes on multiple measures at posttreatment, and most changes were maintained at 2-month follow-up. At posttreatment and follow-up, those who received phenelzine reported significantly less trait anxiety than patients in the other conditions, but there were no other differences between groups. Overall, the four treatments appeared to be equally efficacious, with a slight added benefit of phenelzine on trait anxiety.

Heimberg et al. (1998) randomized 133 patients with DSM-III-R SAD to receive CBGT, phenelzine, pill placebo, or the credible attention-placebo control ES. At posttreatment, both CBGT and phenelzine showed significantly better response rates and symptom reductions than either control condition. However, phenelzine worked more quickly (e.g., the proportion classified as midtreatment responders was almost twice as large for phenelzine than CBGT) and was also significantly better than CBGT at 12 weeks on various SA measures. In ITT analysis, 58% of CBGT, 65% of phenelzine, 33% of pill placebo, and 27% of ES patients were classified as responders. Proportions of responders did not significantly differ between phenelzine and CBGT. Phenelzine effects were large, and CBGT effects were generally medium.

In a follow-up to this study (Liebowitz et al., 1999), phenelzine and CBGT responders entered a 6-month maintenance phase in which phenelzine patients continued on the medication and CBGT patients met monthly. Afterwards, those who continued to respond entered a 6-month treatment-free phase. Relapse did not differ between treatments during maintenance; however, there was a trend toward greater relapse during the treatment-free phase for the phenelzine group. Patients with generalized SAD relapsed significantly more if they received phenelzine (50%) compared to CBGT (0%). Thus, CBGT and phenelzine were both efficacious at posttreatment, although phenelzine worked faster and was superior on some measures; however, more patients receiving phenelzine than CBT tended to relapse after stopping treatment, especially if they presented with generalized SAD.

Oosterbaan, Balkom, Spinhoven, van Oppen, and van Dyck (2001) randomly assigned 82 patients with DSM-III-R SAD to receive 12 weekly 45-minute sessions of CT (based on Scholing, Emmelkamp, & van Oppen, 1996), treatment with the reversible MAOI moclobemide, which included seven visits over 15 weeks, or pill placebo. Medication was administered double-blind. All three groups improved significantly on a composite SA measure at posttreatment and 2-month follow-up. CT was significantly more improved on SA than moclobemide, but not placebo, at posttreatment, and significantly more improved on SA than both moclobemide and placebo at 2-month follow-up. Moclobemide was not superior to placebo at any time.

Studies of other medications support the notion that CBT is as efficacious as, but slower acting than, pharmacotherapy. Otto et al. (2000) compared the benzodiazepine clonazepam and CBGT (twelve 2.5-hour sessions) in an RCT. Clonazepam patients were encouraged to enter into feared situations. Patients receiving both treatments improved significantly, and there were no differences between treatments at 24 weeks on self-report measures or remission rates; in ITT analyses, 20% of clonazepam patients achieved remission, compared to 25% in CBGT. However, clonazepam was faster acting, performing significantly better on a few measures at the 12-week assessment. Long-term outcomes were not assessed.

Turner, Beidel, and Jacob (1994) compared three months of EXP to the beta-blocker atenolol or placebo in 72 adults with DSM-III-R SAD. EXP included imaginal and in vivo exposure. Medication was administered double-blind. EXP yielded significantly more improvements than placebo, whereas atenolol did not. EXP was significantly better than atenolol on measures of avoidance of social situations and global impairment and on behavioral measures derived from a speech task. Significantly more patients who received EXP (88.9%) were rated as at least moderately improved compared to patients who received atenolol (46.6%). The gains made in both groups were maintained at 6-month follow-up.

D. M. Clark et al. (2003) conducted a randomized, placebo-controlled trial in which 60 patients with DSM-IV generalized SAD were randomized to 16 weeks of CT (based on D. M. Clark & Wells, 1995), fluoxetine plus self-exposure (FLU-SE), or placebo plus self-exposure (PLA-SE). Patients in the FLU-SE group were told that as their dose builds up, fluoxetine should increase confidence in social situations and that to acquire the most benefit they need to systematically expose themselves to feared situations. From week 3 forward, they were given exposure homework. Patients in both treatments demonstrated significant improvements, but patients who received CT improved significantly more on SA than patients in FLU-SE or PLA-SE at posttreatment. CT was still superior to FLU-SE at the end of a booster phase and after 12 months.

Combination of Psychotherapy and Medication

Falloon, Lloyd, and Harpin (1981) randomized 16 patients with DSM-III SAD to receive SST plus the beta-blocker propranolol or SST plus pill placebo. Patients from both groups demonstrated increased social competence and decreased anxiety, and gains were sustained at 6-month follow-up. Thus, propranolol did not add to the benefits of SST in this early trial.

D. B. Clark and Agras (1991) conducted an RCT examining buspirone, a member of the azapirone class. Ninety-four patients who were musicians with DSM-III-R SAD with either performance impairment or avoidance received 6 weeks of buspirone, 6 weeks of pill placebo, 5 sessions of group CBT combined with buspirone, or 5 sessions of group CBT with placebo. Medications were administered double-blind. Group CBT led to a greater decrease in subjective anxiety and a greater increase in performance confidence during a musical performance and a speech compared to the buspirone-only and placebo-only groups. Furthermore, rated quality of musical performance was greater for patients who received group CBT than buspirone-only. Findings suggest that buspirone is not as efficacious as CBGT and yields no added benefit to CBGT.

Blanco et al. (2010) conducted a randomized, double-blind, placebo-controlled trial comparing CBGT, phenelzine, their combination, and pill placebo in 128 adults with DSM-IV SAD. Patients who received phenelzine were instructed to expose themselves to feared social situations and informed that the medication makes this easier. The combined group yielded the greatest SA reductions, followed by both monotherapies, followed by placebo. After 24 weeks of treatment, remission rates were 14.8% for placebo, 23.5% for CBGT, 25.7% for phenelzine, and 53.1% for combined treatment; CBGT and phenelzine were not significantly different from each other. Of note, however, both monotherapies performed more poorly in this study than in a previous study by the same research group (Heimberg et al., 1998).

Davidson et al. (2004) conducted a double-blind, placebo-controlled trial and randomized 295 adults with DSM-IV generalized SAD to 14 weeks of fluoxetine, comprehensive cognitive behavioral group therapy (CCBT; essentially similar to Heimberg & Becker’s, 2002, CBGT, with an increased emphasis on SST), placebo, or combinations of CCBT/fluoxetine or CCBT/placebo. All treatment groups were superior to placebo, but fluoxetine worked faster than all other groups (i.e., it was more efficacious than other groups at week 4). In addition, CCBT was superior to CCBT/fluoxetine, CCBT/placebo, and placebo at week 4. At posttreatment, all active treatments yielded significantly greater improvements than placebo but did not differ. This study did not include a follow-up time-point, so it is unclear whether this effect might have changed over time.

Blomhoff et al. (2001) conducted an RCT in which 387 patients with DSM-IV generalized SAD were randomized to 16 weeks of sertraline or placebo with or without exposure therapy in a primary care setting. Patients also completed a final visit at 24 weeks. Exposure was individually designed and included a symptom-monitoring diary and instructions for self-exposure. Patients who took sertraline did significantly better than those who did not, and there was no significant difference between those who received exposure therapy versus those who did not. Both combined sertraline and exposure and sertraline alone were significantly better than placebo. At a follow-up conducted after 52 weeks (Haug et al., 2003), patients from the exposure-only and placebo groups had significantly improved. However, those in the combined treatment and sertraline only groups had significantly deteriorated on a health survey compared to those in exposure alone, suggesting that exposure is more efficacious than sertraline or combined treatment in the long term. This conclusion, however, has been debated (Bandelow, 2004; also see Haug, 2004).

Nordahl et al. (2016) compared the SSRI paroxetine, CT (based on D. M. Clark & Wells, 1995), paroxetine combined with CT, and pill placebo combined with CT in 102 adults with DSM-IV SAD. The paroxetine and pill placebo groups included clinical management and encouragement of self-exposure and lasted 26 weeks. CT consisted of 12 weekly sessions, and the combined treatment group included CT for the first 12 sessions and continued with paroxetine for the remaining 14 sessions. CT and CT combined with paroxetine were not significantly different at posttreatment and were both superior to paroxetine alone and pill placebo. Effect sizes for CT and the combined treatment were large. Gains in CT were maintained at 1-year follow-up, and CT was superior to paroxetine and placebo at 1-year follow-up. There were no differences between the combined treatment, paroxetine, and placebo at 1-year follow-up. Recovery rates at 1-year follow-up were as follows: 68% in CT, 40% in combined treatment, 24% in the paroxetine group, and 4% in the placebo group.

Gingnell et al. (2016) compared ICBT combined with the SSRI escitalopram with ICBT and pill placebo in 48 adults with DSM-IV SAD. ICBT consisted of 9 weekly modules. ICBT combined with escitalopram resulted in higher response rates than ICBT plus placebo (67% and 33%, respectively). ICBT and escitalopram resulted in greater reductions in anticipatory state anxiety before a speech at posttreatment and resulted in a trend-level (p = .09) effect of greater SA reduction at posttreatment compared to ICBT plus placebo. In addition, ICBT combined with escitalopram resulted in greater reductions in right amygdala reactivity to emotional faces than ICBT and placebo. At 15-month follow-up, ICBT combined with escitalopram demonstrated greater SA reductions than ICBT and placebo.

Knijnik et al. (2008) conducted an RCT comparing clonazepam to psychodynamic group therapy (PGT) combined with clonazepam for 58 patients with DSM-IV generalized SAD. Clonazepam treatment included six 20-minute visits over 12 weeks. PGT consisted of 12 weekly 90-minute sessions. Combined PGT and clonazepam resulted in significantly greater improvement in overall global functioning. However, there were no significant differences between groups at posttreatment on measures of depression, SA, or quality of life. Thus, it appeared that psychodynamic group therapy added to clonazepam on global improvement but not other more specific measures.

D-cycloserine

Hofmann et al. (2006) conducted a randomized, double-blind, placebo-controlled trial examining whether D-cycloserine (DCS) augmented exposure therapy. DCS is a partial NMDA receptor agonist, which facilitates extinction of learned fear in animals (Davis, Ressler, Rothbaum, & Richardson, 2006) and humans (Ressler et al., 2004). They randomized 27 patients with DSM-IV SAD with a specific fear of public speaking to receive five weekly sessions of exposure combined with DCS or pill placebo taken 1-hour prior to exposure. The DCS group showed significantly more improvement on two SA measures compared to the exposure plus placebo group at posttreatment and 1-month follow-up. A similar trial by Guastella et al. (2008) essentially replicated these findings. Results from these studies suggest that DCS may be a useful strategy to augment short-term exposure therapy for socially anxious individuals with specific performance fears. However, when a similar strategy was employed in the context of a fully developed group CBT protocol, there was little difference in efficacy between DCS—and placebo-augmented response or remission rates (Hofmann et al., 2013).

Conclusions About CBT and Pharmacotherapy

Research comparing pharmacotherapy to psychotherapy (specifically, CBT in all but one RCT) suggests that MAOIs (i.e., phenelzine) and benzodiazepines (i.e., clonazepam; alprazolam) are as efficacious as CBT for treating SAD. Studies indicate that both phenelzine (Gelenter et al., 1991; Heimberg et al., 1998) and clonazepam (Otto et al., 2000) performed as well as, but were faster acting than, CBT. Notably, in a follow-up study examining the long-term effects of phenelzine and CBT (Liebowitz et al., 1999), relapse rates were higher when patients had received medication than CBT. In contrast, research did not support the use of moclobemide (Oosterbaan et al., 2001), atenolol (Turner et al., 1994), or fluoxetine (D. M. Clark et al., 2003) over CBT for SAD. Thus, it appears that MAOIs and benzodiazepines are efficacious and should be considered when quick treatment gains are needed, but CBT is better for long-term outcome, especially if patients do not wish to remain on medication.

The literature examining the combined effect of psychotherapy and medication is mixed. Studies have found that beta-blockers (Falloon et al., 1981) or fluoxetine (Davidson et al., 2004) combined with CBT are no better than CBT alone. Studies examining whether psychotherapy augments medication have found that CBT combined with buspirone (D. B. Clark & Agras, 1991) and psychodynamic psychotherapy combined with clonazepam (Knijnik et al., 2008) lead to better outcomes than each medication alone. Blanco et al. (2010) found that phenelzine combined with CBT was superior to CBT alone. Blomhoff et al. (2001) demonstrated that sertraline combined with exposure was efficacious, but patients in this combined treatment deteriorated somewhat at follow-up (Haug et al., 2003). CBT alone appeared superior to paroxetine alone, and at 1-year follow-up, was associated with higher recovery rates than combination treatment, paroxetine alone, or placebo (Nordahl et al., 2016). Escitalopram did appear to add to the efficacy of ICBT (Gingnell et al., 2016). DCS appeared to augment short-term exposure therapy (Hofmann et al., 2006), but its efficacy was less clear when used to augment a fuller course of group CBT (Hofmann et al., 2013). Thus, overall the research suggests that combining medication and psychotherapy for SAD does not yield better results than each treatment alone. Furthermore, meta-analytic methods (Mayo-Wilson et al., 2014) found no evidence that combined therapies had greater effects than each monotherapy alone.

Conclusions

Our review suggests that CBT has the most evidence for the treatment of SAD. Though CBT is further along in accumulating an evidence base, acceptance and mindfulness-based therapies are promising and have performed as well as CBT in comparative studies conducted to date. Psychodynamic psychotherapy has also been found to be efficacious for treating SAD but may lead to lower remission rates in the short term and may require more time to achieve efficacy. Further research is needed to form more definitive conclusions on the efficacy of psychodynamic psychotherapy for SAD compared to both active control conditions and established efficacious treatments. RCTs of IPT for SAD provide mixed results and generally do not support the use of IPT over CBTs. However, intensive IPT that includes exposures may be just as helpful as intensive CBT for SAD. The literature is mixed regarding comparisons with pharmacotherapy for SAD but suggests that MAOIs and benzodiazepines are faster acting and as efficacious as CBTs in the short term, but do not have long-lasting effects. There is little support for the combined use of medication and psychotherapy beyond each monotherapy alone.

CBT performs as well in naturalistic, community settings as it does in more highly controlled research settings. Effectiveness studies suggest that findings from RCTs translate to real-life therapy settings. However, effectiveness studies of acceptance—and mindfulness-based therapies and psychodynamic psychotherapy are needed to increase confidence in conclusions drawn from reviews of RCTs in these areas.

Many questions regarding psychological treatments for SAD remain. Little to no research has utilized rigorous, controlled methodology to evaluate the efficacy of psychological treatments across diverse cultures. RCTs and effectiveness trials of these therapies with more racially, ethnically, culturally, sexually, and nationally diverse samples are needed (see Meidlinger & Hope, 2014, for a review on the current state of the SA literature regarding diversity). In addition, though the psychotherapies reviewed in this article lead to significant reductions in SA and rates of SAD, there is much room for improvement. Only about a third of SAD patients in most RCTs of psychological treatments and CBT effectiveness studies reviewed in this article achieve remission. Though more individuals are classified as responders, a substantial number of individuals still report significant SA symptoms after treatment. One limitation of the studies in this review is the short-term nature of the treatments. Most interventions did not exceed 16 sessions, including those in effectiveness studies. Therapy is often much longer and more individualized in real-life settings, raising questions about whether remission rates would be higher if therapy durations in both controlled and effectiveness trials were lengthened. Furthermore, the studies reviewed in this article utilized mostly questionnaires as outcome measures. Though some studies (e.g., Mattick & Peters, 1988) have used behavioral approach tests as one of multiple outcome assessment methods, these tests have not been used as markers of response or remission, which are usually determined based on scores on interview measures (e.g., on the CGI-I, the LSAS). While symptom reduction is of course welcome and often preferred, one’s ability to partake in activities and enter into contexts previously avoided, despite experiencing anxiety, and self-efficacy within these situations, could be seen as a more realistic, and arguably more important, marker of improvement. Along these lines, research on mediators and moderators of treatment on SAD symptom reduction has focused primarily on cognitive and behavioral factors. Furthermore, such research has mostly examined cognitive behavioral treatments. More research on treatment mediators and moderators across various treatments is needed, and potential emotion—or motivation-related variables, such as distress tolerance and willingness, would benefit from examination.

Future research on psychological treatments for SAD may also benefit from examining common elements between various treatments and combining them to maximize benefits for patients. CBT and acceptance—and mindfulness-based therapies have thus far been studied in comparison to one another, but research has yet to draw on their commonalities to see if combining the two approaches to therapy would lead to greater improvements in SA. Mennin, Ellard, Fresco, and Gross (2013) argue that behavioral activation/exposure, attention shifting, acceptance and tolerance of anxiety, and cognitive change that encourages taking new perspectives and defusing from the literal meaning of thoughts, are common elements across therapies, though they may be emphasized to varying degrees and framed differently in each therapy. Research on the development of treatments for generalized anxiety disorder, such as Acceptance-Based Behavior Therapy (Hayes-Skelton, Roemer, & Orsillo, 2013; Roemer & Orsillo, 2014) or Emotion Regulation Therapy (Fresco, Mennin, Heimberg, & Ritter, 2013; Mennin, Fresco, Ritter, & Heimberg, 2015), may provide some direction in that regard.

Table 1. Randomized Controlled Trials of the Treatment of Social Anxiety Disorder Included in the Review

Study

Sample

Exclusion

Intervention

Control

SA Measures

Attrition

Outcome

Comments

1. Beidel et al. (2014)

106 adults with DSM-IV SAD, 48% male, 71% Caucasian, 16% African American, 5% Hispanic, 7% Asian, 2% Biracial, mean age: 36

Psychosis, bipolar disorder, depressive disorder with active suicidal ideation, Axis II diagnoses of borderline, schizoid, paranoid, or schizotypal personality disorder; unstable medication dosage during treatment phase

EXP: imaginal and in vivo; 24 sessions over 12 weeks

SET (based on Turner et al., 1994): EXP + SST; SST involved learning basic conversation skills, making friends, practicing assertiveness, public speaking; 24 sessions over 12 weeks

WL

CGI; BSPS

EXP: 16 (39%)

SET: 16 (35%)

WL: 3 (16%)

Both treatments resulted in significant improvements in distress and remission compared to WL; no difference in remission rates between EXP (54%) and SET (67%) patients; significantly more SET (92%) than EXP (75%) patients classified as responders

SET patients also performed significantly better on measures of social skills & observed social behavior at posttreatment

2. Bjornsson et al. (2011)

45 undergraduates with DSM-IV SAD, 53% male, 89% Caucasian, mean age: 20

Current participation in pharmacological or psychological treatment; current suicidal ideation; psychotic disorder; bipolar disorder; alcohol or substance dependence; primary diagnosis of another disorder

CBGT: abbreviated version of Heimberg and Becker’s (2002) protocol; 8 2-hour weekly sessions

GPT (based on Yalom & Leszcz, 2005): credible control; included nonspecific components of group treatment; 8 2-hour weekly sessions

CGI; LSAS; SIAS; SPS

CBGT: 5 (23%)

GPT: 1 (4%)

Both treatments resulted in significant improvement in SAD (CGI Cohen’s d for CBGT: 0.99; GPT: 1.14). Both groups resulted in significant reduction in SA symptoms; no differences between CBGT and GPT

3. Blanco et al. (2010)

128 adults with DSM-IV SAD, 59% male, 48% White, 23% Black, 21% Hispanic, 9% Other, mean age: 32

Comorbid anxiety disorder more salient than SAD; hx of schizophrenia, bipolar disorder, mental disorder due to general medical condition; MDD or substance use disorder in past 6 months; previous tx failure with phenelzine or CBT for SAD; concurrent psychiatric or psychological tx; pregnancy, lactation, or inability or unwillingness to use contraception for duration of study

CBGT; 12 2.5-hour weekly sessions

Phenelzine (15 mg for 3 days, then 30 mg for 4 days, 45 mg/day for week 2, 60 mg/day for weeks 3 & 4, dosage could be raised to 75 mg for week 5 and 90 mg for weeks 6-12 depending on progress) + nonspecific instructions for self-exposure; 12 weeks

Combined CBGT + Phenelzine

Pill placebo

LSAS; ADIS CSR; CGI; FQ-social phobia; SIAS; SPS

CBGT: 12 (35%)

Phenelzine: 13 (37%)

Combined: 9 (28%)

Placebo: 5 (19%)

Combined tx resulted in greatest SA reductions, followed by both monotherapies, followed by placebo; remission rates were 53% (combined treatment), 26% (Phenelzine), 24% (CBGT), 15% (Placebo); CBGT and Phenelzine did not differ significantly at posttreatment

4. Blomhoff et al. (2001); Haug et al. (2003)

387 adults with DSM-IV generalized SAD, 40% male, no race/ethnicity information provided, mean age: 40

Panic disorder with onset before SAD; any current anxiety disorder, MDD, substance use, or eating disorder; hx of bipolar disorder or psychosis

Sertraline; 50 mg once daily; increased to 100 mg daily after 4 weeks if CGI-I ≤ 3; further dose escalations up to 150 mg after 8 and 12 weeks if needed; 9 visits over 16 weeks & final visit after 24 weeks

Pill placebo + EXP (individually designed; included symptom-monitoring diary and instructions for self-exposure); 9 visits over 16 weeks & final visit after 24 weeks

Sertraline + EXP; 9 visits over 16 weeks & final visit after 24 weeks

Pill placebo once daily; 9 visits over 16 weeks & final visit after 24 weeks

CGI; SPS; BSPS

Attrition not broken down by group.

Withdrawn from further treatment at week 16 due to non-response: 44 (11%)

Total non-completers at 24 weeks: 134 (35%)

Sertraline patients improved significantly more than those who received pill placebo; no differences between patients who received EXP and those who did not; combined sertraline & EXP and sertraline alone groups did better than pill placebo; at 1-year FU, EXP + placebo and placebo-only groups significantly improved, and combined treatment and sertraline-only groups slightly deteriorated compared to EXP + pill placebo (Haug et al., 2003)

Primary care setting; EXP provided by physicians who had received study-specific training

5. Bögels and Voncken (2008)

55 adults with DSM-III-R SAD and primary fears of showing bodily symptoms (e.g., sweating), 56% male, no race/ethnicity information provided, mean age: 35

Substance dependence; psychotic disorder; current suicidal behavior; having received cognitive and/or behavioral treatment for SAD in 6 months prior

SST with special emphasis on fear of showing bodily symptoms; 12 weekly 2-hour sessions

CT with special emphasis on fear of showing bodily symptoms; 12 weekly 2-hour sessions

None

FQ-social phobia; SASSI

SST: 1 (4%)

CT: 4 (15%)

Significant improvements in SA for both SST and CT at posttreatment; Cohen’s ds > 0.8 for both treatments; no differences between groups; gains maintained at 1-month and 1-year FUs

6. Bögels et al. (2014)

47 adults with DSM-IV SAD, 55% male, no race/ethnicity information provided, mean age: 29

CBT or psychodynamic psychotherapy for SAD in past 2 years; substance abuse/dependence; psychotic disorder; suicidal behavior; cluster A and B personality disorders except paranoid and narcissistic; insufficient self-reflection based on interviewer rating of patient’s ability to direct attention and investigate own reactions to an emotional meaningful situation

Psychodynamic psychotherapy; up to 36 sessions (number not determined a priori)

CBT; up to 36 sessions (number not determined a priori)

None

SPAI-Social Phobia Subscale; FQ-Social Phobia

Psychodynamic: 3 (14%)

CBT: 6 (19%)

Both treatments resulted in significant improvements in SA; Cohen’s d > 1 for both groups on main social anxiety measure; rates of clinically significant change for CBT and psychodynamic therapy were 64% & 63%, respectively, at posttreatment and 65% & 75%, respectively, at 1-year FU

Mean number of sessions for CBT = 19.8; mean number of sessions for psychodynamic psychotherapy = 31.4

7. Borge et al. (2008)

80 adults with chronic, highly comorbid, treatment refractory DSM-IV SAD, 49% male, no race/ethnicity information provided, mean age: 38

Current psychotic disorder or substance abuse; organic mental disorder; unwillingness to suspend use of psychotropic medication; previous treatment similar to CT or IPT; non-Norwegian speakers; hx of depression with continued use of antidepressants

Residential CT (based on D. M. Clark & Wells, 1995); 10 weeks; 4 sessions (360 min) of group treatment per week and 1 individual session (45-50 min) per week

Residential IPT; based on Lipsitz et al., 1997); 10 weeks; 4 sessions (360 min) of group treatment per week and 1 individual session (45-50 min) per week

None

ADIS fear and avoidance ratings; SPAI; SAQ; SPWSS; LSAS-SR

Residential CT: 8 (20%)

Residential IPT: 3 (8%)

Both residential CT and IPT yielded significant improvement at posttreatment; no significant differences between groups; both groups showed continued improvement through 1-year FU

Both treatments addressed safety behaviors, included exposure and video-feedback, and emphasized maintaining factors in SAD

8. Butler et al. (1984)

45 adults with DSM-III SAD, 58% male, no race/ethnicity information provided, mean age: 28

Psychological treatment for SAD in past year; avoidant personality disorder

EXP/AM; AM focused on identifying anxiety symptoms, targeting them with relaxation, distraction, rational self-talk; 7 weekly 1-hour sessions + 2 booster sessions after 2 and 6 weeks

EXP + nonspecific control “filler” treatment (associative therapy); 7 weekly 1-hour sessions + 2 booster sessions after 2 and 6 weeks

WL

SADS; FNE; FQ-Social Phobia

EXP/AM: 1 (6%)

EXP: 0 (0%)

Both treatments superior to WL at posttreatment and 6-month FU; EXP/AM superior to EXP at posttreatment and FU

Patients rated EXP as significantly less credible than EXP/AM at the fourth treatment session

9. Carlbring et al. (2007); Carlbring et al. (2009)

57 adults with DSM-IV SAD, 33% male, no race/ethnicity information provided, mean age: 33

Total score ≥ 31 on the MADRS-S & score ≥ 4 on the MADRS-S suicide item; current other psychological treatment; hx of CBT; inconstant dose of anxiety or depression medication in 3 months prior to study; no access to computer with internet connection; not resident of Sweden; inability to speak to therapist on phone on weekly basis; current psychosis or substance misuse

ICBT: 9 modules over 9 weeks, online discussion group, brief weekly phone calls with therapist for feedback and questions

WL

LSAS-SR; SPS; SIAS; SPSQ

ICBT: 2 (7%)

WL: 0 (0%)

ICBT improved significantly more on SA, general anxiety, avoidance, and depression than WL patients; gains maintained at 1-year FU; ICBT patients improved significantly from pre—to posttreatment while WL did not; 66.7% of patients who completed 30-month FU no longer met criteria for SAD; significant improvements from pretreatment and posttreatment to 30-month FU (Carlbring et al., 2009)

10. D. B. Clark and Agras (1991)

34 adults who were musicians with DSM-III-R SAD with either performance impairment or avoidance, no race/ethnicity information provided, 40% male, mean age: 38

Medical problems; other psychiatric disorder; current substance or alcohol dependence;

Buspirone 5 mg 3x daily and increased as tolerated to maximum of 12 5mg tablets daily; 6 weeks

CBGT (5 sessions) + buspirone

CBGT (5 sessions) + pill placebo

Pill Placebo; 6 weeks

SADS; FNE

CBGT + pill placebo: 2 (22%)

CBGT + buspirone: 0 (0%)

Buspirone: 2 (22%)

Pill placebo: 1 (12.5%)

CBGT resulted in greater decrease in anxiety and increase in performance confidence during musical performance and speech compared to buspirone-only and placebo-only groups; combined treatment not better than CBGT alone

11. D. M. Clark et al. (2006)

62 patients with DSM-IV SAD, 50% male, 89% Caucasian, mean age: 32

Current alcohol or substance dependence; hx of psychosis; previous treatment for SAD with exposure or CBT; psychotropic medication unstable or leading to symptomatic improvement in past 2 months; other current psychological treatment; borderline personality disorder

CT (D. M. Clark & Wells, 1995); up to 14 weekly sessions + up to 3 booster sessions in first 3 months of follow-up

EXP + AR: exposure exercises, reducing subtle avoidance, applied relaxation techniques; up to 14 weekly sessions + up to 3 booster sessions in first 3 months of follow-up

WL

Social Phobia Composite consisting of ADIS fear and avoidance ratings, SPS, SIAS, LSAS; SPWSS; SPAI; FNE

CT: 0 (0%)

EXP + AR: 2 (10%)

WL: 0 (0%)

CT and EXP + AR improved significantly more than WL; both treatments had large controlled effect sizes; CT resulted in greater improvements in SA than EXP + AR; at posttreatment, 84% CT patients, 42% EXP + AR patients, and 0% WL patients no longer met criteria for SAD; gains maintained at 1-year FU

12. D. M. Clark et al. (2003)

60 patients with DSM-IV generalized SAD, no race/ethnicity information provided; 48% male, mean age: 33

Current MDD, bipolar disorder, psychosis, alcohol or substance dependence, or epilepsy; pregnancy or intention of pregnancy; previous treatment of SAD with SSRI, CT, or EXP; psychotropic medication during 4 weeks prior to trial; other current psychotherapy; borderline personality disorder

CT (D. M. Clark & Wells, 1995); 16 weeks

Fluoxetine (dose 20 mg–60 mg) + specific self-exposure instructions (FLU-SE)

Pill placebo + specific self-exposure instructions (PLA-SE)

ADIS fear and avoidance ratings; LSAS; FQ-Social Phobia; FNE; SPWSS

CT: 1 (5%)

FLU-SE: 1 (5%)

PLA-SE: 3 (15%)

Patients in CT and FLU-SE showed significant improvements at posttreatment (SA change effect sizes for CT and FLU + SE = 2.14 and 0.92, respectively); CT improved significantly more than FLU-SE or PLA-SE on SA at posttreatment; CT still superior to FLU-SE at 1-year FU

13. Craske et al. (2014)

87 adults with DSM-IV SAD, 54% male, 51% White, 17% Hispanic, 2% African American/Black, 18% Asian American/Pacific Islander, mean age: 28

Active suicidal ideation; severe depression (clinical severity rating > 6); hx of bipolar disorder or psychosis; substance abuse or dependence in previous 6 months; respiratory, cardiovascular, pulmonary, neurological, muscular-skeletal diseases, or pregnancy; left-handedness; metal implants; claustrophobia

CBT (based on Hope et al., 2000); 12 weekly 1-hour sessions

ACT (manual by Eifert & Forsyth, 2005); 12 weekly 1-hour sessions

WL

ADIS CSR and fear and avoidance ratings; LSAS-SR; SIAS; SPS

CBT: 12 (36%)

ACT: 6 (21%)

WL: 2 (8%)

CBT and ACT resulted in significantly greater improvements in SA than WL (Cohen’s ds = 1.02 and 0.97, respectively); no differences between ACT and CBT at posttreatment or 6—or 12-month FU

Lower baseline psychological flexibility related to greater improvement at 12-month FU in CBT compared to ACT; fear of negative evaluation also moderated outcomes, with more extreme scores predicting better outcomes for CBT than for ACT; greater attentional bias related to greater reduction in clinician-rated fear and avoidance in CBT versus ACT [Niles et al. (2013)]; slope of experiential avoidance during treatment mediated the relationship between treatment group and posttreatment SA and depression, such that a steeper decline of experiential avoidance at the start of treatment predicted fewer SA and depression symptoms post-ACT, but not post-CBT [Niles et al. (2014)]

14. Dagöö et al. (2014)

52 patients with DSM-IV SAD, 48% male, no race/ethnicity information provided; mean age: 37

Scoring ≥ 25 on the MADRS-S, score ≥ 4 of 6 on suicidal ideation item of MADRS-S; current alcohol abuse or dependence; hx of psychosis or bipolar disorder; cluster A or B personality disorders; current psychological treatment; CBT in 4 years prior; inconstant dosage of psychotropic medication in 3 months prior to or during trial; psychiatric problem for which outpatient care deemed more appropriate; no access to smartphone or computer with Internet connection; inability to read and write in Swedish

Mobile CBT (mCBT): 9 weekly modules; weekly phone calls for feedback on homework and questions

Mobile IPT (mIPT): 9 weekly modules; weekly phone calls for feedback on homework and questions

None

LSAS-SR; SIAS; SPS

mCBT: 10 (37%)

mIPT: 12 (48%)

Both groups resulted in significant decreases in SA at posttreatment; significantly more patients in mCBT (56%) were classified as responders than in mIPT (8%); between-group Cohen’s ds on SA measures between 0.63-0.72

15. Davidson et al. (2004)

295 adults with DSM-IV SAD, 54% male, 78% Caucasian, mean age: 37

Primary comorbid anxiety disorder; hx of schizophrenia, bipolar disorder, organic brain syndrome, MDD in past 6 months; substance abuse or dependence in past year; mental retardation or pervasive developmental disorder; unstable medical condition; prior failure to respond to fluoxetine at 60 mg/day for at least 4 weeks or to 12 weekly CBT sessions for SAD; current psychiatric treatment or medication; positive urine drug screen; inability to maintain 2-week psychotropic drug-free washout; pregnancy or lactation

Fluoxetine; 14 weeks; started at 10 mg daily, 20 mg daily on day 8, 30 mg daily on day 15, 40 mg daily on day 29, dose could be increased to 50 mg daily on day 43 and 60 mg daily on day 57 if

patient had not yet achieved CGI score of 1 or 2

Comprehensive CBT (CCBT; similar to Heimberg & Becker’s, 2002, CBGT, with increased emphasis on SST); 14 weeks

Combination of CCBT/fluoxetine

Combination of CCBT/placebo

Pill placebo

BSPS; CGI severity scale; SPAI

Fluoxetine: 18 (32%)

CCBT: 12 (20%)

CCBT/fluoxetine: 17 (29%)

CCBT/Placebo: 13 (22%)

Placebo: 24 (40%)

All groups were superior to placebo; fluoxetine worked faster than all other groups; CCBT superior to CCBT/fluoxetine, CCBT/placebo, and placebo at week 4; all treatments superior to placebo at posttreatment, with no differences between treatments; CGI response rates at posttreatment were 51% Fluoxetine, 52% CCBT, 54% CCBT/fluoxetine, 51% CCBT/placebo, 32% placebo

16. El Alaoui et al. (2015)

654 patients (aged 16 and higher) with DSM-IV SAD receiving care at a specialized public ICBT outpatient clinic, 45% male, mean age: 33

Concurrent psychological treatment; unstable dose of psychotropic medication 4 weeks prior to or during study; current psychiatric difficulties (e.g., substance abuse or psychotic syndrome) that made ICBT unsuitable; no access to Internet; MADRS-S score ≥ 35; moderate to high risk of suicide; low motivation, severe apathy, or difficulty concentrating; psychosis; untreated drug or alcohol problems; reading, writing, or language difficulties

ICBT; therapist-guided; weekly modules and homework with therapist feedback; 12-15 weeks

N/A

LSAS-SR

ICBT: 107 (16%)

ICBT led to significant reductions in SA and comorbid depressive symptoms; effect sizes on LSAS-SR were large at posttreatment (d = 0.86) and 6-month FU (d = 1.15); approximately 20% considered in remission at posttreatment and 33% considered in remission at 6-month FU

Effectiveness study

17. Falloon et al. (1981)

16 adults with DSM-III SAD, 63% male, no race/ethnicity information provided, mean age: 27

Evidence of any other psychiatric or physical conditions

SST (4 weeks) + propranolol; propranolol dosage adjusted to reduce resting heart rate to 60 beats per min; dosage ranged from 160-320 mg daily

SST + pill placebo

SAQ

Attrition from SST + propranolol: 2 (25%)

Attrition from SST + pill placebo: 2 (25%)

Both groups demonstrated decreased social anxiety/avoidance at posttreatment; no group differences; gains maintained at 6-month FU

18. Gaston et al. (2006)

112 adults with DSM-IV SAD, 55% male, no race/ethnicity information provided, mean age: 33

Current suicidality, self-harming, or psychosis

CBGT (Rapee & Sanderson, 1998); 10 2.5-hour sessions over 12 weeks with final sessions staggered; conducted at research unit

Same protocol but conducted in private practice

None

SIAS; SPS

Research group: 10 (17%)

Private practice group: 4 (7%)

Both groups resulted in significant reduction in social anxiety at posttreatment with large effect sizes (Cohen’s ds between 1.0-1.3); no significant differences between groups; gains maintained at 3-month FU

Effectiveness study

19. Gelernter et al. (1991)

65 adults with DSM-III-R SAD, 37% male, 91% Caucasian, mean age: 37

MDD, melancholic subtype; pregnancy or intention of pregnancy during study duration; hx of psychosis; current substance abuse; medical condition that contraindicated phenelzine or alprazolam; inability to adhere to rigorous protocol requirements, including drug and dietary restrictions; concurrent psychotherapy

CBGT; 12 weekly 2-hour sessions

Phenelzine; 12 weekly 30-min meetings with psychiatrist & encouragement of self-exposure

Alprazolam; 12 weekly 30-min meetings & encouragement of self-exposure

Pill placebo; 12 weekly 30-min meetings with psychiatrist including encouragement of self-exposure

SADS; FQ-Social Phobia

CBGT: 3 (15%)

Phenelzine: 2 (13%)

Alprazolam: 1 (7%)

Pill Placebo: 0 (0%)

All 4 conditions resulted in significant changes on the SADS and FQ at posttreatment; gains maintained at 2-month FU; at posttreatment and FU phenelzine group reported significantly less trait anxiety than other conditions

20. Gingnell et al. (2016)

48 adults with DSM-IV SAD; no race/ethnicity information provided; 50% male, mean age: 33

Contraindications for magnetic resonance imaging; severe somatic disease; serious psychiatric disorder (e.g., psychosis, severe MDD); psychiatric treatment in past 3 months; menopause; substance or alcohol abuse or dependence

ICBT (based on D. M. Clark & Wells, 1995); 9 weekly modules; written feedback from therapist + escitalopram; 10 mg daily during 1st week; 20 mg daily during remaining 8 weeks

ICBT + pill placebo

CGI-I; LSAS; LSAS-SR; SIAS; SPS; Right amygdala reactivity to emotional faces

Attrition at post-treatment:

ICBT + escitalopram: 1 (4%)

ICBT + placebo: 1 (4%)

Proportion of participants who did not complete all 9 modules:

ICBT + escitalopram: 6 (25%)

ICBT + placebo: 10 (42%)

ICBT + escitalopram resulted in higher response rates than ICBT + placebo (67% and 33%, respectively); ICBT + escitalopram resulted in greater reductions in anticipatory state speech anxiety at posttreatment and greater reduction in SA at 15-month FU; escitalopram resulted in greater decreases in right amygdala reactivity at posttreatment than placebo

21. Goldin et al. (2012)

75 adults with DSM-IV generalized SAD, 53% male, 58% Caucasian, mean age: 33

History of medical disorders or head trauma, current MDD, bipolar, substance abuse, post-traumatic stress, obsessive-compulsive, or thought disorders

Individual CBT for SAD using Hope et al.’s (2000) workbook; 16 weekly 1-hour sessions

WL

LSAS-SR

CBT: 6 (16%)

WL: 5 (14%)

CBT resulted in greater decreases in SA compared to WL, d = 1.03; gains maintained at 1-year post CBT

CR-SE mediated relationship between CBT and change in SA

22. Goldin et al. (2016)

108 adults with DSM-IV SAD, 44% male, 44% Caucasian, 39% Asian, 9.3% Hispanic, 8.3% other, mean age: 33

Past year pharmacotherapy or psychotherapy, CBT for anxiety during past 2 years, previous participation in MBSR or long-term meditation retreats, history of regular meditation practice for at least 10 min 3 times/week, history of neurological, cardiovascular, thought or bipolar disorders, current substance or alcohol abuse or dependence

CBGT (Heimberg & Becker, 2002, with additional material from Hope et al., 2010); 12 weekly 2.5-hour sessions

MBSR; 12 2.5-hour group sessions and daily home practice

WL

LSAS-SR

CBGT: 2 (6%)

MBSR: 3 (8%)

WL: 1 (3%)

Both treatments significantly better than WL at posttreatment; reduction in SA not significantly different in CBGT versus MBSR. SA improvements were maintained at 1-year FU for both treatments

Cognitive reappraisal frequency, attention focusing and shifting, mindfulness skills, and reductions in safety behaviors and cognitive distortions, each mediated the effect of CBGT and MBSR on social anxiety. Increases in reappraisal self-efficacy and decreases in safety behaviors mediated the effect of CBGT vs. MBSR on social anxiety symptoms.

23. Guastella et al. (2008)

56 adults with DSM-IV SAD, 57% male, 77% Caucasian, 10.7% Asian, mean age: 35

Primary diagnosis of MDD, bipolar disorder, psychotic disorders, severe kidney disease, epilepsy, pregnancy, current substance dependence, current participation in other psychotherapy

CBGT+DCS: 5 sessions (session 1: 60 min; sessions 2-5: 90 min) of group EXP; administration of DCS (50 mg) before sessions 2-5; exposures involved increasingly difficult speeches

Same procedure, with administration of placebo rather than DCS

GAF; SPAI; LSAS

CBGT + DCS: 1 (4%)

CBGT + Placebo: 5 (18%)

DCS resulted in greater improvements in SAD symptom severity than placebo; gains maintained at 1-month FU

Relationship between lower negative self-appraisals about speech performance and improvement in SA symptoms moderated by DCS

24. Hedman et al. (2011); Hedman et al. (2014)

126 adults with DSM-IV SAD, 64% male, no race/ethnicity information provided, mean age: 35

Hx of CBT in last 4 years, current psychological tx, inconstant dosage 2 months prior to treatment of any prescribed medication current substance abuse, hx of psychosis or bipolar disorder, score > 20 on the MADRS-S, if MDD criteria met, score greater than 4 of 6 on the suicidal ideation item of the MADRS-S, any cluster A or B personality disorder

ICBT including 15 weekly modules and brief weekly therapist email contact

CBGT (based on Heimberg & Becker, 2002) consisting of 14 2.5-hour group sessions over 15 weeks

None

LSAS; LSAS-SR; SPS; SIAS

ICBT: 13 (20%)

CBGT: 12 (19%)

Both groups significantly improved on SA as measured by the LSAS (ICBT d= 1.42, CBGT d = 1.42); no differences between groups at posttreatment or 6-month FU on scores on the LSAS-SR or response status. Gains maintained at 4-year FU; LSAS-SR scores well within noninferiority range

Non-inferiority margin: difference between ICBT and CBGT < 10 points on LSAS at lower bound of 95% CI

25. Heimberg et al. (1990); Heimberg et al. (1993)

49 adults with DSM-III social phobia, no race/ethnicity information provided, 55% male, mean age: 30

Organic brain disorder, antisocial or avoidant personality disorder, MDD, score > 25 on the HRSD, other anxiety disorder as or more severe than SAD, consumption of alcohol or substance during 6-months prior to treatment if history of alcohol abuse or dependence

CBGT consisting of 12 weekly 2-hour sessions

Educational-supportive psychotherapy group (ES; 12 weekly 2-hour sessions) involving lecture-demonstration-discussions on topics relevant to SAD and a patient-led support group

ADIS CSR

CBGT: 5 (20%)

ES: 4 (17%)

Significantly more CBGT than ES patients were rated as improved at posttreatment (75% vs. 40%, respectively) and 6-month FU (81% vs. 47%, respectively). Gains realized in CBGT were maintained on average five years later (Heimberg et al., 1993)

26. Heimberg et al. (1998); Liebowitz et al. (1999)

133 adults with DSM-III-R SAD, no race/ethnicity information provided, 50% male, mean age: 35

Organic mental disorder, hx of alcohol or substance abuse within the past 6 months or bipolar disorder, schizophrenia, major depression, prominent risk of self-harm, > 6 past sessions of CBT or MAOI treatment (phenelzine ≥ 45 mg/day or equivalent dose of another MAOI for >4 weeks) for SA, serious medical condition, concurrent psychotropic medications

CBGT; 12 2.5-hour weekly sessions

Phenelzine (starting dose 15 mg/d, increased to 30 mg/d on day 4, 45 mg/d on day 8, and 60 mg/d on day 15; dosages could be increased up to 75 mg/d after day 15 and to 90 mg/d if well tolerated)

ES; 12 2.5-hour weekly sessions

Pill placebo

CGI, LSAS, ADIS CSR, SADS, FNE, FQ, SIAS, SPS, behavioral test

CBGT: 8 (22%)

Phenelzine: 5 (16%)

ES: 7 (21%)

Pill placebo: 6 (18%)

CBGT and Phenelzine had equivalent response rate (75% and 77%, respectively) at 12 week; both treatments were superior to ES and placebo; Phenelzine patients demonstrated lower anxiety on most measures; Phenelzine patients reported less SA during behavioral test than CBGT, and CBGT was superior to ES and placebo. At 1-yr FU, significantly more patients with generalized SAD relapsed on Phenelzine than CBGT (Liebowitz et al., 1999)

27. Herbert et al. (2005)

65 adults with DSM-IV generalized SAD, 43% male, 65% Caucasian, 23% African American, 8% Asian, 2% Hispanic, 3% other, mean age: 34

Hx of mental retardation, organic mental disorder, pervasive developmental disorder, substance dependence within the last 6 months, untreated medical condition that could obscure the dx of SAD, acute suicidality, hx of CBT for SAD

CBGT (based on Heimberg & Becker, 2002) consisting of 12 weekly 2-hour sessions

CBGT augmented with SST

None

SPAI, FQ, BFNE, behavioral assessment (consisted of 3 3-minute behavioral tasks)

CBGT: 9 (30%)

CBGT+SST: 11 (31%)

CBGT+SST resulted in greater SA reductions than CBGT at posttreatment and 3-month FU (CBGT+SST d’s = 1.94–2.00; CBGT d’s = 0.61–0.95); no group differences on self-ratings of performance on behavioral tasks; CBGT+SST group demonstrated greater observer-rated improvement on first behavioral assessment

28. Hofmann (2004)

90 patients with DSM-IV SAD with at least moderate public speaking anxiety, 54% male, 90% Caucasian, mean age: 32

“Prior nonresponse to adequately delivered study treatment”; substance abuse or dependence; active suicidality; bipolar disorder; schizophrenia or other psychotic disorders

CBGT (Heimberg, 1991); 12 weekly sessions

EGT: group EXP without explicit cognitive intervention; 12 weekly sessions

WL

SPAI

CBGT: 5 (14%)

EGT: 8 (21%)

WL: 16 (35%)

CBGT and EGT did not differ significantly at posttreatment; both groups were superior to WL; effect sizes for CBGT (d = 0.72) and EGT (d = 0.52) were moderate; gains maintained at 6-month FU; CBGT resulted in greater SA reductions at 6-month FU than EGT

29. Hofmann et al. (2006)

27 adults with DSM-IV SAD with public speaking anxiety, 67% male, 59% White, mean age: 33

Current PTSD, current primary anxiety disorder other than SAD, psychomotor retardation, hx of delusional disorder, psychosis, bipolar disorder, or substance or alcohol abuse or dependence within the last 3 months (other than nicotine), suicidality

CBGT+DCS: 5 sessions (session 1: 60 min; EXP sessions 2-5: 90 min) of individual or group EXP therapy; administration of DCS (50 mg) 1 hour before EXP sessions; exposures consisted of video recorded speeches

Same procedure, with administration of placebo rather than DCS

SPAI, LSAS, CGI-S

CBGT+DCS: 3 (20%)

CBGT + Placebo: 2 (12%)

DCS patients demonstrated greater reductions in SA than placebo patients at posttreatment and 1-month FU

30. Hofmann et al. (2013)

169 adults with DSM-IV generalized SAD, 57% male, 72% White, 12% Asian, 9% African American, 7% Other, mean age: 33

Primary diagnosis other than SAD, abnormalities on ECG, physical exam, or blood, hx of schizophrenia, delusional disorders, bipolar disorder, OCD, or psychosis, eating disorder in past 6 months, substance abuse/dependence in past 6 months, inability to refrain from alcohol use during study period, mental retardation, organic brain syndrome, interfering cognitive dysfunction, PTSD in past 6 months, significant suicidal ideation (score ≥ 3 on item 10 of MADRS), suicidal behaviors in past 6 months, interfering personality dysfunction, medical illness necessitating hospitalization, hx of seizures, hx of head trauma resulting in seizure, current cognitive impairment, and loss of consciousness; psychotropic medication within past 2 weeks, current treatment with isoniazid, concurrent psychotherapy initiated within past 3 months, concurrent psychotherapy specifically for SAD, previous non-response to EXP, current pregnancy or breastfeeding, women of childbearing age unwilling to use contraception

CBGT+DCS (based on Hofmann & Otto, 2008; Hope, Heimberg, & Turk, 2006) consisting of 12 weekly 2.5-hour sessions; administration of DCS (50 mg) 1 hour before sessions 3-7

Same procedure, with administration of placebo rather than DCS

CGI-I, CGI-S, LSAS,

CBGT+DCS: 9 (10%)

CBGT+Placebo: 13 (16%)

DCS and placebo groups did not differ in response (DCS: 79% vs. placebo: 73%) or remission rates (35% vs. placebo: 24%) at posttreatment; results maintained at 1-, 3-, and 6-month FU assessments; DCS patients decreased in global illness severity and SA and achieved remission more quickly than placebo patients

DCS appeared to make smaller impact when used to augment a full-scale CBT program than it did in previous studies of brief EXP for public speaking fears in SAD.

31. Jazaieri et al. (2012)

56 adults with DSM-IV generalized SAD, 48% male, 45% Asian, 41% Caucasian, 7% Hispanic, 11% multiracial, mean age: 33

Current psychotherapy or pharmacotherapy, current comorbid psychiatric disorder other than GAD, agoraphobia without a hx of panic attacks, specific phobia, MDD, or OCD, history of head trauma or other medical disorder, previous MBSR course or regular meditation practice or exercise routine (3 or more times per week for at least two months)

MBSR (based on Kabat-Zinn, 1990) consisting of 8, weekly 2.5 hour group classes plus home practice and a 1-day meditation retreat

Aerobic exercise (AE): two moderate-intensity individual AE workouts and one non-meditation or yoga group AE workout per week for 8 weeks

LSAS-SR, SIAS

MBSR: 5 (16%)

AE: 2 (8%)

MBSR and AE yielded significant reductions in SA at posttreatment and 3-month FU; no differences between groups at posttreatment or 3-month FU

Study also included an untreated group of 29 nonrandomized SAD patients for comparison. Patients receiving MBSR or AE scored significantly better on most measures than this untreated group.

32. Knijnik et al. (2008)

58 adults with DSM-IV generalized SAD, 39% male, no race/ethnicity information provided, mean age: 33

Primary dx other than generalized SAD (or generalized SAD for < 2 years, LSAS score of < 55 and fear and and/or avoidance in < 4 social situations (and < 2 situations involving interpersonal interaction), failed 12-week or longer trial of 2 mg clonazepam, current or prior tx of SAD, hypersensitivity to benzodiazepines, depressive episode (BDI score > 30) or suicide risk in past 6 months, substance use disorder, bipolar disorder, neurological disease, mental retardation, psychotropic or hypnotic drugs in past 4 weeks, current pregnancy or breastfeeding or unwilling to use contraceptives

Psychodynamic group therapy (based on Malan, 1976) consisting of 12 weekly 90-minute sessions + Clonazepam (see below)

Clonazepam (initial dose of 0.5 mg 2x/day; couple be increased up to 1.0 mg 2x/daily in weeks 2-12)

None

CGI-I, LSAS-SR

Psychodynamic group therapy + Clonazepam: 1 (3%)

Clonazepam: 5 (17%)

Psychodynamic therapy patients demonstrated significantly greater improvement in global functioning than clonazepam patients; significantly more psychodynamic therapy than clonazepam patients were classified as responders (79% vs. 54%, respectively); no group differences on the LSAS-SR

33. Kocovski et al. (2013)

137 adults with DSM-IV generalized SAD, 46% male, 62% Caucasian, 20% Asian, 4% Black, 4% Hispanic, 11% other, mean age: 34

Lifetime mania or psychosis, current alcohol or substance abuse or dependence, current MDD, current suicidal intent, hx of CBT or ACT; unstable doses of psychotropic medication in last 3 months

MAGT (Fleming & Kocovski, 2009) consisting of 12 weekly 2-hour sessions

CBGT (based on Heimberg & Becker, 2002) consisting of 12 weekly 2-hour sessions

WL

SPIN, LSAS, CGI

MAGT: 16 (30%)

CBGT: 21 (40%)

MAGT and CBGT led to significantly greater reductions in SA than WL (d = 1.80 and d = 1.42 on SPIN, respectively); no difference in SA reduction between MAGT and CBGT; of completers, 44% in CBGT and 43% in MAGT met criteria for clinically significant change; gains maintained for both treatments at 3-month FU

Cognitive reappraisal related to subsequent change in SA for both CBGT and MAGT; this relationship was significantly stronger for CBGT; mindfulness was associated with subsequent change in SA, and SA was associated with subsequent change in mindfulness, for both CBGT and MAGT (Kocovski et al., 2015)

34. Koszycki et al. (2007)

53 adults with DSM-IV generalized SAD, 47% male, no race/ethnicity information provided, mean age: 38

HRSD score ≥ 14 at baseline, comorbid Axis I disorder other than secondary dysthymia, MDD, GAD, panic disorder, specific phobia, somatization disorder, and agoraphobia, hx of bipolar or psychotic disorder, substance abuse within past 12 months, current suicidality, current significant medical condition that would make participation unsafe, psychotherapy in past 3 months, CBT in the past 12 months, formal stress reduction program including regular yoga and medication practice in past 12 months, unstable doses of psychotropic medication in prior 6 weeks

MBSR (based on Kabat-Zinn & Santorelli, 1993); interview with instructor, 8 weekly 2.5-hour group sessions,1 full-day meditation retreat

CBGT (based on Heimberg & Becker, 2002); individual interview with therapist; 12 weekly 2.5-hour sessions

None

LSAS, SIAS, SPS, CGI

MBSR: 4 (15%)

CBGT: 8 (30%)

CBGT resulted in greater SA reductions than MBSR; response and remission rates were higher in CBGT (88.9% and 44%, respectively) than MBSR (45% and 9%, respectively) at posttreatment

35. Ledley et al. (2009)

38 adults with DSM-IV SAD, 42% male, 79% Caucasian, 13% African-American, 5% Asian, 3% Hispanic, mean age: 35

Primary dx other than SAD, current bipolar disorder or substance dependence, past or current psychotic disorder, suicidal or at risk for self-harm

CBT (based on Hope et al., 2000) consisting of 16 sessions (all sessions 60 min, first exposure session 90 min) over 20 weeks

WL

ADIS CSR, LSAS, CGI-I, SIAS, SPS, BFNE

CBGT: 1 (6%)

WL: 3 (14%)

CBT resulted in significantly greater improvements in SA than WL; significantly more CBT than WL patients were considered responders (73% vs. 6%); CBT patients demonstrated large within-group effect sizes (d =1.03-5.22) on all SA measures; gains made in CBT maintained at 3-month FU

36. Leichsenring et al. (2013); Leichsenring et al. (2014)

495 adults with DSM-IV SAD, 45% male, no race/ethnicity information provided, mean age: 35

Primary dx other than SAD, acute substance-related disorder, psychotic disorder, cluster A and B personality disorders, organic mental disorder, prominent risk of self-harm, severe medical condition, current psychotherapy or pharmacotherapy

CBT (based on D. M. Clark & Wells, 1995); up to 25 weekly 50-minute sessions (up to 6 sessions could be 100 minutes)

Psychodynamic Therapy (based on Luborsky, 1984); up to 25 individual 50-minutes sessions (sessions 7 to 16 could be scheduled twice per week)

WL

LSAS, SPAI

CBT: 50 (24%)

Psychodynamic therapy: 58 (28%)

WL: 21 (27%)

CBT and psychodynamic therapy were superior to WL on remission rates (CBT: 26%; psychodynamic: 36%; WL: 9%) and response rates (CBT: 60%; psychodynamic: 52%; WL: 15%); CBT resulted in significantly greater remission rates than psychodynamic therapy; no significant differences in response rates; CBT additionally resulted in significantly greater reduction in LSAS (d = 0.25) and SPAI (d = 0.33) scores; no differences in depression between treatments at posttreatment; no significant differences between CBT and psychodynamic therapy on any measures at 6-month and 2-year FUs (Leichsenring et al., 2014)

37. Lincoln et al. (2003)

217 adults with DSM-III-R SAD, 57% male, no race/ethnicity information provided, mean age: 34

Primary dx other than SAD, medical conditions that would interfere with or be compromised by EXP

EXP+CR; 5-7 full days of intensive exposure and cognitive restructuring followed by 6 weeks of at-home in vivo exposures

None

SPS, SIAS, self-rating of social phobia impairment

EXP+CR: 18 (8%)

Significant improvement in SA at posttreatment; tx equally efficacious across clinics; effect sizes on SA measures at posttreatment ranged from d = 0.71-0.88; 56% of patients were rated as reliably improved in SA

Effectiveness study; Patients who dropped out demonstrated significantly greater impairment, comorbidity, and depressive sx; subgroups of patients based on common exclusion criteria used in RCTs did not differ in effect sizes of SA

38. Lipsitz et al. (2008)

70 adults with DSM-IV SAD, 57% male, 50% White, 21% Black, 16% Hispanic, 10% Asian/Pacific Islander, 3% American Indian/other, mean age: 35

Hx of psychotic disorder or bipolar disorder, MDD in past 2 months, serious depression sx in past week (HRSD score > 16), OCD in past 6-months, panic disorder, or serious suicidal ideation; alcohol or substance use disorder in past 2 months, ≥ 6 sessions CBT for SAD in past 2 years, pharmacotherapy in past 2 months, psychotherapy in past month

IPT; adapted from Klerman et al., (1984); 14 weekly sessions

Supportive therapy (ST); based on Pinsker’s (1997) supportive therapy; emphasized empathy, relaxed conversational style, expressing emotions; 14 weekly sessions

LSAS, CGI, SIAS, SPS, BFNE

IPT: 8 (22%)

ST: 7 (21%)

Both IPT and ST patients demonstrated significant reduction in SA at posttreatment; of completers, 52% of IPT patients and 48% of ST patients were considered responders; no differences between IPT and ST on any outcome measure

39. McEvoy (2007)

153 adults with DSM-IV SAD, 75% male, no race/ethnicity information provided, mean age: 33

Current schizophrenia, schizoaffective disorder, substance use severe enough to impair SAD treatment, organic brain dysfunction

CBGT; 7 4-hour sessions

None

SPS, SIAS

CBGT: 28 (18%)

CBGT resulted in significant reductions in SA at posttreatment ds = 0.8-1.0; effect sizes for SA measures were within range of comparison studies; effect size for depression was relatively larger than comparison studies; > 50% patients achieved reliable change in SA; > 30% achieved clinically significant change in SA

Effectiveness study; significantly more female patients dropped out; dropouts were significantly younger than completers; BDI score > 18 and age > 50 years were associated with greater decreases in depression

40. McEvoy et al. (2012)

Research unit (RU): 66 adults with DSM-IV SAD, 12% male, no race/ethnicity information provided, mean age: 36

Community mental health clinic (CMHC): 94 adults with DSM-IV SAD, 60% male, no race/ethnicity information provided, mean age: 33

Primary dx other than SAD for RU group, active suicidal ideation, current self-harm, current psychosis, substance use severe enough to impair SAD treatment

Enhanced CBGT (traditional CBGT with additional theory-driven components); 12 weekly 2-hour sessions

None

SPS, SIAS

CMHC: 27%

RU: 18%

Both CMHC and RU patients improved in SA; within group effect sizes were large for both CMHC and RU (d’s = 0.80-1.0); ~60% reliably improved in SA; no group differences in reliably significant improvement in SA or SA symptom reduction; 51.7% of patients across groups achieved clinically significant change on the SIAS and 15.2% on the SPS

Effectiveness study; CMHC patients demonstrated greater SA at pretreatment and were more likely to have comorbid disorders, be using medication, and have MDD or dysthymia; completers were 5 years older than non-completers and were more likely to be married/less likely to be single, and less likely to be depressed; number of comorbid disorders and severity of pretreatment SA predicted posttreatment sx severity

41. Mattick and Peters (1988)

51 adults with DSM-III SAD, 47% male, 100% Caucasian, mean age: 37

Interpersonal anxiety without scrutiny fears, comorbid disorder in more immediate need of treatment (e.g., alcohol abuse), agoraphobia, avoidant personality disorder, psychotic disturbance, organic tremor, lack of avoidance behavior

EXP; 6 weekly 2-hour group sessions

EXP combined with cognitive restructuring (COMB); 6 weekly 2-hour group sessions

None

Behavioral approach test (BAT), SUDS ratings, SPS, FNE, SADS

EXP: 3 (12%)

COMB: 4 (16%)

Both EXP and COMB patients demonstrated improvement in performance on BAT, but COMB patients significantly outperformed EXP patients; SUDS ratings during the BAT decreased equally in both groups from posttreatment to 3-month FU; both COMB and EXP patients reported decreased avoidance from pre—to posttreatment; COMB patients showed further decreases in avoidance between posttreatment and follow-up, whereas EXP patients demonstrated slight losses

42. Mattick et al. (1989)

43 adults with DSM-III SAD, 47% male, no race/ethnicity information provided, mean age: 41

Interaction anxiety without scrutiny fears, disorder other than SAD, lack of avoidance behavior

EXP

Cognitive restructuring without exposure (CR)

Combined EXP and CR (COMB)

*All treatments consisted of 6 weekly 2-hour group sessions

WL

BAT, SUDS ratings, SPS, SIAS, FQ, FNE

EXP: 1 (9%)

CR: 2 (18%)

COMB: 1 (9%)

WL: 1 (10%)

Patients in all three treatment conditions demonstrated significant improvements in SA; COMB and EXP were superior to CR on BAT at posttreatment; at 3-month FU, COMB demonstrated significantly greater behavioral approach than EXP and CR, which did not differ; at posttreatment, COMB was superior to EXP on 2 of 5 self-report measures, and there were no between-group differences in end-state functioning

43. Mörtberg et al. (2006)

26 adults with DSM-IV SAD, 35% male, no race/ethnicity information provided, mean age: 33

Current MDD, psychosis, addiction

IGCT (based on D. M. Clark & Wells, 1995); 2 weeks of daily sessions (41 hours total) separated by 1 week of homework (i.e., 3 week total tx)

WL

LSAS, SIAS, FNE

IGCT: 1 (4%)

WL: 1 (4%)

IGCT patients had significantly lower scores on primary SA measures compared to WL at posttreatment, 3-month FU, and 6-month FU; IGCT continued to improve at 3-month and 6-month FUs. By 6-month follow-up, IGCT patients reported significantly lower levels of SA, avoidance, and safety behaviors; gains maintained at 12-month FU

44. Mörtberg et al. (2007); Mörtberg et al. (2011)

100 adults with DSM-IV SAD, 37% male, no race/ethnicity information provided, mean age: 35

Current depressive episode, addiction, psychosis, stress disorder, bipolar disorder, current psychotherapy or pharmacotherapy

IGCT (based on Mörtberg et al., 2006); 16 sessions over 3 weeks with booster sessions at 4, 8, and 12 months

Individual cognitive therapy (CT; based on D. M. Clark & Wells, 1995); 16 weekly sessions in 4 months with booster session at 8 and 12 months

Treatment as usual (TAU) involving an SSRI and therapy sessions as required for 1 year

LSAS, Social Phobia Composite (SPC; average of scores from LSAS, SPS, SIAS, FQ Social Phobia subscale), FNE, Social Phobia Weekly Summary Scale

IGCT: 4 (13%)

CT: 9 (25%)

TAU: 15 (45%)

All three treatments were associated with decreased SA; CT resulted in significantly greater SA decreases between 4 and 12 months than IGCT or TAU; IGCT was superior to TAU on the LSAS; Significantly more CT patients (56%) rated as clinically improved than IGCT (26%) and TAU (24%)

45. Nordahl et al. (2016)

102 adults with DSM-IV SAD, 93% Caucasian, 49% male, mean age: 31

Any physical disease; psychotic illness; acute suicidality; primary MDD; body dysmorphic disorder; substance or alcohol dependence; cluster A or B personality disorders; previous use of CT or SSRIs; pregnancy or intended pregnancy in next 6 months

Paroxetine and clinical management; encouragement of self-exposure; initial dose of 20 mg daily, with maximum dose up to 60 mg daily; 26 weeks

CT (based on D. M. Clark and Wells, 1995); 12 (max. 60 min) sessions; opportunity for 2 booster sessions

CT + paroxetine; 26 weeks of paroxetine; 12 sessions of CT over first 12 weeks

Pill placebo and clinical management; encouragement of self-exposure

FNE; LSAS

Paroxetine: 5 (19%)

CT: 2 (9%)

CT + Paroxetine: 6 (23%)

Placebo: 3 (12%)

CT (d = 1.96) and combined CT + paroxetine (d = 1.09) were superior to paroxetine and pill placebo at posttreatment; CT and combined CT and paroxetine were not significantly different at posttreatment; gains in CT maintained at 1-year FU, and CT was superior to paroxetine and placebo groups at 1-year FU; no differences in combined treatment, paroxetine, and placebo at 1-year FU; recovery rates at 1-year FU: CT 68%; combined group 40%; 24% paroxetine; 4% placebo

46. Oosterbaan et al. (2001)

82 adults with DSM-III-R SAD, 59% male, no race/ethnicity information provided, mean age: 37

Serious medical problems, OCD, panic disorder with or without agoraphobia, psychotic disorders, MDD, organic mental disorder, substance use disorder, borderline personality disorder

CT; 12 weekly 45-min sessions

Moclobemide; 7 visits over 15 weeks; starting dose: 450 mg/day; after 2 weeks increased to 600 mg or decreased to 300 depending on tolerability

Pill placebo

LSAS, SPS, FQ

CT: 4 (14%)

Moclobemide: 3 (11%)

Placebo: 8 (30%)

All patients improved significantly on SA at posttreatment and 2-month FU; at posttreatment, CT patients (d = 0.92) were more improved than moclobemide (d = 0.29) but not placebo (d = 0.71); at 2-month FU CT patients (d = 1.15) were more improved than moclobemide (d = 0.46) and placebo (d = 0.63)

47. Otto et al. (2000)

45 adults with DSM-III-R SAD, 60% male, no race/ethnicity information provided, mean age: 40

Primary disorder other than SAD, hypersensitivity to or failure to respond to 2 mg clonazepam, allergy to any benzodiazepine, hx of CBT treatment involving EXP and CR, hx of psychosis, bipolar disorder, or schizophrenia, current or recent suicidal tendency, current alcohol or substance abuse/dependence, serious or unstable medical condition, breastfeeding or pregnancy, women unwilling to use contraceptive, psychotropic meds, concurrent psychotherapy for anxiety

CBGT (based on Heimberg, 1991); 12 2.5-hour sessions

Clonazepam; dose 0.25 mg 2x/day for first 2 days, increased to 0.5 mg 2x/daily at end of first week; dose increased 1.0 mg/week yielding a maximum dose of 2.0 mg 2x/day)

None

LSAS, CGI-S, SIAS, SPS, FNE

CBGT: 5 (25%)

Clonazepam: 10 (40%)

Significant and equivalent improvements in SA for CBGT and clonazepam; clonazepam patients demonstrated greater reduction in SA on several self-report measures at visit 12; no differences in remission rates across groups (CBGT: 25%; Clonazepam: 20%)

Baseline SA predicted posttreatment SA for CBGT only

48. Piet et al. (2010)

26 adults with DSM-IV SAD, 31% male, no race/ethnicity information provided, mean age: 22

Psychosis, drug or alcohol dependence, severe depression, cluster A and B personality disorders, bipolar disorder, current psychotherapy or pharmacotherapy

Group mindfulness-based cognitive therapy (MBCT; based on Segal et al., 2002); 8 2-hour sessions

CBGT (based on D. M. Clark & Wells, 1995, and Heimberg & Becker, 2002);12 2-hour sessions

*crossover design; both groups received both types of treatment in reverse order

None

LSAS, SPS, SIAS, FNE

MBCT: 5 (23%)

CBGT: 3 (14%)

Group comparisons for assessment before crossover reported here to best examine differences between treatments; MBCT and CBGT were equally efficacious at posttreatment; CBGT was marginally superior on most outcome measures; both MBCT and CBGT demonstrated medium to large within-group effect sizes on SA (pre—to posttreatment: d = 0.77 for MBCT and 1.14 for CBGT); no differences in percentage of patients meeting criteria for clinically significant change across groups

49. Stangier et al. (2003)

71 adults with DSM-IV SAD, 51% male, no race/ethnicity information provided, mean age: 39

Comorbid mental disorder of greater severity than SAD, current substance abuse or psychosis, personality disorder other than avoidant and obsessive-compulsive, other psychological treatment during study

Group CT (based on D. M. Clark & Wells, 1995); up to 15 weekly 2-hour sessions

Individual CT (based on D. M. Clark & Wells, 1995); 15 weekly 1-hour sessions

WL

SPAI, SPS, SIAS

Group CT: 5 (19%)

Individual CT: 6 (25%)

WL: 1 (5%)

Both treatments resulted in significant improvements in SA and were superior to WL at posttreatment; significantly more individual CT patients were rated as improved than group CT patients; rates of remission were higher in individual CT (50%) than group CT (14%)

50. Stangier et al. (2011)

117 adults with DSM-IV SAD, 44% male, no race/ethnicity information provided, mean age: 35

Comorbid mental disorder of greater severity than SAD, psychosis, current substance abuse or dependence, severe depression (HRSD score > 23), Axis II personality disorders from the dramatic or odd cluster, acute suicidality, current psychotherapy or pharmacotherapy, preference for pharmacotherapy

Cognitive therapy (CT; based on D. M. Clark & Wells, 1995); 16 individual sessions + booster session 2 months posttreatment

IPT; 16 individual sessions + booster session 2 months posttreatment

WL

CGI-I, LSAS, SPAI

CT: 7 (18%)

IPT: 4 (11%)

WL: 2 (5%)

Both CT and IPT were superior to WL; CT was superior to IPT at posttreatment and 1-year follow-up; at posttreatment, 66% of CT patients were considered responders compared with 42% in IPT and 7% in WL; at 1-year follow-up, 68% of CT patients compared with 32% of IPT patients were classified as responders

51. Turner et al. (1994)

72 adults with DSM-III-R SAD, 39% male, 97% White, 1% African American, 1% Asian, mean age: 35

Primary dx other than SAD; secondary Axis I dx other than simple phobia, dysthymia, or GAD; paranoid, antisocial, borderline, schizoid, or schizotypal personality disorder; medical condition contraindicating atenolol

Flooding (imaginal and in vivo); 20 90-minute sessions over 3 months; 2x/week for first two months, 1x/week for third month

Atenolol; 25 mg/day during the first week, 50 mg/day during the second and third week, 100mg/day for the remainder of the study

Pill placebo

SPAI, SAD, FNE, FQ, 10-minute speech task, CGI

Flooding: 5 (24%)

Atenolol: 3 (14%)

Placebo: 1 (5%)

Flooding was superior to placebo at posttreatment, but atenolol was not; flooding patients improved more than atenolol patients on behavioral assessment and SA; more flooding patients showed significant improvement (55.6%) than atenolol (13.3%) and placebo (6.3%) patients; gains maintained for patients who improved irrespective of condition at 1-month and 3-month FUs

Column Headers: Sample (gender (% male/female), race/ethnicity, mean age); Exclusion (exclusion criteria); Intervention (intervention conditions: number/length of sessions); Control (control conditions: number/length of sessions); SA Measures (outcome measures of social anxiety); Attrition (attrition by condition); Outcome (outcome at end of treatment and follow-up); Comments (comments).

Abbreviations: ACT: Acceptance and commitment therapy; ADIS-CSR: Anxiety Disorders Interview Schedule clinician’s severity rating; AM: Anxiety management; AR: Applied relaxation; BAT: Behavioral Approach Test; BFNE: Brief Fear of Negative Evaluation Scale (Leary, 1983); BSPS: Brief Social Phobia Scale (Davidson et al., 1991); CBT: Cognitive behavioral therapy; CBGT: Cognitive behavioral group therapy; CGI: Clinical Global Impression (Guy, 1976); CGI-I: Clinical Global Impression—Improvement Rating (Guy, 1976; Zaider et al., 2003); CGI-S: Clinical Global Impression—Severity Rating (Guy, 1976; Zaider et al., 2003); CI: Confidence interval; CR: Cognitive restructuring; CR-SE: Cognitive reappraisal self-efficacy; CT: cognitive therapy; DCS: D-cycloserine; DSM-III: Diagnostic and Statistical Manual of Mental Disorders, third edition; DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders, third edition, revised; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, fourth edition; ECG: Electrocardiogram; EGT: Exposure group therapy; ES: Educational-supportive Group Psychotherapy; EXP: Exposure; FNE: Fear of Negative Evaluation Scale (Watson & Friend, 1969); FQ: Fear Questionnaire (Marks & Mathews, 1979); FU: Follow-up; GAF: Global Assessment of Functioning; GPT: Group psychotherapy; GAD: Generalized anxiety disorder; HRSD: Hamilton Rating Scale for Depression (Hamilton, 1960); Hx: History; ICBT: Internet-based CBT; IGCT: Intensive group cognitive treatment; IPT: Interpersonal psychotherapy; LSAS: Liebowitz Social Anxiety Scale, clinician-administered version (Liebowitz, 1987); LSAS-SR: Liebowitz Social Anxiety Scale-Self Report (S. L. Baker et al., 2002); MADRS-S: Montgomery Åsberg Depression Rating Scale—Self Report (Svanborg & Åsberg, 1994); MAGT: Mindfulness and acceptance-based group therapy; MAOI: Monoamine oxidase inhibitors; MBSR: Mindfulness-based stress reduction; MDD: Major depressive disorder; Meds: Pharmacotherapy; OCD: Obsessive-compulsive disorder; PTSD: Post-traumatic stress disorder; SA: Social anxiety; SAD: Social Anxiety Disorder; SADS: Social Avoidance and Distress Scale (Watson & Friend, 1969); SAQ: Social Anxiety Questionnaire (Falloon et al., 1981); SASSI: Social Anxiety Self-Statements Inventory (Bögels et al., 1987); SET: Social Effectiveness Therapy (Turner et al., 1994); SIAS: Social Interaction Anxiety Scale (Mattick & Clarke, 1998); SPAI: Social Phobia and Anxiety Inventory (Turner, Beidel, Dancu, & Stanley, 1989); SPIN: Social Phobia Inventory (Connor et al., 2000); SPS: Social Phobia Scale (Mattick & Clarke, 1998); SPSQ: Social Phobia Screening Questionnaire (Furmark et al., 1999); SPWSS: Social Phobia Weekly Summary Scale (D. M. Clark et al., 2003); SSRI: Selective serotonin reuptake inhibitor; SST: Social skills training; SUDS: Subjective Units of Discomfort Scale (Wolpe & Lazarus, 1966); Sx: Symptoms; Tx: Treatment; WL: Waitlist control

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