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1. Treatment Options for Social Phobia............................................................................................................ 1

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Treatment Options for Social Phobia

Author: Lydiard, R Bruce, PhD, MD; Falsetti, Sherry A, PhD Publication info: Psychiatric Annals 25.9 (Sep 1995): 570-576. ProQuest document link Full text: Social phobia has been described for centuries in the literature, but it has only recently been recognized as a discrete and treatable psychiatric condition rather than excessive shyness or a personality disorder. Conceptualizing social phobia as a neurobiological entity with reliable diagnostic features has greatly facilitated epidemiological and treatment research. As has been discussed earlier in this issue, social phobia may be much more common in the general population than was previously believed. The National Comorbidity Survey conducted by Kessler and colleagues1 is a recently published US community survey that employed structured psychiatric interviews to generate DSM-III-R diagnoses. After major depression (17.1%) and alcohol dependence (14.1%), social phobia was the third most frequent lifetime psychiatric disorder in the United States at 13.3%; 12-month prevalence was 7.9%. Even if these most recent figures overestimate the true prevalence of social phobia, it is clear that the previous estimates have been too low. Because of the significant potential for impairment in work and social functioning, academic difficulties, depression, and substance abuse often associated with social phobia, effective and practical treatments are clearly needed. The generalized subtype of social phobia is a more pervasive, severe, and less responsive condition than nongeneralized/discrete social phobia. It should be remembered that improvement of social phobia (especially generalized social phobia) may continue for months and years after acute treatment is completed. This is, in part, due to the typical interruption in normal psychosocial development that occurred at a relatively early age for many of these patients. For many patients, social competence can be achieved only after the individual has been allowed to continue normal social development that was prevented by pathological social fear and avoidance. This article will present a brief overview of the current evidence for efficacy of the available pharmacological and standardized behavioral and cognitive-behavioral treatments. Suggestions for optimizing treatment of social phobia will be presented. Finally, remaining questions and directions for further investigation will be reviewed briefly. PHARMACOLOGICAL TREATMENTS FOR SOCIAL PHOBIA The efficacy of pharmacological treatments for social phobia has now been documented for monoamine oxidase inhibitors (MAOIs), benzodiazepines, and selective serotonin reuptake inhibitors (SSRIs). Beta blockers (atenolol and others) have shown less consistent results. Monoamine Oxidase Inhibitors Similarities between symptoms in individuals experiencing rejection sensitivity as a symptom of atypical depression and the fear of scrutiny, embarrassment, and negative evaluation - a core feature of social phobia stimulated promising open trials with the monoamine oxidase inhibitors phenelzine and tranylcypromine. Additional placebo-controlled studies demonstrated that phenelzine was effective as a treatment for social phobia. The first trial showed that phenelzine (mean dose 74 mg/day), but not atenolol (98 mg/day) was more effective than placebo in both generalized and nongeneralized (i.e., discrete) social phobies. While atenolol was relatively ineffective in treating generalized social phobia, it appeared to have some effect (although not statistically significant) with discrete social phobies (see below).2 The effectiveness of phenelzine has been confirmed in two additional controlled, comparative studies.3'4 Open studies strongly suggest that the MAOI tranylcypromine may also be effective for social phobia. Based on these data and substantial clinical experience, the standard MAOIs, particularly phenelzine, have been established as highly effective 28 November 2013 Page 1 of 9 ProQuest

pharmacotherapy for social phobia, especially for generalized social phobies. Reversible Monoamine Inhibitors The efficacy of two new reversible inhibitors of monoamine oxidase (RIMAs), which preferentially and reversibly inhibit type-A monoamine oxidase, has recently been reported. As a result of this "reversibility," dietary tyramine and other substrates will displace the drug from the enzyme, consequently lowering the risk of hypertensive crisis and eliminating the need for the bothersome low tyramine diet required for treatment with standard MAOIs. Moclobemide, which is currently marketed for the treatment of depression in several countries outside the US (Canada, Europe, South America, and Australia), was the first of these newer agents to be tested for efficacy in social phobia. In a direct comparison with phenelzine and placebo, moclobemide was comparable to phenelzine in efficacy (although less rapidly effective) and was well tolerated.4 Unfortunately, clinical trials in the US resulted in limited enthusiasm for further testing in social phobia, and development of another RIMA, brofaromine, was suspended (at least temporarily). It is hoped that newer RIMAs in the pipeline will become available for clinical use in the relatively near future. Benzodiazepines The benzodiazepines have been an important and powerful clinical tool for the treatment of panic disorder. Although initial open trials were promising, there was concern that the use of these agents for social phobia, with the attendant risks of dependence and withdrawal, may be unwise. However, as it became more clear that social phobia was a debilitating and often chronic illness, double-blind studies confirmed that the high-potency benzodiazepines (alprazolam 1 to 10 mg/day; clonazepam 0.75 to 6 mg/day) were highly effective in the treatment of social phobia. Gelernter et al3 conducted a unique study in which social phobies received either phenelzine (55 mg/day), alprazolam (4.2 mg/day) or cognitive-behavioral therapy over 12 weeks. In that study, alprazolam was less effective than phenelzine and was associated with a greater recurrence of social phobic symptoms 2 months after discontinuation of treatment than either cognitive-behavioral therapy or phenelzine. Davidson et al5 compared clonazepam (2.1 mg/day) and placebo in social phobies and reported amelioration of social phobia symptoms by clonazepam in 78% versus only 20% of the placebo recipients. Clinical improvement in patients with social phobia was sustained throughout long-term treatment with clonazepam (average, 11.3 months), while required dosages decreased from 2.1 mg/day (end of the acute treatment) to 0.94 mg/day at follow up. Social phobia, often a chronic and debilitating disorder, frequently requires long-term treatment. The benefits of benzodiazepine treatment appear to be maintained over time with minimal adverse effects and no apparent tolerance. Selective Serotonin Reuptake Inhibitors The SSRIs (fluoxetine, sertraline, fluvoxamine, and paroxetine) show promise as alternative treatments for social phobia. Czepowicz et al6 reported that 63% (7 of 11 patients) with generalized social phobia experienced substantial improvement following treatment with sertraline (range, 50 to 200 mg daily), and Van Ameringen7 similarly reported that 16 of 22 social phobies responded well to sertraline (average, 147.5 mg/day). Katzelnick et al8 conducted a double-blind, placebo-controlled crossover study of sertraline in 12 social phobic patients and noted moderate to marked improvement in 42%; 17% improved during the placebo phase. Van Vliet et al,9 in the first parallel-design, placebo-controlled study, reported that fluvoxamine was superior to placebo in treating both generalized and nongeneralized social phobies. Thirty subjects with social phobia participated in the study, and results indicated that fluvoxamine was more effective than placebo on measures of social anxiety and anticipatory anxiety. Stein et al10 recently reported that 29 of 37 (78%) generalized social phobies responded to 12 weeks of open treatment with paroxetine (average, 47.85.8 mg). Further, they reported that following double-blind placebo substitution in 16 patients, 5 of 8 receiving placebo relapsed compared to 1 of 8 who continued receiving 28 November 2013 Page 2 of 9 ProQuest

paroxetine over an additional 12-week treatment period. Like other SSRIs, fluoxetine (20 to 80 mg/day) has been reported to produce substantial improvement in open trials, which included both generalized and nongeneralized social phobia patients.11'12 Interestingly, it was observed that social phobies did not experience significant jitteriness/activation during initiation of treatment (in contrast to panic disorder patients, who often experience significant activation) when fluoxetine was initiated at 20 mg/day. Based on the information available at this time, initiating treatment with an SSRI seems reasonable as a first step in treating social phobia - particularly in light of the dietary restrictions and predictable side effects of MAOIs, and the likelihood of physical dependence and bothersome taper-related symptoms associated with chronic benzodiazepine treatment. Beta-Adrenergic Blockers Beta-adrenergic blockers have traditionally been used by professional performing artists to alleviate autonomic peripheral symptoms (such as trembling and palpitations) that may be interpreted as evidence of distress, may disturb actual performance, and lead to increased anxiety. Their effectiveness in reducing some aspects of performance anxiety encouraged researchers to initiate trials with beta blockers in patients with social phobia. Open clinical trials that followed produced favorable results. However, a double-blind, placebo-controlled trial comparing phenelzine and atenolol demonstrated that phenelzine was significantly superior to placebo, but treatment with atenolol resulted in an intermediate response that was not significantly different from placebo.2 Patients with either discrete or generalized social phobia were preferentially responsive to phenelzine. Although the sample size of patients with discrete subtype was too small for statistical comparison, atenolol appeared to be more helpful in this group than in the generalized type. Similarly disappointing results were reported by Turner et al.13 Because beta blockers can be taken on an asneeded basis, it may be useful to assess their effects in an individual with a discrete social anxiety prior to committing the patient to longer term, continuous treatment with a MAOI, SSRI, or benzodiazepine. Other Agents A few investigators have examined the use of buspirone in social phobia in open trials. Munjack et al14 found that 9 of 11 patients who completed an 8-week open-label trial with buspirone at an average dose of 48 mg/day were rated moderately or markedly improved. However, Schneier et al15 reported, in a 12-week open trial with buspirone, that only 47% of 17 patients with social phobia were rated much to very much improved (several who were given as much as 90 mg/day showed no further improvement over the 40 to 50 mg/day range). Bell and colleagues16 recently reported the results of a large (N=275) placebo-controlled, double-blind multicenter trial of ondansetron versus placebo in the treatment of social phobia. In that 10-week trial, the serotonin-3 receptor antagonist ondansetron (0.25 mg bid) was statistically significantly superior to placebo and was well tolerated. Emmanuel et al17 reported a good response to bupropion (300 mg/day) in one patient. Although no studies have found TCAs to be effective in the treatment of social phobia, case reports and our own experience suggest that clomipramine and Imipramine may have some efficacy in some patients with social phobia. Controlled studies currently in progress will provide further information on this issue. Social Phobia and Depression Although social phobia does present as a single disorder, recent research shows individuals with social phobia are at risk for other disorders, including major depression. Schneier et al18 studied social phobia comorbidity in more than 13,000 adults from four US communities involved in the ECA study. The major finding was the presence of substantial comorbidity, especially with other anxiety disorders and major depression. Only 31% of subjects with social phobia had no other lifetime disorder. Major depression and dysthymia occurred in 29% of subjects with social phobia. In 71% of individuals with social phobia with comorbid depression, the depressive 28 November 2013 Page 3 of 9 ProQuest

symptoms developed after the onset of social anxiety. Stein et al19 reported that 35% of patients with social phobia in one clinical sample had experienced at least one major depressive episode; social phobia may confer an increased risk for major depression among patients suffering from panic disorder with comorbid social phobia.20 These data indicate that clinicians must have a high index of suspicion for the presence of a depressive disorder in patients presenting with social phobia. Despite the high prevalence and clinical significance of comorbid social phobia and depression, data regarding the clinical approach to treatment of these individuals is lacking. Until more information regarding treatment is available, the management of social phobia complicated by depression and other comorbid disorders will be guided by treatment of the individual disorders present (e.g., social phobia and depression) with one or more agents, but should include an agent that is an effective antidepressant. As noted above, there is also growing evidence that SSRIs are beneficial in the treatment of social phobia. Because of the inconvenience associated with MAOI treatment, we suggest that a trial with an SSRI may be a reasonable first treatment for social phobia and depression, followed by a MAOI such as phenelzine if the SSRI is ineffective or not tolerated. Addition of a highpotency benzodiazepine may be considered, if necessary. In our experience, a TCA such as Imipramine can be beneficial for some patients with social phobia and major depression. For some patients, additional cognitive-behavioral therapy may be required to control social anxiety. When possible, we recommend concurrent use of cognitive-behavioral therapy to address negative selfevaluation, low assertiveness, and dysfunctional cognitive patterns that may accompany both social phobia and comorbid depression. Comment It appears that several agents have considerable efficacy in patients with uncomplicated social phobia (Table). It is clear that the MAOIs, benzodiazepines, and possibly the SSRIs are effective in the treatment of social phobia. Because social phobia is a chronic, often unremitting condition, long-term treatment may be necessary. The addition of other agents and/or cognitive-behavioral therapy will likely further enhance response.

NONPHARMACOLOGICAL TREATMENTS FOR SOCIAL PHOBIA In parallel with the recent developments of psychopharmacological treatments, researchers began investigating the effectiveness of cognitive-behavioral therapies for this disorder in the fairly recent past. Despite the relative newness of this disorder, considerable research progress has been made. Several types of behavioral and cognitive behavioral techniques and treatments have been investigated, including systematic desensitization, imaginai flooding, applied muscle relaxation, graduated exposure, social skills training, cognitive approaches, and combined cognitive restructuring and graduated exposure.21 It is beyond the scope of this article to provide a detailed review of the relevant literature. Several recent summaries provide the interested reader with a good overview.22-24 This section will highlight selected studies that demonstrate the variety of cognitive behavioral treatments that have been studied in order to provide a representative overview of the effectiveness of these

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treatments - both in comparison to other cognitive behavioral treatments and to pharmacotherapy. Social Skills Training Social skills training is one of the first standardized interventions developed for treating social phobia.24 Social skills training is based on the theory that social phobies (especially generalized) have a deficit in social skills. While social skills deficits may not be universal in social phobies,25 Turner et al24 suggest that social skills training provides counterconditioning through behavioral rehearsal and may be beneficial to most social phobies, regardless of the level of preexisting social competence. Social skills training includes various elements, including education, modeling, role rehearsal, self-monitoring, and individualized homework for patients to practice in real-life situations. To date, investigations of social skills training have yielded mixed results. Falloon and colleagues26 investigated the efficacy of social skills training in 16 social phobies and found significant improvement on self-report instruments, but no improvement in behavioral task performance. Stravynski et al27 combined cognitive restructuring with social skills training and compared this to social skills training only (iV=22) in social phobies who also met diagnostic criteria for avoidant personality disorder. They found no posttreatment group differences, suggesting that the cognitive restructuring component did not significantly enhance treatment effects. Finally, Lucock and Salkovskis28 reported marked improvement in eight subjects who received cognitive social skills training. Exposure Treatments for Social Phobia Exposure-based treatments, which were at one time believed to be ineffective, also have been studied in social phobies. Exposure therapy can include imaginai flooding, in vivo exposure, or the combination. Systematic desensitization, also a form of exposure, consists of asking the patient to imagine being in the feared situation in as much detail as possible. They are asked to go through this scenario several times until anxiety decreases. Actual exposure to the individual's feared situation is typically conducted later in treatment, after the patient has mastered imaginai exposure. The underlying mechanisms in both cases are extinction and/or habituation. In systematic desensitization, patients practice relaxation while at the same time imagining components of their social phobie fears in a gradual hierarchy. This technique - "counterconditioning" - is based on the premise that the patient cannot be both relaxed and anxious at the same time. Thus, combining both a relaxation paradigm and imaginai exposure to the feared situation acts to ctiminish the social anxiety. Butler et al29 compared exposure therapy alone with exposure therapy plus anxiety management training and a waiting list control. Both active treatment groups demonstrated significantly greater improvements than the waiting list group. Comparisons of the two treatment groups indicated that the exposure plus anxiety management groups showed more subjective improvement than controls, as measured by the Fear of Negative Evaluation Scale and the Social Avoidance and Distress Scale. Follow up at 6 months indicated that the exposure plus anxiety management group treatment had significantly more sustained subjective improvement on these and several other self-rating subscales than the controls. Clinician ratings for social phobia and relevant subscales of the Fear Questionnaire, however, did not reveal differential treatment response. Emmelkamp et al25 compared exposure, rational-emotive therapy, and self-instruction training in 34 social phobies. Results indicated no significant differences in self-report measures between groups at posttreatment. However, rational-emotive subjects had lower scores on the Phobic Anxiety Scale (which evaluates five social situations) than self-instruction recipients. Exposure subjects did not differ from the other two treatment groups. At 1-month follow up, the exposure group improved significantly more on the Phobic Anxiety Scale than the other two groups. Cognitive-Behavioral Treatments for Social Phobia In addition to social skills training and therapies that predominantly employ exposure, treatments that emphasize cognitive aspects of social phobia have been developed. The rationale for cognitive-behavioral therapy is that cognitive distortions are a core feature of social phobia. For example, social phobies may think that "Others think Fm stupid or that there is something wrong with me" when they have no objective evidence 28 November 2013 Page 5 of 9 ProQuest

for this belief. Cognitive restructuring skills are designed to help patients identify when they are experiencing pathologically distorted thinking and promote realistic evaluation of these distortions and substitution of more appropriate cognitive responses. Heimberg and colleagues have developed a cognitive behavioral group therapy (CBGT) for social phobia (both discrete and generalized) that has been widely employed in treatment studies. Heimberg et al30 compared CBGT to a placebo treatment group. CBGT included education about social anxiety, cognitive restructuring, and exposure components. The placebo condition included information about anxiety and discussion of coping methods for difficult situations. The treatment consisted of 12 group sessions for 49 subjects. The CBGT group demonstrated significantly more improvement than the placebo group on ratings of phobic severity, both immediately posttreatment and 6 months after treatment. No treatment effects were found on maximum anxiety ratings or the ratio of positive to negative thoughts on self-report instruments at posttreatment. However, at 6-month follow up, the CBGT group was significantly better than the placebo group on maximum anxiety ratings and ratio of positive to negative thoughts compared to the placebo group. A subset of these subjects (n= 19) were later recontacted and agreed to participate in a long-term follow-up study.31 Patients were assessed an average of 5.5 years after they had finished treatment. The patients who had received the CBGT had higher functioning on several measures compared to those who underwent the placebo condition. Overall, 89% of the CBGT and 44% of the placebo patients were judged to be clinically improved by independent raters. CBGT has also been compared to exposure alone and a waiting list control.32 Both of the active treatments were found to be more effective than no treatment, and CBGT was found to be more effective in reducing anxiety in a behavioral test. However, the exposure-alone treatment was found to be more effective than CBGT on several other measures at posttest. At follow up, there were no differences in the two active treatments. The investigators noted that the patients receiving CBGT in this study had improved substantially less than in their other studies, and they were unsure how to interpret this or the above finding. Overall, however, the findings of Heimberg and colleagues have been most impressive and warrant further investigation. In addition to the studies described here, other researchers have also investigated cognitive behavioral therapies that include exposure and cognitive restructuring components,32,33 and they report favorable results. Comparative Efficacy of Pharmacotherapy and CBT Studies comparing cognitive behavioral treatments to pharmacotherapy have also been conducted with social phobies, although more research in this area is needed before any firm conclusions can be drawn. Clark and Agras34 conducted a comparison study of buspirone alone, buspirone plus CBT, CBT with placebo, and placebo alone. These researchers reported that the CBT groups improved significantly more than the drug-only groups. The buspirone group did not appear to be significantly different from the placebo group. In fact, the CBT plus placebo group did better than the CBT plus buspirone group. These findings did not support the usefulness of buspirone for performance anxiety. Turner et al35 compared the efficacy of flooding, atenolol, and placebo in 72 patients (both subtypes) with social phobia. They found that flooding was significantly better than placebo or atenolol on most but not all measures. Subjects who improved with treatment maintained gains at a 6-month follow up regardless of type of treatment. Gelernter et al3 compared cognitive behavioral group treatment (including both discrete and generalized subtypes) with phenelzine, alprazolam, and placebo in a sample of 65 patients. In the medication groups, patients were also instructed in self-exposure. All treatments, including the placebo plus self-instruction exposure, resulted in improvements on selfreport measures. The results indicated that phenelzine was superior on a measure of trait anxiety; however, other results for betweengroup comparisons indicated that treatment effects were very similar at follow up. At a 2month follow up, patients who received CBGT or phenelzine had maintained some of their gains, while those who had initially received alprazolam or placebo had a significant loss of effect. 28 November 2013 Page 6 of 9 ProQuest

Heimberg and Liebowitz are currently conducting a multicenter study comparing phenelzine, CBGT, pill placebo, and educational supportive group therapy (psychological placebo). Preliminary data36 on 77 subjects have indicated that subjects receiving CBGT have an 80% response rate and 71% of subjects receiving phenelzine were rated as responders. Thus, the two active treatments appear to be comparable. Overall, the efficacy of behavioral and cognitive-behavioral treatments for social phobia has been unequivocally demonstrated. In comparison to the "gold standard" MAOI, phenelzine, cognitive-behavioral treatments appear to be about equally effective and may possibly have more lasting effects. CONCLUSION Remarkable progress in the identification of social phobia as a distinct, serious, and common mental disorder has been accompanied by an equally remarkable body of research literature reporting effective, scientifically based treatment strategies. It is clear that much remains to be learned. As ongoing studies contrast cognitivebehavioral and pharmacological treatments for social phobia, studies that examine the effects of combinations of these effective techniques are being initiated. These studies should yield information regarding the optimal duration of treatment with single or combined treatments in terms of speed of recovery as well as relapse prevention after treatment discontinuation. Identification of predictive subtypes, comorbid states, and other factors that will lead the clinician to one choice over another will, we hope, accompany what is sure to be another exciting period of research into the treatments for social phobia. References REFERENCES 1. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994; 51:89. 2. Liebowitz MR, Schneier F, Campeas R, et al. Phenelzine vs atenolol in social phobia: a placebo-controlled comparison. Arch Gen Psychiatry. 1992;49:290-300. 3. Gelernter CS, Uhde TW, Cimbolic P, et al. Cognitivebehavioral and pharmacological treatments of social phobia: a controlled study. Arch Gen Psychiatry. 1991; 48:938945. 4. Versiani M, Nardi AE, Mundim FD, et al. Pharmacotherapy of social phobia: a controlled study with moclobemide and phenelzine. Br J Psychiatry. 1992; 161:353-360. 5. Davidson JR, Potts N, Richichi E, et al. Treatment of social phobia with clonazepam and placebo. J Clin Psychopharmacol. 1993; 13:423-428. 6. Czepowicz V, Johnson MR, Ware M, et al. Sertraline in social phobia. J Clin Psychopharmacol. In press. 7. Van Ameringen M, Mancini C, Streiner D. Sertraline in social phobia. J Affect Disord. 1994; 31:141-145. 8. Katzelnick D, Jefferson J, Greist J, et al. Sertraline in social phobia: a double-blind, placebo-controlled crossover pilot study. Presented at the 34th Annual Meeting of NCDEU; May 31-June 3, 1994; Marco Island, Florida. 9. van Vliet IM, den Boer JA, Westenberg HGM. Psychopharmacological treatment of social phobia; a doubleblind placebo controlled study with fluvoxamine. Psychopharmacology. 1994; 115:128-134. 10. Stein M, Chartier M, Kroft C, et al. Social phobia pharmacotherapy with paroxetine: open-label treatment and double-blind placebo-substitution studies. Presented at the 33rd Annual Meeting of the American College of Neuropsychopharmacology; December 12-16; 1994; San Juan, Puerto Rico. 11. Schneier FR, Chin SJ, Hollander E, et al. Fluoxetine in social phobia. J Clin Psychopharmacol. 1992; 12:6264. 12. Black B, Uhde TW, Tancer ME. Fluoxetine for the treatment of social phobia. J Clin Psychopharmacol. 1992; 12:293-295. 13. Turner SM, Beidel DC, Jacob RG. Social phobia: a comparison of behavior therapy and atenolol. J Consult Clin Psychol. 1994; 62:350-358. 28 November 2013 Page 7 of 9 ProQuest

14. Munjack DJ, Bruns J, Baltazar PL, et al. A pilot study of buspirone in the treatment of social phobia. J Anxiety Disorders. 1991:87-98. 15. Schneier FR, Saoud JB, Campeas R, et al. Buspirone in social phobia. J Clin Psychopharmacol. 1993; 13:251-256. 16. Bell J, DeVeaugh-Geiss J. Multicenter trial of a 5-HT3 antagonist, ondansetron, in social phobia. Presented at the 33rd Annual Meeting of the American College of Neuropsychopharmacology; December 12-16, 1994; San Juan, Puerto Rico. 17. Emmanuel NP, Lydiard RB, Ballenger JC. Treatment of social phobia with bupropion. J Clin Psychopharmacol. 1991; 11:276-277. 18. Schneier FR, Johnson J, Hornig CD, et al. Social phobia: comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry. 1992; 49:282-288. 19. Stein MB, Tancer ME, Gelernter CS, et al. Major depression in patients with social phobia. Am J Psychiatry. 1990; 147:637-639. 20. Reiter SR, Otto MW, Pollack MH, et al. Major depression in panic disorder patients with comorbid social phobia. J Affect Disord. 1991;22:171-177. 21. Schneier F. Social phobia. Psychiatric Annals. 1991; 21:349-353. 22. Heimberg R. Cognitive and behavioral treatments for social phobia: a critical analysis. Clinical Psychology Review. 1989;9:107-128. 23. Heimberg R, Barlow DH. New developments in cognitive behavioral therapy for social phobia. J Clin Psychiatry. 1991; 52(11, suppl):21-30. 24. Turner S, Beidel DC, Townsley RM. Behavioral Treatment of Social Phobia. New York: John Wiley &Sons; 1992. 25. Emmelkamp P, Mersch P, Vissia F, et al. Social phobia: a comparative evaluation of cognitive and behavioral interventions. Behav Res Ther. 1985; 23:365-369. 26. Falloon I, Lloyd GG, Harpin RE. The treatment of social phobia: real-life rehearsal with nonprofessional therapists. J Nerv Ment Dis. 1981; 169:180-184. 27. Stravynski A, Marks I, Yule W. Social skills problems in neurotic outpatients: social skills training with and without cognitive modification. Arch Gen Psychiatry. 1982; 39:1378-1385. 28. Lucock M, Salkovskis P. Cognitive factors in social anxiety and its treatment. Behav Res Ther. 1988; 26:297-302. 29. Butler G, Cullington A, Munby M, et al. Exposure and anxiety management in the treatment of social phobia. J Consult Clin Psychol. 1984; 30. Heimberg RG, Hope DA, Dodge CS, et al. DSM-III-R subtypes of social phobia. Comparison of generalized social phobies and public speaking phobies. J Nerv Ment Dis. 1990; 178:172-179. 31. Heimberg RG. Specific issues in the cognitive-behavioral treatment of social phobia. J Clin Psychiatry. 1993;54:12(suppl). 32. Hope D, Heimberg R, Bruch M. The importance of cognitive interventions in the treatment of social phobia. Presented at the annual meeting of the Phobia Society of America; March, 1990; Washington, DC. 33. Mattick R, Peters L, Clarke J. Exposure and cognitive restructuring for severe social phobia. Behavior Therapy. 1989; 20:3-23. 34. Clark DB, Agras WS. The assessment and treatment of performance anxiety in musicians. Am J Psychiatry. 1991; 148:598-605. 35. Turner SM, Beidel DC, Jacob RG. Social phobia: a comparison of behavior therapy and atenolol. J Consult Clin Psychol. 1994; 62:350-358. 36. Heimberg RB, Liebowitz MR. A multicenter comparison of the efficacy of phenelzine and cognitive behavioral group treatment for social phobia. Paper presented at the 12th Annual Conference on Anxiety 28 November 2013 Page 8 of 9 ProQuest

Disorders, Houston, TX, April 1992. AuthorAffiliation by R. BRUCE LYDIARD, PhD, MD: and SHERRY A. FALSETTI, PhD AuthorAffiliation Dr. Lydiard is Professor and Dr. Falsetti is Assistant Professor of Psychiatry and Behavioral Sciences, Institute of Psychiatry, Medical University of South Carolina, Charleston. Address reprint requests to R. Bruce Lydiard, PhD, MD, Professor of Psychiatry and Behavioral Sciences, Institute of Psychiatry, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC 29425. Publication title: Psychiatric Annals Volume: 25 Issue: 9 Pages: 570-576 Number of pages: 7 Publication year: 1995 Publication date: Sep 1995 Year: 1995 Section: SOCIAL PHOBIA Publisher: SLACK INCORPORATED Place of publication: Thorofare Country of publication: United States Publication subject: Medical Sciences--Psychiatry And Neurology ISSN: 00485713 CODEN: PSANCS Source type: Scholarly Journals Language of publication: English Document type: General Information ProQuest document ID: 894193540 Document URL: http://search.proquest.com/docview/894193540?accountid=15859 Copyright: Copyright SLACK INCORPORATED Sep 1995 Last updated: 2012-02-26 Database: ProQuest Central

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