Cognitive Behavior Therapy For Generalized Social Anxiety Disorder
Cognitive Behavior Therapy For Generalized Social Anxiety Disorder
A R T I C L E I N F O A B S T R A C T
Article history: Early identification and treatment of social anxiety disorder (SAD) is critical to prevent development of a
Received 20 February 2008 chronic course of symptoms, persistent functional impairment, and progressive psychiatric comorbidity.
Received in revised form 12 June 2008 A small but growing literature supports the effectiveness of cognitive behavior therapy (CBT) for anxiety
Accepted 13 June 2008
disorders, including SAD, in adolescence. The present randomized controlled trial evaluated the efficacy
of group vs. individual CBT for adolescents with generalized SAD in relation to an educational/supportive
Keywords:
psychotherapy that did not contain specific CBT elements. All three treatments were associated with
Social anxiety disorder
significant reductions in symptoms and functional impairment, and in improved social skills. No
Adolescence
Social phobia
differences between treatments emerged on measures of symptoms, but the CBT conditions
Cognitive behavior therapy demonstrated greater gains on behavioral measures. The implications of the findings are discussed.
ß 2008 Elsevier Ltd. All rights reserved.
Social anxiety disorder (SAD), also known as social phobia, is associated with the disorder highlight the critical importance of
characterized by a marked and persistent fear and/or avoidance of effective early assessment and intervention.
social situations in which one fears being negatively evaluated by Although children and adolescents often report many types of
others or being subjected to embarrassment (American Psychiatric worries and fears, most of these are transient and do not result in
Association, 2000). SAD is divided into two subtypes: generalized significant impairment in functioning (Muris, Merckelbach, Gadet,
and non-generalized. Individuals with generalized SAD experience & Moulaert, 2000). SAD, however, is associated with high levels of
anxiety across most social situations, whereas those with the non- distress and significant functional impairment. Youths with SAD
generalized subtype fear a specific social or performance situation have few friends, limited extracurricular activities, and may have
(Hofmann et al., 1999). SAD is widely believed to be among the difficulty with school attendance and underachievement (Khalid-
most prevalent of psychiatric conditions, although most indivi- Khan, Santibanez, McMicken, & Rynn, 2007). Additionally, SAD in
duals with the disorder are never identified and do not obtain this population is highly correlated with school refusal, selective
treatment (Chavira, Stein, Bailey, & Stein, 2004; Kessler et al., mutism, and increased comorbidity with depressive, anxiety,
1994). Without treatment, SAD tends to follow a chronic, somatoform, and substance use disorders (Essau, Conradt, &
unremitting course. Onset is typically in the early teens, with a Petermann, 1999; Last & Strauss, 1990). The social fear character-
mean onset of 15.5 years (Schneier, Johnson, Hornig, Liebowitz, & istic of SAD in youth can cause significant impairment in
Weissman, 1992). Although the vast majority of research on SAD functioning, and can have long-term detrimental effects due to
has focused on adults, the early onset, chronicity, high levels of the disorder’s chronic course. See Beidel, Ferrell, Alfano, & Yeganeh
comorbidity, and substantial distress and functional impairment (2001), Kashdan and Herbert (2001) and Khalid-Khan et al. (2007)
for comprehensive reviews of SAD in childhood and adolescence.
Currently, there is limited research on the psychological
treatment of children and adolescents with SAD (Kashdan &
* Corresponding author at: Department of Psychology, Drexel University, Mail
Stop 988, 245 N. 15th Street, Philadelphia, PA 19102-1192, USA.
Herbert, 2001; Khalid-Khan et al., 2007; Sweeney & Rapee, 2005).
Tel.: +1 215 762 1692; fax: +1 215 762 8706. To date, most of the psychological interventions for social anxiety
E-mail address: [email protected] (J.D. Herbert). in children have been designed to target all anxiety disorders (e.g.,
0887-6185/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.janxdis.2008.06.004
168 J.D. Herbert et al. / Journal of Anxiety Disorders 23 (2009) 167–177
mixed anxiety populations). Most of these interventions are significant improvements in anxiety symptoms over time were
derived from cognitive-behavioral models designed for adults observed (Beidel, Turner, & Morris, 1997). In a subsequent study,
(Zaider & Heimberg, 2003), and have generally demonstrated Beidel et al. (2000b) compared the effectiveness of SET-C in 50 SAD
positive results (Barrett, 1998; Barrett, Dadds, & Rapee, 1996; children to an active, non-SAD specific intervention consisting of
Kendall, 1994; Kendall et al., 1997; Rapee, 2000; Silverman et al., test-taking and study skills training. Significant differences were
1999). Relative to untreated controls, treated children are more revealed at post-treatment, with 67% of the SET-C children no
likely no longer to meet criteria for their specific anxiety disorder longer meeting criteria for SAD compared to 5% of those in the
following treatment, and to report fewer symptoms of anxiety and control group. Six month follow-up assessments suggested further
greater improvements in comorbid conditions. A notable limita- treatment gains, with 85% of the children in the SET-C group being
tion of this research, however, is that only a small number of diagnosis free. Gains were maintained at 5-year follow-up (Beidel,
studies have examined interventions specifically targeting SAD. Turner, & Young, 2006).
Two cognitive-behavioral treatment programs specifically More recent studies of SAD in youths have examined
targeting childhood or adolescent SAD have been developed: (1) comparisons of treatment protocols, duration of treatment, and
cognitive-behavioral group therapy (CBGT) (Albano, Marten, Holt, protocol applications to real-world settings. Olivares et al. (2002)
Heimberg, & Barlow, 1995; Hayward et al., 2000; Spence, Donovan, and Garcı́a-López et al. (2002) examined the effects of three
& Brechman-Toussaint, 2000), and (2) social-effectiveness therapy different interventions for adolescent SAD in a school setting in
(SET) (Beidel, Turner, & Morris, 2000b). In addition, ‘‘coping cat’’ Spain. Fifty-nine adolescents were randomized to receive Spanish
child behavior therapy program (Flannery-Schroeder & Kendall, language versions of SET, CBGT, therapy for adolescents with
2000; Kendall, 1990; Kendall, 1994) was designed to target anxiety generalized social phobia (intervención en adolescents con fobia
disorders in general among children, but not SAD specifically. Each social generalizada, IAFSG), or a no-treatment control group. IAFSG
of these treatment approaches shares four critical intervention is a school-based CBT intervention consisting of 12 group sessions.
components: psychoeducation, exposure to feared situations, Results showed that all three active treatments were superior to
anxiety coping skills (e.g., relaxation techniques, cognitive the control group in terms of reductions in social anxiety and
restructuring, problem-solving), and homework assignments to improvements in social skills and self-esteem at post-treatment
facilitate consolidation of skills in real-world situations. The CBGT and at 1-year follow-up. Within-group analyses revealed that all
and SET programs are both modeled after established adult three active interventions produced significant improvements
protocols and are typically conducted in a group format. The from pre-treatment to post-treatment. Five year follow-up data
‘‘coping cat’’ program is typically implemented in an individual demonstrated maintenance of effects in the three treatment
format. conditions (Garcı́a-López et al., 2006). Other school-based inter-
The research on these programs is quite promising. In an ventions have also demonstrated significant reductions in SAD
uncontrolled study of CBGT, Albano et al. (1995) piloted a 16- (Fisher, Masia-Warner, & Klein, 2004; Masia-Warner et al., 2005;
session multicomponent program for 5 adolescents with a primary Masia-Warner, Fisher, Shrout, Rathor, & Klein, 2007). In another
diagnosis of SAD (Albano et al., 1995). This program was largely study, Gallagher, Rabian, & McCloskey (2004) randomly assigned
based on successful adult studies (Heimberg, Salzman, Holt, & 23 children with SAD to a 3-week CBT intervention or WLC. The
Blendall, 1993). The program included skill building strategies brief intervention consisted of three 3-h weekly sessions. Results
(Christoff, Scott, Kelley, Baer, & Kelly, 1985), and parental demonstrated positive effects of the program relative to WLC at
involvement. At 3-months post-treatment, 4 of the 5 youths no post-treatment and 3-week follow-up.
longer met criteria for SAD, and at 1-year follow-up all participants The literature on the treatment of SAD in youths is limited but
were without an SAD diagnosis (Albano et al., 1995). Spence et al. promising. A recent meta-analysis found large effects of CBT
(2000) compared the effectiveness of child-only CBGT (n = 17) to programs for childhood SAD, comparable in size to the effects of
CBGT with a parental component (n = 19), both relative to a pharmacotherapy (Segool & Carlson, 2007). There are, however,
waitlist control (WLC) (n = 14). Children aged 7–14 years were several noteworthy limitations of the current literature. First, as
randomly assigned to one of the three conditions. The treated noted above, most of the studies have not focused specifically on
children received 12 weeks of therapy with booster sessions at SAD, but rather on mixed groups of youths with various anxiety
months 3 and 6 post-treatment. Significantly fewer children in disorders. Moreover, of the studies that focused on SAD, the
both of the active treatment conditions met criteria for SAD at the majority did not specifically target the more severe generalized
end of the treatment relative to those in the WLC condition (87% subtype of the disorder. Second, most studies focused either
remitted in CBGT with parental involvement, 58% in child-only exclusively on preadolescent children, or on samples that included
CBGT, 7% in WLC), and gains were maintained at follow-up. both younger children as well as adolescents. There is a general
Although no significant differences emerged between the two consensus that adolescents with SAD present unique clinical
active treatments, the study was inadequately powered to detect challenges and may be more treatment resistant than younger
such differences, and there appeared to be a trend favoring CBT children, suggesting the importance of a specific focus on
with parental involvement. Hayward et al. (2000) compared CBGT adolescents (Kashdan & Herbert, 2001; Rao et al., 2007). Third,
(n = 12) to a WLC (n = 23) in a group of female adolescents. Relative most of the studies to date have either been uncontrolled pilot
to those in the control condition, treated adolescents had a 50% investigations or have compared a single active treatment to a
reduction in social phobia interference ratings; moreover, 45% of WLC. Such research designs, although representing valuable initial
treated adolescents no longer met criteria for SAD at post- steps, only permit the most basic of conclusions about treatment
treatment, compared to 5% of the controls. Although promising in effects. Fourth, there is a dearth of data on the use of individual
the short-term, at 1-year follow-up no significant differences were treatment with SAD adolescents. Most existing studies have
present between the treatment and control groups. utilized group interventions, and those that have focused on
Social-effectiveness therapy for children (SET-C) has also individual treatment have generally focused on younger children.
demonstrated promising results. This program is delivered in 24 Given the typical onset of SAD in adolescence, as well as the unique
sessions over 12 weeks, with one treatment session per week challenges associated with the treatment of anxiety disorders at
focused on exposure and the second on social skills training. In an this developmental stage, interventions specifically targeting
uncontrolled pilot study consisting of 16 children aged 8–12, adolescents are needed. In terms of delivery format, due to
J.D. Herbert et al. / Journal of Anxiety Disorders 23 (2009) 167–177 169
practical difficulties associated with scheduling groups and given Interview Schedule for DSM-IV: Child Version, a semi-structured
data suggesting that individual CBT programs are equally effective interview based on DSM-IV diagnostic criteria (ADIS-DSM-IV:C,
as group-based programs for adult SAD (e.g., Mörtberg, Clark, Albano & Silverman, 1996). All participants met criteria for a
Sundin, & Åberg Wistedt, 2006), the field has moved toward primary diagnosis of the generalized subtype of SAD according to
individual treatment of SAD among adults over the past decade. the fourth edition of the Diagnostic and Statistical Manual of Mental
However, it remains to be determined how individual vs. group Disorders (American Psychiatric Association, 2000). Inclusion
treatments would compare among adolescents with generalized criteria included age between 12 and 17, literacy in English, and
SAD. a DSM-IV diagnosis of primary SAD, generalized subtype. To meet
The purpose of this study was to evaluate the effectiveness of criteria for the generalized subtype of SAD, the participant must
CBT relative to psychoeducational-supportive psychotherapy. We have reported intense fear and avoidance of at least three distinct
predicted that CBT, delivered in either an individual or group types of social situations, resulting in significant impairment in
format, would result in greater symptom improvement and gains functioning (Herbert et al., 2005; Stemberger, Turner, Beidel, &
in social skills relative to a psychoeducational-supportive psy- Calhoun, 1995). The exclusion criteria included a history of mental
chotherapy. A secondary purpose was to conduct exploratory retardation, pervasive developmental disorder, organic mental
analyses on the delivery format of CBT. Given the lack of previous disorder, bipolar disorder, a psychotic disorder, or borderline or
research in this area, we made no specific predictions about the schizotypal personality disorder. Other Axis I disorders such as
effects of group vs. individual CBT. generalized anxiety disorder, major depression, or dysthymia were
acceptable as long as SAD was judged to be clearly primary to and
1. Method of greater severity than the secondary diagnosis. Primacy was
defined as the disorder with the earliest onset, and severity was
1.1. Participants defined in terms of the level of symptomatology associated with
the condition as well as the degree of impairment attributed to it.
Potential participants were recruited through community Additional exclusion criteria were the presence of imminent
media announcements and a network of local school personnel suicidal risk (as assessed by the diagnostician using the ADIS-DSM-
and social service agencies for a psychological treatment program IV:C and the Beck Depression Inventory), substance abuse or
for adolescent social anxiety disorder (SAD) offered under the dependence within the past year, or a previous trial of behavior or
auspices of a university-based anxiety clinic. Parents of potential cognitive behavior therapy for SAD. Due to epidemiological data
participants underwent a preliminary 20-min telephone screening indicating a high comorbidity of other Axis I disorders with SAD
in order to ascertain if their child was likely to meet study inclusion (Schneier et al., 1992), we included participants with secondary
criteria; those who appeared to be eligible were invited to the comorbid Axis I disorders in order to enhance the external validity
clinic for further assessment. All participants and their parents of the results.
were informed of the nature of the study and provided written See Table 1 for a breakdown of demographic variables by
consent for participation. The adolescent participants were treatment condition. The randomized sample was comprised of 73
interviewed by trained diagnosticians using the Anxiety Disorders adolescents (56% female) diagnosed with primary SAD, generalized
Table 1
Demographic and baseline variables by randomized condition
% n % n % n
Gender
Female 75 18 44 10 54 14
Male 25 6 56 13 46 12
Race/Ethnicity
African-American 46 11 39 9 50 13
Caucasian 54 13 52 12 34 9
Hispanic 0 0 0 0 8 2
Asian/other 0 0 9 2 8 2
Note: I-CBT, Individual Cognitive Behavior Therapy; G-CBT, Group Cognitive Behavior Therapy; PST, Psychoeducational-Supportive Therapy; M, mean; S.D., standard
deviation.
a
Some variables have missing data.
170 J.D. Herbert et al. / Journal of Anxiety Disorders 23 (2009) 167–177
type. Most of the sample was either Caucasian (47%) or African- receive one of the three treatments did not differ in overall
American (44%), with the remaining participants being Latino or symptom severity or in the average time awaiting treatment, while
Asian. Average age was 15 years and grade level was 9. The also avoiding an excessive delay between subjects’ initial
majority of participants (59%) met criteria for at least one evaluation and the onset of treatment. Participants were informed
comorbid psychiatric disorder and 26% had two or more comorbid of the assigned treatment after the participant was deemed eligible
disorders: generalized anxiety disorder (n = 19), dysthymia and enrolled in the study.
(n = 15), specific phobia (n = 14), major depressive disorder
(n = 6), school refusal (n = 5), separation anxiety (n = 3), obses- 1.3. Interventions
sive-compulsive disorder (n = 3), panic disorder (n = 2), post-
traumatic stress disorder (n = 2), and attention deficit-hyperactiv- All three treatment conditions involved 12 weekly sessions of
ity disorder (n = 1). Fifteen percent of the sample was stabilized psychotherapy. Therapists were advanced doctoral candidates in
(i.e., at least 3 months with no change in medication or dosage) on clinical psychology trained and supervised by the first author, who
a psychiatric medication regimen (typically an antidepressant) at is a licensed clinical psychologist with substantial experience in
the start of the study. Treatment attendance was good, with the cognitive-behavioral treatment of SAD. A total of 6 therapists
completers attending an average of 10.5 (S.D. = 2.2) out of 12 conducted treatment groups, and all therapists ran an approxi-
sessions and 90% regularly completing homework assigned as part mately equal number of groups in each condition, thereby
of treatment. Twenty-nine percent of patients sought additional controlling for any specific therapist effects. Therapists received
treatment for SAD (i.e., psychiatric medications and/or psychother- weekly individual and group supervision for quality assurance and
apy) during the 6-month follow-up period; no patients obtained to ensure adherence to the treatment manuals. All groups were
additional treatment during the active phase of study treatment audio or videotaped to facilitate supervision and for treatment
itself. See Fig. 1 for a depiction of subject flow throughout the fidelity; treatment fidelity results are described below.
study.
1.3.1. Group Cognitive-Behavior Therapy (G-CBT)
1.2. Randomization The G-CBT group met for 2-h sessions each week and were co-
led by 2 therapists. Groups ranged in size from 4 to 6 patients. The
Once individuals were enrolled into the study, they were major treatment components of G-CBT included psychoeducation,
randomly assigned to one of three treatment conditions (see below breathing retraining, cognitive restructuring, simulated and in vivo
for description of conditions) using a block design with block sizes exposure to phobic stimuli, and social skills training. The overall
of 6. The blocked randomization design helped to ensure balanced format of the group and the exposure and cognitive restructuring
sample sizes in each experimental condition as well as to help components were derived largely from the treatment program
minimize the ‘‘correct guess’’ probability (successfully anticipating developed by Heimberg (1991) and Heimberg and Becker (2002)
the next randomly assigned treatment). This block randomizing and was similar to the application of Heimberg’s protocol to
procedure was designed to ensure that participants assigned to adolescents described by Albano (1995).
1.3.2. Individual Cognitive Behavior Therapy (I-CBT) 1.4.3. Social Phobia Anxiety Inventory for Children (SPAI-C; Beidel, T,
Participants in the individual therapy condition met for 1 h per & Morris, 1995)
week. The I-CBT program followed the same format and covered The SPAI-C consists of 26 items rated on a 3-point Likert scale
the same content as the group program described above. (never or hardly ever, sometimes, most of the time or always). The
items assess a range of potentially anxiety-producing situations
1.3.3. Psychoeducational-Supportive Therapy (PST) and assess physical and cognitive characteristics of SAD as well as
Like those in the G-CBT condition, participants in the PST group avoidance behaviors. Nine of the 26 items have sub-items allowing
conditions met for 2-h sessions and were co-led by two therapists. the child to rate his or her distress based on specific characteristics
PST groups were comprised of 4 to 6 participants. The PST program of the interpersonal partner. The SPAI-C was adapted from the
was based upon the protocol utilized by Heimberg et al. (1990) and adult version of the instrument (Beidel, Turner, Stanley, & Dancu,
Heimberg et al. (1993). The PST program included discussions each 1989b). The SPAI-C has been found to have high internal
session around various topics relevant to SAD. Therapists offered consistency and test–retest reliability (Beidel et al., 1995; Storch,
support but did not provide specific advice, teach skills, problem- Masia-Warner, Dent, Roberti, & Fisher, 2004). The SPAI-C was also
solve, or assign exposure exercises. shown to have good discriminative validity, convergent validity,
and external validity (Beidel, Turner, & Fink, 1996; Beidel, Turner,
1.4. Assessment Hamlin, & Morris, 2000a). In addition, the SPAI-C has been found to
have good sensitivity and specificity (Inderbitzen-Nolan, Davies, &
Measures were completed at pre-treatment, post-treatment, McKeon, 2004).
and 6-months following termination of treatment. All three groups
had identical pre, post, and follow-up assessments. Assessments 1.4.4. Social Anxiety Scale for Children (SAS-C; La Greca & Stone,
included a semi-structured interview, various self-report ques- 1993)
tionnaires, as well as video-taped behavioral assessment tasks. The SAS-C consists of 18 self-statements and 4 filler items rated
Interviewers, all of whom were doctoral candidates in clinical on a 5-point Likert scale. Based on results from factor analysis, the
psychology, were extensively trained in the administration of the SASC-R yields the following three subscales: Fear of Negative
instruments via didactic instruction, role plays, observation, and Evaluation, Social Avoidance and Distress for New Situations, and
practice ratings of patient videotapes. All diagnoses were General Social Avoidance and Distress. A parent version of the scale
confirmed through weekly review of the interview data by the (SAS-P) was also completed in the study. The measure possesses
first author. In the event of diagnostic uncertainty, the case was adequate internal consistency and good construct validity (Gins-
discussed in a team meeting to achieve consensus. Trained burg, La Greca, & Silverman, 1998).
interviewers who conducted the outcome assessments were blind
to group assignment and assessment occasion. In addition, 1.4.5. Reaction to Treatment Questionnaire (RTQ; Holt & Heimberg,
observers who provided ratings of various social performance 1990)
indices derived from the behavioral tasks were likewise blind to The RTQ is a 17-item scale in which 1–10 Likert ratings are
group assignment and assessment occasion. All self-report made on a variety of dimensions related to patients’ expectancies
measures were well established and widely used in studies of SAD. of the treatment. The scale was administered immediately
following the first intervention session.
1.4.1. Anxiety Disorders Interview Schedule for DSM-IV: Child Version
(ADIS-DSM-IV:C; Albano & Silverman, 1996) 1.4.6. Behavioral assessment
The ADIS-DSM-IV:C is a structured interview designed for the Three standardized 3-min behavioral tasks were administered
assessment of anxiety disorders and other Axis I disorders in for assessment of behavioral performance. They included (a) a
children and adolescents. The SAD subsection of the ADIS-DSM-IV:C dyadic role play involving a simulated interaction with a
contains separate ratings made by the child or adolescent during the confederate; (b) a triadic role play involving an interaction with
interview of the severity of the anxiety and avoidance across various two confederates; and (c) an impromptu speech. The first author
social situations. The ADIS-DSM-IV:C has been found to have reviewed the videotapes of all behavioral assessments to ensure
excellent test–retest reliability in symptom scale scores and good to standardization. Role play tests are commonly used in the
excellent test–retest reliability for deriving diagnoses (Silverman, behavioral assessment of social anxiety (Glass & Arnkoff, 1989;
Saavedra, & Pina, 2001). High interrater reliability has been reported Herbert et al., 2005; Herbert, Rheingold, & Brandsma, 2001;
with a sample of participants with SAD (Silverman & Eisen, 1992; Herbert, Rheingold, Gaudiano, & Harwell, 2004b; Herbert,
Silverman & Nelles, 1988; Silverman & Rabian, 1995). In addition, Rheingold, & Goldstein, 2002; McNeil, Ries, & Turk, 1995), and
the ADIS-DSM-IV:C and the social anxiety diagnosis in particular have sufficient reliability and validity for social performance
has demonstrated good concurrent validity with the Multidimen- ratings (Arkowitz, Lichtenstein, McGovern, & Hines, 1975; Beidel,
sional Anxiety Scale for Children (MASC) (Wood, Piacentini, Turner, Jacob, & Cooley, 1989a; Merluzzi & Biever, 1987). For this
Bergman, McCracken, & Barrios (2002). study, the role play interactions and the impromptu speech were
videotaped and rated by two trained observers on quality of verbal
1.4.2. The Clinical Global Impression Scale—Severity (CGI-S: National content, non-verbal behavior, paralinguistic features, and overall
Institute of Mental Health, 1985) social performance using 5-point Likert scales. The observers were
The CGI-S consists of a 1–7 clinician-rated scale assessing blind to assessment time point and treatment condition. Prior to
overall symptom severity. The CGI-S scale is commonly used in rating tapes, assessors developed anchors for ratings and were
clinical trials of the anxiety disorders and specifically with social trained until a reliability of greater than .80 was achieved.
anxiety trials (Davidson et al., 1993; Heimberg et al., 1998; Calculated agreement between raters was high (intraclass
Liebowitz et al., 1992; Schneier et al., 1998; Simpson et al., 1998). It correlation a = .96) based on reliability checks between the raters
has demonstrated good concurrent validity with both self-report on a random sample of 30% of the tapes. Immediately following
and clinician-administered measures of social anxiety sympto- each role play task, participants were asked to provide a single
matology and impairment (Zaider, Heimberg, Fresco, Schneier, & self-rating of their overall performance using the same 5-point
Liebowitz, 2003). Likert scale.
172 J.D. Herbert et al. / Journal of Anxiety Disorders 23 (2009) 167–177
1.4.7. Subjective Units of Discomfort Scale (SUDS) A Student t-test revealed that pre-treatment SPAI-C scores were
Immediately prior to each of the behavioral assessments tasks, significantly higher in the current sample (M = 39.7, S.D. = 16.8)
participants were asked to provide a rating of anxiety on a 0–100 compared to the Beidel et al. clinical sample (M = 21.8, S.D. = 8.5,
SUD scale, with higher numbers indicating increased anxiety t = 8.64, d.f. = 65, p < .001). The difference found was not surprising
(Wolpe & Lazarus, 1966). Immediately following each task parti- given that all patients in the current sample were diagnosed with
cipants were asked to rate their level of anxiety at that time, as well the generalized subtype of SAD, and we utilized minimal subject
as their highest level of anxiety during the task. The observers exclusion criteria. Also, an independent samples t-test revealed no
provided a subjective rating of each participant’s expressed significant difference between male and female pre-treatment
anxiety for each behavioral assessment task. Reliability of SUDS SPAI-C scores in the current sample (p > .05), which was consistent
self-reports of anxiety during an impromptu speech has been with the findings of Beidel et al.
shown to be adequate (Beidel et al., 1989a; Beidel et al., 1989b).
2.1.2. Preliminary group comparisons
1.5. Statistical analyses ANOVAs and post hoc tests revealed no pre-treatment group
differences on study measures, age, grade level, or number of
We first conducted analyses to test our primary hypothesis that sessions attended (ps > .05) (see Table 1). Chi square analyses
patients receiving CBT (group or individual) would show greater revealed no significant differences between the groups on any of
improvement on outcome measures compared to those receiving the categorical variables, including gender, race/ethnicity, par-
PST. Secondary analyses were then conducted to explore potential ental marriage status, follow-up treatments received (i.e., non-
differences between the G-CBT, I-CBT, and PST conditions. Alpha study related psychiatric treatment obtained between post-
was set at p < .05. Hierarchical linear modeling (HLM) (Bryk & treatment and 6-month follow-up periods), homework completed,
Raudenbush, 1987; Raudenbush, Bryk, Cheong, & Congdon, 2004; or concurrent psychiatric medication usage during the study (all
Singer & Willett, 2003) was used to examine trends in change over ps > .05).
time. This approach is especially useful because HLM accommo-
dates missing data in repeated measurements using empirical 2.1.3. Treatment credibility
Bayesian estimates. We first examined overall group trends, The treatment conditions were compared on expectancy for
regardless of treatment condition, and then conducted analyses improvement based on participants’ initial assessment of treat-
to examine if treatment condition accounted for differential ment credibility using the Reaction to Treatment Questionnaire
symptom change over time. The data were hierarchically structured (RTQ) total score. This measure was completed after the treatment
with 158 self-report assessments nested within 68 participants and rationale was explained to participants in the first session. A one-
152 behavioral assessments within 68 participants. Coefficients way ANOVA showed that the groups did not differ in their
representing assessment level were estimated for each person (level assessment of treatment credibility or expectancy for improve-
1) and group differences in these coefficients were estimated (level ment from treatment (F = 0.14, d.f. = 2, 51, p = .87).
2). To assess whether treatment condition predicted change in
symptomatology over time, we used the following covariates: time, 2.1.4. Treatment fidelity
treatment condition, and time treatment; interpretation of Treatment fidelity was assessed by having independent
results focused on the interaction term. All models were random raters review audio tapes of sessions and rate whether or not
intercept models with a specified unstructured error covariance various treatment components were covered using standardized
structure. For our primary analyses, comparing PST to CBT rating forms. For example, during session one of I-CBT, raters
(individual or group), total linear change (b11) consists of three assessed whether or not the therapist assigned breathing
parameters: (1) linear change for individuals, with a treatment retraining homework according to the prescribed schedule
value of 0 (i.e., CBT) (g10); (2) linear change for individuals, with a (i.e., 10 min/2 times daily). Approximately 25% of I-CBT, G-
treatment value of 1 (i.e., PST) (g11); and 3) unexplained error (m1). CBT, and PST sessions were randomly selected for review,
Effect sizes (Cohen’s d) were estimated using t statistics and their stratified by treatment time point (i.e., early, middle, or late). The
corresponding degrees of freedom derived from the HLM analyses number of items correctly covered in sessions was divided by the
(using software developed by Devilly (2005)). total number of items assessed to obtain a summary score.
We utilized the d statistic conventions described by Cohen Treatment fidelity was excellent: G-CBT = 97%, I-CBT = 100%, and
(1988) as follows: small effect = .20, a medium effect = .50, and a PST = 100%.
large effect = .80. It is important to emphasize that there is
currently no agreed upon method of estimating effect sizes in HLM 2.1.5. Study attrition
analyses, and that different software programs may calculate A chi square test revealed no differences in drop out rates
somewhat different degrees of freedom (Snijders & Bosker, 1999). between groups (I-CBT n = 6 or 26%, G-CBT n = 6 or 27%, PST n = 4 or
Therefore, one should be cautious when attempting to generalize 17%, p > .05). Furthermore, no differences in missing follow-up
effect sizes across studies. We considered a medium effect (d = .50) data between groups were identified (I-CBT n = 4 or 24%, G-CBT
to represent a clinically meaningful difference between treat- n = 3 or 19%, PST n = 4 or 21%, p > .05). Finally, no significant
ments. To have 80% power for detecting a medium effect size differences were found between those who dropped out or had
(d = .50) difference for our primary analyses (CBT vs. PST), a total missing follow-up data and those with complete data on any study
sample size of approximately 64 was needed. variables (all ps > .05).
2.1. Preliminary analyses Descriptive statistics for study measures are presented in
Table 2. First, analyses were conducted to test for overall
2.1.1. Sample severity group change, regardless of treatment (i.e., null models), as
The overall severity of the current sample was examined by well as the presence of significant within group variability in
comparing it to the clinical sample described in Beidel et al. (1995). change.
J.D. Herbert et al. / Journal of Anxiety Disorders 23 (2009) 167–177 173
CBT = 0 and G-CBT = 0 represented PST) and G-CBT served as the 3. Discussion
control condition to facilitate comparison between CBT conditions
(i.e., I-CBT = 0 and PST = 0 represented G-CBT). Although a growing literature supports the effectiveness of
cognitive-behavioral therapies for youth with anxiety disorders in
2.4.1. Symptom severity measures general, less is known about the efficacy of such treatments for
Results showed non-significant findings for the three treatment adolescents with SAD in particular. It is not known how individual
group differences over time on the SPAI-C. Further, there was no and group CBT programs for adolescents with generalized SAD
difference between treatment conditions on the SAS-C and SAS-P compare to one another, or to an active alternative treatment that
total scores. In addition, results showed no significant differences does not involve specific CBT components. We evaluated three
in CGI-Severity score over time according to condition (all such treatments in a sample of severely impaired adolescents with
ps > .05). generalized SAD.
The results revealed that all three treatments were effective in
2.4.2. Behavioral assessment measures reducing symptoms and distress and in improving psychosocial
Significantly greater change over time in average self-rating in functioning. In addition, the results were not limited to standar-
role play performance was found between PST and I-CBT dized symptom measures; behavioral assessments likewise
(g11 = 0.47, t = 3.06, d.f. = 59, p = .003, d = .80), suggesting those revealed significant gains in social performance. Given the severity
in I-CBT showed greater improvement. There was no difference of this particular sample and the high level of psychiatric
between PST vs. G-CBT or I-CBT vs. G-CBT on this measure. comorbidity, these treatment gains were respectable. For example,
Additionally, a significant difference over time was found between large effect sizes were demonstrated on self-reported symptoms
I-CBT and G-CBT, with those in I-CBT reporting a lower SUDS over (e.g. SPAI-C d = 1.08), clinician-rated symptoms (e.g., CGI-S
time for the role plays, t = 2.03, d.f. = 59, p = .044, d = .53. There d = 2.18), and behavioral assessment of social skills (e.g., blind
was no significant difference between PST and either CBT condition observer ratings d = 1.30). These effect sizes are comparable to
in change in SUDS ratings. Finally, no significant differences were those reported in other studies of the cognitive-behavioral
found between conditions in average social skills ratings across treatment of adolescent SAD (e.g., Beidel et al., 2000a; Beidel
time; although it appeared the trend of greater improvement in G- et al., 2000b).
CBT approached significance as compared to the PST condition, In terms of differential effects of the three treatments, the
t = .84, d.f. = 46, p = .068, d = .25. results were more mixed. On both self-report and clinician-rated
measures of symptoms and functioning, no differences emerged
2.5. Recovery rates across the conditions. With regard to the behavioral data, however,
the CBT conditions, considered together, resulted in greater gains
The clinical significance of treatment gains was determined by than the psychoeducational-supportive treatment. Secondary
calculating percentages of patients in each condition who no longer analyses suggested that individual CBT in particular was more
met criteria for social phobia at post-treatment and follow-up. effective than psychoeducational-supportive psychotherapy at
These analyses were conducted using the subsample of completers post-treatment, although there were no differences between group
with available data. Based on the criteria used by Beidel et al. and individual CBT. In terms of diagnostic recovery, immediately
(2000a) and Beidel et al. (2000b), patients were designated as following treatment the recovery rates for individual CBT (29%)
recovered if they met both of the following criteria: (1) SPAI-C total and group CBT (27%) were nearly identical. Although apparently
score <18 (social phobia diagnostic cutoff score established by greater than the recovery rate for the psychoeducational-
Beidel et al., 1995), and (2) CGI rating <4 (below diagnostic supportive condition (16%), this difference did not reach statistical
threshold based on severity and functional impairment). At post- significance. By 6-month follow-up, however, the recovery rate for
treatment, there were no significant differences between recovery the group CBT condition grew to 54%, significantly higher than that
rates for the I-CBT (29%, n = 5), G-CBT (27%, n = 3), and PST (16%, of either individual CBT (15%) or the psychoeducational-supportive
n = 3) conditions (p > .05). However, there was a significant psychotherapy (19%), which did not differ from one another.
difference between I-CBT (15%, n = 2), G-CBT (54%, n = 7), and PST However, these findings should be interpreted cautiously because
(19%, n = 3) at follow-up (x2 = 5.93, d.f. = 2, p = .05), with higher they were based on treatment completers only. Although the
recovery rates for the G-CBT condition; see Fig. 2. finding that the psychoeducational-supportive treatment was as
effective as the CBT conditions on the symptom measures was
surprising, it is worth noting that this was not a ‘‘placebo’’
treatment, but rather an active intervention consisting of relevant
group discussions, provision of relevant information regarding
social anxiety and related topics, and supportive encouragement to
meet personally relevant goals. Although systematic exposure was
not included in the protocol, the group format, in which active
participation was stressed, provided a type of regular exposure to
peers. Considered in this light, the effectiveness of the psychoe-
ducational-supportive intervention is less surprising. Indeed, this
finding was similar to that of Heimberg et al. (1990), who likewise
found comparable results of group CBT and a similar group
supportive psychotherapy on most measures among adults with
social phobia.
Overall, these findings are consistent with the larger literature
suggesting that relatively brief CBT treatment programs can be
effective for many adolescents with generalized SAD. In addition,
the results suggest that individual CBT appears to be at least as
Fig. 2. Proportion of patients recovered following treatment. effective as the more commonly studied group CBT, at least at post-
J.D. Herbert et al. / Journal of Anxiety Disorders 23 (2009) 167–177 175
treatment. However, this conclusion must be tempered by the quently-occurring comorbid conditions, experimental controls for
intriguing finding that group CBT was associated with higher therapist-specific effects, and a multi-modal assessment strategy
diagnostic recovery rates at follow-up. It may be that the additional consisting of self-ratings, ratings by diagnostic interviewers, and
exposure to social stimuli afforded by the group CBT program behavioral data.
ultimately resulted in a higher percentage of participants making Future research is needed to replicate and extend these
clinically significant gains in the longer term. However, the findings. More work is needed to determine if individual CBT,
relatively small number of participants who were available for which is more feasible in most clinical settings than group
assessment at follow-up precludes strong interpretations of this treatment, is indeed as effective. Although our results suggest that
finding. The present results are consistent with a study by this is the case, the higher recovery rates at follow-up among those
Manassis et al. (2002), who found comparable efficacy of group who received group treatment raises questions about this
and individual CBT in a mixed sample of 9–12 year old children conclusion. Moreover, group treatment may be more cost-
with various anxiety disorders. effective in some settings. In addition, innovations are needed
Despite the apparently encouraging findings, careful examina- to maximize treatment gains, as even most of the treatment
tion of the results suggests that more sobering conclusions are in completers in the present study remained symptomatic. Despite
order. Although improved, most participants nevertheless mixed findings in prior studies, incorporating parents into the
remained symptomatic at post-treatment. For example, the mean treatment process may prove useful. Parents can encourage their
post-treatment score on the SPAI-C was 33.4, well above the mean child to follow through with homework exercises, and can support
of non-clinical samples (M = 13.7, Beidel et al., 1995). It is the adolescent with his or her treatment goals. A combination of
significant that the present sample consisted of adolescents with individual and group therapy may provide incremental effects by
severe symptoms, significant functional impairment, and high drawing on the potential advantages of each modality. Drawing
rates of comorbidity, all of whom met diagnostic criteria for the from the adult literature on SAD, possible innovations might
generalized subtype of SAD. Most prior studies of childhood or include the use of videotaped feedback (Clark et al., 2003), or the
adolescent SAD did not focus specifically on those with this integration of mindfulness and acceptance techniques (e.g.,
generalized subtype, and included children whose fears were Dalrymple & Herbert, 2007; Herbert & Cardaciotto, 2006). In
confined to more limited situations (e.g., Gallagher et al., 2004; addition, although little research has examined the efficacy of
Spence et al., 2000) and samples that excluded comorbid mood and antidepressant medication in adolescent SAD, the recent Treat-
anxiety disorders (e.g., Hayward et al., 2000). Furthermore, as ment for Adolescents with Depression Study (TADS Team, 2007),
noted above, our sample reported significantly higher symptoms which found additive effects of combining fluoxetine with CBT
than the Beidel et al. (1995) sample. It is widely believed that over either monotherapy alone for adolescents with major
generalized SAD is significantly less responsive to treatment than depression, suggests that evaluation of combined treatment in
the specific subtype of the disorder, and that comorbidity further adolescent SAD is warranted, especially because the comorbidity
complicates treatment efforts. with depression is very high in this population.
There are several limitations of this study. Most importantly,
the sample size was relatively small, particularly for comparisons
Acknowledgements
of I-CGT and G-CBT, thereby limiting statistical power and the
confidence in the results. Caution is needed when interpreting
This study was supported by National Institute of Mental Health
HLM results in smaller samples. However, we also analyzed the
grant R01 MH052232 awarded to Dr. Herbert. We would like to
data using more convention ANOVAs and found similar results,
thank Lisa Uebelacker, Ph.D. for her helpful feedback on the
somewhat mitigating this potential concern. Furthermore, it is
statistical analyses.
worth noting that small samples are the norm in studies of
adolescent SAD due to difficulties with participant recruitment.
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