Psychotherapy of Social Anxiety Disorder Kristin Pontoski, MA, Richard G. Heimberg, PhD, Cynthia L. Turk, PhD, Meredith !.

Co"es, PhD

#ebruary $$, %&&' A cha(ter to a((ear in) *tein, D.+., Ho""ander, !., Rothbaum, ,.-. .%&&'/. Te0tbook o1 an0iety disorders.

2ashington, DC) American Psychiatric Press, 3nc.

Kristin Pontoski, MA, Doctora" *tudent in C"inica" Psycho"ogy, Adu"t An0iety C"inic o1 Tem("e, De(artment o1 Psycho"ogy, Tem("e 4ni5ersity, $6&$ 7orth $8th *treet, Phi"ade"(hia, PA $9$%%: ;&'<, Te"e(hone) .%$</ %&=:$<6<, #a0) .%$</ %&=:<$'=, !mai") (ontoski>tem("e.edu

Richard G. Heimberg, Ph.D. .Corres(onding Author/, Pro1essor and Distinguished #acu"ty #e""o? in Psycho"ogy, Director o1 the Adu"t An0iety C"inic o1 Tem("e, De(artment o1 Psycho"ogy, Tem("e 4ni5ersity, $6&$ 7orth $8th *treet, Phi"ade"(hia, PA $9$%%:;&'<, Te"e(hone) .%$</ %&=:$<6<, #a0) .%$</ %&=:<$'=, !mai") heimberg>tem("e.edu

Cynthia L. Turk, PhD, Assistant Pro1essor, De(artment o1 Psycho"ogy, 2ashburn 4ni5ersity, $6&& Co""ege, To(eka, K* ;;;%$, Te"e(hone) .6'</ ;6&:$<;%, !mai") cindy.turk>?ashburn.edu

% Meredith !. Co"es, PhD, Assistant Pro1essor, De(artment o1 Psycho"ogy, ,inghamton 4ni5ersity .*47@/, ,inghamton, 7@ $89&%:;&&&, Te"e(hone) .;&6/ 666:=6$&, #a0) .;&6/ 666:%$88, !mai") mco"es>binghamton.edu

8 Introduction *ince the (ub"ication o1 D*M:333 .American Psychiatric Association, APA, $9'&/, the body o1 "iterature in5estigating the e11icacy o1 (sycho"ogica" treatments 1or socia" an0iety disorder has matured. 7ear"y three decades o1 research ha5e resu"ted in the de5e"o(ment o1 se5era" em(irica""y:su((orted cogniti5e:beha5iora" treatments inc"uding 5ariations o1 e0(osure and cogniti5e restructuring techniAues 1or adu"ts (resented in both grou( and indi5idua" 1ormats. 3n addition, a gro?ing body o1 "iterature has demonstrated the e11icacy o1 cogniti5e:beha5iora", (sychosocia", and 1ami"y inter5entions 1or chi"dren and ado"escents ?ith socia" an0iety disorder. More recent research has 1ocused on s(eci1ic 1actors that contribute to success1u" treatment outcome and enhancements to standard treatments that may increase "ong:term gains 1or di11icu"t:to:treat (atients. Cognitive-Behavior Therapy (CBT) Theoretical Model Underlying CBT for Social Anxiety Disorder The centra" concern o1 (ersons ?ith socia" an0iety disorder is the 1ear that they ?i"" be negati5e"y e5a"uated by others. 3ndi5idua"s ?ith socia" an0iety ?orry that they ?i"" do or say something to e"icit negati5e e5a"uation 1rom others or that they ?i"" demonstrate (hysica" sym(toms during a socia" situation that ?i"" make them a((ear e0cessi5e"y an0ious to others .APA %&&&/. Ra(ee and Heimberg .$996/ and C"ark and 2e""s .$99</ (resent t?o simi"ar mode"s that describe the maintenance o1 socia" an0iety and demonstrate ?hy socia""y an0ious indi5idua"s do not bene1it 1rom e5eryday interactions ?ith others. *(ace "imitations (rohibit thorough e0("ication o1 these mode"s, and the reader is re1erred to the origina" sources. Ho?e5er, they both suggest that indi5idua"s ?ith socia" an0iety disorder (ercei5e socia" situations as dangerous and that the (erce(tion o1 (otentia" e5a"uation by others initiates a cogniti5e routine

= that 1urthers the e0(erience o1 an0iety. #or instance, Ra(ee and Heimberg .$996/ suggest that the (erce(tion o1 an e5a"uati5e audience "eads the indi5idua" to 1ocus on a menta" re(resentation o1 ho? he or she a((ears to that audience. This menta" re(resentation, ?hich is "ike"y to be negati5e"y distorted, is com(ared to an estimate o1 ?hat the (erson be"ie5es may be e0(ected o1 him or her by that audience. As this discre(ancy increases in a negati5e direction, the (ercei5ed (robabi"ity o1 negati5e e5a"uation 1rom the audience is increased. The (erson becomes hy(er5igi"ant 1or negati5e e0terna" cues .e.g., signs o1 boredom or disinterest 1rom the audience/ and interna" cues .e.g., un("easant (hysio"ogica" sensations/, and these cues 1urther in1orm the (ersonBs menta" re(resentation as seen by the audience. The cyc"e re(eats itse"1, ?ith an0iety increasing as the (erson continua""y antici(ates negati5e outcomes, and the situation comes to an end or the (erson esca(es. Therea1ter, the (erson may engage in (ost:e5ent (rocessing .,roCo5ich and Heimberg in (ress/, re(eated"y re5ie?ing and reconstructing the memory o1 the situation in a negati5e and u"timate"y ma"ada(ti5e 1ashion. The (erson is thus (osed to e0(erience eAua" or greater an0iety at the ne0t occurrence o1 a simi"ar situation. This conce(tua"iCation and that o1 C"ark and 2e""s .$99</ suggest that it is critica" to (ro5ide e0(eriences that ?i"" a""o? the (atient to re:e5a"uate his or her cogniti5e construction o1 the se"1 and others. Consistent ?ith these conce(tua"iCations, e0(osure, cogniti5e restructuring, and the combination o1 e0(osure and cogniti5e restructuring ha5e been most common"y e0amined as a means o1 modi1ying (atientsB schemas and reducing sym(toms o1 socia" an0iety. *e5era" other cognitive and ehavioral techni!ues have een utili"ed as #ell$ including applied relaxation and social s%ills training& Exposure Techniques

< !0(osure thera(y is designed to gi5e socia""y an0ious (atients access to their 1eared socia" situations 5ia imagery .imagina" e0(osure/ or direct con1rontation .in vivo e0(osure/ and has been recogniCed as an essentia" com(onent o1 most success1u" treatments 1or an0iety 1or many years .,ar"o? and 2o"1e $9'$/. According to beha5iora" mode"s o1 socia" an0iety, e0(osure (ro5ides the o((ortunity 1or the natura""y:occurring (rocess o1 habituation to the 1eared stimu"us and increases contact ?ith rein1orcers 1or non:(hobic beha5ior .Mc7ei" et a". %&&$/. Cogniti5e mode"s assert that e0(osure (ro5ides the o((ortunity 1or contact ?ith (o?er1u" correcti5e in1ormation ?hich 1aci"itates the modi1ication o1 dys1unctiona" be"ie1s and the a"teration o1 in1ormation (rocessing biases, thereby decreasing an0iety .C"ark and 2e""s $99<D Ra(ee and Heimberg $996/. !0(osure techniAues are ma0ima""y e11ecti5e ?hen (atients are 1u""y engaged in the emotiona" and (hysio"ogica" arousa" associated ?ith the 1eared situations .#oa and KoCak $9';/, as is most "ike"y to occur ?hen (atients are instructed to 1ocus their attention 1u""y on the e0(osure e0(erience .2e""s and Pa(georgiou $99'/. Recent research .see ,outon %&&%/ suggests that e0(osure (roduces ne? "earning ?hich com(etes ?ith the (re5ious"y "earned 1ear res(onse. Ho?e5er, much o1 that ne? "earning may be conte0t:s(eci1ic, and the "ike"ihood o1 return o1 1ear a1ter e0(osure increases ?ith the degree o1 simi"arity o1 the ne? situation to the origina""y 1eared situation. 7e5erthe"ess, e0(osure techniAues e11ecti5e"y reduce socia" an0iety .e.g., #a5a et a". $9'9/. 3n com(arati5e studies, e0(osure has (ro5en su(erior to (rogressi5e musc"e re"a0ation training .A":Kubaisy et a". $99%D A"strEm et a". $9'=/, (i"" ("acebo .Turner et a". $99=b/, ?aiting "ist contro"s .,ut"er et a". $9'=D 7e?man et a". $99=/, and a contro" thera(y consisting o1 education, se"1:e0(osure instructions, and uns(eci1ied an0io"ytic medication .A"strEm et a". $9'=/. Ho?e5er, there is some Auestion as to the durabi"ity o1 gains ?hen e0(osure is administered a"one .Heimberg and +uster $99</, and e0(osure has o1ten been

; combined ?ith cogniti5e techniAues in the treatment o1 socia" an0iety disorder. The e11ecti5eness o1 this a((roach is discussed in the ne0t section. Com ined Cognitive !estructuring and Exposure Contem(orary cogniti5e mode"s o1 socia" an0iety disorder (ro(ose that an0iety is "arge"y maintained by dys1unctiona" be"ie1s and biased in1ormation (rocessing strategiesD there1ore, success1u" treatment ?i"" be associated ?ith modi1ication o1 these cogniti5e (rob"ems .e.g., C"ark and 2e""s $99<D Ra(ee and Heimberg $996/. *ocia""y an0ious indi5idua"s ?ho engage in se"1: e0(osure may not e0(erience an0iety reduction because they do not recei5e adeAuate 1eedback 1rom their en5ironment regarding the accuracy o1 their 1ear o1 negati5e e5a"uation .,u"ter $9'</. *e5era" historic cogniti5e thera(ies ha5e in1"uenced the de5e"o(ment o1 contem(orary cogniti5e and beha5iora" techniAues. Rationa":emoti5e thera(y .R!TD !""is, $9;%/ (osits that indi5idua"s de5e"o( irrationa" be"ie1s that cause and sustain negati5e emotiona" states. 3ndi5idua"s ?ith socia" an0iety disorder can be conce(tua"iCed as c"inging to the irrationa" be"ie1 that one shou"d be com("ete"y com(etent, adeAuate, and achie5ing in order to be 5ie?ed as a ?orth?hi"e (erson. The goa" o1 R!T is to con1ront and modi1y these irrationa" be"ie1s through discussion and (ersuasion to change the (atientBs 1undamenta" ideo"ogy. Modi1ied 5ersions o1 R!T ha5e been associated ?ith signi1icant treatment gains among indi5idua"s ?ith socia" an0iety disorder in se5era" studies .e.g., DiGiuse((e et a". $99&D !mme"kam( et a". $9'<D Mattick and Peters $9''D Mattick et a". $9'9D Mersch et a". $9'9/. Treatment gains are durab"e, ?ith (atients maintaining their im(ro5ements at $':month 1o""o?:u(s .*cho"ing and !mme"kam( $99;a, $99;b/. ,eckBs theoretica" a((roach asserts that negati5e emotions are (roduced by cogniti5e (rocessing errors such that (atients "abe", inter(ret, and e5a"uate their e0(eriences in a biased, high"y (ersona"iCed, o5er"y arbitrary, or e0treme manner .,eck $96;/. ,eckBs cogniti5e thera(y

6 attem(ts to correct these errors through "ogic, *ocratic discussion, and em(irica" testing o1 negati5e cognitions. The goa" o1 thera(y is to remo"d the (atientBs rigid, ma"ada(ti5e ru"es to be more accurate, rea"istic, and 1"e0ib"e. ,eckBs cogniti5e thera(y ?as in1"uentia" in the de5e"o(ment o1 Cogniti5e ,eha5iora" Grou( Thera(y .C,GT/ 1or socia" an0iety disorder .re5ie?ed be"o?/. #or the treatment o1 socia" an0iety disorder, ,eckFs cogniti5e thera(y has been sho?n to (roduce treatment gains simi"ar to those (roduced by R!T and su(erior to those (roduced by a ?aiting "ist contro" .DiGiuse((e et a". $99&/. *e"1:instructiona" training .*3T/ is a modi1ied 5ersion o1 MeichenbaumBs .$9'</ stress: inocu"ation training. 3n *3T, (atients obser5e and record the negati5e thoughts and 1ee"ings they e0(erience in (rob"ematic situations to 1aci"itate the de5e"o(ment o1 more ada(ti5e a((raisa"s. They then ?ork co""aborati5e"y ?ith their thera(ist to de5e"o( co(ing thoughts and ski""s re"e5ant to antici(ating the (rob"ematic situation, engaging the situation, and thinking about the situation a1ter it has conc"uded. Patients (ractice these co(ing thoughts and ski""s in imagina" rehearsa", ro"e:("ays, and rea":"i1e situations. 3n three studies, *3T (roduced signi1icant im(ro5ements among indi5idua"s ?ith socia" an0iety disorder .DiGiuse((e et a". $99&D !mme"kam( et a". $9'<D +errema"m et a". $9';/. 2ith 1e? e0ce(tions, most cogniti5e thera(ies 1or socia" an0iety disorder inc"ude systematic e0(osure to 1eared socia" situations and beha5iora" e0(eriments .+uster and Heimberg, $99'/. Thus, these treatments are not G(ure"yH cogniti5e. A gro?ing body o1 research su((orts the e11icacy o1 treatments incor(orating both cogniti5e techniAues and e0(osure. 3n com(arati5e studies, these treatments ha5e been sho?n to be su(erior to ?aiting "ist contro" grou(s .,ut"er et a". $9'=D C"ark et a". %&&;D DiGiuse((e et a". $99&D Ho(e et a". $99<a/, an educationa":su((orti5e

' contro" thera(y .Heimberg et a". $99'D Heimberg et a". $99&D Heimberg et a". $998D Lucas and Te"ch $998/, and (i"" ("acebo .C"ark et a" %&&8D Heimberg et a". $99'/. Cognitive Behavioral "roup Therapy A di5erse "iterature has accumu"ated in5estigating the e11icacy o1 cogniti5e beha5iora" grou( thera(y .CG,T/, resu"ting in a treatment (rotoco" designed s(eci1ica""y 1or socia" an0iety disorder .Heimberg ,ecker, %&&%/. C,GT consists o1 $% ?eek"y % I hour grou( sessions, the

1irst t?o o1 ?hich are designed to introduce the rationa"e 1or treatment, enhance the de5e"o(ment o1 grou( cohesion, and teach cogniti5e restructuring conce(ts. *ubseAuent sessions 1ocus on integrating cogniti5e restructuring ski""s ?ith e0(osure so that (atients "earn to recogniCe, e0amine, and cha""enge their negati5e and inaccurate thoughts be1ore, during, and a1ter (artici(ating in ro"e:("ays o1 1eared socia" situations in the grou( conte0t. !0(osures in session a""o? (atients to test the accuracy o1 the automatic thoughts that arise during di11icu"t socia" situations. Treatment in session u"timate"y 1ocuses on e0("oring the core be"ie1s that under"ie and maintain each (atientBs socia" concerns and on the ado(tion o1 achie5ab"e and obJecti5e goa"s in socia" situations rather than more abstract and unattainab"e ones .e.g., "ack o1 ner5ousness, 1"a?"ess (er1ormance/. Patients a"so engage in e0(osures bet?een sessions and (ractice a(("ying cogniti5e restructuring ski""s to rea":?or"d an0iety:(ro5oking situations ?ith the goa" o1 "earning to be their o?n cogniti5e thera(ists. A series o1 in5estigations contributed to the de5e"o(ment and e11icacy o1 this treatment (rotoco". C,GT ?as com(ared to educationa":su((orti5e grou( thera(y .!*/, a (sychosocia" treatment consisting o1 "ectures, discussions, and grou( su((ort .Heimberg et a". $99&/. !* ?as designed to contro" 1or thera(ist attention, treatment credibi"ity, and (atient e0(ectancies. #orty: nine (atients meeting criteria 1or D*M:333 socia" an0iety disorder ?ere treated. Patient ratings

9 con1irmed that treatment credibi"ity and outcome e0(ectations ?ere simi"ar 1or C,GT and !*. #o""o?ing treatment, c"inica" assessors assigned 6<K o1 C,GT (atients, but on"y =&K o1 !* (atients, se5erity ratings be"o? the "e5e" de1ined as c"inica""y im(aired. A1ter treatment, C,GT (atients a"so re(orted "ess an0iety be1ore and during an indi5idua"iCed beha5ior test than !* (atients. ,oth grou(s sho?ed simi"ar im(ro5ement on se"1:re(ort measures, but at si0:month 1o""o?:u(, C,GT (atients maintained their gains on se"1:re(ort measures and remained more im(ro5ed than !* (atients on both assessor and beha5ior test an0iety ratings. 7ineteen o1 these (atients (artici(ated in a "ong:term 1o""o?:u( study in ?hich the 1o""o?:u( inter5a" ranged 1rom =.< to ;.%< years .Heimberg et a". $998/. The subset o1 1o""o?:u( (artici(ants ?as "ess im(aired be1ore and a1ter treatment than non:(artici(ants. Ho?e5er, no (retreatment di11erences ?ere 1ound bet?een C,GT and !* 1o""o?:u( (artici(ants. At "ong:term 1o""o?:u(, '9K o1 C,GT (atients ?ere rated be"o? the c"inica" thresho"d by inde(endent assessors, com(ared to ==K o1 !* (atients. Assessor ratings indicated that C,GT (atients e0(erienced a "e5e" o1 an0iety not much greater than the genera" (o(u"ation. C,GT (atients ?ere rated as "ess an0ious and more socia""y ski""ed during a beha5ior test than !* (atients. Lucas and Te"ch .$998/ com(ared the e11ecti5eness o1 C,GT, !*, and an indi5idua" 5ersion o1 the C,GT (rotoco" .3C,T/ in the treatment o1 ;; (atients ?ith D*M:333:R .APA, $9'6/ socia" an0iety disorder. This study re("icated Heimberg et a".Bs .$99&/ 1inding that (atients treated ?ith C,GT ?ere more im(ro5ed than (atients treated ?ith !*. C,GT and 3C,T resu"ted in simi"ar gains, both su(erior to !*. Ho?e5er, the grou( (rotoco" ?as more cost:e11ecti5e. C,GT has a"so been com(ared to se5era" (harmacothera(ies ?ith (re5ious"y:estab"ished e11icacy 1or the treatment o1 socia" an0iety disorder. Heimberg et a". .$99'/ com("eted a t?o:site study in ?hich $88 (atients ?ere randomiCed to C,GT, the monoamine o0idase inhibitor

$& .MA-3/ (hene"Cine, !*, or (i"" ("acebo conditions. A"" treatments ?ere de"i5ered at each site, one kno?n 1or cogniti5e:beha5iora" treatment and the other 1or (harmaco"ogica" treatment o1 an0iety disorders. At the ?eek ; .midtreatment/ assessment, inde(endent assessors rated (hene"Cine (atients as more im(ro5ed and "ess an0ious than (atients in a"" other conditions. At the $% ?eek .(osttreatment/ assessment, the inde(endent assessors rated 6<K o1 C,GT (atients, 66K o1 (hene"Cine (atients, 8<K o1 !* (atients, and =$K o1 ("acebo (atients as treatment res(onders .either moderate"y or marked"y im(ro5ed/. Thus, a1ter $% ?eeks o1 treatment, C,GT and (hene"Cine (roduced simi"ar (ro(ortions o1 treatment res(onders, and both acti5e treatments had higher (ro(ortions o1 res(onders than ("acebo or !* conditions. A1ter $% ?eeks, ho?e5er, (hene"Cine (atients ?ere signi1icant"y more im(ro5ed than C,GT (atients on some measures. !ncouraging"y, there ?as no signi1icant site by treatment interaction, suggesting that these treatments can be e11icacious at 1aci"ities ?ith di11ering theoretica" orientations. A1ter the $% ?eeks o1 acute treatment described abo5e .Heimberg et a". $99'/, (atients demonstrating a (ositi5e res(onse to either C,GT or (hene"Cine recei5ed month"y maintenance treatment 1or si0 months, ?hich ?as 1o""o?ed by a ;:month 1o""o?:u( .Liebo?itC et a". $999/. -5er the course o1 maintenance and 1o""o?:u(, (atients treated ?ith C,GT ?ere "ess "ike"y to re"a(se than (atients treated ?ith (hene"Cine, and this ?as es(ecia""y the case among (atients ?ith genera"iCed socia" an0iety disorder. Thus, (hene"Cine may (ro5ide some?hat more immediate re"ie1, but C,GT may (ro5ide greater (rotection against re"a(se. C,GT has a"so been demonstrated to be rough"y eAui5a"ent to the benCodiaCe(ine c"onaCe(am in acute e11icacy .-tto et a". %&&&/. To in5estigate the e11icacy o1 combining C,T ?ith (hene"Cine, the same mu"ti:site research grou( com("eted a randomiCed contro""ed tria" com(aring the e11icacy o1 C,GT, (hene"Cine, combined C,GTL(hene"Cine, and (i"" ("acebo in

$$ $%' (atients ?ith socia" an0iety disorder .Heimberg %&&8/. Pre"iminary ana"yses suggest that the combined treatment out(er1ormed (i"" ("acebo, 1ared better than (hene"Cine on some measures o1 socia" an0iety, and a"?ays did better than C,GT a"one. A 5ariant o1 C,GT, com(rehensi5e cogniti5e beha5iora" grou( thera(y .CC,TD #oa et a". un(ub"ished manua"/ ?as recent"y com(ared to 1"uo0etine .#L4/, ("acebo .P,-/, and their combinations .CC,TL#L4 and CC,TLP,-/ in a "arge, mu"tisite sam("e o1 indi5idua"s ?ith genera"iCed socia" an0iety disorder .Da5idson et a". %&&=/. CC,T inc"udes e0(osure and cogniti5e restructuring and an additiona" em(hasis on socia" ski""s training to address de1icits in socia" ski""s that cou"d im(ede (rogress. A1ter $= ?eeks o1 treatment, a"" acti5e treatments ?ere su(erior to the P,- and the combined treatments did not seem to o11er any additiona" e11icacy o5er the indi5idua" thera(ies. Heimberg and co""eagues ha5e ada(ted C,GT to an indi5idua" 1ormat .Ho(e et a". %&&&, %&&;/. This ?orkbook:dri5en indi5idua" cogniti5e beha5iora" treatment in5o"5es $; one:hour ?eek"y sessions, conducted o5er $;:%& ?eeks and is com(rised o1 the same com(onents as C,GT M (sychoeducation, cogniti5e restructuring, and in:session and in vivo e0(osure. Naider et a". .%&&8/ demonstrated that this indi5idua"iCed C,T (ro5ided su(erior outcomes to a ?ait"ist contro" and (roduced e11ect siCes simi"ar to the grou( (ackage. Clar#$s %ndividual CBT for Social Anxiety Disorder C"arkBs cogniti5e thera(y .CT/ has been ?ide"y a(("ied to the indi5idua" treatment o1 socia" an0iety disorder. ,ased on the cogniti5e mode" o1 socia" an0iety discussed abo5e .C"ark 2e""s $99</, this treatment 1ocuses on the identi1ication o1 s(eci1ic sa1ety beha5iors that maintain socia""y an0ious sym(toms by 1ostering a5oidance. The treatment consists o1 $; ?eek"y indi5idua" sessions during ?hich the thera(ist and (atient 1ormu"ate a s(eci1ied 5ersion o1 C"arkBs CT mode" ?ith (ersona"iCed thoughts, images, sa1ety beha5iors, and attentiona"

$% strategies. An e0(eriment is then conducted in ?hich (atients ro"e ("ay a situation 1irst using interna" 1ocus and sa1ety beha5iors and ne0t attem(ting to 1ocus out?ard and dro( sa1ety beha5iors. Throughout the course o1 thera(y, CT techniAues are used to encourage (atients to shi1t 1ocus e0terna""y to gain a more accurate understanding o1 the ?ay in ?hich others inter(ret their beha5ior. 3n addition, 5ideo 1eedback .see be"o?/ is used to he"( correct distortions o1 se"1: imagery, and beha5iora" e0(eriments are conducted to con1ront 1eared socia" situations ?hi"e dro((ing sa1ety beha5iors and 1ocusing attention e0terna""y both in:session and 1or home?ork. C"arkBs CT has demonstrated e11icacy in t?o recent randomiCed contro""ed tria"s. C"ark et a". .%&&8/ com(ared CT to 1"uo0etine ("us se"1:e0(osure .#L4 O *!/ to ("acebo ("us se"1: e0(osure .PLA O *!/ in ;& (atients ?ith socia" an0iety disorder. A1ter $; ?eeks, there ?ere signi1icant im(ro5ements 1rom a"" three treatments but CT ?as su(erior to both medication and ("acebo at midtreatment, (osttreatment, and $%:month 1o""o?:u(. 3t is unc"ear ?hether di11erences in session "ength or the inc"usion o1 se"1:e0(osure instructions in the administration o1 medication and ("acebo con1ounded the inter(retation o1 these resu"ts, a"though the di11erence bet?een CT and the other conditions ?as substantia". C"arkBs CT ?as ne0t com(ared to e0(osure ("us a(("ied re"a0ation .!PP O AR/ and to a ?ait"ist in a randomiCed, contro""ed tria" o1 ;& indi5idua"s ?ith socia" an0iety disorder .C"ark et a". %&&;/. #o""o?ing $% ?eeks o1 treatment, both acti5e treatments ?ere su(erior to ?ait"ist on most measures o1 distress and (sycho(atho"ogy, and the CT treatment ?as su(erior to !PP O AR on the measures o1 socia" an0iety. These gains ?ere maintained at $:year 1o""o?:u(. 3n (articu"ar, t?ice as many (atients recei5ing CT than those recei5ing !PP O AR ?ere characteriCed as treatment res(onders. "roup versus %ndividual CBT for Social Anxiety Disorder

$8 Recent e11orts ha5e been made to com(are the e11icacy o1 indi5idua" CT to grou( thera(y 1or socia" an0iety disorder. *tangier et a". .%&&8/ com(ared C"arkBs CT to a grou( C,T based on C"arkBs mode" in a sam("e o1 indi5idua"s ?ith socia" an0iety disorder. ,oth the indi5idua" and the grou( treatments resu"ted in im(ro5ements on genera" 1unctioning and socia" an0iety, but gains on measures o1 socia" an0iety ?ere "arger among those recei5ing indi5idua" C,T. Mortberg et a". .%&&6/ com(ared indi5idua" CT .3CT/ to a 5ariant o1 grou( thera(y ca""ed intensi5e grou( cogniti5e treatment .3GCT/ and treatment as usua" .TA4D (harmaco(thera(y ?ith an se"ecti5e serotonin reu(take inhibitor, **R3/ in a sam("e o1 $&& (atients ?ith socia" an0iety disorder. A1ter $= ?eeks o1 treatment, a"" thera(ies sho?ed some e11icacy, and 3CT ?as su(erior to 3GCT and TA4. Ho?e5er, these resu"ts are di11icu"t to inter(ret gi5en that the 3GCT ?as de"i5ered in "onger sessions o5er a 8:?eek (eriod, ?hereas 3CT and TA4 ?ere de"i5ered in ?eek"y sessions o5er a $;:?eek (eriod. Reca"" that Lucas and Te"ch .$998/ 1ound no di11erences bet?een indi5idua" and grou( 1ormats based on HeimbergBs mode". The resu"ts o1 meta:ana"yses .re(orted be"o?/ a"so 1ai" to re5ea" di11erences in e11icacy bet?een grou( and indi5idua" C,T, "ea5ing the Auestion ?ithout a satis1actory ans?er. !elaxation Techniques 'elaxation techni!ues are designed to help patients control the physiological co(ponent of their social anxiety$ #ith the rationale that excessive arousal i(pedes perfor(ance in social situations& Several variations of relaxation have historically een used to treat social anxiety either alone or paired #ith exposure to fear-evo%ing i(agery& Progressi5e musc"e re"a0ation training as a so"e treatment has sho?n "itt"e e11icacy 1or socia" an0iety disorder .A":Kubaisy et a". $99%D A"strEm et a". $9'=/. *e"1:contro" desensitiCation, in ?hich (atients use (rogressi5e musc"e re"a0ation in res(onse to an0iety e0(erienced ?hi"e

$= 5isua"iCing increasing"y more an0iety:e5oking scenes, and systematic desensitiCation, a techniAue ?hich combines (rogressi5e musc"e re"a0ation and the 5isua"iCation o1 scenes o1 gradua""y increasing an0iety:e5oking (otentia", both resu"ted in im(ro5ement on many measures, but this im(ro5ement ?as not consistent"y su(erior to ?aiting "ist conditions .Kanter Go"d1ried, $969D MarCi""ier et a". $96;/. 2hen indi5idua"s are s(eci1ica""y trained to a(("y re"a0ation ski""s in 1eared socia" situations, the resu"ts are more (romising .+errema"m et a". $9';D Qst et a". $9'$/. 3n a(("ied re"a0ation, (atients "earn to increase their a?areness o1 the ear"iest signs o1 an0iety, to (ractice re"a0ation techniAues unti" they are ab"e to achie5e a moderate"y re"a0ed state Auick"y, and then to a(("y their re"a0ation ski""s during an0iety:(ro5oking situations .Qst $9'6/. Thus, a(("ied re"a0ation combines re"a0ation ?ith e0(osure techniAues, ?ith re"a0ation ski""s being used as a means o1 co(ing ?ith an0iety. C"ark et a". .%&&;/$ revie#ed a ove$ co(pared cognitive therapy to exposure plus applied relaxation to a #aitlist control for individuals #ith social anxiety disorder& Both active treat(ents sho#ed significant treat(ent co(pared to the control group$ ut the cognitive therapy #as (ore effective than the exposure plus relaxation group& #uture studies shou"d com(are a(("ied re"a0ation ?ith e0(osure a"one to determine ?hether the inc"usion o1 re"a0ation enhances treatment e11icacy, as ?e"" as in5estigate the combined e11icacy o1 cogniti5e thera(y, re"a0ation, and e0(osure. Social S#ills Training *ocia" *ki""s Training .**T/ is another beha5iora" inter5ention designed to teach the ski""s necessary to achie5e good socia" outcomes. **T is based on the assum(tion that socia""y an0ious (atients e0hibit beha5iora" de1iciencies .e.g., (oor eye contact, di11icu"ty maintaining a con5ersation/ that e"icit negati5e reactions 1rom others and "ead to (erce(tion o1 (oor

$< inter(ersona" outcomes .Lucock and *a"ko5skis $9''/. The "iterature e0amining the socia" ski""s o1 socia""y an0ious indi5idua"s has (roduced mi0ed resu"ts, ?ith some studies suggesting beha5iora" de1iciencies .Ha"1ord and #oddy $9'%D *to(a and C"ark $998/ and others not .+R C"ark and Arko?itC $96<D G"asgo? and Arko?itC $96<D Ra(ee and Lim $99%/. !5en ?hen beha5iora" de1icits are obser5ed, it is unc"ear ?hether they are a 1unction o1 a "ack o1 socia" kno?"edge or ski"", o1 beha5iora" inhibition (roduced by an0iety, or a combination o1 these and other 1actors. *ocia""y an0ious indi5idua"s o1ten re(ort a "ack o1 ski""s to interact in 5arious situationsD ho?e5er, obser5ation o1 their (er1ormance during e0(osures o1ten re5ea"s their beha5ior to be ?ithin acce(tab"e "imits. This obser5ation is consistent ?ith research suggesting that indi5idua"s ?ith socia" an0iety disorder o1ten underestimate the adeAuacy o1 their socia" (er1ormance .e.g., Ra(ee and Lim $99%/. TechniAues common"y used in socia" ski""s training inc"ude thera(ist mode"ing, beha5iora" rehearsa", correcti5e 1eedback, socia" rein1orcement, and home?ork assignments. Ho?e5er, bene1its attributed to socia" ski""s training cou"d a"so be e0("ained by training as(ects .e.g., re(eated (ractice o1 1eared socia" beha5iors/, the e0(osure as(ects .e.g., con1rontation o1 1eared situations/ or the cogniti5e e"ements .e.g., correcti5e 1eedback about the adeAuacy o1 oneBs socia" beha5ior/ inherent in the (rocedures .Heimberg %&&%D Turk et a". $999/. 3n the on"y contro""ed study o1 socia" ski""s training, $< ?eeks o1 training 1ai"ed to (roduce im(ro5ements in socia" an0iety, socia" ski""s, and o5era"" c"inica" adJustment su(erior to those demonstrated by a ?ait:"ist contro" grou( .MarCi""ier et a". $96;/. 3n se5era" other studies, socia" ski""s training resu"ted in signi1icant im(ro5ements in 5arious as(ects o1 socia" an0iety disorder such as reductions in se"1:re(orted an0iety, de(ression and di11icu"ty in socia" situations .#a""oon et a". $9'$D Lucock and *a"ko5skis $9''D *tra5ynski et a". $9'%D Tro?er et a". $96'D

$; 2"aC"o et a". $99&/. Ho?e5er, none o1 these studies inc"uded adeAuate contro" conditions. Turner et a". .$99=a/ re(orted in an uncontro""ed study that *ocia" !11ecti5eness Thera(y, a treatment that combines **T ?ith (sychoeducation and e0(osure, resu"ted in signi1icant gains 1or (atients ?ith genera"iCed socia" an0iety disorder and that these gains ?ere maintained at %:year 1o""o?:u( .Turner et a". $99</. 3t is not (ossib"e to state ?ith con1idence 1rom these uncontro""ed studies that these treatments ?ere res(onsib"e 1or success1u" outcomes or that **T is su11icient as a stand:a"one treatment, and there is "itt"e e5idence to su((ort the "atter conc"usion .Ponniah and Ho""on, %&&6/. Ho?e5er, a recent study incor(orated an **T modu"e into standard C,GT and com(ared this treatment to C,GT a"one 1or (atients ?ith genera"iCed socia" an0iety disorder. ,oth treatments ?ere e11icacious but the combination grou( demonstrated signi1icant"y greater gains .Herbert et a"., %&&</. Meta&analytic 'indings *e5era" meta:ana"ytic re5ie?s o1 the e11icacy o1 5arious cogniti5e:beha5iora" techniAues 1or the treatment o1 socia" an0iety disorder ha5e been conducted ?ith the o5era"" 1inding that cogniti5e beha5iora" treatments tend to be su(erior to contro" conditions .Chamb"ess and Ho(e $99;D #edoro11 and Tay"or %&&$D #eske and Chamb"ess $99<D Gou"d et a". $996D Tay"or, $99;/. Tay"or .$99;/ e0amined indi5idua" tria"s 1or socia" an0iety disorder com(aring se5era" cogniti5e:beha5iora" treatments inc"uding cogniti5e restructuring, **T, e0(osure, and e0(osure combined ?ith cogniti5e restructuring to ?ait:"ist and ("acebo contro"s. A"" acti5e treatments ?ere su(erior to ?ait:"ist, but on"y e0(osure combined ?ith cogniti5e restructuring ?as su(erior to ("acebo. The acti5e treatments demonstrated reductions in se"1:re(orted sym(toms o1 socia" an0ietyD these reductions ?ere maintained, and o1ten 1urther im(ro5ements ?ere made, se5era"

$6 months a1ter treatment ?as discontinued. There ?ere no di11erences among the acti5e treatments in e11ect siCe at 1o""o?:u( and no di11erences bet?een grou( and indi5idua" treatment. Gou"d et a". .$996/ 1ound no di11erences in outcome or attrition in their meta:ana"ysis o1 C,T, (harmacothera(y, and combined treatment 1or socia" an0iety disorder. Gains resu"ting 1rom C,T ?ere maintained during 1o""o?:u(. !0(osure a"one, cogniti5e restructuring ("us e0(osure, and **R3s had "arge e11ect siCes, ?hereas cogniti5e restructuring a"one, **T, MA-3s, and benCodiaCe(ines had moderate e11ect siCes. Like Tay"or .$99;/, Gou"d et a". 1ound no di11erences bet?een grou( and indi5idua" treatment. 3n the meta:ana"ysis by #edoro11 and Tay"or .%&&$/, benCodiaCe(ines and **R3s ?ere su(erior to ?ait"ist, (i"" ("acebo, and attention ("acebo contro"s and a(("ied re"a0ation. ,enCodiaCe(ines ?ere su(erior to MA-3s, cogniti5e restructuring, cogniti5e restructuring ("us e0(osure, and **T. Cogniti5e restructuring ("us e0(osure ?as su(erior to a(("ied re"a0ation and to attention ("acebo and ?ait"ist contro"s. There ?ere no other di11erences among the (sycho"ogica" treatments. )actors Affecting Treat(ent *utco(e in CBT for Social Anxiety Disorder Su type of Social Anxiety Disorder and Avoidant (ersonality Disorder 3ndi5idua"s ?ith genera"iCed socia" an0iety disorder begin treatment ?ith greater se5erity o1 sym(toms and greater im(airment than those ?ith non:genera"iCed socia" an0iety disorder and are there1ore "ess "ike"y to achie5e high end:state 1unctioning a1ter cogniti5e:beha5iora" treatment. 3n addition, the (resence o1 a5oidant (ersona"ity disorder .APD/, a disorder that is diagnosed in about ;&K o1 indi5idua"s ?ith socia" an0iety disorder, a"so may a11ect treatment outcome, but resu"ts are mi0ed. *ome studies ha5e 1ound treatment to be "ess e11ecti5e 1or indi5idua"s ?ith socia" an0iety disorder and comorbid APD .Chamb"ess et a". $996D #eske et a".

$' $99;/, ?hereas others ha5e 1ound that APD does not signi1icant"y com("icate treatment outcome .,ro?n et a". $99<D Ho(e et a". $99<b/. *ome researchers consider APD to be a more se5ere 5ariant o1 socia" an0iety disorder .Heimberg, $99;/ and ha5e noted that it remits ?ith standard treatment 1or socia" an0iety disorder. #or e0am("e, ,ro?n et a". .$99</ 1ound that =6K o1 (atients ?ith socia" an0iety disorder and comorbid APD no "onger met criteria 1or APD a1ter C,T 1or socia" an0iety disorder. Comor id Anxiety and Mood Disorders The e11ects o1 comorbid an0iety and mood disorders on the e11icacy o1 C,T 1or socia" an0iety disorder ha5e been in5estigated. Chamb"ess et a". .$996/ 1ound that, in a sam("e o1 indi5idua"s recei5ing C,GT 1or socia" an0iety disorder, higher se"1:re(orted de(ression at (retreatment ?as re"ated to decreased reduction in an0ious antici(ation o1 a beha5iora" test, a"though this same (attern ?as not 1ound 1or c"inician ratings o1 de(ression. !r?in et a". .%&&%/ com(ared indi5idua"s ?ith uncom("icated socia" an0iety disorder, comorbid an0iety disorder, and comorbid mood disorder. Those ?ith comorbid mood disorder tended to ha5e greater se5erity o1 sym(toms both be1ore and 1o""o?ing $% ?eeks o1 C,GT. Those ?ith comorbid an0iety disorders 1ared as ?e"" as those ?ith uncom("icated socia" an0iety disorder. Led"ey et a". .%&&</ re(orted that higher "e5e"s o1 de(ressi5e sym(toms ?ere re"ated to more se5ere socia" an0iety, "ess change in socia" an0iety, and greater attrition in the recent ("acebo:contro""ed study by Da5idson et a". .%&&=/. Mosco5itch et a". .%&&</ 1ound that in a sam("e o1 indi5idua"s recei5ing C,GT 1or socia" an0iety disorder, changes in de(ression ?ere 1u""y mediated by changes in socia" an0iety .accounting 1or 9$K o1 the 5ariance in de(ression scores/, ?hereas changes in socia" an0iety ?ere on"y (artia""y mediated by changes in de(ression .accounting 1or on"y ;K o1 the 5ariance in

$9 socia" an0iety scores/, suggesting that im(ro5ements in the sym(toms o1 de(ression tend to track im(ro5ements in the sym(toms o1 socia" an0iety in this grou( o1 (atients. Comor id Social Anxiety Disorder and Alcohol A use *ocia" an0iety disorder tends to co:occur at (articu"ar"y high rates ?ith a"coho" use disorders .A4D/. According to the 7ationa" !(idemio"ogica" *ur5ey on A"coho" and Re"ated Conditions, near"y ha"1 o1 indi5idua"s ?ith a "i1etime diagnosis o1 socia" an0iety disorder a"so had a "i1etime diagnosis o1 an A4D .Grant et a". %&&</. 3n addition, ado"escent socia" an0iety disorder (redicts "ater de5e"o(ment o1 a"coho" de(endence by age 8&, e5en ?hen contro""ing 1or de(ression or other an0iety disorders .,uckner et a". %&&'/. 3ndi5idua"s ?ith socia" an0iety disorder o1ten re(ort the use o1 a"coho" as se"1:medication to reduce their an0iety in stress1u" situations .,uckner et a". %&&;/. There1ore, ?hen the se5erity o1 the a"coho" use ?arrants a diagnosis o1 A4D, (atients might "ack moti5ation to decrease their a"coho" use. Moti5ationa" !nhancement Thera(y .M!TD 2R Mi""er et a". $99%/ is a (romising inter5ention 1or A4D. The goa" o1 M!T is to reso"5e ambi5a"ence around the desire to change (rob"ematic drinking beha5iors. A recent case study demonstrates the success1u" treatment o1 a 88:year:o"d ma"e ?ith comorbid genera"iCed socia" an0iety disorder and A4D using a combined M!T:C,T a((roach. #o""o?ing $9 sessions the (atient had remitted 1rom both disorders and continued to do ?e"" at ;: month 1o""o?:u( .,uckner et a". in (ress/. Contro""ed tria"s in5estigating the combination o1 these t?o treatments in this s(ecia" (o(u"ation are necessary to better understand their e11icacy. Motivation) expectancy) home*or# compliance) and other aspects of treatment process Patients o1ten ha5e mi0ed reactions to treatment and may e0(ress ambi5a"ence about their abi"ity to make "asting changes. *e5era" studies ha5e e0amined the e11ects o1 treatment e0(ectancy and home?ork com("iance on treatment outcome in socia" an0iety disorder. 3n t?o

%& studies, (atients ?ho 1ound treatment to be credib"e and e0(ected treatment gains did better than those ?ho he"d more negati5e e0(ectations regarding treatment .Chamb"ess et a". $996D *a1ren et a". $996/. Home?ork com("iance has a"so been re"ated to treatment gains. 3ndi5idua"s ?ho ?ere more com("iant made greater gains than "ess com("iant indi5idua"s both immediate"y 1o""o?ing treatment .Leung and Heimberg $99;/ and at a si0:month 1o""o?:u( .!de"man and Chamb"ess $99</. Ho?e5er, 2oody and Adessky .%&&%/ did not 1ind su((ort 1or this re"ationshi(. Patients can a"so di11er in their degree o1 moti5ation 1or thera(y. A recent (i"ot study ?ith a mi0ed grou( o1 (atients ?ith (anic disorder, socia" an0iety disorder, and genera"iCed an0iety disorder e0amined the bene1it o1 adding three sessions o1 moti5ationa" inter5ie?ing (rior to grou( C,T .2estra and DoCois %&&;/. 3ndi5idua"s ?ho recei5ed moti5ationa" inter5ie?ing, as com(ared to those ?ho recei5ed no (retreatment inter5ention, sho?ed an increase in (ositi5e e0(ectancy 1or an0iety change be1ore C,T, ?ere more com("iant ?ith assigned home?ork during treatment, and ?ere more "ike"y to be res(onders to C,T. -ther (rocesses o1 treatment may in1"uence outcome, and one o1 these may be grou( cohesion. Taube:*chi11 et a". .%&&6/ e0amined cohesion among (ersons recei5ing C,GT, 1inding that it increased o5er the "i1e o1 the grou(. 3m(ortant"y, contro""ing 1or base"ine 5a"ues, grou( cohesion (redicted outcomes on measures o1 socia" an0iety, de(ression, and im(airment. The nature o1 the a""iance bet?een thera(ist and (atient may a"so be im(ortant in C,T 1or socia" an0iety disorder. Hayes et a". .%&&6/ demonstrated that a strong a""iance ?as associated ?ith (atients engaging ?ith the session and 1inding the session he"(1u". Ho?e5er, a moderate a""iance ?as most (roducti5e ?hen the measure ?as the amount o1 an0iety reduction e0(eriences during in:session e0(osures to 1eared situations. *(ecu"ati5e"y, an a""iance that is too ?eak may not (ro5ide a su11icient sense o1 sa1ety 1or some (atients, ?hereas a 5ery strong a""iance may

%$ su((ress (atientsB an0iety e0(erience and indirect"y inter1ere ?ith their abi"ity to o5ercome it. #ina""y, in a study com(aring grou( C,T, e0(osure grou( thera(y, and ?ait:"ist contro" conditions, Ho1mann .%&&=/ e0amined ?hether changes in estimated socia" cost, or negati5e cogniti5e a((raisa", mediated (retreatment to (osttreatment changes in both acti5e treatment grou(s. -n"y the grou( recei5ing grou( C,T sho?ed continued im(ro5ement 1rom (osttreatment to the ;:month 1o""o?:u(. Continued bene1it ?as associated ?ith an o5era"" reduction in estimated socia" cost, suggesting that the cogniti5e:beha5iora" inter5ention ?as associated ?ith greater treatment gains that are mediated through changes in estimated socia" cost. Anger 2e ha5e a"so e0amined ho? (atient anger a11ects treatment outcome. 3ndi5idua"s ?ho e0(erienced anger more 1reAuent"y, ?ere more Auick:tem(ered, and ?ere more "ike"y to (ercei5e un1air treatment by others ?ere "ess "ike"y to stay in treatment 1or the 1u"" $%:session course o1 C,GT .!r?in et a". %&&8/. Among those ?ho com("eted treatment, (atients ?ho e0(erienced more e0treme anger and ?ho ?ere more "ike"y to inhibit their anger made sma""er treatment gains than "ess angry (atients. -ne might s(ecu"ate that anger inter1eres ?ith the (ersonBs abi"ity to engage 1u""y in e0(osure to 1eared situations or to 1orm a 5iab"e ?orking a""iance ?ith the thera(ist or other grou( members. The studies re5ie?ed here ha5e identi1ied numerous 5ariab"es that (redict treatment outcome. Attem(ts to mani(u"ate these (redictors may ser5e to im(ro5e a"ready e11ecti5e treatments. #or e0am("e, techniAues 1or modi1ying negati5e e0(ectancies, increasing home?ork com("iance, or reducing anger may "ead to better outcomes. These studies a"so ha5e (ro5ided us ?ith in1ormation about (atients ?ho may reAuire additiona" or more intensi5e treatment, such as (atients ?ith genera"iCed socia" disorder andLor comorbid de(ression.

%% *ther Psychosocial Treat(ents for Social Anxiety Disorder Cogniti5e beha5iora" treatments are by 1ar the most e0tensi5e"y researched (sychosocia" a((roaches 1or socia" an0iety disorder. Ho?e5er, in c"inica" (ractice, other a((roaches are o1ten uti"iCed. There is a sma"" but gro?ing body o1 "iterature on the e11icacy o1 these a((roaches. (sychodynamic (erspectives Gabbard .$99%/ (ro(osed three mode"s 1or understanding the sym(toms o1 socia" an0iety disorder) a/ shame e0(eriences regarding unconscious ?ishes to be the center o1 attention, b/ gui"t concerning ?ishes to e"iminate com(etitors ?hi"e doubting ones abi"ity to actua""y do so, and c/ se(aration an0iety concerning attem(ts 1or autonomy "eading to "ong:term "oss o1 a caregi5erFs "o5e. An indi5idua" case o1 socia" an0iety disorder conce(tua"iCed 1rom a (sychodynamic (ers(ecti5e is (resented by Nerbe .$996/. Like Gabbard, Nerbe .$996/ (ro(osed that shame is an im(ortant under"ying dynamic in socia" an0iety disorder. Nerbe (resented the case o1 a ?oman ?ith 1ears o1 (er1ormance situations .e.g., (ub"ic s(eaking/ and interaction situations .e.g., dating/ based on the be"ie1 that she cou"d ne5er Gmeasure u(H to the demands o1 other (eo("e. Nerbe attributed the de5e"o(ment o1 socia" an0iety disorder in this (atient to a "ack o1 nurturance and su((ort 1rom her (arents during chi"dhood. Nerbe .$996/ asserted that Gone can sa1e"y assume that the ear"y traumatogenic en5ironment o1 this (atient ("ayed a substantia" ro"e in the etio"ogy o1 her socia" (hobiaH .(. $&/. Recent"y, a short:term treatment manua" has been de5e"o(ed 1or socia" an0iety disorder that is based on LuborskyFs su((orti5e:e0(ressi5e .*!/ thera(y .Leichsenring et a". %&&6/. The treatment inc"udes se5era" e"ements such as a 1ocus on the core con1"ictua" re"ationshi( theme that in1"uences the (atientBs (rimary sym(toms, goa" setting, enhancing insight, and understanding the ro"e o1 shame and unrea"istic demands. 3n addition, there is a com(onent

%8 simi"ar to e0(osure in ?hich (atients are encouraged to con1ront 1eared socia" situations. This treatment manua" is current"y being used in a "arge:sca"e in5estigation com(aring (sychodynamic thera(y to cogniti5e:beha5iora" thera(y 1or socia" an0iety disorder. %nterpersonal (sychotherapy 3nter(ersona" Psychothera(y .3PT/ is based on the assum(tion that (sychiatric disorders occur and are maintained ?ithin a (sychosocia" and inter(ersona" conte0t. The main goa" o1 3PT is to im(ro5e the (atientBs inter(ersona" 1unctioning as a means o1 achie5ing sym(tomatic reco5ery. 3PT is a time:"imited .$%:$; ?eek/ thera(y that e11icacious in the treatment o1 acute de(ression .1or a re5ie?, see DeMe""o et a". %&&</, dysthymic disorder .Marko?itC $99=/, and other disorders ?ith an inter(ersona" com(onent such as bu"imia ner5osa .2i"1"ey et a". %&&%/. Li(sitC et a". .$999/ modi1ied 3PT 1or socia" an0iety disorder. 3n this treatment, core inter(ersona" (rob"em areas are identi1ied and then e0amined through mu"ti("e techniAues .e.g., e0("oration o1 1ee"ings and thoughts re"ated to the (rob"em area, encouragement o1 a11ecti5e e0(ression, c"ari1ication o1 1ee"ings, communication and decisions ana"ysis and ro"e ("aying/. An initia" uncontro""ed study o1 3PT ?ith nine indi5idua"s ?ith socia" an0iety disorder yie"ded (romising resu"ts .Li(sitC et a". $999/. #o""o?ing treatment, 6'K o1 (atients ?ere c"assi1ied as res(onders by inde(endent e5a"uators. Ratings o1 im(ro5ement ?ere a"so signi1icant on a c"inician:administered measure o1 socia" an0iety, and se"1:ratings o1 g"oba" sym(tom se5erity and socia" distress a"so decreased 1o""o?ing treatment. Ho?e5er, a randomiCed tria" that com(ared 3PT to a su((orti5e thera(y contro" .*T/ 1or socia" an0iety disorder 1ai"ed to re("icate these initia" 1indings .Li(sitC et a". in (ress/. This study inc"uded 6& (atients ?ho recei5ed $= ?eek"y sessions o1 indi5idua" 3PT or *T. ,oth grou(s demonstrated im(ro5ement on se5era"

%= measures o1 socia" an0iety, but the t?o treatment conditions ?ere not signi1icant"y di11erent on the maJority o1 outcome measures or the (ro(ortion o1 treatment res(onders. Another recent study did, ho?e5er, (ro5ide some su((ort 1or the e11icacy o1 3PT 1or socia" an0iety disorder .,orge et a"., in (ress/. Conducted in an in(atient setting, this study com(ared $& ?eeks o1 residentia" 3PT to residentia" cogniti5e thera(y in a sam("e o1 '& indi5idua"s ?ith socia" an0iety disorder. Treatments ?ere modi1ied to inc"ude indi5idua" and grou( com(onents to best 1it an in(atient setting. ,oth grou(s demonstrated im(ro5ements on measures o1 socia" an0iety, and these gains ?ere maintained at $:year 1o""o?:u(. The e11icacy o1 residentia" 3PT ?as simi"ar to that o1 3PT de"i5ered in an out(atient setting. Ho?e5er, de1initi5e conc"usions about the e11icacy o1 3PT 1or socia" an0iety disorder cannot be made as there ?ere 1e? di11erences bet?een residentia" 3PT and C,T in this study .C,T ?as su(erior on a sing"e secondary measure/, and no contro" condition ?as inc"uded. Morita Therapy Morita thera(y is a +a(anese thera(y 1or an0ious (atients that em(hasiCes beha5ior change and (ersona" gro?th .Reyno"ds $9'&/. 3t encourages (atients to re"inAuish contro" o1 emotions and redirect their attention to?ard more acti5e and constructi5e (ursuits. The e0(erience o1 ego transcendence .i.e., 1orgetting onese"1 and oneBs sym(toms/ through immersion in acti5ities is be"ie5ed to ("ay an integra" ro"e in (atientsB re1ormu"ation o1 themse"5es and their beha5iora" ca(acities. A"though Morita thera(y does contain some uniAue as(ects .e.g., not e0("icit"y attem(ting to reduce or e"iminate an0ious sym(toms/, it shares other com(onents ?ith 2estern thera(ies .e.g., use o1 reattribution, attentiona" re1ocusing, modi1ying dys1unctiona" be"ie1s, (ositi5e reinter(retation/. Morita thera(y em(hasiCes that an0iety is not an abnorma" e0(erience or trait, that an0iety can be acce(ted as it is, and that attem(ts to mani(u"ate

%< or e0("icit"y reduce an0iety o1ten (arado0ica""y resu"t in increased (reoccu(ation ?ith sym(toms. 3n 1eared situations, (atients are instructed to (erse5ere through an0ious moments 1ocusing on the task at hand, to recogniCe they ha5e a choice o1 action and not emotion, and to consider that the intensity o1 emotion is a re1"ection o1 the im(ortance o1 the task. A sma"" body o1 "iterature has addressed the a(("ication o1 Morita thera(y to shyness and socia" an0iety .A"den $9''D 3shiyama $9'6/. 3shiyama .$9'6/ (osits three 1undamenta" (hi"oso(hica" (remises in Morita thera(y regarding socia" an0iety) $/ socia" an0iety is a norma" human emotion, %/ socia" an0iety has a se"1:actua"iCing meaning, and 8/ socia" an0iety can be used as a moti5ator:1aci"itator o1 constructi5e action. Case studies ha5e sho?n Morita thera(y to be success1u" in he"(ing (atients to acce(t their an0iety and redirect their attention a?ay 1rom it .A"1onso $99%D 3shiyama $9';/. 3n a study o1 1i5e socia""y an0ious co""ege students, 3shiyama .$99$/ 1ound Morita thera(y to reduce (atientsB target com("aints, increasing co(ing e11ecti5eness, and reducing socia" an0iety and a5oidance.

%; Acceptance and Commitment Therapy +ACT, Acce(tance and Commitment Thera(y .ACT/ has been recent"y a(("ied to the treatment o1 socia" an0iety disorder ?ith (romising resu"ts. Da"rym("e and Herbert .%&&6/ in5estigated the e11icacy o1 a $%:?eek (rogram integrating e0(osure thera(y and ACT. *e5era" measures ?ere administered to assess socia" an0iety sym(toms, e0(erientia" a5oidance .the attem(t to a"ter the 1orm, 1reAuency, or situationa" sensiti5ity o1 (ri5ate e5ents e5en ?hen doing so causes beha5iora" harmD Hayes et a". $99;/, and genera" Aua"ity o1 "i1e. 7ineteen (artici(ants recei5ed $% ?eek"y $:hour sessions that inc"uded (resentation o1 the 1our main com(onents o1 ACT. The 1irst stage .sessions $:%/ in5o"5ed Gcreati5e he"("essnessH in ?hich (artici(ants come to understand the 1uti"ity o1 their (ast e11orts to contro" an0iety. The ne0t (hase .starting ?ith session 8/ (resented the conce(t o1 G?i""ingnessH to ha5e un?anted or distressing thoughts ?hi"e being e0(osed to di11icu"t socia" situations. Mind1u"ness techniAues ?ere (resented in the third stage .beginning in session =/ to he"( teach nonJudgmenta" e0(erience and a((raisa" o1 an0ious thoughts and to mo5e to?ards cogniti5e de1usion, the e0ercise o1 se(arating the se"1 1rom interna" e0(eriences. The 1ina" stage .beginning in session 6/ 1aci"itated (artici(ation in e0(eriences that re1"ect oneBs 5a"ued choices. These ACT conce(ts ?ere demonstrated using meta(hors and e0(erientia" e0ercises. The treatment a"so incor(orated traditiona" beha5ior thera(y techniAues such as in:session ro"e:("ays, in vivo e0(osure, and socia" ski""s training. Partici(ants ?ere assessed at (ost:treatment and 8:month 1o""o? u(. They dis("ayed a signi1icant decreases in socia" an0iety, 1ear o1 negati5e e5a"uation, e0(erientia" a5oidance, and a signi1icant increase in Aua"ity o1 "i1e. A mid:treatment decrease in e0(erientia" a5oidance (redicted (ost:treatment decrease in an0iety. *imi"ar resu"ts ?ere re(orted in a sma"" uncontro""ed tria" o1 ACT:based grou( thera(y 1or socia" an0iety disorder .-ssman et a". %&&;/.

%6 Meditation&Based Stress !eduction A recent randomiCed tria" com(ared C,GT to a meditation:based stress reduction (rogram .M,*RD KosCycki et a". %&&6/. The authors suggest that M,*R might be bene1icia" 1or socia" an0iety disorder because it may he"( (atients shi1t 1rom 1ocus on threat:re"ated socia" cues to an e0terna" 1ocus on the socia" ?or"d. Mind1u"ness techniAues may a"so he"( decrease (hysio"ogica" sym(toms such as increased heart rate, b"ushing, tremb"ing, and s?eating, thus making socia" interactions more manageab"e .Mi""er, #"etcher, Kabat:Ninn, $99</. #i1ty:three

(artici(ants ?ere random"y assigned to recei5e either grou( M,*R or C,GT. The C,GT grou( recei5ed $% ?eek"y %:hour grou( sessions according to the Heimberg and ,ecker .%&&%/ treatment manua" de"i5ered by thera(ists e0(erienced in C,T 1or an0iety. The M,*R treatment inc"uded ':?eek"y %:hour sessions and one a"":day meditation retreat de"i5ered by a meditation instructor. The (rogram inc"uded (sychoeducation about meditation and yoga techniAues and instruction to (er1orm dai"y audiota(e:guided meditation. ,oth the M,*R and the CG,T conditions demonstrated c"inica""y meaning1u" changes on measures o1 socia" an0iety, de(ression, and Aua"ity o1 "i1eD ho?e5er, (atients recei5ing C,GT demonstrated greater reductions in se"1:re(orted 1ear o1 negati5e e5a"uation and c"inician:rated beha5iora" a5oidance. A"though it ?as some?hat "ess e11icacious than C,GT, M,*R a((eared to (roduce meaning1u" im(ro5ements in socia""y an0ious (atients. M,*R cou"d be disseminated to a 5ariety o1 settings by "ay (eo("e e0(ert in meditation but not necessari"y in menta" hea"th (ractice, (erha(s he"(ing to reach those socia""y an0ious (ersons re"uctant to (ursue more traditiona" treatment o(tions. #urther research shou"d be conducted in5estigating the e11icacy o1 incor(orating meditationLmind1u"ness techniAues into standard C,T (ractices to see ?hether they enhance treatment outcome.

%' +ong-ter( Treat(ent There is "itt"e research on "ong:term treatment o1 socia" an0iety disorder, and this is an im(ortant 1uture research agenda. #o""o?:u( data 1or short:term treatments suggest maintenance o1 gains 1or C,T 1or inter5a"s u( to 1i5e years .Heimberg et a". $998D Tay"or $99;/ and modest re"a(se .Liebo?itC et a". $999/. 7e5erthe"ess, there is a need 1or study o1 "onger:term treatment, es(ecia""y 1or (atients ?ho do not sho? com("ete res(onse to acute treatments. Special Populations

%9 CBT for Children and Adolescents *ith Social Anxiety Disorder As the 1ie"d o1 (sycho"ogy has mo5ed to em(hasiCe (re5ention o1 (sycho(atho"ogy, an im(ortant area o1 research 1ocuses on the treatment o1 chi"dhood and ado"escent socia" an0iety disorder, and much more ?ork is needed in this area. Ho?e5er, most studies combined socia""y an0ious chi"dren and chi"dren ?ith other an0iety disorders ?ithout considering (ossib"e diagnosis e11ects. Kenda"" .$99=/ and Kenda"" et a". .$996/ in5estigated the e11icacy o1 a $;: session cogniti5e:beha5iora" treatment (rogram 1or an0iety disorders in chi"dren .ages 9 to $8/. ,oth studies inc"uded sam("es o1 ado"escents ?ith o5er:an0ious disorder, se(aration an0iety disorder, and a5oidant disorder .socia" an0iety disorder/. Kenda"" .$99=/ sho?ed cogniti5e: beha5iora" treatment to be su(erior to a ?ait:"ist condition, and im(ro5ements in the cogniti5e: beha5iora" grou( ?ere maintained at one:year 1o""o?:u(. Kenda"" et a". .$996/ re("icated these 1indings, and more than <&K o1 treated chi"dren no "onger met criteria 1or their (rimary an0iety disorder. A1ter an a5erage o1 6.= years 1o""o?ing treatment, (artici(ants demonstrated continued im(ro5ements in an0iety based on inter5ie?s o1 ado"escents and their (arents, and (ositi5e res(onders sho?ed a reduced amount o1 substance abuse com(ared to "ess (ositi5e res(onders .Kenda"" et a". %&&=/.

8& To address the (otentia" im(ortance o1 1ami"y 1actors in the maintenance o1 an0iety, #ami"y An0iety Management .#AMD ,arrett et a"., un(ub"ished manuscri(t/ ?as designed as an adJunct to indi5idua" C,T 1or an0ious chi"dren. #AM in5o"5es the training o1 (arents to re?ard courageous beha5ior, e0tinguish an0ious beha5ior, co(e ?ith their o?n an0iety, and he"( ?ith communication and (rob"em:so"5ing ski""s. ,arrett et a". .$99;/ com(ared C,T a"one, C,T ("us #AM, and a ?ait"ist condition in 69 chi"dren ?ith o5er:an0ious disorder, se(aration an0iety disorder, or socia" an0iety disorder. ,oth treatment conditions ?ere su(erior to the ?ait"ist, and #AM augmented the e11icacy o1 C,T. Rates o1 res(onse did not di11er by diagnosis. *(ence et a". .%&&&/ a"so in5estigated the e11icacy o1 chi"d:1ocused C,T com(ared to C,T ("us (arent in5o"5ement .C,T:P3/ and a ?ait"ist contro" 1or $% ?eek"y grou( sessions. The C,T grou(s inc"uded **T, re"a0ation training, gradua" e0(osure to 1eared socia" situations, and cogniti5e restructuring. #i1ty socia""y an0ious chi"dren ?ere random"y assigned to one o1 the three conditions. The (arent in5o"5ement com(onent ?as in5estigated to determine ?hether (arents can "earn ho? to mode" and rein1orce socia" ski""s, discourage situationa" a5oidance, and rein1orce home?ork com("iance. At (ost:treatment, chi"dren in both C,T conditions sho?ed a greater decrease in socia" an0iety sym(toms and greater (arent:rated socia" ski""s than the ?ait"ist grou(D these gains ?ere maintained at $:year 1o""o?:u(. There ?as a trend to?ards greater im(ro5ement in the C,T:P3 grou(, but di11erences ?ere not statistica""y signi1icant.

8$ -ther studies ha5e e0amined inter5entions s(eci1ica""y designed 1or chi"dren and ado"escents ?ith a (rimary diagnosis o1 *AD. A grou( treatment (rogram based on Heimberg et a".Bs .$99&/ C,GT ?as ada(ted 1or ado"escents ?ith socia" an0iety .C,GT:AD A"bano et a". $99</. The (rogram inc"uded (sychoeducation, (rob"em:so"5ing techniAues, asserti5eness training, cogniti5e restructuring, and graduated e0(osure to distressing socia" situations. A"bano et a". demonstrated e11icacy o1 C,GT:A ?ith 1i5e ado"escent (atients, 1our o1 ?hom dis("ayed subc"inica" "e5e"s o1 socia" an0iety disorder at (ost:treatment and at $:year 1o""o?:u(. Hay?ard et a". .%&&&/ random"y assigned 8< socia""y an0ious 1ema"e ado"escents to recei5e either C,GT: A or no treatment. The treatment grou( dis("ayed signi1icant gains a1ter $; ?eeks com(ared to the no:treatment grou(D ho?e5er, these gains ?ere not maintained at $:year 1o""o?:u(. Another recent C,T inter5ention ?as designed to target a younger grou( o1 socia""y an0ious chi"dren .Ga""gher et a". %&&=/. T?enty:three (reado"escent chi"dren .ages 'M$$/ ?ere random"y assigned to either a 8:?eek cogniti5e:beha5iora" grou( inter5ention or a ?ait"ist contro" grou(. Treatment ?as de"i5ered o5er 8 ?eeks in three intensi5e grou( sessions that 1ocused on (sychoeducation, cogniti5e e0ercises, and beha5iora" e0(osure. 3m(ro5ements in an0iety and de(ression at (ost:treatment in the acti5e grou( ?ere signi1icant"y greater than those in the ?ait"ist according to (arent and chi"d re(ort.

8% ,eide" et a". .%&&&/ com(ared *ocia" !11ecti5eness Thera(y 1or Chi"dren .*!T:C/ to an acti5e, nons(eci1ic com(arison treatment in chi"dren ages ':$% ?ith socia" an0iety disorder. *!T:C inc"udes grou( **T, (eer genera"iCation sessions, and indi5idua""y:tai"ored in vivo e0(osure. Chi"dren in the *!T:C grou( demonstrated increased socia" ski""s and socia" interaction and decreased socia" an0iety sym(toms at (ost:treatmentD ;6K o1 the *!T:C grou(, com(ared ?ith <K o1 the contro" condition, did not meet criteria 1or socia" an0iety disorder at (ost:treatment, and gains ?ere maintained at ;:month 1o""o?:u(. #urthermore, at a 8:year 1o""o?:u(, 6%K o1 the chi"dren in the *!T:C grou( continued to be 1ree o1 the diagnosis o1 socia" an0iety disorder .,eide" et a". %&&</, and at <:year 1o""o?:u( the maJority o1 im(ro5ements made during treatment continued to be maintained .,eide" et a". %&&;/. This 1inding is (articu"ar"y com(e""ing gi5en that most (artici(ants had reached mid:ado"escenceSthe time (eriod considered to be the (eak age o1 onset 1or socia" an0iety disorderSby this time, yet treatment e11ects ?ere maintained across measures o1 genera" (sycho(atho"ogy and socia" an0iety. These 1o""o?:u( data suggest that indi5idua"s treated ?ith the *!T:C (rogram acAuire ski""s that they can continue to im("ement 1or se5era" years a1ter com("eting treatment and at <:year 1o""o?:u(.

88 Masia:2arner et a". .%&&</ com("eted a randomiCed contro""ed tria" in5estigating the e11icacy o1 a schoo":based grou( treatment (rogram ca""ed *ki""s 1or *ocia" and Academic *uccess .*A**/ com(ared to a ?ait"ist contro" in a sam("e o1 8< ado"escents ?ith socia" an0iety disorder. The (rogram ?as designed to 1"e0ib"y con1orm to the schedu"ing con1"icts o1 a high schoo" ca"endar and consisted o1 $% ?eek"y grou( schoo" sessions .a((ro0imate"y =& min each/, t?o $<:min indi5idua" meetings, and t?o grou( booster sessions. Additiona""y, 1our 9&:min ?eekend socia" e5ents that inc"uded (rosocia" (eers, ca""ed G(eer assistants,H (ro5ided rea":?or"d e0(osures and o((ortunities 1or ski""s genera"iCation and 1ee"ings o1 mastery. Parents and teachers each attended t?o grou( meetings to he"( integrate the ski""s "earned into both home and schoo" settings. Ado"escents in the *A** grou( demonstrated signi1icant"y greater reductions in socia" an0iety and a5oidance and im(ro5ed 1unctioning com(ared to the ?ait"ist grou( as indicated by (arent, ado"escent, and assessor re(orts. #urthermore, ;6K o1 treated subJects, com(ared to ;K o1 ?ait"ist (artici(ants, no "onger met criteria 1or socia" an0iety disorder 1o""o?ing treatment. 3m(ortant"y, this study demonstrates the e11ecti5eness o1 disseminating C,T techniAues to a schoo" setting. 3n summary, se5era" inter5entions ha5e demonstrated e11icacy 1or decreasing socia" an0iety and im(ro5ing genera" Aua"ity o1 "i1e in chi"dren and ado"escents. #uture studies shou"d continue to in5estigate the (otentia" ad5antage o1 (arent and teacher in5o"5ement, the conte0tua" 1actors that best 1oster "ong:term treatment gains .i.e. schoo", home, neighborhood, or c"inic/, and 1actors that a11ect treatment e11icacy. Minority (opulations #ink et a".Bs .$99;/ treatment o1 a 89 year:o"d A1rican:American ?oman i""ustrates the im(ortance o1 cu"tura" 1actors in the treatment o1 socia" an0iety disorder. The (atient (resented in this case study initia""y re(orted 1ear o1 interacting ?ith co""eagues in the medica" 1ie"d. 2hen

8= her 1ears ?ere 1urther e0amined, it became e5ident that she ?as (articu"ar"y 1ear1u" o1 interactions ?ith Caucasian indi5idua"s, inc"uding settings in ?hich she interacted ?ith ma"e Caucasian (hysicians and c"assroom settings in ?hich she ?as the on"y A1rican:American student among many Caucasian students. 3nc"usion o1 these cu"tura""y re"e5ant 1actors in the (atientBs imagina" e0(osure scenes and in vivo home?ork assignments .e.g. imagining or interacting ?ith Caucasian doctors or students/ enhanced the socia":e5a"uati5e, 1ear:(ro5oking nature o1 the sceneLe5ent and enhanced the e11icacy o1 the e0(osure e0ercise. #ink et a". .$99;/ argued that is un"ike"y that the "ong:term success rea"iCed by their (atient ?ou"d ha5e been obser5ed i1 her core concerns regarding cu"tura" 1actors had not been addressed. Litt"e em(irica" research has e0amined the e11ects o1 ethnicity or cu"tura" 1actors on the outcome o1 treatment 1or socia" an0iety disorder. 3n a study by Tread?e"" et a". .$99</, cogniti5e: beha5iora" treatment ?as eAua""y e11ecti5e among an0ious chi"dren o1 di11erent ethnic grou(s. Ho?e5er, this study did not s(eci1ica""y address socia" an0iety disorder. 'efractory Patients To date, C,TSde"i5ered either in indi5idua" or grou( 1ormatSis the most o1 the e11icacious (sycho"ogica" treatment 1or socia" an0iety disorder. A"though these treatments tend to he"( the maJority o1 (atients, more ?ork needs to address strategies to enhance treatment 1or more di11icu"t:to:treat (atients ?ith socia" an0iety. -ne o1 the most "ogica" o(tions to (ursue ?hen C,T 1ai"s to (roduce signi1icant treatment gains is augmentation ?ith .or s?itch to/ (harmacothera(y. Ho?e5er, "itt"e research has been de5oted to the to(ic o1 C,T:re1ractory (atients, and o(tions 1or (atients ?ho do not res(ond ?e"" to medication treatments or ?ho (re1er not to (ursue (harmacothera(y are "ess c"ear. Research that e0amines randomiCation to secondary treatments a1ter an initia" course o1 C,T has been insu11icient"y e11icacious and

8< (atient or c"inica" 5ariab"es ?hich might moderate e11ects o1 the secondary treatments are an im(ortant agenda 1or 1uture research. -ne im(ortant as(ect o1 treatment to re5isit in re1ractory (atients is an accurate and thorough case conce(tua"iCation. The in1ormation gathered in the beginning o1 thera(y 1orms the 1oundation o1 a ?e"":conce(tua"iCed case, but in di11icu"t:to:treat (atients, this in1ormation shou"d be continua""y u(dated. As the thera(ist "earns more about the (atient, his or her com("e0 di11icu"ties cou"d e0tend beyond the rea"m o1 a 1undamenta" 1ear o1 negati5e e5a"uation and cou"d, there1ore, reAuire additiona" techniAues to address comorbid (rob"ems, such as de(ression, anger, or substance abuse .2right et a". %&&;/. 3t is a"so he"(1u" 1or thera(ists to s(eak direct"y ?ith (atients about ho? they understand the rationa"e o1 C,T and the abi"ity 1or C,T techniAues to adeAuate"y address their (rob"ems. A recent com(arison o1 dro(outs and com("eters o1 treatment 1or socia" an0iety 1ound that com("eters rated the treatment to be more "ogica" than dro(outs .Ho1mann and *u5ak %&&;/. -ther research re5ie?ed abo5e suggests that (atients ?ho do not be"ie5e in the credibi"ity o1 their treatments are "ess "ike"y to res(ond (ositi5e"y. Discussion of Practical Techni!ues and ,xperi(ental Approaches 3n addition to the more traditiona" cogniti5e:beha5iora" techniAues to treat socia" an0iety disorder inc"uding e0(osure, cogniti5e restructuring, re"a0ation, and socia" ski""s training, some e0(erimenta" techniAues sho? (romise 1or the 1uture treatment o1 socia" an0iety disorder. -ne 5ery use1u" techniAue that deser5es much 1urther study is 5ideo 1eedback, em("oyed in the indi5idua" thera(ies o1 both C"ark and Heimberg. There are consistent data demonstrating that (atients ?ith socia" an0iety disorder underestimate the Aua"ity o1 their beha5iora" (er1ormance, and this distortion begs 1or correction .Ra(ee and Lim $99%D *to(a and C"ark $998/. A1ter an in:session e0(osure, the (atient and thera(ist 5ie? the ta(e, but they do so in a

8; 5ery s(eci1ic manner, re1erred to in the "iterature as cogniti5e (re(aration. The (atient is 1irst asked to imagine ?hat hisLher (er1ormance may ha5e been "ike and to s(eci1ica""y e5a"uate se5era" beha5iors o1 concern. He or she is then instructed to 5ie? the 5ideo 1rom a stance o1 neutra"ity, as i1 ?atching the (er1ormance o1 a stranger. *e5era" studies suggest that this strategy (roduces im(ro5ements in se"1:(erce(tion o1 beha5ior and that it may be most use1u" among those ?hose se"1:(erce(tions are most discre(ant 1rom the ratings o1 their beha5ior by others .Har5ey et a". %&&&D Kim et a". %&&%, Rodebaugh and Chamb"ess %&&%D Rodebaugh and Ra(ee %&&</. Ho?e5er, 1e? studies ha5e e0amined the e11icacy o1 5ideo 1eedback in c"inica" sam("es or as an integrated (ortion o1 an o5era"" cogniti5e beha5iora" a((roach, and not a"" studies re(ort (ositi5e resu"ts .e.g., see *mits et a". %&&;/. A (re"iminary study recent"y e0amined a techniAue to direct"y address memories o1 un("easant socia" e0(eriences among socia" an0iety (atients .2i"d et a". in (ress/. 3n one session "asting a((ro0imate"y $.< hours, (atients ?ere instructed in cogniti5e restructuring and a (rocess ca""ed memory rescri(ting. During memory rescri(ting, (atients imagined the e5ent at the age it had occurred, then imagined it at their current age ?atching their younger se"1 and inter5ening i1 they ?ished, and 1ina""y imagined it as their younger se"1 ?ith the adu"t se"1 in the room, inter5ening as be1ore. 3n the contro" condition, a thera(ist encouraged the (atient to ta"k about the ear"y memory and the image associated ?ith it, (ro5iding su((orti5e "istening and re1"ection ?ithout cha""enging the (atient. 3ndi5idua"s ?ho recei5ed the rescri(ting session ?ere "ess "ike"y to 1u""y be"ie5e the enca(su"ated be"ie1 re(resented in the memory, ?ere "ess distressed by the memory, and ga5e "o?er an0iety ratings ?hen 5isua"iCing 1eared socia" situations than contro" subJects. The uti"ity o1 integrating this a((roach ?ith other cogniti5e restructuring techniAues shou"d be e5a"uated in 1uture research. #urthermore, techniAues o1 this nature are consistent ?ith

86 the 1inding that some (atients ?ith socia" an0iety disorder react to memories o1 stress1u" socia" e0(eriences as do (atients ?ith (ost:traumatic stress disorder a1ter a traumatic e5ent .!r?in et a". %&&;/, and this suggests the (otentia" uti"ity o1 (ro"onged imagina" e0(osure to these GtraumaticH memories as a (otentia""y use1u" treatment inter5ention. Rirtua" rea"ity e0(osure .RR!/ o11ers an ad5antage o5er traditiona" e0(osure because it a""o?s 1or the simu"ation o1 1eared situations in session ?hich may other?ise be di11icu"t to coordinate .e.g., (ub"ic s(eaking situations in ?hich a siCeab"e audience is reAuired/ or ?hich the (atient might be re"uctant to a((roach in vivo. A (re"iminary o(en tria" o1 indi5idua" C,T 1or (ub"ic s(eaking an0iety using RR! ?as recent"y conducted .Andersen et a". %&&</. Ten (artici(ants recei5ed 1our sessions o1 an0iety management training and 1our sessions o1 RR!. Decreases in se"1:re(orted (ub"ic s(eaking an0iety ?ere demonstrated and at (ost:treatment and 8:month 1o""o?:u(. 3n addition, a recent in5estigation o1 8; socia""y an0ious indi5idua"s com(ared Rirtua" Rea"ity Thera(y .RRT/ to C,GT .K"inger et a". %&&</. Partici(ants in the RRT grou( ?ere e0(osed 1or %&:min inter5a"s to simu"ations o1 (ub"ic s(eaking, asserti5eness, scrutiny, and intimacy situations. ,oth treatments resu"ted in c"inica""y signi1icant reductions in socia" an0iety. The magnitude o1 e11ect o1 the t?o treatments ?as simi"ar, suggesting that RRT may be a 5iab"e a"ternati5e to more studied methods o1 treatment 1or socia" an0iety disorder. Additiona" study is c"ear"y ?arranted. Another area o1 great (otentia" (romise is augmentation o1 the e11icacy o1 e0(osure or other 1orms o1 C,T ?ith chemica" aids. D:cyc"oserine .DC*/, a (artia" agonist o1 the -: methy": D:as(artate rece(tor, has been sho?n to augment "earning and memory, and doses o1 DC* recei5ed short"y a1ter e0(osure 1aci"itates e0tinction to 1eared stimu"i in anima"s. The use o1 DC* in anima" tria"s and in the treatment o1 human an0iety is summariCed in cha(ter PP o1 this

8' 5o"ume. Ho1mann et a". .%&&;/ (resent 5ery com(e""ing (i"ot data o1 the uti"ity o1 DC* in the cogniti5e:beha5iora" treatment o1 socia" an0iety disorder. An im(ortant 1uture direction 1or the treatment o1 genera"iCed socia" an0iety disorder is the de5e"o(ment o1 treatments that are more accessib"e to those indi5idua"s re"uctant to seek treatment because o1 1ear or embarrassment associated ?ith doing so (Newman et al. 2003). Individuals with social anxiety disorder who have not sought treatment list fear of negative evaluation by the treatment provider as a significant barrier to treatment-seeking (Olfson et al. 2000), and there is a population of persons who use the internet as a resource whose social anxiety symptoms are more severe than those of persons seeking treatment (Erwin et al. 2004), making the dissemination of treatment via the web an important priority. A recent trial of 64 individuals with generalized social anxiety disorder compared a 9-week internet-based self-help CBT manual to a waitlist control condition (Andersson et al. 2006). In addition to the manual, participants in the active treatment condition completed two in-person group exposure sessions and had email contact with a therapist. The internet-based therapy was associated with significant improvements in social anxiety, fear, avoidance, depression, and generalized anxiety compared to the waitlist control group, and these gains were maintained at 1-year follow-up. Future studies should compare the efficacy of such treatments (as well as fully self-administered web-based treatments) to empirically-supported therapies such as CBGT. Conclusion .ey Clinical (oints At this (oint, there is considerab"e e5idence su((orting the e11icacy o1 C,T 1or socia" an0iety disorder, and this a((ears to be the case ?hether treatment is de"i5ered in grou( or indi5idua" thera(y .note, ho?e5er, that there is "itt"e research about ?ays in ?hich these

89 moda"ities might be use1u""y combined/. !0(osure is certain"y a key ingredient in the e11icacy o1 C,T, and it is "ike"y .a"though "ess de1initi5e"y demonstrated/ that the combination o1 e0(osure and cogniti5e restructuring yie"ds the most c"inica""y signi1icant outcomes. A(("ied re"a0ation a((ears to ha5e c"inica" uti"ity. The su((ort 1or socia" ski""s training is much more mi0ed, ?ith the data suggesting it is not a su11icient stand a"one treatment but that it might ha5e a ro"e as an adJunct to other cogniti5e:beha5iora" techniAues. Litt"e is kno?n about "ong:term treatment or the uti"ity o1 booster sessions 1or socia" an0iety disorder. C,T com(ares ?e"" to (harmacothera(y in acute e11icacy, but so 1ar as it has been e5a"uated, success1u" C,T a((ears to con1er (rotection against re"a(se that is "ess "ike"y ?ith common (harmacothera(ies. The data on the combination o1 C,T and (harmacothera(y does not (ro5ide us ?ith c"ear direction M combined treatment is not c"ear"y su(erior, and the ro"e o1 either treatment in augmenting the e11icacy o1 the other is "arge"y unkno?n. 3n adu"ts, C,T outcome is (redicted to a degree by the (resence o1 genera"iCed 1ear, a5oidant (ersona"ity disorder, and de(ression, a"though resu"ts 1or each o1 these 5ariab"es is mi0ed, and a"" may be (ro0ies 1or the se5erity o1 socia" an0iety disorder. The (resence o1 other an0iety disorders does not seem to ad5erse"y a11ect outcome. Anger and substance abuse are certain to com("icate the course o1 treatment, but so"utions 1or these (rob"ems ha5e not been studied. !0(ectancy 1or a (ositi5e treatment outcome, com("iance ?ith bet?een:session thera(y assignments, and grou( cohesion do a((ear to (redict (ositi5e outcomes, and changes in cognition a((ear to mediate change in C,T. ,eyond C,T, the "iterature becomes s(arse. 3nter(ersona" thera(y has been the most e0tensi5e"y studied, but ?ith decided"y mi0ed resu"ts. Psychodynamic treatments "ack em(irica" data, a"though a tria" is current"y under?ay. Acce(tance and mind1u"ness strategies ha5e yie"ded

=& (romising (re"iminary data but reAuire much 1urther research. Regard"ess o1 thera(y a((roach, the use o1 the ?or"d ?ide ?eb to reach out to (ersons ?ho might not other?ise access treatment is an im(ortant consideration 1or the 1uture. Much "ess is kno?n about the treatment o1 chi"dren and ado"escents ?ith socia" an0iety disorder, (art"y because that "iterature does not tend to e0amine outcomes 1or se(arate an0iety disorders as a matter o1 courseD ho?e5er, much head?ay has been made in that direction, and C,T a((ears to be associated ?ith signi1icant (ositi5e change. 3n5o"5ement o1 1ami"y members, es(ecia""y 1or younger chi"dren, may be an im(ortant as(ect o1 treatment, and in5o"5ement o1 (eers is "ike"y to be he"(1u" 1or ado"escents. An Algorithm for /ptimal Treatment /utcome The "iterature thus 1ar on C,T 1or socia" an0iety disorder does not a""o? a consensus statement regarding an a"gorithm 1or o(tima" treatment outcome. 3t does a((ear that the 1o""o?ing com(onents o1 treatment are im(ortant) .a/ (sychoeducation about socia" an0iety disorder inc"uding a cogniti5e:beha5iora" conce(tua"iCation o1 the (atientBs s(eci1ic di11icu"ties, .b/ training in the ski""s necessary to 5ie? and e5a"uate oneBs thinking and beha5ior 1rom a distanced and obJecti5e (ers(ecti5e, .c/ e0(osure to 1eared socia" andLor (er1ormance situations in a graduated manner, .d/ beha5iora" e0(eriments testing s(eci1ic negati5e be"ie1s or (redictions he"d by the (atient, .e/ genera"iCation o1 ne? "earning across a number o1 en5ironments, and .1/ he"(ing the (atient de5e"o( an attitude o1 a((roach to?ard an0iety:e5oking situations so that desired outcomes can be accom("ished, an0iety or no. Re"a0ation techniAues, i1 taught in the 1ashion o1 a(("ied re"a0ation may be use1u", but socia" ski""s training is "ike"y to be needed on"y as an adJunct to other treatments 1or (atients ?hose socia" beha5ior is c"ear"y de1icient. !ecommended !eadings

=$ ,ande"o? ,, *tein D+ .eds/) *ocia" An0iety Disorder. 7e? @ork, 7@, Marce" Dekker, %&&= CroCier 2R, A"den L! .eds/) The !ssentia" Handbook o1 *ocia" An0iety 1or C"inicians. Chichester, 4nited Kingdom, +ohn 2i"ey *ons, Ltd, %&&<

Heimberg RG, ,ecker R!) Cogniti5e:,eha5iora" Grou( Thera(y 1or *ocia" Phobia) ,asic Mechanisms and C"inica" *trategies. 7e? @ork, 7@, Gui"1ord Press, %&&% Ho(e DA, Heimberg RG, +uster H, Turk CL) Managing *ocia" An0iety) A Cogniti5e:,eha5iora" Thera(y A((roach .C"ient 2orkbook/. 7e? @ork, 7@, -01ord 4ni5ersity Press, %&&& Ho(e DA, Heimberg RG, Turk CL) Managing *ocia" An0iety) A Cogniti5e:,eha5iora" Thera(y A((roach .Thera(ist Guide/. 7e? @ork, 7@, -01ord 4ni5ersity Press, %&&; Led"ey DR, Heimberg RG) *ocia" an0iety disorder, in 3m(ro5ing -utcomes and Pre5enting Re"a(se in Cogniti5e ,eha5iora" Thera(y. !dited by Antony MM, Led"ey DR, Heimberg RG. 7e? @ork, 7@, Gui"1ord Press, %&&<, (( 8':6; Turk CL, Heimberg RG, Magee L) *ocia" an0iety disorder, in C"inica" Handbook o1 Psycho"ogica" Disorders .=th edition/. !dited by ,ar"o? DH. 7e? @ork, 7@, Gui"1ord Press, %&&', (( $%8:$;8 0e Sites of %nterest htt()LL???.academyo1ct.orgL .Academy o1 Cogniti5e Thera(y/ htt()LL???.tem("e.eduL(hobiaL .Adu"t An0iety C"inic o1 Tem("e 4ni5ersity/ htt()LL???.adaa.orgLGettingHe"(LAn0ietyDisordersL*ocia"Phobia.as( .An0iety Disorders Association o1 America/ htt()LL???.abct.org .Association 1or ,eha5iora" and Cogniti5e Thera(ies/ htt()LL???.nimh.nih.go5LHea"th3n1ormationLsocia"(hobiamenu.c1m .7ationa" 3nstitute o1 Menta" Hea"th/

=% htt()LL???.nmha.orgLgoLin1ormationLget:in1oLan0iety:disordersLsocia":(hobias .7ationa" Menta" Hea"th Association/ htt()LL???.socia"(hobia.orgL .*ocia" An0ietyL*ocia" Phobia Association/ htt()LL???.(aruresis.comL .3nternationa" Paruresis Association/

=8 'eferences A"bano AM, Marten PA, Ho"t C*, et a") Cogniti5e:beha5iora" grou( treatment 1or socia" (hobia in ado"escents) a (re"iminary study. + 7er5 Ment Dis $'8);=9:;<;, $99< A"den L!) Morita thera(y ?ith socia""y a5oidant c"ients. 3nternationa" ,u""etin o1 Morita Thera(y $)=8:<$, $9'' A"1onso R) ,rie1 Morita inter5ention ?ith a socia""y an0ious c"ient) a case study. 3nternationa" ,u""etin o1 Morita Thera(y <)%;:8=, $99% A":Kubaisy T, Marks 3M, Logsdai" *, et a") Ro"e o1 e0(osure home?ork in (hobia reduction) a contro""ed study. ,eha5ior Thera(y %8)<99:;%$, $99% A"strEm +!, 7ord"und CL, Persson G, et a") !11ects o1 1our treatment methods on socia" (hobic (atients not suitab"e 1or insight:oriented (sychothera(y. Acta Psychiatr *cand 6&)96:$$&, $9'= American Psychiatric Association) Diagnostic and *tatistica" Manua" o1 Menta" Disorders, 8rd !dition. 2ashington, DC, American Psychiatric Association, $9'& American Psychiatric Association) Diagnostic and *tatistica" Manua" o1 Menta" Disorders, 8rd !dition, Re5ised. 2ashington, DC, American Psychiatric Association, $9'6 American Psychiatric Association) Diagnostic and *tatistica" Manua" o1 Menta" Disorders, =th !dition, Te0t Re5ision. 2ashington, DC, American Psychiatric Association, %&&& Anderson PL, Nimand !, Hodges L#, Rothbaum ,-) Cogniti5e beha5iora" thera(y 1or (ub"ic: s(eaking an0iety using 5irtua" rea"ity 1or e0(osure. De(ress An0iety %%)$<;:$<', %&&< Andersson G, Car"bring P, Ho"mstrEm A, et a") 3nternet:based se"1:he"( ?ith thera(ist 1eedback in 5i5o grou( e0(osure 1or socia" (hobia) a randomiCed contro""ed tria". + Consu"t C"in Psycho" 6=);66:;';, %&&;

== ,ande"o? ,, *tein D+ .eds/) *ocia" An0iety Disorder. 7e? @ork, 7@, Marce" Dekker, %&&= ,ar"o? DH, 2o"1e ,!) ,eha5iora" a((roaches to an0iety disorders) a re(ort on the 73MH: *47@, A"bany, research con1erence. + Consu"t C"in Psycho" =9)==':=<=, $9'$ ,arrett PM, Dadds MR, Ra(ee RM) #ami"y treatment o1 chi"dhood an0iety) a contro""ed tria". + Consu"t C"in Psycho" ;=)888:8=%, $99; ,eide" DC, Turner *M, Morris TL) ,eha5iora" treatment o1 chi"dhood socia" (hobia. + Consu"t C"in Psycho" ;')$&6%:$&'&, %&&& ,eide" DC, Turner *M, @oung, ,+, Pau"son A) *ocia" e11ecti5eness thera(y 1or chi"dren) three: year 1o""o? u(. + Consu"t C"inica" Psycho" 68)6%$:6%<, %&&< ,eide" DC, Turner *M, @oung ,+) *ocia" e11ecti5eness thera(y 1or chi"dren) 1i5e years "ater. ,eha5ior Thera(y 86)=$;:=%<, %&&; ,orge #M, Ho11art A, *e0ton H, C"ark, DM, Marko?itC +C, McManus #) Residentia" cogniti5e thera(y 5ersus residentia" rnter(ersona" thera(y 1or socia" (hobia) a randomiCed c"inica" tria". + An0iety Disorders, in (ress ,outon M!) Conte0t, ambiguity, and un"earning) sources o1 re"a(se a1ter beha5iora" e0tinction. ,io" Psych <%)96;:9';, %&&% ,ro?n !,, Heimberg RG, +uster HR) *ocia" (hobia subty(e and a5oidant (ersona"ity disorder) e11ect on se5erity o1 socia" (hobia, im(airment, and outcome o1 cogniti5e:beha5iora" treatment. ,eha5ior Thera(y %;)=;6:=';, $99< ,uckner +D, !gg"eston AM, *chmidt 7,) *ocia" an0iety and (rob"ematic a"coho" consum(tion) the mediating ro"e o1 drinking moti5es and situations. ,eha5ior Thera(y 86)8'$:89$, %&&;

=< ,uckner +D, *chmidt 7,, Lang AR, *ma"" +, *ch"auch RC, Le?insohn PM) *(eci1icity o1 socia" an0iety disorder as a risk 1actor 1or a"coho" and cannabis de(endence. +ourna" o1 Psychiatric Research =%)%8&:%89, %&&' ,uckner +D, Led"ey DR, Heimberg RG, *chmidt 7,) Treating comorbid socia" an0iety and a"coho" use disorders) combining moti5ation enhancement thera(y ?ith cogniti5e:beha5iora" thera(y. C"inica" Case *tudies, in (ress ,ut"er G) !0(osure as a treatment 1or socia" (hobia) some instructi5e di11icu"ties. ,eha5 Res Ther %8);<$:;<6, $9'< ,ut"er G, Cu""ington A, Munby M, et a") !0(osure and an0iety management in the treatment o1 socia" (hobia. + Consu"t C"in Psycho" <%);=%:;<&, $9'= Chamb"ess DL, Ho(e DA) Cogniti5e a((roaches to the (sycho(atho"ogy and treatment o1 socia" (hobia, in #rontiers o1 Cogniti5e Thera(y. !dited by *a"ko5skis PM. 7e? @ork, 7@, Gui"1ord Press, $99;, (( 8=<:8'% Chamb"ess DL, Tran GT, G"ass CR) Predictors o1 res(onse to cogniti5e:beha5iora" grou( thera(y 1or socia" (hobia. + An0iety Disorders $$)%%$:%=&, $996 C"ark DM, 2e""s A) A cogniti5e mode" o1 socia" (hobia, in *ocia" Phobia) Diagnosis, Assessment and Treatment. !dited by Heimberg RG, Liebo?itC MR, Ho(e DA, *chneier #R. 7e? @ork, 7@, Gui"1ord Press, $99<, (( ;9:98 C"ark DM, !h"ers A, McManus #, et a") Cogniti5e thera(y 5ersus 1"uo0etine in genera"iCed socia" (hobia) a randomiCed ("acebo:contro""ed tria". + Consu"t C"in Psycho" 6$)$&<':$&;6, %&&8 C"ark DM, !h"ers A, Hackmann A, et a") Cogniti5e thera(y 5ersus e0(osure and a(("ied re"a0ation in socia" (hobia) a randomiCed contro""ed tria". + Consu"t C"in Psycho" 6=)<;':<6', %&&;

=; C"ark +R, Arko?itC H) *ocia" an0iety and se"1:e5a"uation o1 inter(ersona" (er1ormance. Psycho" Re( 8;)%$$:%%$, $96< CroCier 2R, A"den L! .eds/) The !ssentia" Handbook o1 *ocia" An0iety 1or C"inicians. Chichester, 4nited Kingdom, +ohn 2i"ey *ons, Ltd, %&&<

Da"rym("e K L, Herbert +D) Acce(tance and commitment thera(y 1or genera"iCed socia" an0iety disorder. ,eha5ior Modi1ication 8$)<=8:<;', %&&6 Da5idson +RT, #oa !,, Hu((ert +, et a") #"uo0etine, com(rehensi5e cogniti5e beha5iora" thera(y, and ("acebo in genera"iCed socia" (hobia. Arch Gen Psychiatry ;$)$&&<M$&$8, %&&= DeMe""o M#, de +esus Mari +, ,aca"tchuk +, Rerde"i H, 7eugebauer R) A systematic re5ie? o1 research 1indings on the e11icacy o1 inter(ersona" thera(y 1or de(ressi5e disorders. !ur Arch Psychiatry %<<)6<:'%, %&&< DiGiuse((e R, McGo?an L, *utton:*imon K, Gardner #) A com(arati5e outcome study o1 1our cogniti5e thera(ies in the treatment o1 socia" an0iety. +ourna" o1 Rationa":!moti5e and Cogniti5e:,eha5ior Thera(y ')$%9:$=;, $99& !de"man R!, Chamb"ess DL) Adherence during sessions and home?ork in cogniti5e:beha5iora" grou( treatment o1 socia" (hobia. ,eha5 Res Ther 88)<68:<66, $99< !""is A) Reason and !motion in Psychothera(y. 7e? @ork, Ly"e *tuart, $9;% !mme"kam( PM, Mersch PP, Rissia !, 5an der He"m M) *ocia" (hobia) a com(arati5e e5a"uation o1 cogniti5e and beha5iora" inter5entions. ,eha5 Res Ther %8)8;<:8;9, $9'< !r?in ,A, Heimberg RG, +uster H, Mind"in, M) Comorbid an0iety and mood disorders among (ersons ?ith socia" an0iety disorder. ,eha5 Res Ther =&)$9:8<, %&&%

=6 !r?in ,A, Heimberg RG, *chneier #R, Liebo?itC MR) Anger e0(erience and e0(ression in socia" an0iety disorder) (retreatment (ro1i"e and (redictors o1 attrition and res(onse to cogniti5e:beha5iora" treatment. ,eha5ior Thera(y 8=)88$:8<&, %&&8 !r?in ,A, Turk CL, Heimberg RG, et a") The internet) home to a se5ere (o(u"ation o1 indi5idua"s ?ith socia" an0iety disorderU + An0iety Disorders $') ;%9:;=;, %&&= !r?in ,A, Heimberg RG, Mar0 ,P, #rank"in M!) Traumatic and socia""y stress1u" "i1e e5ents among (ersons ?ith socia" an0iety disorder. + An0iety Disorders %&)'9;:9$=, %& '9;:9$=, %&&; #a""oon 3RH, L"oyd GG, Har(in R!) The treatment o1 socia" (hobia) rea":"i1e rehearsa" ?ith non(ro1essiona" thera(ists. + 7er5 Ment Dis $;9)$'&:$'=, $9'$ #a5a GA, Grandi *, Canestrari R) Treatment o1 socia" (hobia by home?ork e0(osure. Psychother Psychosom <%)%&9:%$8, $9'9 #edoro11 3C, Tay"or *) Psycho"ogica" and (harmaco"ogica" treatments 1or socia" an0iety disorder) a meta:ana"ysis. + C"in Psycho(harm %$)8$$:8%=, %&&$ #eske 4, Chamb"ess DL) Cogniti5e beha5iora" 5ersus e0(osure on"y treatment 1or socia" (hobia) a meta:ana"ysis. ,eha5ior Thera(y %;);9<:6%&, $99< #ink CM, Turner *M, ,eide" DC) Cu"tura""y re"e5ant 1actors in the beha5iora" treatment o1 socia" (hobia) a case study. + An0iety Disorders $&)%&$:%&9, $99; #oa !,, KoCak M+) !motiona" (rocessing o1 1ear) e0(osure to correcti5e in1ormation. Psycho" ,u"" 99)%&:8<, $9'; Gabbard G-) Psychodynamics o1 (anic disorder and socia" (hobia. ,u"" Menninger C"inic <;)A8:$8, $99%. Ga""gher HM, Rabian ,A, McC"oskey M*) A brie1 cogniti5e:beha5iora" inter5ention 1or socia" (hobia in chi"dhood. + An0iety Disorders $')=<9:=69, %&&=

=' G"asgo? R!, Arko?itC H) The beha5iora" assessment o1 ma"e and 1ema"e socia" com(etence in dyadic interactions. ,eha5ior Thera(y ;)='':=9', $96< Gou"d RA, ,uckminster *, Po""ack MH, et a") Cogniti5e:beha5iora" and (harmaco"ogica" treatment 1or socia" (hobia) a meta:ana"ysis. C"in Psycho") *ci Prac =)%9$:8&;, $996 Grant ,#, Hasin D*, ,"anco C, et a") The e(idemio"ogy o1 socia" an0iety disorder in the 4nited *tates) resu"ts 1rom the 7ationa" !(idemio"ogica" *ur5ey on A"coho" And Re"ated Conditions. + C"in Psychiatry ;;)$8<$:$8;$, %&&< Ha"1ord K, #oddy M) Cogniti5e and socia" ski""s corre"ates o1 socia" an0iety. ,r + C"in Psycho" %$)$6:%', $9'% Har5ey AG, C"ark DA, !h"ers A, Ra(ee RM) *ocia" an0iety and se"1:im(ression) cogniti5e (re(aration enhances the bene1icia" e11ects o1 5ideo 1eedback 1o""o?ing a stress1u" socia" task. ,eha5 Res Ther 8')$$'8:$$9%, %&&& Hayes *A, Ho(e DA, RanDyke M, Heimberg RG) 2orking a""iance 1or c"ients ?ith socia" an0iety disorder) re"ationshi( ?ith session he"(1u"ness and ?ithin:session habituation. Cogniti5e ,eha5iour Thera(y 8;)8=:=%, %&&6 Hayes *C, 2i"son KG, Gi11ord !R, #o""ette RM, *trosah" K) !0(erientia" a5oidance and beha5iora" disorders) a 1unctiona" dimensiona" a((roach to diagnosis and treatment. + Consu"t C"in Psycho" ;=)$$<%M$$;', $99; Hay?ard C, Rarady *, A"bana AM, Thienemann M, Henderson L, *chatCberg A#) Cogniti5e: beha5iora" grou( thera(y 1or socia" (hobia in 1ema"e ado"escents) resu"ts o1 a (i"ot study. + American Academy o1 Chi"d and Ado"escent Psychiatry 89)6%$:6%;, %&&&

=9 Heimberg RG) *ocia" (hobia, a5oidant (ersona"ity disorder, and the mu"tia0ia" conce(tua"iCation o1 inter(ersona" an0iety, in Trends in Cogniti5e and ,eha5ioura" Thera(ies. !dited by P. *a"ko5skis. *usse0, !ng"and, +ohn 2i"ey *ons Ltd., $99;, (( =8:;%

Heimberg RG. Cogniti5e:beha5iora" and (sychothera(eutic strategies 1or socia" an0iety disorder. A (a(er (resented at the annua" meeting o1 the An0iety Disorders Association o1 America, Toronto, -ntario, Canada, March %&&8 Heimberg RG, ,ecker R!) Cogniti5e:,eha5iora" Grou( Thera(y 1or *ocia" Phobia) ,asic Mechanisms and C"inica" *trategies. 7e? @ork, 7@, Gui"1ord Press, %&&% Heimberg RG, +uster HR) Cogniti5e:beha5iora" treatments) "iterature re5ie?, in *ocia" Phobia) Diagnosis, Assessment and Treatment. !dited by Heimberg RG, Liebo?itC MR, Ho(e DA, *chneier #R. 7e? @ork, 7@, Gui"1ord Press, $99<, (( %;$:8&9 Heimberg RG, Dodge C*, Ho(e DA, et a") Cogniti5e:beha5iora" grou( treatment o1 socia" (hobia) com(arison to a credib"e ("acebo contro". Cogniti5e Thera(y and Research $=)$:%8, $99& Heimberg RG, Liebo?itC MR, Ho(e DA, et a") Cogniti5e:beha5iora" grou( thera(y 5ersus (hene"Cine in socia" (hobia) $%:?eek outcome. Arch Gen Psychiatry <<)$$88:$$=$, $99' Heimberg RG, *a"Cman DG, Ho"t C*, et a") Cogniti5e:beha5iora" grou( treatment 1or socia" (hobia) e11ecti5eness at 1i5e:year 1o""o?:u(. Cogniti5e Thera(y and Research $6)8%<:889, $998 Herbert +D, Gaudiano ,A, Rheingo"d AA, et a") *ocia" ski""s training augments the e11ecti5eness o1 cogniti5e beha5iora" grou( thera(y 1or socia" an0iety disorder. ,eha5ior Thera(y 8;) $%<: $8', %&&<

<& Ho1mann *G) Cogniti5e mediation o1 treatment change in socia" (hobia. + Consu"t C"in Psycho" 6%)89%:899, %&&= Ho1mann *G, *u5ak M) Treatment attrition during grou( thera(y 1or socia" (hobia. + An0iety Disorders %&)9;$:96%, %&&; Ho1mann *G, Meuret A!, *mits +A+, *imon 7M, Po""ack MH, !isenmenger K, *hiekh M, -tto, M2) Augmentation o1 e0(osure thera(y ?ith D:cyc"oserine 1or socia" an0iety disorder. Arch Gen Psychiatry ;8)%9':8&= Ho(e DA, Heimberg RG, ,ruch MA) Dismant"ing cogniti5e:beha5iora" grou( thera(y 1or socia" (hobia. ,eha5 Res Ther 88);86:;<&, $99<a Ho(e DA, Herbert +D, 2hite C) Diagnostic subty(e, a5oidant (ersona"ity disorder, and e11icacy o1 cogniti5e beha5iora" grou( thera(y 1or socia" (hobia. Cogniti5e Thera(y and Research $9)%'<:8&8, $99<b Ho(e DA, Heimberg RG, +uster H, Turk CL) Managing *ocia" An0iety) A Cogniti5e:,eha5iora" Thera(y A((roach .C"ient 2orkbook/. 7e? @ork, 7@, -01ord 4ni5ersity Press, %&&& Ho(e DA, Heimberg RG, Turk CL) Managing *ocia" An0iety) A Cogniti5e:,eha5iora" Thera(y A((roach .Thera(ist Guide/. 7e? @ork, 7@, -01ord 4ni5ersity Press, %&&; 3shiyama #3) ,rie1 Morita thera(y on socia" an0iety) a sing"e case study o1 thera(eutic changes. Canadian +ourna" o1 Counse"ing %&)<;:;<, $9'; 3shiyama #3) 4se o1 Morita thera(y in shyness counse"ing in the ?est) (romoting c"ientsB se"1: acce(tance and action taking. + Counse"ing and De5e"o(ment ;<)<=6:<<$, $9'6 3shiyama #3) A +a(enese re1raming techniAue 1or brie1 socia" an0iety treatment) an e0("oratory study o1 cogniti5e and thera(eutic e11ects o1 Morita thera(y. + Cogniti5e Psychothera(y <)<<: 6&, $99$

<$ +errema"m A, +ansson L, Qst L:G) Cogniti5e and (hysio"ogica" reacti5ity and the e11ects o1 di11erent beha5iora" methods in the treatment o1 socia" (hobia. ,eha5 Res Ther %=)$6$:$'&, $9'; Kanter 7+, Go"d1ried MR) Re"ati5e e11ecti5eness o1 rationa" restructuring and se"1:contro" desensitiCation in the reduction o1 inter(ersona" an0iety. ,eha5ior Thera(y $&)=6%:=9&, $969 Kenda"" PC) Treating an0iety disorders in chi"dren) resu"ts o1 a randomiCed c"inica" tria". + Consu"t C"in Psycho" ;%)$&&:$$&, $99= Kenda"" PC, #"annery:*chroeder !, Paniche""i:Minde" *M, et a") Thera(y 1or youths ?ith an0iety disorders) a second randomiCed c"inica" tria". + Consu"t C"in Psycho" ;<)8;;:8'&, $996 Kenda"" PC, *a11ord *, #"annery:*chroeder !) Chi"d an0iety treatment) outcomes and im(act on substance use and de(ression at 6.=:year 1o""o?:u(. + Consu"t C"in Psycho" 6%)%6;:%'6, %&&= Kim H:@, Lundh L:G, Har5ey A) The enhancement o1 5ideo 1eedback by cogniti5e (re(aration in the treatment o1 socia" an0iety. A sing"e session e0(eriment. + ,eha5 Ther !0( Psychiatry 88)$9:86, %&&% K"inger !, ,ouchard *, LVgeron P, et a". Rirtua" rea"ity thera(y 5ersus cogniti5e thera(y 1or socia" (hobia) a (re"iminary contro""ed study. Cyber(sycho"ogy and ,eha5ior ')6;:'', %&&< KosCycki D, ,enger M, *h"ik +, ,rad?eJn, +) RandomiCed tria" o1 a meditation:based stress reduction (rogram and cogniti5e beha5ior thera(y in genera"iCed socia" an0iety disorder. ,eha5 Res Ther =<)%<$':%<%;, %&&6 Led"ey DR, Heimberg RG) *ocia" an0iety disorder, in 3m(ro5ing -utcomes and Pre5enting Re"a(se in Cogniti5e ,eha5iora" Thera(y. !dited by Antony MM, Led"ey DR, Heimberg RG. 7e? @ork, 7@, Gui"1ord Press, %&&<, (( 8':6;

<% Led"ey DR, Hu((ert +D, #oa !,, et a") 3m(act o1 de(ressi5e sym(toms on the treatment o1 genera"iCed socia" an0iety disorder. De(ress An0iety %%)$;$:$;6, %&&< Leichsenring #, ,eute" M, Leibing !) Psychodynamic (sychothera(y 1or socia" (hobia) a treatment based on su((orti5e:e0(ressi5e thera(y. ,u"" Meninger C"inic 6$)<;:'8, %&&6 Leung A2, Heimberg RG) Home?ork com("iance, (erce(tions o1 contro", and outcome o1 cogniti5e:beha5iora" treatment o1 socia" (hobia. ,eha5 Res Ther 8=)=%8:=8%, $99; Liebo?itC MR, Heimberg RG, *chneier #R, et a") Cogniti5e:beha5iora" grou( thera(y 5ersus (hene"Cine in socia" (hobia) "ong:term outcome. De(ress An0iety $&)'9:9', $999 Li(sitC +D, Marko?itC +C, Cherry *, #yer A+) -(en tria" o1 inter(ersona" (sychothera(y 1or the treatment o1 socia" (hobia. Am + Psychiatry $<;)$'$=:$'$;, $999 Li(sitC +D, Gur M, Rermes D, Petko5a !, Cheng +, Mi""er 7, et a") A randomiCed tria" o1 inter(ersona" thera(y 5ersus su((orti5e thera(y 1or socia" an0iety disorder. De(ress An0iety, in (ress Lucas RA, Te"ch M+) Grou( 5ersus indi5idua" treatment o1 socia" (hobia. Pa(er (resented at the annua" meeting o1 the Association 1or Ad5ancement o1 ,eha5ior Thera(y, At"anta, GA, 7o5ember $998 Lucock MP, *a"ko5skis PM) Cogniti5e 1actors in socia" an0iety and its treatment. ,eha5 Res Ther %;)%96:8&%, $9'' Marko?itC +C) Psychothera(y o1 dysthymia. Am + Psychiatry $<$)$$$=:$$%$, $99= MarCi""ier +*, Lambert C, Ke""et +) A contro""ed e5a"uation o1 systematic desensitiCation and socia" ski""s training 1or socia""y inadeAuate (sychiatric (atients. ,eha5 Res Ther $=)%%<:%8', $96;

<8 Masia:2arner C, K"ein RG, Dent HC, #isher PH, A"5ir +, A"bano A, Guardino M) *choo":based inter5ention 1or ado"escents ?ith socia" an0iety disorder) resu"ts o1 a contro""ed study. + Abnorm Chi"d Psycho" 88)6&6:6%%, %&&< Mattick RP, Peters L) Treatment o1 se5ere socia" (hobia) e11ects o1 guided e0(osure ?ith and ?ithout cogniti5e restructuring. + Consu"t C"in Psycho" <;)%<$:%;&, $9'' Mattick RP, Peters L, C"arke +C) !0(osure and cogniti5e restructuring 1or socia" (hobia) a contro""ed study. ,eha5ior Thera(y %&)8:%8, $9'9 Mc7ei" D2, LeJueC C2, *orre"" +T) ,eha5iora" theories o1 socia" (hobia) contributions o1 basic beha5iora" (rinci("es, in #rom *ocia" An0iety to *ocia" Phobia) Mu"ti("e Pers(ecti5es. !dited by Ho1mann *G, Di,arto"o PM. 7eedham Heights, MA, A""yn ,acon, %&&$ Mersch PPA, !mme"kam( PMG, ,Ege"s *M, 5an der *"een +) *ocia" (hobia) indi5idua" res(onse (atterns and the e11ects o1 beha5iora" and cogniti5e inter5entions. ,eha5 Res Ther %6)=%$: =8=, $9'9 Mi""er ++, #"etcher K, Kabat:Ninn +) Three:year 1o""o?:u( and c"inica" im("ications o1 a

mind1u"ness meditation:based stress reduction inter5ention in the treatment o1 an0iety disorders. Genera" Hos(ita" Psychiatry $6)$9%:%&&, $99< Mi""er 2R, N?eben A, DiC"emente CC, Rychtarik RG) Moti5ationa" !nhancement Thera(y manua") a c"inica" research guide 1or thera(ists treating indi5idua"s ?ith a"coho" abuse and de(endence. Rock5i""e, MD) 7ationa" 3nstitute on A"coho" Abuse and A"coho"ism, $99% MErtberg !, C"ark DM, *undin Q, 2istedt AA) 3ntensi5e grou( cogniti5e treatment and indi5idua" cogniti5e thera(y 5s. treatment as usua" in socia" (hobia) a randomiCed contro""ed tria". Acta Psychiatrica *cand $$<)$=%:$<=, %&&6

<= Mosco5itch DA, Ho1mann *G, *u5ak MK, 3n:A"bon T) Mediation o1 changes in an0iety and de(ression during treatment o1 socia" (hobia. + Consu"t C"inica" Psycho" 68)9=<:9<%, %&&< 7e?man MG, Ho1mann *G, Trabert 2, et a") Does beha5iora" treatment o1 socia" (hobia "ead to cogniti5e changesU ,eha5ior Thera(y %<)<&8:<$6, $99= -"1son M, Guardino M, *truening !, *chneier #R, He""man #, K"ein D#) ,arriers to treatment o1 socia" an0iety. Am + Psychiatry $<6)<%$:<%6, %&&& -ssman 2A, 2i"son KG, *toraas"i RD, Mc7ei"" +2) A (re"iminary in5estigation o1 the use o1 acce(tance and commitment thera(y in a grou( treatment 1or socia" (hobia. 3nternationa" + Psycho"ogy and Psycho"ogica" Thera(y ;)896:=$;, %&&; Qst L:G) A(("ied re"a0ation) descri(tion o1 a co(ing techniAue and re5ie? o1 contro""ed studies. ,eha5 Res Ther %<)896:=&9, $9'6 Qst L:G, +errema"m A, +ohansson +) 3ndi5idua" res(onse (atterns and the e11ects o1 di11erent beha5iora" methods in the treatment o1 socia" (hobia. ,eha5 Res Ther $9)$:$;, $9'$ -tto M2, Po""ck MH, Gou"d, RA, et a") A com(arison o1 the e11icacy o1 c"onaCe(am and cogniti5e:beha5iora" grou( thera(y 1or the treatment o1 socia" (hobia. + An0iety Disorders $=)8=<M8<', %&&& Ponniah K, Ho""on *D) !m(irica""y su((orted (sycho"ogica" inter5entions 1or socia" (hobia in adu"ts) a Aua"itati5e re5ie? o1 randomiCed contro""ed tria"s. Psycho" Med 8')8:$=, %&&6 Randa"" CL, Thomas *, The5os AK) Concurrent a"coho"ism and socia" an0iety disorder) a 1irst ste( to?ard de5e"o(ing e11ecti5e treatments. A"coho"ism) C"inica" and !0(erimenta" Research %<)%$&:%%&, %&&$ Ra(ee RM, Heimberg RG) A cogniti5e:beha5iora" mode" o1 an0iety in socia" (hobia. ,eha5 Res Ther 8<)6=$:6<;, $996

<< Ra(ee RM, Lim L) Discre(ancy bet?een se"1: and obser5er ratings o1 (er1ormance in socia" (hobics. + Abnorm Psycho" $&$)6%':68$, $99% Reyno"ds DK) The Tuiet Thera(ies. Hono"u"u, 4ni5ersity Press o1 Ha?aii, $9'& Rodebaugh TL, Chamb"ess DL) The e11ects o1 5ideo 1eedback on se"1:(erce(tion o1 (er1ormance) a re("ication and e0tension. Cogniti5e Thera(y and Research %;);%9:;==, %&&% Rodebaugh TL, Ra(ee RM) Those ?ho think they "ook ?orst res(ond best) se"1:obser5er discre(ancy (redicts res(onse to 5ideo 1eedback 1o""o?ing a s(eech task. Cogniti5e Thera(y and Research %9)6&<:6$<, %&&< *a1ren *A, Heimberg RG, +uster HR) C"ient e0(ectancies and their re"ationshi( to (retreatment sym(tomato"ogy and outcome o1 cogniti5e beha5iora" grou( treatment 1or socia" (hobia. + Consu"t C"in Psycho" ;<);9=:;9', $996 *mits +A+, Po?ers M,, ,u0kam(er R, Te"ch M+. The e11icacy o1 5ideota(e 1eedback 1or enhancing the e11ects o1 e0(osure:based treatment 1or socia" an0iety disorder) a contro""ed in5estigation. ,eha5 Res Ther ==)$668M$6'<, %&&; *tangier 4, Heidenreich T, PeitC M, Lauterbach 2, C"ark DM) Cogniti5e thera(y 1or socia" (hobia) indi5idua" 5ersus grou( treatment. ,eha5 Res Ther =$)99$:$&&6, %&&8 *to(a L, C"ark DM) Cogniti5e (rocesses in socia" (hobia. ,eha5 Res Ther 8$)%<<:%;6, $998 *tra5ynski A, Marks 3, @u"e 2) *ocia" ski""s (rob"ems in neurotic out(atients) socia" ski""s training ?ith and ?ithout cogniti5e modi1ication. Arch Gen Psychiatry 89)$86':$8'<, $9'% Taube:*chi11 M, *u5ak MK, Antony MM, ,ie"ing P+, McCabe R!) Grou( cohesion in cogniti5e:beha5iora" grou( thera(y 1or socia" (hobia. ,eha5 Res Ther =<);'6M;9', %&&6 Tay"or *) Meta:ana"ysis o1 cogniti5e:beha5iora" treatments 1or socia" (hobia. + ,eha5 Ther !0( Psychiatry %6)$:9, $99;

<; Tread?e"" KRH, #"annery:*chroeder, !C, Kenda"" PC) !thnicity and gender in re"ation to ada(ti5e 1unctioning, diagnostic status, and treatment outcome in chi"dren 1rom an an0iety c"inic. + An0iety Disorders 9)868:8'8, $99< Turk CL, #resco DM, Heimberg RG) *ocia" (hobia) cogniti5e beha5ior thera(y, in Handbook o1 Com(arati5e Treatments o1 Adu"t Disorders, %nd edition. !dited by Hersen M, ,e""ack A*. 7e? @ork, +ohn 2i"ey *ons, $999, (( %'6:8$; Turk CL, Heimberg RG, Magee L) *ocia" an0iety disorder, in C"inica" Handbook o1 Psycho"ogica" Disorders .=th edition/. !dited by ,ar"o? DH. 7e? @ork, 7@, Gui"1ord Press, %&&', (( $%8:$;8 Turner *M, ,eide" DC, Coo"ey MR, et a") A mu"ti:com(onent beha5iora" treatment 1or socia" (hobia) *ocia" !11ecti5eness Thera(y. ,eha5 Res Ther 8%)8'$:89&, $99=a Turner *M, ,eide" DC, +acob, RG) *ocia" (hobia) a com(arison o1 beha5ior thera(y and ateno"o". + Consu"t C"in Psycho" ;%)8<&:8<', $99=b Turner *M, ,eide" DC, Coo"ey:Tui""e MR) T?o:year 1o""o?:u( o1 socia" (hobics treated ?ith *ocia" !11ecti5eness Thera(y. ,eha5 Res Ther 88)<<8:<<<, $99< 2e""s A, Pa(ageorgiou C) *ocia" (hobia) e11ects o1 e0terna" attention in an0iety, negati5e be"ie1s, and (ers(ecti5e taking. ,eha5ior Thera(y %9)8<6:86&, $99' 2estra HA, DoCois D+A) Pre(aring c"ients 1or cogniti5e beha5iora" thera(y) a randomiCed (i"ot study o1 moti5ationa" inter5ie?ing 1or an0iety. Cogniti5e Thera(y and Research 8&)='$:=9', %&&; 2i"d +, Hackmann A, C"ark DM) Rescri(ting ear"y memories "inked to negati5e images in socia" (hobia) a (i"ot study. ,eha5ior Thera(y, in (ress

<6 2i"1"ey D!, 2e"ch RR, *tein R3, *(urre" !,, Cohen LR, *a"ens ,!, et a") A randomiCed com(arison o1 grou( cogniti5e beha5ior thera(y and grou( inter(ersona" thera(y 1or the treatment o1 o5er?eight indi5idua"s ?ith binge:eating disorder. Arch Gen Psychiatry <9)6$8: 6%$, %&&% 2"aC"o N, *chroeder:Hart?ig K, Hand 3, et a") !0(osure in 5i5o 5s. socia" ski""s training 1or socia" (hobia) "ong:term outcome and di11erentia" e11ects. ,eha5 Res Ther %')$'$:$98, $99& 2oody *R, Adessky R*) Thera(eutic a""iance, grou( cohesion, and home?ork com("iance during cogniti5e:beha5iora" grou( treatment o1 socia" (hobia. ,eha5ior Thera(y 88)<:%6, %&&% 2right +H, ,asco MR, Thase M!) Learning cogniti5e:beha5ior thera(y) an i""ustrated guide. 2ashington, DC, American Psychiatric Pub"ishing, %&&; Naider T, Heimberg RG, Roth DA, Ho(e DA, Turk CL) 3ndi5idua" C,T 1or socia" an0iety disorder) Pre"iminary 1indings. A (a(er (resented at the annua" meeting o1 the Association 1or Ad5ancement o1 ,eha5ior Thera(y, ,oston, MA, 7o5ember %&&8 Nerbe K+) 4ncharted ?aters) (sychodynamic considerations in the diagnosis and treatment o1 socia" (hobia, in #ear o1 Humi"iation) 3ntegrated Treatment o1 *ocia" Phobia and Comorbid Conditions. !dited by Menninger 22. 7e? +ersey, +ason Aronson 3nc, $996