Elsevier

Journal of Anxiety Disorders

Volume 11, Issue 3, May–June 1997, Pages 221-240
Journal of Anxiety Disorders

RESEARCH PAPERS
Predictors of Response to Cognitive-Behavioral Group Therapy for Social Phobia

https://doi.org/10.1016/S0887-6185(97)00008-XGet rights and content

Abstract

Response to cognitive-behavioral group therapy for social phobia was assessed at posttest and 6-month follow-up in a sample of 62 clients (41 generalized subtype, 21 nongeneralized). Predictors assessed were depression, expectancy, personality disorder traits, clinician-rated breadth and severity of impairment, and frequency of negative thoughts during social interactions. Outcome measures included self-report questionnaires and behavioral tests of dyadic interaction and a public speech. Although no predictor was related to outcome across all domains of measurement, higher depression, more avoidant personality traits, and lower treatment expectancy were each related to poorer treatment response on one or more outcome criteria. Cognitive change was consistently associated with change on self-report symptom measures, but, contrary to expectation, lower rates of negative thinking at posttest did not predict better maintenance of treatment gains at follow-up. © 1997 Elsevier Science Ltd

Section snippets

Social Impairment

Socially phobic people share the common fear of being negatively evaluated, yet are quite diverse in their degree of social impairment (American Psychiatric Association (1987), American Psychiatric Association (1994)). Clients with social phobia can be classified as belonging to specific (or nongeneralized) or generalized subtypes on the basis of the pervasiveness of their social fear, with the latter being associated with more severe symptoms (e.g., Tran and Chambless, 1995).

Several studies

Depression

The notable prevalence of a comorbid diagnosis of depression in clients with a primary diagnosis of social phobia (e.g., van Ameringen et al., 1991) prompts examination of the effect of mood state on clients' response to treatment. In such research, it is important to control for initial severity of social phobia, which is typically higher in more depressed clients (e.g., Heimberg et al., 1990b). Mixed findings have been obtained. Feske and colleagues (Feske et al., 1996) found that, compared

Personality Disorders

Research on personality disorders and treatment outcome for social phobia has focused almost exclusively on the effect of avoidant personality disorder (APD), the most common comorbid personality disorder for social phobia. The findings are inconsistent. Feske and associates (1996) found that, among clients with generalized social phobia, those with APD reported less improvement on overall functioning, but not on social anxiety, at termination of eclectic-behavior therapy than those without

Treatment Expectancy

The effect of treatment expectancy on outcome for social phobia has yet to be examined, but findings from subclinical speech phobia research suggest the importance of this variable. In studies conducted to date, clients' perceptions of treatment credibility and their expectations for improvement significantly predicted their responses to short-term therapy for speech anxiety (Kirsch and Henry, 1977Kirsch and Henry, 1979).

Posttreatment Negative Cognitions and Treatment Maintenance

Beck and Emery (1985) propose that socially phobic individuals are hypersensitive to the possibility of external evaluation and believe that they lack the personal resources (e.g., social skills, physical attractiveness, intellectual ability) to prevent social devaluation and rejection. At the core of the disorder are a vigilant cognitive set for rejection, rigid rules for socially appropriate behaviors, and exaggerated expectations about the consequences of failure.

Consistent with cognitive

Research Questions

In the present study, we examine the independent and shared effects of the following potential predictors of improvement after group CBT for social phobia at posttest and 6-month follow-up: degree of social impairment, depression, personality disorder traits, and treatment expectancy. Further, we test the relationship between cognitive change and treatment outcome, in particular the hypothesis that clients who have higher rates of negative thinking at posttest will relapse at a greater rate

Participants

The sample included 27 men and 35 women2 who entered the treatment program for social phobia at the American University Agoraphobia and Anxiety Program. All clients met DSM-III-R (American Psychiatric Association, 1987) criteria for a primary diagnosis of social phobia and were classified as generalized (n = 41) or specific (n = 21) in

Preliminary Analyses

Attrition. Of the 64 social phobic clients accepted for treatment, 2 refused treatment and 2 dropped out after pretest assessment. Of the remaining 60 clients who completed treatment, 59 provided posttest data. Forty-eight treatment completers returned 6 months later for follow-up assessment. We did not attempt to collect follow-up data from the first group of participants (n = 5). Because of missing data on some measures, sample sizes vary slightly in the analyses conducted.

Compositing outcome

Client Attributes and Treatment Outcome

Predictor intercorrelations. Two types of predictors were considered to assess their effects on short-term (pre/post) and long-term (pre/follow-up) symptom changes with treatment: predictors of substantive interest (treatment expectancy, depression, social impairment, and personality disorder traits) and predictors as control variables (psychotropic medication and additional therapy during follow-up). With the exception of depression, there was minimal overlap among most predictors.

Data

DISCUSSION

As has been true of previous research on social phobia and of research on other anxiety disorders (e.g., Steketee and Shapiro, 1995), the results of the present study yielded few predictors of treatment outcome for social phobia, and even these were not consistent across outcome measures.

The most salient predictor was depression. Clients with higher pretreatment scores on the Beck Depression Inventory were less likely to improve or remain improved on anxious apprehension and on self-rated

Acknowledgements

The authors wish to thank the many graduate students at American University who made this research possible by participating as raters, role play partners, and research assistants. We also thank Richard Heimberg for his generosity in sharing his treatment manual and Kristin Staroba and Melina Walker for their assistance in data analysis and reliability ratings.

References (60)

  • G.S. Steketee et al.

    Methodological issues in prediction of treatment outcome

    Clinical Psychology Review

    (1992)
  • G.S. Steketee et al.

    Predicting behavioral treatment outcome for agoraphobia and obsessive-compulsive disorder

    Clinical Psychology Review

    (1995)
  • L. Stopa et al.

    Cognitive processes in social phobia

    Behaviour Research and Therapy

    (1993)
  • G.Q. Tran et al.

    Psychopathology of social phobia: Effects of subtype and of avoidant personality disorder

    Journal of Anxiety Disorders

    (1995)
  • M. van Ameringen et al.

    Relationship of social phobia with other psychiatric illness

    Journal of Affective Disorders

    (1991)
  • J.P. Watson et al.

    Physiological habituation to continuous phobic stimulation

    Behaviour Research and Therapy

    (1972)
  • S.R. Woody et al.

    Self-focused attention in the treatment of social phobia

    Behaviour Research and Therapy

    (1997)
  • American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed. rev.)....
  • American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington,...
  • R.A. Baron et al.

    The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations

    Journal of Personality and Social Psychology

    (1986)
  • Beck, A.T., & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic...
  • Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York:...
  • Beck, A.T., & Steer, G. (1987). Manual for the revised Beck Depression Inventory. San Antonio, TX: The Psychological...
  • Belsley, D.A., Kuh, E., & Welsch, R.E. (1980). Regression diagnostics: Identifying influential data and sources of...
  • M.A. Bruch et al.

    States of mind model and cognitive change in treated social phobics

    Cognitive Therapy and Research

    (1991)
  • Chambless, D.L., & Hope, D.A. (1996). Cognitive approaches to the psychopathology and treatment of social phobia. In P....
  • Chambless, D.L., Perry, K.J., Fydrich, T., & Belecanech, M. (1996). Inter-rater reliability, stability, and concurrent...
  • D.M. Clark et al.

    A comparison of cognitive therapy, applied relaxation, and imipramine in the treatment of panic disorder

    British Journal of Psychiatry

    (1994)
  • U. Feske et al.

    Avoidant personality disorder as a predictor for severity and treatment outcome among generalized social phobics

    Journal of Personality Disorders

    (1996)
  • Frank, J.D. (1991). Persuasion and healing. Baltimore: Johns Hopkins University...
  • Cited by (187)

    • Positivity-approach training for depressive symptoms: A randomized controlled trial

      2019, Journal of Affective Disorders
      Citation Excerpt :

      Depressive symptoms are, for instance, associated with a higher chronic disease burden (Poole and Steptoe, 2018) and a higher mortality risk (Everson-Rose et al., 2004). They also predict worse treatment outcome in other psychological disorders, such as social phobia (Chambless et al., 1997), obsessive-compulsive disorder (Keijsers et al., 1994), or drug dependence (Compton et al., 2003). Thus, reducing depressive symptom severity in clinical settings is an important treatment target.

    View all citing articles on Scopus
    1

    Dianne Chambless is now at the University of North Carolina-Chapel Hill.

    View full text