© 2007 The Royal College of Psychiatrists
Treatment of social phobia through pure self-help and therapist-augmented self-help
Department of Psychology, Macquarie University, Sydney
Department of Psychology, University of Sydney
Department of Psychology, Macquarie University, Sydney
Macquarie University Anxiety Research Unit, Macquarie University, Sydney, New South Wales, Australia
Correspondence: Dr Ronald M. Rapee, Department of Psychology, Macquarie University, Sydney, NSW 2109, Australia. Email: Ron.Rapee{at}mq.edu.au
Declaration of interest R.M.R. authored the book used for bibliotherapy and receives royalties.
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Background Self-help for social phobia has not received controlled empirical evaluation.
Aims To evaluate the efficacy of pure self-help through written materials for severe social phobia and self-help augmented by five group sessions with a therapist. These conditions were compared with a waiting-list control and standard, therapist-led group therapy.
Method Participants with severe generalised social phobia (n=224) were randomised to one of four conditions. Assessment included diagnoses, symptoms and life interference at pretreatment, 12 weeks and at 24 weeks.
Results A larger percentage of patients no longer had a diagnosis of social phobia at post-intervention in the pure self-help group than in the waiting-list group, although this percentage decreased slightly over the next 3 months. Symptoms of social anxiety and life interference did not differ significantly between these groups. Augmented self-help was better than waiting list on all measures and did not differ significantly from group treatment.
Conclusions Self-help augmented by therapist assistance shows promise as a less resource-intensive method for the management of social phobia. Pure self-help shows limited efficacy for this disorder.
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Although treatments for social phobia (social anxiety disorder) have shown good efficacy (Gould, et al, 1997; Fedoroff & Taylor, 2001), traditional models of treatment delivery are associated with several limitations. These include their cost, the limited availability of mental health workers and most especially the small percentage of people with this disorder who seek traditional treatment (Meltzer et al, 2000; Issakidis & Andrews, 2002). Self-help and minimal therapist treatments provide a possible alternative to traditional therapy models. Bibliotherapeutic interventions have been applied with success to a wide range of difficulties (Scogin et al, 1990; Marrs, 1995), including anxiety disorders (Newman et al, 2003; Barlow et al, 2005). In contrast to research into other anxiety disorders, there has been little investigation into bibliotherapy for social phobia (e.g. Newman et al, 2003). The few studies that have been conducted have all included some degree of researcher involvement, hence limiting the conclusions that can be drawn about `pure' self-help. Our study was designed to determine the value of two forms of self-help through the use of bibliotherapeutic materials in the reduction of social phobia: pure bibliotherapy that involved almost no contact with the researchers, and therapist-augmented bibliotherapy in which printed material was supplemented with five group sessions conducted by a therapist. Benchmarks for these conditions were provided by comparison with a no-treatment waiting list and standard ten-session group therapy conducted by a therapist.
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Participants
Participants for the study were 224 individuals meeting DSM–IV criteria (American Psychiatric Association, 1994) for social phobia, randomly allocated to one of four treatment conditions: standard group treatment, `pure' self-help, self-help augmented with minimal therapist assistance, and waiting list. Participants were included if they were aged 20–65 years, met criteria for social phobia as their main (or most interfering) disorder, and had sufficient English and education to read a tabloid newspaper in English. In order to maximise external validity, exclusions were kept to a minimum. The only planned exclusions were problems requiring immediate attention such as clear suicidal intent, severe substance misuse or dependence, or florid psychosis, assessed during the structured interviews. Concurrent pharmacotherapy or psychotherapy was allowed as long as dosages had been consistent for 3 months and there was no plan to change. No participant was in concurrent psychotherapy. However, 6.8% were taking benzodiazepines or other anxiolytics, 21.2% were taking selective serotonin reuptake inhibitors or other antidepressants and 9.9% were taking other prescription medications.
Diagnoses of Axis I disorders were made by graduate students in clinical
psychology using a structured clinical interview, the Anxiety Disorders
Interview Schedule for DSM–IV (ADIS–IV;
Di Nardo et al,
1994). Data from our laboratory using this interview and including
a proportion of the current sample have indicated a moderate to strong
interrater reliability for diagnoses of anxiety and mood disorders, including
a very high reliability for a diagnosis of social phobia (
=0.89). In
addition, the avoidant personality disorder questions from the ICD–10
International Personality Disorder Examination
(Loranger et al,
1997) were also asked of all participants. Interrater reliability
for a diagnosis of avoidant personality disorder was moderate (=0.65).
Among the current sample, 95.7% met criteria for the generalised subtype of
social phobia and 55.8% met criteria for a diagnosis of avoidant personality
disorder. As would be expected in such a severely affected sample, Axis I
comorbidity was also high: 42.9% met criteria for an additional anxiety
disorder, 33.9% met criteria for an additional mood disorder and 4.0% met
criteria for an additional substance use or alcohol disorder. The mean age of
the sample was 35.5 years (s.d.=11.0) and 50.4% were female.
Measures
Participants were assessed with the following measures at a pre-treatment
interview and 12 weeks later. Participants in active treatment were also
followed up 12 weeks after that (24 weeks after the initial assessment).
Social Interaction Anxiety Scale and Social Phobia Scale
The Social Interaction Anxiety Scale (SIAS) and the Social Phobia Scale
(SPS) (Mattick & Clarke,
1998) are companion scales that assess the main fears and
avoidance of social phobia, focusing respectively on interaction fears and
more specific performance-based fears. They have excellent psychometric
properties (Peters, 2000).
Brief Fear of Negative Evaluation scale
The Brief Fear of Negative Evaluation scale (BFNE;
Leary, 1983) assesses the
cognitive aspects relevant to social phobia, especially those related to
negative evaluation. Psychometric properties are sound and it has shown
stronger validity that the previous Fear of Negative Evaluation scale
(Rodebaugh et al,
2004)
Albany Panic and Phobia Questionnaire
The Albany Panic and Phobia Questionnaire social phobia sub-scale
(APPQ–S; Rapee et al,
1994) is a brief set of items designed to tap social fears that
are relatively distinct from overlap with agoraphobic fears. Later examination
has shown consistent factor structure, solid reliability and clear concurrent
validity (Brown et al,
2005).
Self Consciousness Scale
The Self Consciousness Scale social anxiety sub-scale (SCS–A;
Fenigstein et al,
1975) is a six-item scale containing items tapping a variety of
broader aspects of shyness and social reticence. It has shown solid
psychometric properties in a number of translations and has been widely used
in the social anxiety literature.
Life Interference Scale
To provide a measure of the life impact of individuals' social fears, six
Likert scales (scored 0–8) asked respondents to indicate the impact of
their fears on various components of their life including work, family life
and leisure activities. The scales were summed to provide a total interference
rating from 0 (no interference) to 48 (maximum interference). Previous
analysis in our centre has shown that the six items show excellent internal
consistency (
=0.90) and the total correlates significantly with the
12-item Short-Form Health Survey (SF–12;
Ware et al, 1996)
mental component sub-scale (r=0.56).
Treatment conditions
Standard group treatment
Standard treatment was included to represent the `gold standard' treatment
effect. Treatment was conducted in groups of approximately six participants
with two graduate psychology student therapists who received minimal
supervision from an experienced clinical psychologist. Therapy extended for
ten 2 h sessions across 12 weeks. Treatment was manualised, based on
principles and components described in a book by Rapee & Sanderson
(1998). Components included
those typically found in empirically validated treatments for social phobia
including cognitive restructuring of negative evaluation beliefs, exposure to
feared social situations, realistic feedback of social performance, and
attention training. Participants engaged in home exercises and received
various handouts as relevant.
`Pure' self-help
Participants were given a copy of the book Overcoming Shyness and
Social Phobia: A Step by Step Guide
(Rapee, 1998) and told to read
it and work their way through the exercises described in the book. The
strategies outlined paralleled those in the standard group treatment, and
practice sheets and exercises formed part of the book. In order to encourage a
reasonable rate of progress, participants were given a cover letter with the
book welcoming them to the programme and providing a suggested rate of
progress in order to complete it in 12 weeks. They were told that
post-treatment assessment would occur at 12 weeks and thereafter they would
have no additional contact with the researchers. This condition was designed
to simulate conditions under which a person might obtain written materials
without professional assistance (for example, buying the book in a shop or
being given a manual while waiting for treatment).
Self-help augmented by therapist assistance
Participants in the augmented self-help condition were given a copy of the
same book as those in the pure self-help group and told to read and practise
the exercises described. They also met in groups of five to seven participants
with a therapist (a graduate psychology student) on five occasions across the
12 weeks. Each group session ran for 2 h; thus, the total therapist time was
exactly half of that in the standard group therapy programme. The same
therapists participated in this condition and in the standard treatment
condition. The aims of the group sessions were to problem-solve application of
the principles described in the book to the personal context of each
participant and to provide motivation and encouragement to apply these
principles.
Waiting list
Participants on the waiting list were told that they had been randomly
allocated to receive no treatment for 12 weeks. At the end of the 12-week
period they were offered our best available treatment.
Procedure
Potential participants contacted the Macquarie University Anxiety Research
Unit through the usual referral sources, including general practitioners,
mental health professionals, occasional media coverage and word of mouth.
These volunteers were screened by telephone and those who appeared to have
social anxiety-related difficulties were invited to attend for a structured
interview. Those who met inclusion criteria were randomly allocated to one of
the four conditions. Randomisation was done using a pre-assigned random number
generator in blocks of eight to allow for group delivery. Participants in the
pure self-help group were given a copy of the book and the cover letter and
were then simply contacted again after 12 weeks for a second assessment.
Participants in the augmented self-help group were given a copy of the book
and a schedule of group meetings. Participants in the standard treatment group
were simply given a schedule of meeting times. The procedures were approved by
the Macquarie University human research ethics committee.
Statistical analysis
Primary outcomes for this trial were a reduction in clinical diagnoses of
social phobia as assessed by the ADIS–IV, reduction in a composite of
social phobia symptom measures, and reductions in self-rated life
interference.
Following earlier research (Clark et al, 1994), several related symptom measures were grouped together and combined into a standardised composite to reduce the number of statistical tests performed and hence the type 1 error rate. A composite score was produced to represent total social phobia symptom severity. This comprised scores on the clinician-rated severity of social phobia derived from the ADIS–IV, the SPS and SIAS, the social phobia subscale of the APPQ, the social anxiety subscale of the SCS and the BFNE. Scores on each scale were standardised across all groups on all measurement occasions before being summed and re-standardised to give a mean for all groups and all measurement occasions of 0 and a standard deviation of 1.
The proportions of participants whose phobia was in remission at the post-treatment assessments and 3-month follow-up in each treatment condition were compared using Fisher's exact test. Differences between treatments in change in the standardised social phobia symptom composite and rating of life interference were examined using mixed models containing random intercept and random slope terms as well as fixed effects for treatment received (Gibbons et al, 1993). All analyses were conducted using the Statistical Package for the Social Sciences version 13.0.1 for Windows. Confidence intervals for the number needed to treat were calculated following Altman (1998).
Missing data
The number of participants who provided no data at post-treatment and at
3-month follow-up is shown in Fig.
1. The last value carried forward strategy was used to substitute
missing data if data were not available at the 3-month follow-up or at both
post-treatment and 3-month follow-up. Interpolation was used if post-treatment
data only were not available. As a precaution against biasing effects of these
methods of handling missing data, analyses were conducted with and without
missing data substituted. Analyses with missing data substituted are
equivalent to intent-to-treat analyses. However, analyses without missing data
substituted are not equivalent to so-called `completer' analyses. In most
clinical trials completer analyses include only those participants who receive
a sufficient `dose' of treatment (e.g. attend enough treatment sessions);
however, this cannot be determined in participants undergoing self-help.
Therefore analyses without missing data substitution may include some
participants who did not implement any of the self-help, even though they
returned data. There was no significant difference in the pre-treatment social
phobia symptom composite score between those who provided post-treatment and
follow-up data and those who did not (t(222)=–1.135,
P>0.05).
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Fig. 1 Study profile.
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Demographic data on the sample broken down across the four allocated groups are presented in Table 1.
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Table 1 Characteristics of the four groups of participants
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Diagnosis-free status
The number and percentage of participants from each treatment condition who
no longer met criteria for a diagnosis of social phobia at the post-treatment
and follow-up assessments are shown in
Table 2. At post-treatment
assessment, participants who received active treatments showed significantly
greater diagnosis-free rates (group treatment 22%, n=13; augmented
self-help 19%, n=11; pure self-help 20%, n=11) than the
waiting-list group (6%, n=3; Fisher's exact test
P<0.008). There was no significant difference in diagnosis-free
rates at post-treatment assessment between those who received some form of
group therapy (augmented self-help 19%, n=11; group treatment 22%,
n=13), and those who received pure self-help (20%, n=11;
Fisher's exact test P=0.522).
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Table 2 Participants without a clinical diagnosis of social phobia at
post-treatment and 3 month follow-up assessments
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At 3-month follow-up there were significantly more participants who no longer met ADIS–IV diagnostic criteria for social phobia in the group treatment and augmented self-help conditions (22%, n=13; 26%, n=15, respectively) compared with the self-help condition (11%, n=6; Fisher's exact test P<0.05).
The number needed to treat comparing pure self-help with augmented self-help is 7 (1/(0.107–0.263)=6.4) with a 95% confidence interval of 3.4 to 62.8. This indicates that seven patients with social phobia need to be treated with bibliotherapy augmented by face-to-face group interventions before one additional patient achieves a reduction in social phobia over and above that achieved from bibliotherapy alone.
Change in composite outcome measures
Changes in the mean standardised composite of social phobia symptom
measures and standardised life interference ratings are shown in
Table 3, as are the changes
from pre-treatment to 24-week follow-up expressed as standardised mean
difference effect sizes. In order to facilitate comparison of our data with
other research, an additional table has been included that lists means and
standard deviations for several of the main outcome measures
(Table 4). To maintain a
reasonable type 1 error rate, these individual scores were not subjected to
independent statistical analyses – they are for descriptive purposes
only.
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Table 3 Continuous outcome measure scores over time
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Table 4 Main social anxiety symptom measure scores
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Hierarchical linear or mixed models containing random intercept and slope
parameters were fitted to the standardised composite social phobia symptom
measures, and to standardised ratings of life interference due to social
anxiety. The random intercept parameter allows for individuals differing
within groups on their level of severity, whereas the random slope parameter
allows for within-group variance in the rate of change over time. Models with
an autoregressive covariance structure for the random slope effect were
attempted but did not converge, so results from models with diagonal
covariance structure for the random slope are described. Because of a trend
toward differences between groups in the pre-treatment diagnosis of avoidant
personality disorder (
2=6.196, d.f.=3, P=0.102),
pre-treatment clinician-rated severity of avoidant personality disorder was
included as a covariate. The best-fitting model containing random intercept,
slope, pre-treatment avoidant personality disorder and treatment effects gave
a –2 log likelihood of 1104.298. (Because around 30% of the sample were
taking medication, we tested models that contained medication use as a
covariate; there was no improvement in model fit, and hence medication use was
not included in the analyses.)
There was a significant group by time interaction on the social phobia composite (F(4,216.9)=16.131, P<0.001), so planned follow-up tests were conducted to examine specific differences between groups. There was a trend toward differences between the pure self-help and waiting-list interventions post-treatment (t(246.443)=1.69, P=0.093), and significant differences between waiting list and augmented self-help (t(247.133)=4.457, P<0.001) and group treatment (t(247.060)=4.131, P<0.001) also both at post treatment.
At the 24-week follow-up assessment, augmented self-help and group treatment resulted in significantly lower levels of the standardised social phobia composite than the pure self-help condition (augmented v. pure self-help t(254.695)=–3.582, P<0.001; group treatment v. pure self-help t(254.120)=–3.447, P<0.001). There was no significant difference between the augmented self-help and group treatment for this measure at the 24-week assessment (t(254.900)=0.137, NS). The same pattern of results was observed when missing data were excluded.
Similar results were observed for ratings of the extent to which social anxiety interfered with a range of activities (total score on the Life Interference Scale). A mixed model containing random intercept and slope terms and including baseline clinician-rated severity of avoidant personality disorder as a covariate was the best fit to the data and gave a –2 log likelihood of 1368.75. There was a significant group by time interaction (F(4,258.892)=7.4398, P<0.001) indicating that participants in the four conditions changed at significantly different rates. At the post-treatment assessment, augmented self-help and group treatment led to significantly lower ratings of life interference than the waiting-list control (augmented self-help v. waiting list t(234.272)=–2.577, P<0.01; group treatment v. waiting list, t(234.243)=–2.41, P<0.02) while there was no significant difference between the pure self-help and waiting list groups (t(233.998)=–0.716, NS). At 24-week follow-up both augmented self-help and group treatment led to significantly less life interference compared with the pure self-help condition (augmented v. pure self-help, t(249.894)=–2.514, P<0.02; group treatment v. pure self-help t(249.671)=–2.236, P<0.05) with no significant difference between the two interventions involving group therapy (t(249.972)=0.294, NS). Again results were consistent when missing data were not substituted.
Mediation of change in bibliotherapy
Participants in the two conditions that involved use of the self-help book
differed significantly in the number of chapters they reported reading: pure
self-help 4.11, (s.d.=2.95); augmented self-help 7.48 (s.d.=2.08,
t(59)=3.37, P<0.001). The number of chapters read was
significantly related to the overall level of the social phobia symptom
composite (F(13,95.099)=1.858, P<0.05),
indicating that the more severe the social anxiety in general the greater the
number of chapters read. Number of chapters read was also significantly
related to the rate of change in the social phobia symptom composite
(F(26,124.804)=1.677, P<0.05), so that reading
more chapters was associated with a significantly greater improvement.
However, the interaction between time, number of chapters read and treatment
condition was not significant (F(8,119.649)=1.372, NS),
indicating that the number of chapters read did not explain the differences in
the rate of change between the book only and book plus group
interventions.
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Value of pure self-help
The major question addressed in this study was whether marked reductions in social phobia could be achieved through self-help delivered in the form of printed material. The results provided mixed support for the value of bibliotherapy in reducing both social fears and the degree of life interference caused by social anxiety. Specifically, the extent of the reductions was markedly influenced by the method of delivering bibliotherapy.
When bibliotherapy was delivered in a `pure' form – that is, with no significant involvement from a therapist – results were relatively modest. A reasonable proportion of patients no longer met diagnostic criteria for social phobia using pure self-help, although this proportion appeared to be declining by the follow-up point. Changes in symptoms showed a trend to be greater than those of the waiting-list control alone and were maintained reasonably over time, but reductions in life interference were not significantly greater than in the waiting-list group. Hence as a clinical intervention, pure bibliotherapy appears to show limited value for social phobia. However, the modest indications of efficacy (e.g. the moderate effect size change in life interference) suggest that pure bibliotherapy could have a role in population-level interventions or in provision of help to groups who might not have access to extensive mental health services. However, such a suggestion would require more thorough investigation including sample sizes sufficient to detect the small effect sizes that might still have benefits across an entire population.
From a theoretical perspective the modest efficacy of pure self-help for social phobia stands in interesting contrast to the stronger effects shown with many other disorders (Scogin et al, 1990; Marrs, 1995; Newman et al, 2003; Barlow et al, 2005). Social phobia is one of the most chronic of the anxiety disorders (Bruce et al, 2005) and has marked personality-like characteristics (Rapee & Spence, 2004). Hence self-help may be far more difficult to conceptualise and implement for this ego-syntonic condition than for disorders that involve more overt shifts from normal functioning. Our sample was also especially severely phobic and contained a large proportion of people with avoidant personality disorder. It is possible that individuals with more circumscribed forms of social phobia might be more amenable to self-help, although interestingly our data indicated that it was the more severely affected individuals who read more chapters of the book. Finally, the underlying fears in social phobia (e.g. `if I make a mistake people will think badly of me') are typically far less veridical and hence more open to biases in interpretation than many of the concerns in other disorders (e.g. `riding on a bus will lead to a heart attack'). This feature may make social phobia less amenable than other disorders to pure self-help. Although the current study provided one of the most valid tests of pure self-help, it is not possible to test a true model of self-help as it would be used in the real world. Specifically, self-help in our study differed from real-world use through the inclusion of pre-treatment assessment and contact, a contact letter, the `structure' of a research trial, and post-treatment assessments. These inclusions might have led to overestimation of the efficacy of pure self-help.
Augmented self-help
In contrast to pure self-help, augmentation of self-help with five
therapist-led group sessions resulted in marked improvements in symptoms of
social phobia and life interference that were as great as those produced by
standard group treatment. The lack of a five-session, therapist-only condition
does not allow complete conclusions to be drawn about the role of written
materials. Although unlikely, it is possible that five group sessions with a
therapist might have resulted in equivalent benefit to the augmented
bibliotherapy. Nevertheless, this method may provide a template for a highly
resource-effective method of treatment delivery. The effect size change in
social phobia symptoms produced by augmented self-help (1.08) was larger than
the typical effects of cognitive–behavioural therapy shown in
meta-analyses (around 0.8) (Fedoroff &
Taylor, 2001). Interestingly, a recent treatment for social phobia
using internet-delivered self-help combined with some therapist input and
in vivo exposure demonstrated an effect size of 0.87
(Andersson et al,
2006). Although treatment based on more recent models of social
phobia has shown larger effects, this is accompanied by a markedly increased
cost (e.g. Clark et al,
2003). Hence we can begin to flesh out the range of options
available to mental health services. At one extreme, expert therapists
treating individual patients under detailed supervision can produce extremely
efficacious results at a higher cost and limited accessibility. At the other
extreme, simple provision of printed materials can produce small changes at
extremely low cost and broad accessibility. Augmentation of printed materials
with a few therapist-led sessions provides one mid-point alternative. Future
research needs to explore further alternatives that might provide the best
balance between efficacy and resource use. As an example, John Walker and
colleagues (personal communication) have shown good effects from augmenting
bibliotherapy with group sessions led by lay facilitators.
Mechanisms of change
Further improvements in the efficacy of bibliotherapy could come from
research into mediators of change. The results of our study showed that the
amount of reading was positively related to outcome. Although this is not
surprising, it does imply that identifying methods to increase reading of
materials might increase the efficacy of bibliotherapy. Surprisingly, although
the use of therapist augmentation was associated with a considerably greater
amount of reading, this difference did not explain significant variance in the
differences between groups. It appears that therapist augmentation of
bibliotherapy provides benefits over and above simple motivation to read the
materials. Candidate variables could include better interpretation of
procedures, training in additional strategies or more positive outcome
expectancies. Several other methods of augmentation have shown promise,
including return of weekly homework tasks, `check-in' and reminders through
post, telephone, palm-top computers or email. Electronic delivery of self-help
is enjoying popularity and may result in some benefits. In many cases internet
systems simply consist of written materials in electronic form and will
provide no greater benefit than printed materials. However, the use of
sophisticated computer programs does allow several interesting features such
as individually tailored applications, regular feedback and tracking of
progress, and built-in reminders
(Griffiths & Christensen,
2006). Research into the efficacy of bibliotherapy would benefit
from systematic examination of predictors. Significant predictors should be
used both to screen participants who are most likely to benefit
(Baillie & Rapee, 2004) and
to inform the development of future modes of delivery.
Implications
Mental health services around the world are limited in their reach and
scope. In addition, a large proportion of people with anxiety disorders
including social phobia do not seek help from traditional mental health
services (Meltzer et al,
2000; Issakidis & Andrews,
2002). Many of these people report preferring to deal with
difficulties themselves (Issakidis &
Andrews, 2002). For these people in particular, self-help might
provide an acceptable alternative to traditional therapy. Advantages of
self-help include freeing up mental health professionals to allow them to deal
with individuals who do require more intensive intervention
(Baillie & Rapee, 2004) and
providing a more easily accessible and less stigmatising alternative for
individuals who are unwilling or unable to access traditional services. Thus,
continued investigation into the efficacy of self-help methods can have major
implications for public health. Several studies have demonstrated the value of
self-help for a variety of anxiety disorders. The current data suggest that
pure self-help appears to be less efficacious for social phobia than for other
anxiety disorders. Nevertheless, the indications shown here for small effects
suggest that larger studies with clearer implications for population health
would be of value.
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONREFERENCES |
|---|
- Altman, D. G. (1998) Confidence intervals for
the number needed to treat. BMJ,
317, 1309
-1312.
[Free Full Text] - American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM–IV) . APA.
- Andersson, G., Carlbring, P., Holmstrom, A., et al (2006) Internet-based self-help with therapist feedback and in vivo exposure for social phobia: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 74, 677 -686.[CrossRef][Medline]
- Baillie, A. J. & Rapee, R. M. (2004) Predicting who benefits from psychoeducation and self help for panic attacks. Behaviour Research and Therapy, 42, 513 -527.[CrossRef][Medline]
- Barlow, J. H., Ellard, D. R., Hainsworth, J. M., et al (2005) A review of self-management interventions for panic disorders, phobias and obsessive-compulsive disorders. Acta Psychiatrica Scandinavica, 111, 272 -285.[CrossRef][Medline]
- Brown, T. A., White, K. S. & Barlow, D. H. (2005) A psychometric reanalysis of the Albany Panic and Phobia Questionnaire. Behaviour Research and Therapy, 43, 337 -355.[CrossRef][Medline]
- Bruce, S. E., Yonkers, K. A., Otto, M. W., et al
(2005) Influence of psychiatric comorbidity on recovery and
recurrence in generalized anxiety disorder, social phobia, and panic disorder:
a 12-year prospective study. American Journal of
Psychiatry, 162, 1179
-1187.
[Abstract/Free Full Text] - Clark, D. M., Salkovskis, P. M., Hackmann, A., et al
(1994) A comparison of cognitive therapy, applied relaxation
and imipramine in the treatment of panic disorder. British Journal
of Psychiatry, 164, 759
-769.
[Abstract/Free Full Text] - Clark, D. M., Ehlers, A., McManus, F., et al (2003) Cognitive therapy versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. Journal of Consulting and Clinical Psychology, 71, 1058 -1067.[CrossRef][Medline]
- Di Nardo, P. A., Brown, T. A. & Barlow, D. H. (1994) Anxiety Disorders Interview Schedule for DSM–IV–Lifetime Version. Graywind.
- Fedoroff, I. C. & Taylor, S. (2001) Psychological and pharmacological treatments of social phobia: a meta-analysis. Journal of Clinical Psychopharmacology, 21, 311 -324.[CrossRef][Medline]
- Fenigstein, A., Scheier, M. F. & Buss, A. H. (1975) Public and private self-consciousness: assessment and theory. Journal of Consulting and Clinical Psychology, 43, 522 -527.[CrossRef]
- Gibbons, R. D., Hedeker, D., Elkin, I., et al
(1993) Some conceptual and statistical issues in analysis of
longitudinal psychiatric data: application to the NIMH Treatment of Depression
Collaborative Research Program dataset. Archives of General
Psychiatry, 50, 739
-750.
[Abstract/Free Full Text] - Gould, R. A., Buckminster, S., Pollack, M. H., et al (1997) Cognitive – behavioral and pharmacological treatment for social phobia: a meta-analysis. Clinical Psychology: Science and Practice, 4, 291 -306.
- Griffiths, K. M. & Christensen, H. (2006) Review of randomised controlled trials of Internet interventions for mental disorders and related conditions. Clinical Psychologist, 10, 16 -29.[CrossRef]
- Issakidis, C. & Andrews, G. (2002) Service utilisation for anxiety in an Australian community sample. Social Psychiatry and Psychiatric Epidemiology, 37, 153 -163.[CrossRef][Medline]
- Leary, M. R. (1983) A brief version of the Fear of Negative Evaluation Scale. Personality and Social Psychology Bulletin, 9, 371 -375.[Abstract]
- Loranger, A. W., Janca, A. & Sartorius, N. (1997) Assessment and Diagnosis of Personality Disorders: The ICD–10 International Personality Disorder Examination (IPDE). Cambridge University Press.
- Marrs, R. W. (1995) A meta-analysis of bibliotherapy studies. American Journal of Community Psychology, 23, 843 -870.[CrossRef][Medline]
- Mattick, R. P. & Clarke, J. C. (1998) Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455 -470.[CrossRef][Medline]
- Meltzer, H., Bebbington, P., Brugha, T., et al (2000) The reluctance to seek treatment for neurotic disorders. Journal of Mental Health, 9, 319-327.[CrossRef]
- Newman, M. G., Erickson, T., Preworski, A., et al (2003) Self-help and minimal-contact therapies for anxiety disorders: is human contact necessary for therapeutic efficacy? Journal of Clinical Psychology, 59, 251 -274.[CrossRef][Medline]
- Peters, L. (2000) Discriminant validity of the Social Phobia and Anxiety Inventory (SPAI), the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS). Behaviour Research and Therapy, 38, 943 -950.[CrossRef][Medline]
- Rapee, R. M. (1998) Overcoming Shyness and Social Phobia: A Step by Step Guide. Lifestyle Press.
- Rapee, R. M. & Sanderson, W. C. (1998) Social Phobia: Clinical Application of Evidence-Based Psychotherapy. Jason Aronson.
- Rapee, R. M. & Spence, S. H. (2004) The etiology of social phobia: empirical evidence and an initial model. Clinical Psychology Review, 24, 737 -767.[CrossRef][Medline]
- Rapee, R. M., Craske, M. G. & Barlow, D. H. (1994) Assessment instrument for panic disorder that includes fear of sensation-producing activities: the Albany Panic and Phobia Questionnaire. Anxiety, 1, 114-122.[Medline]
- Rodebaugh, T. L., Woods, C. M., Thissen, D. M., et al (2004) More information from fewer questions: the factor structure and item properties of the original and brief Fear of Negative Evaluation Scale. Psychological Assessment, 16, 169 -181.[CrossRef][Medline]
- Scogin, F., Bynum, J., Stephens, G., et al (1990) Efficacy of self-administered treatment programs: meta-analytic review. Professional Psychology: Research and Practice, 21, 42 -47.[CrossRef]
- Ware, J. E., Kosinski, M. & Keller, S. D. (1996) A12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Medical Care, 34, 220 -233.[CrossRef][Medline]
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