Journal of Anxiety Disorders 27 (2013) 692–702

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Journal of Anxiety Disorders

Review

What do we know today about the prospective long-term course of social anxiety disorder? A systematic literature review Christiane Steinert a,∗ , Mareike Hofmann a , Falk Leichsenring a , Johannes Kruse a,b a b

Clinic for Psychosomatic Medicine and Psychotherapy, University of Giessen, Ludwigstrasse 76, 35392 Giessen, Germany Clinic for Psychosomatic Medicine and Psychotherapy, University of Marburg, Marburg, Germany

a r t i c l e

i n f o

Article history: Received 13 March 2013 Received in revised form 28 June 2013 Accepted 16 August 2013 Keywords: Social anxiety disorder Social phobia Prospective course Psychotherapy Follow-up Review

a b s t r a c t While we know that social anxiety disorder (SAD) is today’s most common anxiety disorder knowledge on its prospective long-term course is sparse. We conducted a systematic literature search using databases Medline and PsycINFO for naturalistic and psychotherapy outcome studies with follow-up durations of at least 24 months. Four naturalistic cohorts and nine psychotherapy trials were included in the review. The naturalistic course in clinical was less favorable than in non-clinical samples (27% vs. 40% recovery rate after 5 years). Psychotherapy trials, all applying (cognitive) behavioral methods, yielded stable outcomes with overall large pre- to follow-up effect sizes on self-report scales. Observer rated remission rates varied considerably (36% to 100%) depending on study design and follow-up length. The results of psychotherapy trials and that of naturalistic studies can hardly be compared due to differences in methodology. More standardized remission and recovery criteria are needed to enhance the understanding of the longitudinal course. © 2013 Elsevier Ltd. All rights reserved.

Contents 1.

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3.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1. Long-term course: Research approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1.1. Naturalistic course: Summary of retrospective findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1.2. Long-term course after psychotherapy: Research state . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2. Aims of the present study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Objective I: Naturalistic course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.1. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Objective II: Course after psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.1. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and concluding discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Comparison with other anxiety disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Methodological factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5. Clinical implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role of the funding source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

∗ Corresponding author. Tel.: +49 641 99 45647; fax: +49 641 99 45669. E-mail address: [email protected] (C. Steinert). 0887-6185/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.janxdis.2013.08.002

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1. Introduction Social anxiety disorder (SAD), also referred to as social phobia, is the most frequent anxiety disorder and the second most common of all DSM-IV disorders (Kessler, Chiu, Demler, Merikangas, & Walters, 2005). Information about its lifetime prevalence is ranging between 7% and 13% (Fehm, Pelissolo, Furmark, & Wittchen, 2005; Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012; Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996). The symptomatology of SAD is characterized by intensive fear that is caused by social situations in which the concerned person is afraid of being scrutinized by others. This involves communication with other people, eating or speaking in public as well as making direct eye contact. The associated fears are usually very intense and persistent and often are accompanied by bodily reactions such as sweating or blushing, which themselves can have a fear inducing character. These fears often lead to avoidance of supposedly dangerous situations or to an immense discomfort and tension, when escape is not possible. The avoidance behavior associated with social phobia can involve enormous impairments and even lead to social isolation. Epidemiological studies investigating individuals with SAD found a reduced quality of life as well as negative consequences on the individuals’ social and occupational life (Fehm, Beesdo, Jacobi, & Fiedler, 2008; Fehm et al., 2005). Besides considerable work absence, studies found a high unemployment rate, an increased utilization of social welfare and therefore all in all substantial societal costs (Lecrubier et al., 2000). SAD is usually accompanied by other mental disorders, especially depression, other anxiety disorders, substance abuse (Fehm et al., 2005) or personality disorders (Leichsenring, Jaeger, Rabung, & Streek, 2003). Comorbidity rates range between about 69% and 99% (e.g. Leichsenring et al., 2003; Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992), depending on the investigated study population and setting. Fehm et al. (2005) stated that “comorbidity in social phobia [is] the rule rather than the exception” (p. 456). The authors also emphasized that the amount of comorbidity hampers the possibility to distinguish between long-term outcomes due to SAD and those due to comorbid disorders. Longitudinal studies provided evidence for the assumption that social phobia and the associated comorbidities are causally related, in the sense that depression and substance abuse are consequences of the anxiety symptoms and disabilities that go along with the disorder (Robinson, Sareen, Cox, & Bolton, 2011; Stein et al., 2001). Only about 5% of people with SAD seek adequate help (Weiller, Bisserbe, Boyer, Lepine, & Lecrubier, 1996). This may partially be due to the fact that they do not regard themselves as being ill, but rather as very shy. It is often not until comorbid disorders occur and bring along an additional psychological strain that people suffering from SAD seek medical help (Magee et al., 1996). 1.1. Long-term course: Research approaches Information about the prospective longitudinal course of social phobia has on the one hand been gathered through naturalistic long-term studies, investigating community, primary care or clinical samples. In these studies, participants were followed naturalistically over a certain time span and treatment – if it took place – was not systematically controlled for. On the other hand, we gained knowledge about the long-term course of SAD through psychotherapy trials with multiannual follow-ups. Here, all participants received treatment and were followed naturalistically after its termination. Although different in the applied methods, both approaches allow an insight into how SAD develops over longer time spans.

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1.1.1. Naturalistic course: Summary of retrospective findings The course of social phobia and possible course predictors have been studied in naturalistic investigations since its inclusion in the DSM-III in 1980. The first systematic investigations were mostly retrospective and characterized the course as markedly chronic (Chartier, Hazen, & Stein, 1998; DeWit, Ogborne, Offord, & MacDonald, 1999). In these studies the mean onset age was found to be 13 years and the mean duration of illness lay at around 25 years. SAD involved extensive impairments and only about 38% to 50% of participants were judged as recovered at the time of the interview. Younger age and higher severity of illness proved to be the strongest predictors of an unfavorable course. Thus, SAD is a highly prevalent disorder and early studies assessing its course retrospectively suggested that it has a pronounced tendency to take a chronic course over many years. Our goal therefore was to investigate, if this finding was also true for prospective long-term studies with a follow-up duration of at least 2 years. 1.1.2. Long-term course after psychotherapy: Research state There is evidence for the short- and long-term effectiveness of psychotherapy in the treatment of social phobia (Acarturk, Cuijpers, van Straten, & de Graaf, 2009; Ponniah & Hollon, 2008). In their meta-analysis of psychological treatments for SAD, Acarturk et al. (2009) included nine studies with follow-up periods of 7 to 18 months and reported a pooled effect size of d = 0.15 for the change between posttreatment and follow-up. This result suggested that effects of psychological treatments for social phobia remained stable up to 1.5 years after therapy. Recent research with somewhat shorter follow-up periods of up to 12 months supports this finding (Furukawa et al., 2013; Goldin et al., 2012; Piet, Hougaard, Hecksher, & Rosenberg, 2010). We do, however, not know what happens beyond the time span of 18 months, as most results from psychotherapy outcome studies predominantly apply to immediate and medium-length effects of treatment. Methodological reasons play an enormous role in this context: Outcome studies with longer follow-up periods are more time- and cost intensive, moreover attrition and uncontrollable confounding variables (e.g. additional treatment) during the follow-up impede the interpretation of results (Chambless & Ollendick, 2001). Thus, the long-term effects of psychotherapy for individuals with social phobia beyond a time span of 18 month remain unclear. To complement the results from naturalistic studies, the second part of this review therefore addresses findings concerning the durability of change after psychotherapeutic interventions. 1.2. Aims of the present study As discussed above, we focus on two main research lines: Objective I. Summarize findings from naturalistic studies on the prospective long- term course of SAD with a minimum follow-up duration of 24 months. Objective II. Summarize the evidence concerning the long-term course of SAD that has been gathered through psychotherapeutic outcome studies with long-term follow-ups of ≥24 months. As most findings from psychotherapy trials with shorter followup durations of up to 18 months have been summarized previously (Acarturk et al., 2009; Ponniah & Hollon, 2008) our aim was to specifically investigate how SAD develops beyond this time, both naturalistically and after psychotherapy. Additionally, questions of a more exploratory nature will be examined: How extensive is the literature in this field? Which factors might be predictive of the long-term course of SAD? To our best knowledge, no review to date has systematically presented findings about the prospective long-term course of social

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Fig. 1. Selection of naturalistic studies that investigated the course of SAD.

phobia or combined them with data from treatment outcome studies. However, such information is very important. Studies on the long-term course of SAD and on the predictors of its course help to identify subgroups with a favorable or unfavorable prognosis and to determine the proportion of patients who do (not) benefit from the available treatments in the long run. It is those who do not experience a significant symptom-relief that future efforts should be focused on to develop more innovate, suited treatments (Stein & Stein, 2008). 2. General method To identify relevant literature, electronic databases Medline and PsycINFO were searched up to June 2013 for English language articles by two independent researchers (C.S., M.H.). We excluded articles that were editorials, comments and others that were not reviews or empirical studies. Manual searches of reference lists of included studies, reviews and (where appropriate) meta-analyses and textbooks were performed. 2.1. Objective I: Naturalistic course 2.1.1. Method Search terms included ‘social phobia’, ‘social anxiety’ and ‘course’ (see Table A1). The following selection criteria were applied: (i) naturalistic cohort study with a follow-up period of at least 2 years, (ii) adult participants diagnosed with social phobia as principal diagnosis, (iii) social phobia diagnosed using a diagnostic interview or checklist based on Research Diagnostic Criteria (RDC),

DSM-III/III-R/IV criteria or ICD-9/10 criteria, (iv) studies examining the long-term course concerning the social phobic symptomatology, presenting at least one follow-up measurement. To enhance generalizability of findings we excluded studies that only comprised participants of certain age groups. As can be seen in Fig. 1 this applied to one cohort (Karlsson et al., 2010). The authors investigated a population-based sample of elderly subjects (baseline age ≥70 years). First onset of social phobia after the age of 25 is rare and if it occurs it is mostly secondary to other psychiatric disorders (Wittchen & Fehm, 2003). Thus, we assume that a different underlying course in elderly people is likely. 2.1.2. Results All in all nine prospective studies reporting on four different cohorts fulfilled the inclusion criteria (see Table 1). The Harvard/Brown Anxiety Research Project (Bruce et al., 2005; Keller, 2006) is the longest and probably most extensive investigation that examined clinical patients, as did Alnæs and Torgersen (1999). One study examined the natural course of social phobia in primary care patients (Beard, Moitra, Weisberg, & Keller, 2010), another one in the community (Blanco et al., 2011). In the studies investigating clinical patients (Alnæs & Torgersen, 1999; Bruce et al., 2005), subjects were recruited from treatment centers, i.e. subjects had sought treatment for their symptoms and therefore most followed-up individuals received treatment. In the study investigating primary care patients (Beard et al., 2010), 68% of patients received treatment at study intake. Treatment in these studies was heterogeneous and consisted of psychopharmacological and/or different kinds of psychosocial

Table 1 Long-term outcome of naturalistic studies. Study

Sample

Follow-up duration

Recovery rate

Remission rate

Chronic course

Alnæs and Torgersen (1999) Bruce et al. (2005)

Clinical Clinical

6 12

56% About 45%

44% –

Beard et al. (2010) Blanco et al. (2011)

Primary care Community

5 3

– 20% after 2 years, 27% after 5 years, 37% after 12 years 40% –

– 77%

– 23%

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interventions. None of the studies found treatment to be predictive of SAD course. The only community study (Blanco et al., 2011) included in this review recorded treatment seeking in the past 12 months and found it to be predictive of an unfavorable course. The reviewed studies used heterogeneous definitions of remission and recovery which make a comparison of results difficult. Especially the criteria for recovery varied in its strictness between studies (e.g. loss of diagnostic criteria versus having only minor occasional or no symptoms at all over a certain time period). In an attempt to differentiate between the applied criteria, we will report which criteria were used in each particular study. In general we will refer to the term recovery as comprising more improvement than not fulfilling the diagnostic criteria anymore at a certain point in time (as the latter might only reflect a momentary shift in symptom severity). 2.1.2.1. Findings from naturalistic studies with clinical patients. The two studies investigating patient samples applied different methods regarding a variety of factors, including follow-up-length, number of assessments and outcome criteria. The Harvard/Brown Anxiety Research Project (HARP) followed-up 176 psychiatric patients with SAD in short intervals using the Longitudinal FollowUp Evaluation (LIFE) (Keller et al., 1987). LIFE employs a 6-point psychiatric status rating (PSR) scale to indicate the severity of mental pathology. Recovery was defined as being nearly asymptomatic for two consecutive months, while recurrence was defined as the onset of symptoms at a PSR level of 5 (full criteria) or greater for two consecutive weeks following a recovery. After six month 8% of patients with social phobia achieved recovery, after 2 years this percentage went up to 20%. After 5 years 27%, after eight to 10 years 36%, and after 12 years 37% of patients were recovered (Bruce et al., 2005). Social phobia patients’ chances of reaching partial remission were slightly better, but still after 8 years only about 45% had gained symptom relief. Of the patients who eventually reached recovery 29% had a recurrence within 4–5 years, 34% within 10 years and 39% within 12 years (Bruce et al., 2005; Keller, 2006). Predictors of a negative course were mostly comorbid disorders, i.e. alcohol disorders, avoidant personality disorder, generalized anxiety disorder as well as agoraphobia (the latter only for women). Furthermore a lower probability of recovery could be seen in patients with lower functioning and previous suicide attempts (Yonkers, Dyck, & Keller, 2001a,b). Interestingly a comorbid depressive disorder had no negative influence on the longitudinal course of social phobia, neither at the 8-year (Massion et al., 2002) nor at the 12-year follow-up (Bruce et al., 2005). The second study (Alnæs & Torgersen, 1999) assessed the long-term course of SAD in a sample of 48 psychiatric outpatients who were re-interviewed 6 years after treatment at an outpatient department. Social phobia showed a high stability with 44% chronic cases, 56% were judged as remitted (i.e. they did not meet diagnostic criteria anymore). In both studies a substantial proportion of patients had recurrences, so an even higher chronicity rate is considered likely. 2.1.2.2. Findings from naturalistic community and general practice studies. The only naturalistic study so far that followed primary care patients with a social phobia diagnosis, was conducted by Beard et al. (2010). Within the Primary Care Anxiety Project (PCAP) 182 patients were annually interviewed (LIFE) over a time span of 5 years. The cumulative probability of recovery after 5 years was 40%. Predictive of a remission were a shorter episode duration before intake into the study, higher functioning and the absence of comorbid panic disorder with agoraphobia. Finally, the only community study conducted so far, investigated a representative population-based sample of US-citizens (Blanco et al., 2011). Data of 989 participants diagnosed with SAD were gathered at two time points, 37 months apart. Participants who fulfilled the diagnostic

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criteria at both time points were classified as chronic, this occurred in 22.3% of the cases. The remaining participants (about 77%) did not fulfill the diagnostic criteria anymore, which means that they experienced some kind of symptom relief that however might in some cases just have reflected a momentary shift in SAD severity. The fear of social interaction situations, a higher number of avoided social situations, treatment seeking within the last 12 months and comorbidity with affective disorders independently predicted the persistence of social phobia. Results show that participants from primary care settings seemed to have a more favorable long-term course (40% recovery rate after 5 years) than participants from clinical samples (27% recovery rate after 5 years). Between about 45% and 56% of clinical patients experienced a remission from their symptoms over 6 to 8 years (Alnæs & Torgersen, 1999; Keller, 2003), while in the community this rate was 77% after 3 years. 2.2. Objective II: Course after psychotherapy 2.2.1. Method For the second objective our aim was to identify psychotherapy outcome studies with follow-up periods of at least 24 months. Search terms were broad and included ‘social phobia’, ‘social anxiety’, ‘psychother*’, ‘cognitive therap*’, ‘behav* therap*’, ‘interpersonal therap*’, ‘psychodynamic therap*’, ‘psychoanal* therap*’ and ‘psychoanalysis’ (see Table A2). The following selection criteria were applied: (i) psychotherapy trial with a follow-up duration of at least 2 years, (ii) adult participants diagnosed with social phobia as principal diagnosis, (iii) social phobia diagnosed using a diagnostic interview or checklist based on Research Diagnostic Criteria (RDC), DSM-III/III-R/IV criteria or ICD-9/10 criteria, (iv) studies presenting at least one long-term follow-up measurement. A flow chart showing the process of study selection is given in Fig. 2. 2.2.2. Results The search yielded nine studies that met inclusion criteria. The therapeutic methods used were all behavioral or cognitive–behavioral. Up to date there is no study that used interpersonal or psychodynamic forms of treatment and conducted a long-term follow-up of 2 years or more, except for the study by Leichsenring et al. (2013) whose 2-year follow-up data are presently evaluated. Session numbers were generally low and ranged from 8 to 29. In total, the studies report results of about 354 participants with SAD who completed the long-term follow-ups. The smallest study included four, the largest 71 followed-up individuals. Follow-up times ranged between 2 and 12 years. The proportion of treated men and woman was nearly balanced (56% women). Different forms of CBT were applied. Two studies (Carlbring, Nordgren, Furmark, & Andersson, 2009; Hedman et al., 2011) provided internet-based psychotherapy using basic CBT-interventions (e.g. exposure, cognitive restructuration) in combination with the working through of self-help texts and an online feedback system. One study (Willutzki, Teismann, & Schulte, 2012) reported on the long-term follow-ups of patients that had been treated with either manualized cognitive therapy (CT) or manualized resourceoriented cognitive–behavioral therapy (ROCBT). Amongst using well known CT strategies, the latter focuses on an individual’s already existing resources and encourages patients to explore their goals as well as past situations that had been accomplished successfully in order to gain new insights. Turner and colleagues (Turner, Beidel, & Cooley-Quille, 1995) applied Social Effectiveness Therapy (SET). This treatment contained psychoeducation, social skills training, exposure and consolidating exercises. The therapy administered by Fava et al. (2001) consisted mainly of homework exercises for which the patients were encouraged to expose

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Fig. 2. Selection of psychotherapy trials that provided information on the long-term course of SAD.

themselves to difficult situations, followed by feedback of the therapist who himself was not present during these exposures. Two studies applied group therapy (Heimberg, Salzman, Holt, & Blendell, 1993; Prasko et al., 2006), in one study participants received group or individual cognitive therapy (Mörtberg, Clark, & Bejerot, 2011) and finally Stravynski, Arbel, Lachance, and Todorov (2000) applied social skills group training which mainly focuses on behavior modification strategies concerning specific social situations. One of the nine trials (Willutzki et al., 2012) relied solely on self-reports for follow-up examinations, the other studies mostly used a combination of well known self-report scales and interviews, some conducted via telephone. Main characteristics and outcome of reviewed studies are presented in Table 2. 2.2.2.1. Long-term outcome on self-report scales. Six of the nine trials (Carlbring et al., 2009; Hedman et al., 2011; Heimberg et al., 1993; Mörtberg et al., 2011; Turner et al., 1995; Willutzki et al., 2012) reported pre- to follow-up effect sizes of change on selfrating-scales—respectively data from which we could derive these effect sizes, which was the case in two studies. We calculated the effect sizes (d) for change by dividing the absolute difference between the follow-up mean score and the pretreatment mean score by the pretreatment standard deviation (Cohen, 1988). Pre- to follow-up effect sizes of main outcome measures, assessing social phobic symptomatology, were large and ranged between d = 0.90 and d = 2.34 after 2 to 10 years in five of the six studies (Carlbring et al., 2009; Hedman et al., 2011; Mörtberg et al., 2011; Turner et al., 1995; Willutzki et al., 2012). One study (Heimberg et al., 1993) reported a slightly lower pre- to follow-up effect size of d = 0.70. Comparisons between posttreatment and long-term follow-up scores in these studies indicated that treatment gains achieved by CBT were stable in all studies and in most cases even significantly improved over the course of follow-up. In the study by Heimberg et al. (1993), patients who received cognitive–behavioral group therapy were able to maintain their treatment gains from posttreatment to 5-year follow-up, while patients who had received educational-supportive group therapy generally profited less and had follow-up scores that suggested need for further treatment. 2.2.2.2. Long-term outcome from an observer’s perspective. Six studies (Carlbring et al., 2009; Fava et al., 2001; Hedman et al., 2011;

Mörtberg et al., 2011; Prasko et al., 2006; Stravynski et al., 2000) reported observer rated outcomes. Remission rates varied between 36% and 100% after 2 to 2.5 years in four studies (Carlbring et al., 2009; Fava et al., 2001; Prasko et al., 2006; Stravynski et al., 2000). All of these studies only followed up treatment completers or remitted treatment completers, i.e. patients who had dropped-out or did not remit after treatment were not considered. This makes it likely that some of the more severe cases were missed. One study (Carlbring et al., 2009) took this into account by providing two percentages: 84.2% of participants completing a follow-up telephone interview no longer fulfilled the diagnostic criteria 30 months posttreatment. The authors rightly allude to the fact that this figure would be lower, namely 56%, if subjects not responding to followup had been regarded as treatment failures. Studies that comprised longer follow-up periods found remission rates that ranged between 48% and 85% after 5 years (Fava et al., 2001; Hedman et al., 2011; Mörtberg et al., 2011). Again, the composition of the follow-up samples differed: While Fava et al. (2001) had included remitted treatment completers and found an 85% remission rate, Mörtberg et al. (2011) had considered all reachable patients and remission rates lay at 65% and 72% (individual CT versus intensive group CT). As expected, Hedman et al. (2011) who regarded drop-outs as treatment-failures found the lowest remission rate (48%). In the study with the longest follow-up (Fava et al., 2001) the remission rate still was 85% after 10 years. Generally, studies that reported the long-term outcome of all treated patients or treated drop-outs as non-responders – in comparison to studies following (remitted) treatment completers only – yielded more unfavorable results. 2.2.2.3. Predictors of the long-term course. One of the nine trials (Fava et al., 2001) investigated possible long-term course predictors. Three of 18 investigated risk factors significantly predicted a negative long-term outcome: A comorbid personality disorder, the degree of residual symptomatology after treatment (patients who could overcome their avoidance behavior had a better course) and the use of benzodiazepines after treatment. 3. Summary and concluding discussion To our knowledge this is the first systematic review that comprehensively presents the current knowledge about the long-term

Table 2 Characteristics of included psychotherapy studies. Study

Primary diagnosis/assessed with

Sample size; mean age (years) and gender (% female)

Conducted therapy

No. of sessions or duration of therapy

Follow-up length

Main outcome measures

Main findings

Carlbring et al. (2009)

Social phobia (DSM-IV)/SCID (telephone interviews)

44 (of 57) completed follow-up; mean age and gender (of the original group): 33, 65%

Internet-delivered guided CBT

9-week internet-based program, with or without short weekly telephone calls

2.5 years

LSAS-SR SPS SIAS SPSQ SCID CGI

LSAS-SR, SPS, SIAS, SPSQ: d = 1.10-1.73 (Pre- to follow-up)

Social phobia (DSM-IV)/SADS1

45 (of 70) completed follow-up; mean age and gender 30.6, 62%

Behavior therapy based on exposure homework and feedback

8 sessions

2–12 years (mean time 6 years)

Paykel’s clinical interview for depression

Hedman et al. (2011)

Social phobia (DSM-IV)/SCID (telephone interviews)

71 (of 80) completed follow-up; mean age and gender (of the original group): 35, 70%

Internet-delivered guided CBT

9-week internet-based program

5 years

LSAS-SR SIAS SPS SCID CGI

Heimberg et al. (1993)

Mörtberg et al. (2011)

Social phobia (DSM-III)/ADIS

Social phobia (DSM-IV)/SCID

19 (of 49) completed follow-up; mean age and gender: 34, 32%

48 (of 67 resp. 100) completed follow-up; mean age and gender: 38.5, 62%

1. CBGT 2. ES

1. IGCT 2. ICT

12 group sessions (both)

16 sessions

4.5–6.25 years (mean time 5.5 years)

3.8–6.25 years (mean time 5.2 years)

SADS2 CSRS

SPCb SCID

Prasko et al. (2006)

Social phobia (ICD-10, DSM-IV)/ADIS-R

64 (of 81) completed follow-up; mean age and gender of treatment completers (n = 66): 27.2, 56%

1. MCLB + SG 2. Group CBT + pill placebo 3. MCLB + group CBT

SG: 14 individual sessions CBT: 13 group and 4 individual sessions

2 years

CGI

Stravynski et al. (2000)

Social phobia (DSM-IV)/diagnostic interview (non-standardized)

4 (of 5) completed follow-up; mean age and gender: 37, 75%

Behavioral group treatment

14 sessions

2 years

ADIS

48%a without diagnosis Large improvements (CGI): 63.7% SADS2 (Pre- to follow-up): CBGT: d=.70f ES: d=.12f classified as significantly improved: 89% CBGT 44% ES SPCc (Pre- to follow up): ICT: d = 1.61 IGCT: d = 1.29

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Fava et al. (2001)

84.2% resp. 56%a without diagnosis Large improvements (CGI): 64.8% Remission ratesb : 98% after 2 years, 85% after 5 years, 85% after 10 years Relapse rateb : 13% over 12 years LSAS-SR, SIAS, SPS: d = 0.95-1.40 (Pre- to follow-up)

72% IGCT without diagnosise 65% ICT without diagnosise Relapse (CGI < 3 or necessity for new treatment or hospitalization)b : 79% MCLB + SG 64% MCLB + CBT 48% CBT + placebo 100%d without diagnosis

697

698

Table 2 (Continued) Primary diagnosis/assessed with

Sample size; mean age (years) and gender (% female)

Conducted therapy

No. of sessions or duration of therapy

Follow-up length

Main outcome measures

Main findings

Turner et al. (1995)

Social phobia (DSM-III-R)/ADIS-R

8 (of 17) completed follow-up; mean age and gender: 37.5, 38%

SET

Circa 29 single- and group sessions

2 years

SPAI FQ-SOC

Willutzki et al. (2012)

Social phobia (DSM-IV)/SCID

51/27 (of 83) completed 2/10 year follow-up; mean age and gender: 37.2, 41%/40.2, 18%

1. ROCBT 2. CT

ROCBT: 23 CT: 25 (both individual sessions)

2.4 and 10.7 years

SPS SIAS

SPAI: d = .90 (Pre- to follow up)f GQ-SOC: d = 2.3 (Pre- to follow up)f ROCBT SPS, SIAS: d = 1.05-1.10 (Pre- to 2 year follow up) CT SPS, SIAS: d = 1.02-1.06 (Pre- to 2 year follow up) ROCBT + CT SPS, SIAS: d = 1.56-1.63 (Pre- to 10 year follow up) FNE: d = 2.34 (Pre- to 10 year follow up) SCL-GSI: d = 1.45 (Preto 10 year follow up)

Note: ADIS = Anxiety Disorders Interview Schedule; ADIS-R = Anxiety Disorders Interview Schedule-revised; CBGT = cognitive–behavioral group therapy; CBT = cognitive behavioral therapy; CSRS = Clinician’s Severity Rating Scale; CGI = Clinical Global Impression Of Improvement; CT = cognitive therapy; d = Cohen’s d; DSM = Diagnostic and Statistical Manual of Mental Disorders; ES = educational-supportive group psychotherapy; FNE = Fear of Negative Evaluation Scale; FQ-SOC = Fear Questionnaire Social Phobia sub-scale; HAMA = Hamilton Rating Scale for Anxiety; ICT = individual cognitive therapy; IGCT = intensive group cognitive therapy; LSAS-SR = Liebowitz Social Anxiety Scale self-report version; MCLB = moclobemide; ROCBT = resource-oriented cognitive–behavioral therapy; SADS1 = Schedule for Affective Disorders and Schizophrenia; SADS2 = Social Avoidance and Distress Scale; SCID = Structured Clinical Interview for DSM-IV; SCL-GSI = Symptom Check List-90-Global Severity Index; SET = social effectiveness training; SG = supportive guidance; SIAS = Social Interaction Anxiety Scale; SPAI = Social Phobia And Anxiety Questionnaire; SPC = Social Phobia Composite; SPS = Social Phobia Scale; SPSQ = Social Phobia Screening Questionnaire. a Non-responders to follow-up regarded as treatment failures. b Only remitted treatment completers were included in the follow-up. c Including LSAS-SR, SPS, SIAS, FQ-SOC, and FNE. d Of treatment completers. e All reachable patients. f As they were not given in the study, we calculated the effect sizes (d) for change by dividing the absolute difference between the follow-up mean score and the pretreatment mean score by the pretreatment standard deviation.

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Study

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course of SAD that was derived from naturalistic studies as well as psychotherapy treatment trials with naturalistic long-term followups. While it can be concluded that large parts of participants in the naturalistic studies were treated, we think that this kind of treatment is different than the systematic investigation of treatment effects in psychotherapy trials. That is why we decided to evaluate these two kinds of studies separately. The number of studies reviewed is small considering the frequency of the disorder which ranks as second most common mental disorder. As the essential DSM-IV diagnostic criteria for SAD remained the same, we believe that our findings are also valid for DSM-5 SAD. Four naturalistic cohorts and nine treatment trials were considered. Major findings can briefly be summarized as follows: (a) The course of social phobia within clinical samples from secondary and tertiary care was mostly chronic. Only about half of the patients experienced symptom relief within 6 to 8 years (Alnæs & Torgersen, 1999; Keller, 2003). After 2 years 20%, after 5 years 27% and after 12 years 37% were recovered (Bruce et al., 2005). (b) Individuals with SAD from the general population and primary care settings seemed to have a better longitudinal course than patients from clinical samples. The remission rate in the general population was 77% after 3 years, the recovery rate of primary care patients was 40% after 5 years. (c) Self-reports from long-term follow-ups after psychotherapeutic treatment for social phobia point towards significant enduring effects over time spans of 2 to 10 years for CBT methods. Observer-rated remission rates generally ranged between 36% and 100% and still lay at 85% in one study after 10 years. Outcome in psychotherapy trials largely depended on the composition of the followed-up samples. (d) Four studies investigated possible course predictors. Comorbid mental disorders (i.e. alcohol disorders, personality disorders, affective disorders, generalized anxiety disorder and panic with agoraphobia) seem to be the most reliable course predictor, therefore special attention regarding this factor is needed in clinical settings. In agreement with retrospective data (DeWit et al., 1999) severity of illness, a factor that is in itself linked to comorbidity, but also reflects criteria as number of avoided situations, onset age, treatment-seeking or illness duration seems to play a role within the longitudinal outcome of social phobia, too. 3.1. Comparison with other anxiety disorders Compared with other disorders of the anxiety spectrum, social phobia had the lowest recovery rate with 37% after 12 years in the HARP-cohort (Bruce et al., 2005). Patients from the same cohort with panic disorder had an 82% chance of recovery, for patients with GAD the probability of recovery was 58% and for patients with panic disorder with agoraphobia it was 48% (Bruce et al., 2005). Alnæs and Torgersen (1999), too, found social phobia to be the most chronic anxiety disorder with a 56% remission rate in comparison to 75% in panic patients, 82% in patients with agoraphobia, 93% in GAD patients and 74% in patients with simple phobia after 6 years. However, findings on that matter are not consistent, as some studies (Andersch & Hetta, 2003; Faravelli, Paterniti, & Scarpato, 1995; Katschnig et al., 1995; Rodriguez et al., 2006; Woodman, Noyes, Black, Schlosser, & Yagla, 1999) reported long-term outcomes for other anxiety disorders that lay within the range of those for social phobia. Woodman et al. (1999) reported 18% full remission after 5 years for GAD patients and 45% for panic patients. Andersch and Hetta (2003) reported a stable recovery rate of 31% after 15 years for panic patients.

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3.2. Methodological factors For the interpretation of results on the course of mental disorders, it is important to keep in mind where participants were recruited and thus to differentiate between clinical and non-clinical samples. Our findings show that patients receiving clinical care had more unfavorable long-term courses than subjects from the community or primary care settings. However, as clinical – i.e. treatment seeking – subjects may have more severe forms of an illness, it is important to note that findings derived from clinical samples may be biased (Berkson, 1946) which may consequently lead to an overestimation of the severity and chronicity of an illness as well as a limitation in generalizability to non-clinical populations. Our findings are in line with these considerations (27% vs. 40% recovery rate after 5 years in clinical versus primary care populations; 45–56% vs. 77% remission rate in clinical versus community samples). For a similar reason, naturalistic studies did not find associations between treatment and long-term outcome. As participants with more severe forms of a disorder are those with a greater likelihood of seeking and receiving treatment and as patients in naturalistic studies are not randomly assigned to any kind of treatment, treatment effects are usually neither expected nor found. In one study (Blanco et al., 2011) treatment seeking within the last 12 months was predictive of an unfavorable course which may reflect that individuals with more severe forms of a disorder are more motivated to seek treatment and hence confirms the mentioned treatment bias effect as well as previous findings regarding the association between treatment seeking and course persistence in mental disorders (Demyttenaere et al., 2004). It is also important to keep in mind that to date no community study has longitudinally assessed full recovery in a sample of SAD subjects—with the exception of Karlsson et al. (2010) who only included elderly subjects who might be subjected to a different underlying course. Consequently, our knowledge on the naturalistic course of SAD is still limited. There are other methodological factors that have to be taken into account, as they contribute to the findings: Recovery and remission are not consistently defined in studies investigating SAD and therefore often refer to different outcomes. These differences lead to different remission and recovery rates and in some cases might not reflect true symptom relief. For example an outcome often referred to is ‘not fulfilling the diagnostic criteria anymore’. This might not be a valid criterion for recovery as it could just reflect minor course fluctuations, covering some kind of improved symptomatology at a certain point in time. Furthermore, a lack of full symptomatology is not necessarily linked to mental health, quality of life or well-being, aspects that should be included in a clinically relevant remission or recovery (Fava, Ruini, & Belaise, 2007). It also does not give information about the stability of the observed symptom relief as it is only a momentary measure. Moreover, studies examining social phobia from a spectrum disorder point of view (Degonda & Angst, 1993; Merikangas, Avenevoli, Acharyya, Zhang, & Angst, 2002) show that there are considerable oscillations between different severity stages rather than clearer distinguishable phases like recovery and recurrence. There also is evidence that residual symptomatology can be predictive of an unfavorable course in affective disorders (Fava, Grandi, Zielezny, Rafanelli, & Canestrari, 1996) which emphasizes the importance of finding a clinically more reliable definition of recovery, remission and long-term outcome in general. Studies on the long-term effectiveness of psychotherapy on SAD are rare for CBT and up to date non-existent for psychodynamic and other treatment approaches - with one exception whose results are currently evaluated (Leichsenring et al., 2013). The findings included in our review show that symptom relief can be achieved in a notable rate of patients with the help of rather short CBT

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Table A1 Search terms, search strategy and hits for objective I, searched up to June 2013. PsycINFO and medline 1 Social phobia 2 Social anxiety 3 Course 4 1 or 2 5 3 and 4 6 Limit 5 to: human, adult, English language 7 Remove duplicates 8 Articles screened

Hits 18,764 20,288 633,972 31,727 6337 2788 2638 2638

Table A2 Search terms, search strategy and hits for objective II, searched up to June 2013. PsycINFO and medline

Hits

1 Social phobia 2 Social anxiety 3 1or 2 4 Psychother* 5 Cognitive therap* 6 Behav* therap* 7 Interpersonal therap* 8 Psychodynamic therap* 9 Psychoanal* therap* 10 Psychoanalysis 11 4 or 5 or 6 or 7 or 8 or 9 or 10 12 3 and 11 13 Limit 12 to: human, adult, English language 14 Limit: 1 and 2 in title 15 Remove duplicates 16 Articles screened

18,764 20,288 31,727 377,116 72,069 143,021 2320 2687 44,570 108,816 550,473 16,150 7673 1751 1343 1343

the use of certain standardized instruments). As a consequence the presented articles are heterogeneous, difficult to compare and do not allow the performing of a formal meta-analysis. Therefore, our conclusions are not built upon a strong evidence-base but rather on a number of studies with significant findings. Only this, on the other hand, allowed us to present a comprehensive review of the current research state and point out future strategies needed to facilitate interpretation. Furthermore, by focusing on a follow-up period of 24 months or longer some information, especially on short- and medium-term outcome of psychotherapy trials is missed. However, the majority of findings on this matter has been summarized in earlier reviews (Acarturk et al., 2009; Ponniah & Hollon, 2008; Powers, Sigmarsson, & Emmelkamp, 2008). It is also important to note that no naturalistic study with a shorter follow-up period that we are aware of would have met our inclusion criteria. By specializing on a longer follow-up period, we were able to: • show that psychotherapy, i.e. cognitive–behavioral or behavioral therapy, has enduring effects over follow-up periods covering two to 12 years, • point out to the research community a lack of studies on the long-term course of this disorder, especially for participants that underwent psychotherapeutic treatments. Long-term follow-ups should be planned and included in future psychotherapy trials as only they can proof the longitudinal stability of achieved treatment gains. 3.4. Conclusion

interventions. There is however room for improvement as can be seen regarding the percentages of SAD patients that – according to observer ratings – did not remit after psychotherapeutic treatment which was the case in up to about 64% of patients included in the long-term follow-ups. The available intervention studies only allow a limited view into the long-term course of this disorder after treatment, as they often only followed-up treatment completers or even treatment responders, an approach that is of course adequate for other research questions. To alleviate comparisons between the natural course and long-term effects of psychotherapeutic treatment, it would be very useful if all participants studied were included in the follow-upexaminations (Hensley, Nadiga, & Uhlenhuth, 2004), as treatment completers or remitted patients might display a subgroup of possibly less severe affected patients with a better long-term outcome. In addition to the difficulties discussed above, the results of reported psychotherapy studies have to be interpreted with caution, as they either relied solely on self-reports (Willutzki et al., 2012), followed only subsamples of study participants (Fava et al., 2001; Prasko et al., 2006; Stravynski et al., 2000; Willutzki et al., 2012), included only very small sample sizes (Stravynski et al., 2000; Turner et al., 1995) or were subjected to high attrition (Heimberg et al., 1993; Mörtberg et al., 2011; Willutzki et al., 2012). However, the reported results are still quite impressive, especially considering the shortness of the conducted psychotherapeutic interventions. It can be said that large percentages of those patients who responded to psychotherapy in the first place seemed to benefit from the interventions still a long time after these had ended.

In conclusion, recent naturalistic studies on the long-term course of SAD that followed samples from the community or primary care settings presented findings that allow a modified look on the long-term course of this disorder as they put the findings from clinical samples in a different – that is slightly less severe – perspective. Final conclusions cannot be drawn as current data is too sparse. Findings from therapy outcome studies with follow-up-durations of 24 months or longer show that social phobia is a treatable disorder, treatment effects can be stable over several years and that the prognosis allows for some positive outlook, as remission rates of treatment responders can lie as high as 85% after up to 10 years.

3.3. Limitations

Role of the funding source

This review has some limitations. By trying to present all articles that have been published in the research area in focus, the selection criteria used were not very strict (i.e. concerning factors like sample size, uniform remission, recurrence or recovery criteria or

This research was supported by grants from the Dr. Karl-WilderStiftung. The sponsor had no involvement in study design; in collection, analysis and interpretation of data; in writing the article; and in the decision to submit the article for publication.

3.5. Clinical implications Are there consequences for clinical practice? It becomes clear that social phobia, especially in secondary and tertiary care settings, can often be chronic with serious impairments in different areas of life. The knowledge of the longitudinal course of a disorder in different settings as well as possible course predictors is vital for treatment planning. Considering the rather stable long-term course of SAD with little evidence for full recovery in a majority of clinical patients and the possible development of subsequent psychiatric disorders, early interventions, such as early recognition and effective treatments are needed to prevent the consolidation of avoidance strategies and associated impairments as soon as possible. A special focus should hereby be put on patients with residual symptoms, comorbid disorders and treatment non-responders.

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