Cognitive-behavioral therapy in social phobia
Terapia cognitivo-comportamental da fobia social
Lígia M Ito,1 Miréia C Roso,1 Shilpee Tiwari,2
Philip C Kendall,2 Fernando R Asbahr1
Objective: This article is a review of relevant aspects of social phobia and the stages of treatment within cognitive-behavioral therapy
in children and adolescents, as well as in adults. Method: A review of the literature published on the treatment of social phobia using
cognitive-behavioral treatments was performed using the Medline database. Results: A review of the literature suggests that social
phobia is a chronic and prevalent condition, characterized by social inhibition and excessive shyness. Diagnosis and treatment of the
disorder are usually determined by distress level and functional impairment. Population studies indicate that lifetime prevalence rates for
social phobia range from 2.5 to 13.3%. The main techniques used in cognitive-behavioral therapy for social phobia are described and
exemplified in a case report. Conclusions: There is a general consensus in the literature that cognitive-behavioral therapy is efficacious
in the treatment of youth and adults with social phobia. Because of the early onset associated with social phobia, the identification of
children at high risk for the development of social phobia should be prioritized in future investigations.
Descriptors: Social phobia; Cognitive-behavioral therapy; Shyness; Anxiety; Literature review
Objetivo: Este artigo revisa aspectos relevantes da fobia social e os estágios de tratamento através da terapia cognitivo-comportamental
em crianças, adolescentes e adultos. Método: A partir do banco de dados Medline, realizou-se revisão da literatura publicada a respeito
do tratamento da fobia social por meio da terapia cognitivo-comportamental. Resultados: Revisão da literatura sugere que a fobia social
é uma condição prevalente e crônica, caracterizada por inibição social e timidez excessiva. Tanto o diagnóstico como o tratamento desse
transtorno são comumente determinados pelo nível de incômodo e pelo prejuízo funcional. Estudos populacionais indicam taxas de
prevalência ao longo da vida para a fobia social entre 2,5 e 13,3%. As principais técnicas utilizadas na terapia cognitivo-comportamental
para a fobia social são descritas e exemplificadas em um relato de caso. Conclusões: Há consenso geral na literatura de que a terapia
cognitivo-comportamental é eficaz tanto para o tratamento de jovens como de adultos com fobia social. Uma vez que a fobia social
com freqüência tem início precoce, a identificação de crianças com risco acentuado para o desenvolvimento de fobia social deve ser
priorizada em investigações futuras.
Descritores: Fobia social; Terapia cognitiva comportamental; Timidez; Ansiedade; Revisão de literatura
1 Psychiatry Institute, Hospital das Clínicas, School of Medicine, Universidade de São Paulo (USP), São Paulo (SP), Brazil
2 Temple University, Philadelphia (PA), USA
Fernando R Asbahr
R. Ovídio Pires de Campos, s/n
São Paulo, SP, Brazil
Rev Bras Psiquiatr. 2008;30(Suppl II):S96-101
S97 Ito LM et al.
Cognitive-behavioral therapy (CBT)
Social phobia (SP) represents a mental health problem with
1. Theoretical model
disabling characteristics. The most common is fear of being
According to the cognitive-behavioral model, individuals with
humiliated or mocked in social situations by having improper
anxiety perceive the world as a dangerous place, a potential threat
attitudes or anxiety symptoms such as tremors, excessive sweating,
that demands constant surveillance. Patients with SP are extremely
and inattention. Social interaction becomes more threatening when
sensitive to clues that denote the possibility of negative evaluation
associated with lack of motor control seen in behaviors such as
by other people. Excessive attention to these clues produces
drinking, eating or writing.
exaggerated self-criticism and distorted perception of behaviors that
SP can be categorized as generalized or circumscribed, depending
could go unnoticed. Therefore, a brief silence in social interaction,
on the amount or diversity of feared social situations. Lifetime
for example, is interpreted as lack of interest, and refusal to accept
prevalence rates for both types of SP are estimated to range
an invitation may mean constant isolation and loneliness.
between 25 and 13.3%.1,2 In adults, it is more frequent in women
Interpretation or meaning of a given experience is permeated by
and is likely to onset in adolescence, although many adults report
beliefs or values built by the individual. Clark & Wells describe the
experiencing symptoms of SP since childhood. In children, it is as
main beliefs in patients with SP as a fear of making mistakes and
common in females as in males.3 Individuals with SP, regardless
being rejected, as well as of being incapable, abnormal and inferior.
of age group, have a higher risk of having comorbid psychiatric
Viewed through a distorted lens, neutral stimuli are misinterpreted as
diagnoses such as generalized anxiety disorder, depression,
negative, whereas positive and safe stimuli are ignored.15 Memories
specific phobia, and psychoactive substance dependence (e.g.,
of successful situations, with use of proper coping resources in the
alcohol or tranquilizers).3-5 In addition, many SP individuals have
past, are underestimated or given low importance. Such distorted
characteristics of avoidant personality disorder (APD), a long-lasting
perception may trigger physical, behavioral and cognitive symptoms,
avoidance pattern of interpersonal contact, which is considered by
generating discomfort and reinforcing a negative self-image, sense
some as the most severe form of SP, with longer disease course and
of inadequacy and feelings of humiliation, thereby contributing to
higher number and variety of feared social situations.6
withdrawal from social experience. Avoidance and isolation intensify
There are multiple factors associated with SP etiology. Family
the self-focused attention and prevent disconfirmation of the perceived
studies have shown a pattern of family aggregation in SP,
threatening natured of the environment and social relationships.
especially of the generalized subtype. The higher incidence of
SP in first-degree relatives of affected individuals suggests a
possible genetic component.7 More recent genetic studies have
CBT is educational and has a focused approach. It focuses on
suggested the possibility of polygenic inheritance, with candidate
practical discussions performed during sessions and homework
genes in research.8 Functional neuroimaging studies, performed
assignments. The therapist has a collaborative and active role in
using magnetic resonance imaging (MRI) or positron-emission
the treatment. Studies have shown that, for circumscribed SP, 12 to
tomography (PET), have shown hyperstimulation of temporal
16 weekly group or individual sessions are enough to significantly
structures (amygdala, prefrontal cortex, hippocampus, and striatum)
reduce the symptoms. For generalized SP, treatment response
in response to random images of human faces, suggesting a
depends on the number of comorbidities and symptom severity;
hypersensitive limbic system not only to harmful stimuli but also
treatment is usually longer and results are more limited.16
to stimuli that are considered affectively neutral.8,9
In addition to the biological vulnerability reported in genetic
and neurobiological studies,10,11 a frequently investigated area
Before treatment begins, the fol owing data are col ected: disease
is the relationship between behavioral inhibition (BI) – which
course, onset and duration; family history, including biological
encompasses introversion, shyness, avoidance, and fear of strange
diathesis; family and school experience; social, affective, and sexual
people and objects – in infants and small children and SP in
relationships; physiological, cognitive and behavioral symptoms;
adolescence or early adult life.12 BI is a personality trait defined as
identification of comorbidities; need for psychiatric assessment and
the individual’s tendency to move away from novelties. Behavioral y
use of drugs; triggering situations of symptoms and their degree of
inhibited children are four to five times as likely to develop SP.
interference and impairment in the individual’s life; environmental
However, the presence of personality traits, such as shyness and
factors and family influence; and preexisting social skills.
BI, is not a sufficient condition for SP since not all individuals who
The data col ected during the evaluation inform treatment planning.
have such characteristics develop this disorder, which reaffirms the
Therapy should initially prioritize the symptoms that cause the highest
importance of environmental and biological factors in its etiology.13
degree of impairment. Group or individual therapy is recommended,
Furthermore, research on child development has correlated early
depending on the severity of SP, degree of avoidance and the patient’s
social inhibition with exaggerated protection and control responses
by parents. These, in turn, reinforce the child’s withdrawal and
consequently make exposure to social situations difficult, forming
a vicious cycle.14
It is essential, in the beginning of the therapy, to include a
session to educate the patients about their disorder and treatment.
Concurrent pharmacological therapy and the importance of including
The therapeutic approaches empirically tested and recognized
the family in the treatment should be discussed. Family guidance
as efficacious for SP are pharmacotherapy, individual (ICBT) and
should include explanations on how to cope with the difficulties
group (GCBT) cognitive-behavioral therapy. Due to the focus of this
that arise when interacting with the patient.
article, cognitive-behavioral therapy (CBT) approaches in children,
adolescents and adults are now described.
Therapist and patient work together to determine the objectives
Rev Bras Psiquiatr. 2008;30(Suppl II):S96-101
CBT in social phobia S98
of the therapy. The most frequent objectives include reduction in
asked about the meaning of identified thoughts: “What does this
anticipatory anxiety, physiological symptoms commonly found in
thought mean to you, what does it say about you?”
anxiety, negative cognitions that maintain dysfunctional beliefs,
Some authors believe that the main belief in SP is self-deprecating
phobic avoidance, and improvement in social skil s. These objectives
(“I’m incompetent, insignificant”).15 For that reason, conditional
should be reevaluated during and at the end of treatment. When
beliefs are built throughout life, with the aim to “hide” this “self-
working with children and adolescents, in addition to reducing
deprecation,” such as “if I show my insecurity by blushing, I’ll be
social anxiety, treatment involves increasing self-esteem, helping
humiliated”; “if I’m not impeccable in my behavior, I’ll be despised.”
the youth develop confidence in social situations. The focus of the
The compensatory strategy to cope with this type of belief involves
treatment, which generally requires active participation from the
the constant and excessive observation of one’s own behavior, such
youth’s parents/guardians, is to increase the youth’s exposure to
that no “slips” are al owed, in addition to an exaggerated expectation
different situations, with many people and activities,17,18 leading to
of one’s own performance.
an increased sense of mastery in social situations.
The modification of conditional beliefs, compensatory strategies
and core beliefs is performed through the use of different procedures
that should be chosen according to the characteristics and objectives
1. Social skills training (SST) and assertiveness training (AT)
of each case.
The main goal of SST and AT is to provide the patient with
a wide and varied repertoire of more adaptive social behaviors,
3. Stress management and relaxation
reducing passivity and feelings of impotence or anger, taking into
Stress management and relaxation techniques are also used in
consideration the patient’s characteristics and the social group
the treatment of SP with the aim of making the patient learn how
they belong to.
to have more control over the physiological responses typical of
SP patients often report difficulties with starting, establishing,
anxiety. Thus, these techniques are often used in the treatment of
maintaining and ending a conversation; maintaining the focus and
all patients with anxiety.
interest in the topic being discussed; tolerating silences; selecting
In stress management, the patient is advised to identify the signs
topics to discuss and knowing how to discuss them; changing the
that indicate an increase in his/her anxiety and to use distraction
subject if necessary; establishing and maintaining friends.19 These
and/or a breathing exercise to prevent anxiety from increasing.
difficulties are addressed in SST and AT.
Relaxation techniques are general y useful to reduce basal anxiety
The training should initially occur during the visits with the
and also foster the perception of anxiety self-control. The most widely
therapist and should take place in familiar environments, followed
used relaxation training script is that by Jacobson,21 which advises
by practicing skills in the wider social environment with friends
the patient to observe each muscle group to identify muscle tension
and relax the muscle.
2. Cognitive approach
4. Exposure tasks
Cognitive restructuring involves identification of distorted thoughts,
Exposure to feared situations reduces anxiety and phobic behavior.
conditional beliefs and the patient’s core belief, thus allowing the
It can be performed by facing in vivo (“real life”) or imaginary
therapist to gain insight into the patient’s cognitive processes and
The patient and therapist work together to identify anxiety-
A diary may be used to help the patient record his/her “automatic”
provoking situations. Once identified, the situations are hierarchical y
distorted thoughts and the anxiety that ensues in a social situation.
classified according to the degree of anxiety they produce, from
Next, the patient is advised to observe such thoughts “at a distance”
situations causing less anxiety to the most feared situations. With
and question them, so that he/she can view their distortions
the guidance of the therapist, the patient then gradually faces the
and reframe them (see things differently) to lower the anxiety
situations, from least to most anxiety-provoking, until his/her anxiety
they generate. The challenge of automatic distorted thoughts is
is reduced (a phenomenon called habituation). Exposure to each
performed through the technique of Socratic questioning and the
of the situations should be systematic (i.e., very frequent and for a
review of evidence confirming or disconfirming the patient’s negative
long period of time) to result in habituation.
The use of a diary is recommended for the patient to evaluate
By questioning thoughts, it is possible to determine the types
his/her anxiety before, during and after the exposure task, recording
of associated logical errors. The most common errors in SP are
all the difficulties encountered. A diary also helps the patient track
mental reading (“he thinks I’m incompetent”); guessing and
his/her progress and respective reduction in anxiety.
catastrophizing (“if I have to sign my name, I won’t be able to do
In vivo exposure tasks involve deliberately seeking confrontation
it”); and personalization (“they are not paying attention to me. I
with real situations that generate anxiety. Imaginal exposure involves
must have said something stupid”).20
thinking about confronting an anxiety-provoking stimulus and can
Identifying, questioning and modifying negative dysfunctional
be useful in helping the patient prepare for in vivo exposure tasks.
thoughts are resources that allow the patient to recognize the
In the treatment of SP, some difficulties in performing exposure
relationship between thoughts and their symptoms. In addition,
tasks are expected. Some social situations that cause anxiety are
such learning enables the patient to reduce the negative interference
often unpredictable and last for a short time, which may prevent
of thoughts and emotions, thus increasing self-control and self-
the experience of habituation. Therefore, it is important to be careful
when developing the list that wil define the hierarchy of situations to
Once distorted thoughts are identified, it is possible to find the core
facilitate task execution and maximize treatment-induced gains.
underlying belief that generated and is maintaining such thoughts,
Groups can be helpful. A group enables performance of some
as well as the conditional beliefs and compensatory strategies that
exercises between group members and helps create situations that
the patient uses to cope with this belief. To do so, the patient is
generate anxiety without necessarily having to rely on chance.
Rev Bras Psiquiatr. 2008;30(Suppl II):S96-101
S99 Ito LM et al.
5. Scheduling homework assignments
Clark et al. also compared CT to treatment with fluoxetine/self-
Throughout treatment, part of the session is devoted to scheduling
exposure and placebo/self-exposure.26 Stangier et al. and Mörtberg
and following-up on homework assignments. These should be
et al. compared ICBT with GCBT.27,28 Across studies, the CT program
practiced daily, using what was learned in-session as a model.
proved to be superior to exposure, and, in the latter two studies,
The need to complete homework tasks should be discussed and
GCBT results were not as favorable as those by Clark et al.26 Stangier
et al. found that patients who received CT and GCBT had better
results on posttreatment assessment measures than those in the
wait-list control condition.27 Fol ow-up results indicated that patients
The therapy in its weekly format may be terminated when most
who received ICBT fared better than those who received GCBT.
symptoms have significantly reduced in intensity and are causing
minimal interference with the patient’s daily routine. At this stage,
the techniques are reviewed and the patient is advised to continual y
Andrew* was a 10 year-old male with a lasting history of social
practice them to maintain clinical improvement. Attention should
anxiety and avoidance. Although he reported that he enjoyed playing
also be paid to recurrences and their potential triggering factors.
with peers, Andrew did not feel comfortable playing with more than
Following weekly therapy sessions, it is permissible for the patient
one child at a time. If he was invited to play at a peer’s house, he
to return at longer intervals for maintenance sessions.
always declined. Andrew frequently complained to his mother that
he did not have any friends. Attending school was also a major issue
Group cognitive-behavioral therapy (GCBT)
for Andrew. Prior to, or on the way to school, he often complained of
Heimberg et al. found that GCBT is an ef icacious treatment for SP
feeling sick (e.g., “My stomach hurts; I think I have to throw up”).
when compared with a control group of waiting list and non-specific
When in the school’s cafeteria, he was unable to eat because he
treatments involving emotional support.22 Although it is not superior to
felt so distressed being around other children – Andrew was afraid
the individual format, clinical impression suggests that it is an ef icacious
that he would throw up and that his peers would laugh at him.
alternative for some patients. Advantages relative to individual therapy
This social distress increased to such an extent that Andrew began
include members sharing the same dif iculty, increased opportunities
refusing to attend school, eat at restaurants, or attend any social
for in vivo exposure, direct evidence against cognitive distortions, public
gatherings unless accompanied by his mother or father.
commitment to change, and vicarious learning.
Andrew had a significant family history of psychiatric problems.
Some criteria should be considered, especially for group
His father suffered from generalized anxiety disorder and his mother
composition. The group should be balanced by gender, age and
suffered from depression. Although not presenting any significant
SP severity. Patients with severe depression and anxiety, a primary
problems during his early developmental years, Andrew was
disorder other than SP, comorbid personality disorders, and those
described as “extremely shy since he was born.” Facing new or
who are excessively hostile and demanding, at increased risk
unfamiliar situations had always been a problem for him.
of developing anger responses to defend against fear of social
Following a referral by his pediatrician, Andrew was evaluated by
interaction, may not benefit from this therapy and should be
a child psychiatrist. Information provided during the initial intake
excluded. Indications for GCBT are patients with similar severity
interview was consistent with a diagnosis of SP accompanied by
that have proper interpersonal performance in situations that trigger
avoidance. No clinical y meaningful depressive symptoms were
The ideal number of patients to compose the group is around six,
The therapeutic strategy that was undertaken consisted of 12
and it is recommended that the group be led by two therapists. The
sessions of CBT, with three main components (or strategies): 1)
treatment should consist of approximately 12 weekly sessions, each
relaxation training in the first 2-3 weeks, with “homework practice”
lasting two hours, fol owing a structured schedule for each phase of
in between sessions, using a relaxation CD; 2) SST to increase social
therapy. Cognitive-behavioral techniques are similar to those used
engagement, including basic conversation skil s, such as introducing
in individual sessions.
himself and asking simple questions. Skills such as keeping eye
contact and maintaining the same voice volume were also included;
Efficacy of cognitive-behavioral therapy
and 3) in vivo exposure tasks, such as weekly conversations with
Among the varied modalities of psychotherapy, CBT is the most
peers and adults, designed to allow conversational skills to be
efficacious treatment for SP.23 However, extant research is limited: in
practiced. Fol owing general guidelines for conducting exposure
many studies, assessments at the end of the treatment and during
treatment with anxious youth, situations were practiced within
follow-up indicate that many patients no longer meet diagnostic
session with the therapist before they were attempted elsewhere,
criteria for SP, but still experience significant difficulties in social
using imaginal exposure and role-play. Andrew was encouraged
situations, which could be considered subsyndromic manifestations
to anticipate difficulties he might encounter, and together with the
of this disorder.24
therapist, he brainstormed effective coping strategies to manage his
Some studies have examined the cognitive and behavioral
anxiety during exposure tasks. It was also important for exposure
approaches in detail to determine the essential components of
tasks to closely resemble anxiety-provoking situations in the “real
each treatment. Clark et al. have recently showed that a cognitive
world.” In Andrew’s case, for the exposure task to be genuine and
therapy (CT) program increased total remission of symptoms in
truly elicit anxiety, situations where a large number of children would
62 social phobic patients and was significantly better than the
be present were chosen. For example, a local restaurant near his
combination of exposure and relaxation techniques, as indicated
therapist’s office was one of the sites for an in vivo exposure task.
by posttreatment and 1-year follow-up assessments.25 At fol ow-up,
Accompanied by his therapist, Andrew practiced greeting other
84% of patients receiving only CT no longer met diagnostic criteria,
youngsters and having brief conversations with some of them.
whereas only 42% of the group treated with exposure tasks and
These initial exposure tasks were designed to help Andrew establish
relaxation techniques met that criteria.
a sense of mastery and success. Once Andrew evidenced that he
Rev Bras Psiquiatr. 2008;30(Suppl II):S96-101
CBT in social phobia S100
succeeded in these particular tasks, he began to practice peer
interactions in other, more difficult, social situations in which the
CBT is an efficacious treatment for patients with SP. In GCBT,
therapist was not always present.
a higher number of patients are seen by a therapist, significantly
As the treatment progressed, Andrew’s parents were informed
reducing treatment costs. In addition, the group treatment approach
about the treatment and its strategies, particularly the exposure
itself facilitates in vivo exposure. However, GCBT superiority over
tasks. In some instances, the parents were included (accompanied
ICBT has not been established in empirical studies.
Andrew and the therapist) for the in vivo exposure tasks. Parental
Patients with generalized SP, which runs a long-lasting
involvement was also necessary for the implementation of exposure
course and is often associated with comorbid disorders,
tasks that took place between therapy sessions, such as coordinating
require individual therapy. For these patients, even a combined
times when a friend would visit Andrew’s house or when Andrew
treatment with pharmacotherapy can be insufficient for a
could attend a birthday party. The therapist helped Andrew’s parents
complete resolution of symptoms, since a residual condition
problem-solve ways that they could manage his distress, as well
may remain and facilitate recurrences. In such cases, even
as any distress they might experience by extension, during anxiety-
empirically-supported treatment may not produce satisfactory
provoking situations. After the completion of treatment, several
responses; therefore, the use of several efficacious therapy
positive gains were observed. The therapist noted that Andrew
techniques may be necessary. The combination of CBT and
had made clear progress, given that his distress level during social
pharmacotherapy for these patients is a promising research field
situations had decreased considerably. Also, there was a significant
that warrants further investigation.
increase in the number of social situations in which Andrew took
In the case of a mental disorder that can have an early onset,
part, including playing soccer with his street neighbors, going to
the identification of children at high risk for the development of SP
school peers’ birthday parties, and, eventually, spending an entire
may al ow for SP prevention throughout childhood and adolescence.
afternoon at a friend’s house, suggesting that he was no longer
Parents, teachers, pediatricians and psychologists working with
avoiding social situations. This friend was soon considered to be his
youths could be educated to change the approach toward them,
best friend. During the last session, the therapist met with Andrew
with the aim of bringing benefits to patients with SP. Disseminating
and his parents to discuss relapse prevention plans to ensure the
self-help and information manuals for adolescents and young adults
maintenance of treatment gains.
can be another form of preventing SP. Prevention may reduce the
* Andrew is a pseudonym used for confidentiality.
suffering caused by social anxiety and be a less expensive alternative
to treatment in the future.
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