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ORIGINALARTICLE
Cognitive Therapy vs Interpersonal Psychotherapy
in Social Anxiety Disorder
ARandomizedControlled Trial
Ulrich Stangier, PhD; Elisabeth Schramm, PhD; Thomas Heidenreich, PhD; Matthias Berger, MD; David M. Clark, DPhil
Context:Cognitivetherapy(CT)focusesonthemodi- MainOutcomeMeasures:Theprimaryoutcomewas
fication of biased information processing and dysfunc- treatmentresponseontheClinicalGlobalImpressionIm-
tional beliefs of social anxiety disorder (SAD). Interper- provement Scale as assessed by independent masked
sonal psychotherapy (IPT) aims to change problematic evaluators. The secondary outcome measures were in-
interpersonalbehaviorpatternsthatmayhaveanimpor- dependent assessor ratings using the Liebowitz Social
tantroleinthemaintenanceofSAD.Nodirectcompari- Anxiety Scale, the Hamilton Rating Scale for Depres-
sons of the treatments for SAD in an outpatient setting sion, and patient self-ratings of SAD symptoms.
exist.
Objective: To compare the efficacy of CT, IPT, and a Results:Attheposttreatmentassessment,responserates
waiting-list control (WLC) condition. were 65.8% for CT, 42.1% for IPT, and 7.3% for WLC.
Regarding response rates and Liebowitz Social Anxiety
Design: Randomized controlled trial. Scale scores, CT performed significantly better than did
IPT,andbothtreatmentsweresuperiortoWLC.At1-year
Setting: Two academic outpatient treatment sites. follow-up, the differences between CT and IPT were
largelymaintained,withsignificantlyhigherresponserates
Patients: Of 254 potential participants screened, 117 in the CT vs the IPT group (68.4% vs 31.6%) and better
hadaprimarydiagnosisofSADandwereeligibleforran- outcomesontheLiebowitzSocialAnxietyScale.Nosig-
domization;106participantscompletedthetreatmentor nificant treatment site interactions were noted.
waiting phase.
Conclusions:CognitivetherapyandIPTledtoconsid-
Interventions:Treatmentcomprised16individualses- erable improvements that were maintained 1 year after
sions of either CT or IPT and 1 booster session. Twenty treatment; CT was more efficacious than was IPT in re-
weeksafterrandomization,posttreatmentassessmentwas ducing social phobia symptoms.
conductedandparticipantsintheWLCreceived1ofthe
treatments. Arch Gen Psychiatry. 2011;68(7):692-700
OCIAL ANXIETY DISORDER (CT)havebeenshowntobeeffective.Cog-
(SAD) is a common mental nitivetherapyisbasedonthecognitivemodel
Author Affiliations: disorderthatisassociatedwith of Clark and Wells8 of the maintenance of
Department of Psychology, considerable vocational and SAD.Efficacyhasbeendemonstratedagainst
University of Frankfurt, Spsychosocialhandicapandan exposuretherapy,groupCT,selectivesero-
Frankfurt (Dr Stangier); increasedriskofcomorbiddisorders,such tonin reuptake inhibitor treatment, and
Department of Psychiatry and asdepression,otheranxietydisorders,and waiting-listcontrol(WLC)conditionsin4
Psychotherapy, University of 1,2 9-12
alcohol abuse. If untreated, SAD gener- randomizedcontrolledtrials.
Freiburg, Freiburg ally takes a long-term course.3 Whereasthecognitiveapproachmainly
(Drs Schramm and Berger); Biological,cognitive,andinterpersonal emphasizes intrapersonal mechanisms,
Department of Social Work, factorshasbeenimplicatedinthecausesof otherresearchershavemorestronglyem-
Health and Nursing, University 4,5
of Applied Sciences, Esslingen SAD, andeachhadledtothedevelopment phasized interpersonal relationship pat-
(Dr Heidenreich), Germany; ofdistinctivetreatments.Amongpsychologi- terns and the fulfillment of social roles in
cal treatments, group cognitive behavior 13 Accordingly,in-
and Department of Psychology, themaintenanceofSAD.
6
Kings College London, London, therapies(CBTs)(Heimbergetal andDa- terpersonal psychotherapy (IPT), which
7 14
England (Dr Clark). vidsonetal )andindividualcognitivetherapy wasoriginallydevelopedbyKlermanetal
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15
andWeissmanetal forunipolardepressionandwhich PATIENTS
focusesonthemodificationofdysfunctionalpatternsof
interpersonal relationships, may represent a useful al- Participantswererecruitedviatheprivatepracticesofpsychia-
ternative to CT. Randomized controlled trials have es- trists and psychologists, outpatient clinics, and advertise-
16 mentsinlocalnewspapersandontheInternet,withuseofthe
tablished that IPT is effective in depression andineat- different referral routes varying with the local circumstances
ingdisorders.17Afterencouragingresultsinanopentrial18
19 of each site. All individuals interested in participating in the
of patients with SAD, Lipsitz et al in 2008conducteda study took part in a telephone screening based on the Social
randomizedcontrolledtrialthatconfirmedtheimprove- 25
mentsobservedwithIPTintheopentrialbutfoundno PhobiaInventory. Patientswhoseemedeligiblewereinvited
foradiagnosticinterview.Thestudywasapprovedbytheethi-
significant differences between IPT and supportive cal committees at the University of Frankfurt and the Univer-
therapy. sity of Freiburg. Participants were provided with a complete
FewdirectcomparisonsbetweenCBTsandIPThave study description, and written consent was obtained.
beenconducted.TheNationalInstituteofMentalHealth Socialanxietydisorderandotherpsychiatricdiagnoseswere
Treatment of Depression Collaborative Research Pro- assessed using Structured Clinical Interview for DSM-IV Axis I
26-28
20 and Axis II disorders. All the diagnostic evaluations were
gram foundthatbothtreatmentswereeffective,butin conducted by trained and certified clinical psychologists and
posthocanalysis,someevidenceindicatedthatIPTwas werereviewedbyseniorstudyinvestigators(U.S.,E.S.,andT.H.).
more effective with the most severely depressed pa- The17-itemHamiltonRatingScaleforDepression(HRSD)29,30
17,21
tients. Twotrials ofbulimianervosademonstratedthe wasusedtoassessseverityofdepression.Onthebasisof6vid-
superior effectiveness of CBT over IPT at the posttreat- eotapedinterviews,theintraclasscorrelationcoefficientforthe
mentassessmentbutnotatthe1-yearfollow-up.ANor- HRSDwas0.97.
22
wegiangroup comparedpredominantlygroup-basedver- Individuals were invited to participate if they met the fol-
sionsofIPTandCTinpatientswithSADinaresidential lowinginclusioncriteria:diagnosisofSADaccordingtotheDSM-
settingandfoundlimited,notsignificantlydifferent,im- IV, any comorbid mental disorder provided that severity did
provementsofsymptomsinbothapproaches.However, not exceed that of SAD, and age 18 to 65 years. The exclusion
both treatments differed substantially from the indi- criteria werepsychosis,currentsubstancedependencyorabuse,
vidualIPTandCTprogramsthathavereceivedthestron- AxisIIpersonalitydisordersfromthedramaticoroddcluster,
gest support in randomized controlled trials. Interpre- severe depression (HRSD score 23), acute suicidality, cur-
tation of the trial findings is further complicated by low rent psychopharmacologic or other psychotherapeutic treat-
therapist competency ratings. ment, and preference for psychopharmacologic treatment.
Of697individualswhocontactedthestudycenters,254were
TheaimofthepresentstudywastocompareinSAD assessedbyinterview;137individualswereexcludedowingto
the short- and long-term efficacy of individual CT and a failure to meet the inclusion criteria or for other reasons
IPTwiththatofaWLCcondition.Tocontrolfortherapy (Figure 1). Of 44 patients who refused to participate, 8 who
site allegiance effects and for capacity to deliver the treat- met the inclusion criteria withdrew after signing the consent
mentswithasufficientdegreeofcompetence,23,24thein- form but before randomization. The remaining 117 individu-
vestigationwasconductedat2researchcenters,1ofwhich als met the inclusion criteria and were randomized. Thirty-
(Frankfurt, Germany) had previously specialized in CT eight participants were allocated to CBT, 38 to IPT, and 41 to
and1ofwhich(Freiburg,Germany)hadpreviouslyspe- WLC.Nineteentherapists(16clinicalpsychologistsand3psy-
cialized in IPT. Therapists at each site were trained to chiatrists) with advanced or completed psychotherapy/
provide both treatments. clinical training participatedinthetrial.The8therapiststreat-
ing patients receiving CT and 11 therapists treating patients
receivingIPThadcomparablelevelsofclinicalexperience(CT:
5.3 years; IPT: 6.6 years; t =−0.73, P=.48), experience with
METHODS 17
the treatment (CT or CBT: 4.5 years; IPT: 4.1 years; t =0.78,
17
P=.44),andexperiencewiththetreatmentofSAD(CT:1.5years;
DESIGN IPT: 1.5 years; t =0.04, P=.97). In each treatment condition,
17
therapists received 40 hours of training workshops and ad-
Ateachtrialsite,patientswererandomlyassignedtotheCT,IPT, heredtotreatmentmanuals(D.M.C.,unpublisheddata,1997;
31
or WLC group. Randomization was stratified according to site translatedandrevisedbyStangier,Ehlers,andClark ;J.D.Lip-
and presence or absence of comorbid depression. After patient sitz, PhD,andJ.C.Markowitz,PhD,unpublisheddata,1996).
eligibility was assessed and informed consent was obtained, pa- TheworkshopsforCTwereconductedby3ofus(U.S.,T.H.,
tients were formally enrolled in the study. Allocation was based and D.M.C.) and for IPT by Dr Lipsitz and one of us (E.S.).
onacomputer-generatedlistthatwasconcealedfromtheinves- Each therapist treated at least 2 pilot cases under supervision
tigators. Treatment comprised up to 16 individual sessions con- beforeparticipatinginthetrial.Additionaltrainingintheform
ductedonamainlyweeklybasis.Aboostersessionwasoffered2 ofdetailedfeedbackonvideotapesorcasedescriptionswaspro-
monthsaftertheendoftreatment.TheWLCgroupreceivedtreat- videdbyoneofus(D.M.C.)andDrLipsitz.Atbothtrialsites,
mentaftera20-weekwaitingperiod.Themainassessmentpoints continuous supervision was established for therapists in each
were before treatment/wait, after treatment/wait, and 1 year af- condition.Afterreachinganadequatelevelofadherence,thera-
ter treatmentcompletion.Twotreatmentsitesthatwereeachex- pists treated an average of 4 patients each.
perienced in conducting trials with 1 of the 2 treatment ap-
proachesparticipated: Frankfurt University (CT; U.S. and T.H.)
andFreiburgUniversity(IPT;E.S.andM.B.).Thestudydesign, TREATMENTS
thus, included 3 factors: (1) treatment condition (CBT vs IPT vs
WLC),(2)arepeated-measuresfactor(pretreatmentvsposttreat- Thetreatmentscomprised16individualsessionsconductedover
mentvsfollow-up),and(3)treatmentsite(FrankfurtvsFreiburg) 20weeks.Mostsessionswere50minutes,buttheprotocolal-
to control for any site allegiance effects. lowed therapists to extend up to 6 sessions to a maximum of
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697Patients contacted trial centers (A: 420, B: 277)
254Patients were assessed for eligibility (A: 99, B: 155) 137Patients were excluded (A: 39, B: 98)
25Did not meet SAD criteria (A: 9, B: 16)
37Did not meet other inclusion criteria (A: 12, B: 25)
44Refused to participate (A: 13, B: 31)
117Met the inclusion criteria and were randomized (A: 60, B: 57) 31Other reasons (A: 5, B: 26)
Pretreatment Pretreatment Pretreatment
38Started CT (A: 19, B: 19) 38Started IPT (A: 19, B: 19) 41Started WLC (A: 22, B: 19)
31Completed CT (A: 14, B: 17) 34Completed IPT (A: 19, B: 15)
Posttreatment Posttreatment Posttreatment
36Assessed 36Assessed 39Assessed
2Declined (A: 2, B: 0) 2Declined (A: 0, B: 2) 2Declined (A: 2, B: 0)
1-y follow-up 1-y follow-up
34Assessed 34Assessed
4Declined (A: 2, B: 2) 4Declined (A: 0, B: 4)
Figure 1. Flowchart of attrition. A indicates the Freiburg site; B, the Frankfurt site; CT, cognitive therapy; IPT, interpersonal psychotherapy; SAD, social anxiety
disorder; and WLC, waiting-list control condition.
100 minutes to facilitate behavioral experiments (CT) or in- other people’s beliefs about the significance of blushing, stut-
depth discussions and role-plays (IPT). With respect to mean tering,sweating,etc;and(6)behavioralexperimentstotestnega-
session length, no significant differences between both treat- tive beliefs in anxiety-provoking social situations while giving
ments (mean [SD] number of minutes per session: IPT, 65.3 up safety behaviors and adopting an external focus of atten-
[9.8]; CT, 67.8 [14.4]; t , 0.77; P=.45). Both treatments were tion. TherapistswereinstructednottousecomponentsofIPT,
50
manualized (D.M.C., unpublished data, 1997; translated and suchasexploringandmodifyinginterpersonalrelationshipsor
31
revised by Stangier, Ehlers, and Clark ; J. D. Lipsitz and J. C. using role-plays to enhance communication of affect and so-
Markowitz, unpublished data, 1996). Patients on the waiting cial skills.
list received no treatment for 20 weeks, after which they were
offered1ofthe2treatments.Noneofthepatientsreceivedany Interpersonal Psychotherapy
other form of psychotherapy or pharmacotherapy during the
treatmentphaseofthestudy.Thesessionswerevideotaped.A For SAD, IPT was based on a revised version of the standard
randomlyselectedsubsetofCTvideotapeswasauditedbyone 13,14
ofus(D.M.C.),andwrittenfeedbackwassenttothetherapist. manual developed by Lipsitz and Markowitz (J. D. Lipsitz
andJ.C.Markowitz,unpublisheddata,1996)andusedintrials
AdherencetotheCTmanualwasreviewedby2ofus(U.S.and 18,19
T.H.) during routine, videotape-based supervision. Similarly, byLipsitz et al. Duringthefirstphaseoftreatment,theIn-
IPT videotapes were systematically checked by 1 of us (E.S.), terpersonalInventoryisconductedwiththeaimofrelatingso-
and additional feedback was provided by Dr Lipsitz. The in- cial anxiety symptoms to 1 of the 4 problem areas. J. Lipsitz
tegrity and boundaries of each therapy were carefully moni- (writtencommunication,2002)replacedtheproblemarea“so-
tored. Checklists of “encouraged” and “prohibited” interven- cial deficits” with the concept of “role insecurity/role deficits”
tionswerecompletedbythetherapistaftereachsessiontoensure asbeingmorespecifictoSAD.Mostcommonlyusedinthistrial
that techniques unique to the other treatment were not ap- was the area of role transition, either in terms of life changes
plied. or in terms of a therapeutic role transition. Therapeutic role
transitionmeansthatthepatientrecognizesthatSADisnotpart
of his or her personality but rather a temporary state or role.
Cognitive Therapy In the second stage of treatment, the formulated problem area
is addressed by clarifying roles and their associated emotions,
TheCTprogramwasbasedonthecognitivemodelofSADof givingadvice,usingrole-playifindicated,andencouragingthe
ClarkandWells8andincludedthefollowingcomponents8,9:(1) patient to communicate and express feelings. As in standard
establishing a personal version of the model using the IPT, the interventions generally aim to enable the patient to
patient’s own thoughts, images, focus of attention, safety be- build a social network by forming and maintaining close and
haviors, and symptoms; (2) conducting role-play–based be- trustingrelationships.Duringthelastphaseoftreatment,therapy
havioralexperimentstodemonstratetheadverseeffectsofself- completion is explicitly addressed, progress is discussed, and
focusedattentionandsafetybehaviors;(3)practicingexternal therapeutic gains are consolidated to prevent future relapses.
focus of attention in nonsocial and social situations; (4) re- In the present study, therapists were instructed not to use CT
structuringdistortedself-imageryusingvideotapefeedbackand interventions for safety behaviors, attentional processes, be-
other methods; (5) discussing surveys providing feedback on havioral experiments, and cognitive restructuring.
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Table 1. Sample Characteristics
Cognitive Therapy Interpersonal Psychotherapy Waiting-List Control
Characteristic (n = 38) (n = 38) (n = 41) P Value
Age, mean (SD), y 34.6 (12.9) 33.9 (9.5) 38.1 (12.9) .15a
Female sex, No. (%) 17 (44.7) 22 (57.9) 26 (63.4) .23b
High school diploma, No. (%) 25 (65.8) 25 (65.8) 22 (53.7) .62b
Age at onset of SAD, mean (SD), y 13.1 (7.2) 14.8 (8.0) 18.3 (11.8) .12a
Duration of SAD, mean (SD), y 19.7 (11.3) 18.6 (11.8) 16.8 (11.3) .68a
Generalized subtype of SAD, No. (%) 25 (65.8) 21 (55.3) 21 (51.2) .51b
Any additional Axis I diagnoses, No. (%) 21 (55.3) 24 (63.2) 19 (46.3) .32b
Comorbid mood disorders, No. (%) 14 (36.8) 13 (34.2) 14 (34.1) .96b
Abbreviation: SAD, social anxiety disorder.
aBy analysis of variance.
b 2
By test.
ASSESSMENTPROCEDURES RESULTS
Theprimary outcome measure was treatment response as as-
32 DESCRIPTIONOFTHESAMPLE
sessed by the Clinical Global Impression Scale (CGI-I). In
6 7
agreementwithHeimbergetal andDavidsonetal, wechose
CGI-I as the primary outcome measure because it is a stan- Patient characteristics are given in Table 1. No signifi-
dardprimaryoutcomemeasureinpsychopharmacologicstud- cant differences were noted between treatment condi-
ies and provides information that is of high clinical relevance. tions regarding any of the sociodemographic or clinical
The psychometric properties of CGI-I have been found to be variables. Fifty-eight percent of patients met the criteria
33
good. Independentassessorsmaskedtothetreatmentcondi- forthegeneralizedsubtypeofSAD.Fifty-fourpercentof
tioncompletedthe7-pointratingscaleattheposttreatmentand patientsalsometthediagnosticcriteriafor1ormoreother
1-year follow-up assessments. Patients rated 1 or 2 (markedly current Axis I disorders: major depressive disorder
ormoderatelyimproved)wereclassifiedasresponders,andthose
rated 3 or higher were classified as nonresponders. (24.6%),dysthymia(13.6%),specificphobia(5.9%),and
Thesecondaryoutcomemeasureswereindependentasses- panicdisorder(3.4%).Sixty-sevenpercentofpatientsmet
sorratingsontheLiebowitzSocialAnxietyScale(LSAS)34-36and the criteria for 1 or more personality disorders, primar-
37
theHRSD andthepatient-completedSocialPhobiaandAnxi- ily avoidant type (50.8%).
etyInventory(SPAI)(T.Fydrich,PhD,A.Scheurich,PhD,and
E.Kasten,DiplPsych,unpublisheddata,1995).Eachwascom- TREATMENTANDASSESSMENTCOMPLIANCE
pletedatthepretreatment/wait,posttreatment/wait,and1-year
follow-upassessments.Attheendofthefirstsession,patients Figure 1 shows the flow of patients through the trial.
rated the credibility of their treatment using a rating scale de-
38 Elevenof76patients(14.5%)attendedfewerthan12of
veloped by Borkovec and Nau. In addition, a therapist ver-
sion of this questionnaire was used to assess allegiance. After 16sessionsandwereconsideredtohavereceivedasub-
each therapy session, patients and therapists separately com- optimaldoseoftreatment(7patientsreceivingCT[18.4%]
39 2
pleted the Bernese Post-Session Report, which includes sat- and4patients receiving IPT [10.5%], =0.96, P=.26).
isfactorily reliable patient- and therapist-rated therapeutic al- 1
Separate analyses for both sites reveal that no signifi-
liancescales.Forthepresentanalysis,allianceratingsafterthe cantdifferencewasnotedbetweenCTandIPTintheat-
first therapy session were used. trition rate in Frankfurt (CT=2,IPT=4;2=0.79,n=38,
1
STATISTICALANALYSES P=.66), but in Freiburg, the rate of patients not receiv-
ing an adequate treatment dose was significantly higher
for CT than for IPT (CT=5, IPT=0; 2=5.76, n=38,
Data were analyzed using a commercially available software 1
package (SPSS; SPSS Inc, Chicago, Illinois). All the statistical P=.046).Forthesepatients,thenumberofsessionsranged
analyses were intent-to-treat. Patients who were allocated to from 2 to 10. Six patients (5%) did not attend the post-
CTor IPT were considered to have had an adequate dose of treatment/wait assessment interview and were coded as
therapy if they attended at least 12 (of 16) sessions. Individu- nonresponders.Eightof76patients(10.5%)didnotpar-
als who attended fewer sessions were still assessed and in- ticipate in the 1-year follow-up assessment (CT=4,
cluded in the intent-to-treat analysis. Missing data were re- IPT=4).Therewerenosuicides,suicideattempts,orother
placed using the last-observation-carried-forward approach. major adverse events.
Categorical analyses were conducted using binary logistic re-
gression.Dimensionalmeasuresweresubmittedtoanalysesof TREATMENTCREDIBILITY,THERAPEUTIC
covariance in which pretreatment scores were controlled for. ALLIANCE,ANDADHERENCE
Analysesofcovariancewereperformedseparatelyforthepost-
treatment and 1-year follow-up assessments. To determine Nosignificant differences were noted between IPT and
whether treatment site affected outcome, all the analyses in-
cluded an estimation of site and treatment site interaction CTineitherpatientortherapistratingsoftreatmentcred-
effects. Statistical significance was set at P.05 (2-tailed). ibility or in the quality of the therapeutic alliance. For
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