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Two-year follow-up of social phobics treated with Social Effectiveness Therapy
Pergamon
0005-7967(94)00086-7
Behav. Res. Ther. Vol. 33, No. 5, pp. 553-555, 1995 Copyright © 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0005-7967/95 $9.50 + 0.00
CASE HISTORIES AND SHORTER COMMUNICATIONS Two-year follow-up of social phobics treated with Social Effectiveness Therapy S A M U E L M. T U R N E R , l D E B O R A H C. B E I D E L 1 a n d M I C H E L E R. C O O L E Y - Q U I L L E 2 i Anxiety Prevention and Treatment Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, U.S.A. and 2Department of Psychology, George Mason University, Fairfax, VA 22030, U.S.A.
(Received 4 October 1994) Snmmary--A 2-yr follow-up assessment was conducted with patients treated with Social Effectiveness Therapy (SET), a multi-component treatment for social phobia. Eight of the 13 patients who completed the treatment study were available for the follow-up. The results indicated that treatment gains were maintained over the 2-yr follow-up interval, and there was some indication of further improvement over that attained at posttreatment. The findings are discussed in terms of the efficacy of SET and the durability of behavioral treatment of social phobia.
Social phobia is a complex clinical syndrome with a characteristic onset in adolescence and a chronic unremitting course (Liebowitz, Gorman, Fyer & Klein, 1985; Turner & Beidel, 1989). Since the diagnostic category was introduced in the third edition of the Diagnostic and Statistical Manual (DSM-III; American Psychiatric Association, 1980), a number of behavioral and cognitive-behavioral treatment studies have been reported. Although all of these studies generally report improvement as a function of treatment (Turner, Cooley-Quille & Beidel, in press), the treatments appear to be rather narrowly focused and do not in most cases address the multi-faceted syndromal features characteristic of social phobia. Turner, Beidel, Cooley, Woody and Messer (1994) reported the initial evaluation of Social Effectiveness Therapy (SET), a multi-component program designed to treat the specific deficiencies associated with social phobia. In this initial report, 17 chronic and severe social phobics were entered into a four month treatment program. At posttreatment, there was significant improvement in social phobia as assessed by a number of self-report, clinician ratings and behavioral measures. In addition, a composite index indicated that 84% of the patients showed moderate to high endstate functioning at posttreatment. Although the available follow-up data on treated social phobics show that the effects of behavioral treatment appear to be durable (e.g. Heimberg, Salzman, Holt & Blendel, 1993; Wlazlo, Schroeder-Hartwig, Hand, Kaiser & Munchan, 1990), the number of subjects evaluated to date is small, particularly for a period of time longer than 6 months posttreatment. The purpose of this report is to provide information on the status of social phobics treated with SET 2 years following the termination of treatment. METHOD
Subjects Of the 17 subjects who entered the treatment described in Turner et al. (1994), 13 completed treatment. Of that 13, 8 participated in the 2-yr (21-24 months) follow-up assessment reported here. Three were female (37.5%), 5 were male (62.5%) and all were Caucasian. The mean age was 37.5 years (SD = 13.1; range 25~52 yr), mean age of onset was 16.0 yr (SD = 4.8), mean chronicity was 25.4 yr (SD = 12.6), 5 were married (62.5%) and all were college graduates and currently employed full-time. All patients were assigned the generalized subtype. Diagnoses were made following a multi-step procedure (see Turner et al., 1994). Patients with a primary diagnosis of social phobia (DSM-III-R; APA, 1989), who had symptoms of at least moderate severity and no secondary Axis I disorder other than GAD, simple phobia or dysthymia, were included. Twenty-five percent had a concomitant Axis I diagnosis of GAD or dysthymia. Additionally, 6 patients (75.0%) had either APD, OCPD or both, based on SCID-II (Spitzer & Williams, 1986) interviews. Patients were excluded if they had an Axis II diagnosis of schizotypal, schizoid, borderline, paranoid or antisocial personality disorder. Finally, according to the 8-point rating scale of severity included in the ADIS-R, the mean social phobia severity rating was 5.3. The severity ratings and high percentage of Axis I and 1I disorders highlights the severely ill nature of the sample. Using X2 or t-tests, there were no significant demographic or diagnostic differences (gender, marital status, education, employment status, onset, chronicity, concomitant Axis I disorders, Axis II disorders, severity of social phobia at pre-treatment) between the 8 participants who participated in the follow-up assessment and the 5 who did not.
Assessment Self-report inventories. At 21-24 months posttreatment, the following subset of instruments used in the original study were administered. Self-report inventories included the Eysenck Personality Inventory (EPI; Eysenck & Eysenck, 1968), the Fear Questionnaire (FQ; Marks & Matthews, 1979), and the Social Phobia and Anxiety Inventory (SPAI; Turner, Beidel, Dancu & Stanley, 1989). 553
554
CASE HISTORIESAND SHORTER COMMUNICATIONS
Clinician ratings. Three rating scales were used: the Hamilton Rating Scale for Anxiety (HAMA; Hamilton, 1959), the Hamilton Rating Scale for Depression (HAMD; Hamilton, 1960) and the Clinical Global Impressions (CGI) Severity of illness rating (Guy, 1976). None o f the behavioral assessments were administered because patients did not come into the clinic. Treatment
Social Effectiveness Therapy (SET) is a multi-component behavioral treatment program for social phobia (Turner et al., 1994). This comprehensive treatment is designed to address the various aspects of the social phobic syndrome including maladaptive social anxiety and fear, social avoidance, limited interpersonal skills, poor self-concept and the restricted range of social functioning. The treatment consists of 4 interrelated components: education, social skills training (SST; social environment awareness, interpersonal skill enhancement, presentation skill enhancement), in vivo and/or imaginal exposure, and programmed practice (see Turner et al., 1994 for a detailed description of the treatment). Treatment implementation. SET was implemented in a combined individual and small group format (3-4 patients). Sessions were co-led by doctoral level clinical psychologists or a master's level nurse clinician. The education phase was completed in one 2-hr group session. This was followed by SST (twice per week 90 min sessions for 4 weeks). After the completion of SST, individual imaginal and/or in vivo exposure sessions were conducted twice per week for 8 weeks, averaging approximately 90 min per session. There was one individual and one group session each week. The last four SET sessions consisted of individual programmed practice sessions wherein the patient and therapist generated in vivo exposure assignments that the patient completed independently between weekly sessions. Follow-up assessment procedure
All 13 treatment completers in the original study were contacted by mail to request their participation in a follow-up assessment of the long-term effects o f SET. Participants were asked to complete the self-report instruments based on their current clinical status. Eight subjects returned the self-report battery. Additionally, subjects were asked permission to be interviewed by telephone. The 5 subjects who consented were contacted by a doctoral-level clinical psychologist who, following a general clinical interview, completed the clinician ratings. RESULTS Initially, comparisons were made on the outcome variables between those who participated in the follow-up assessment and those who did not. There were no statistically significant pre or posttreatment differences between follow-up participants and non-participants on the EPI, FQ, SPAI, H A M D or HAMA. In addition, there was no difference between the groups on the posttreatment severity of illness rating (t-tests, P > 0.05). Treatment outcome
Because those who completed follow-up represented only a sub-group of the sample reported in Turner et al. (1994), the pre and posttreatment scores for those patients who completed the follow-up assessment were examined. The EPI and H A M D were not administered at posttreatment and the CGI was not included at pretreatment. Thus, these measures were not included in this analysis. Similar to the initial sample, there were significant treatment effects on the FQ Social Phobia subscale and the FQ Troubled by Problem subscale (M = 17.75 vs M = 11.25, P < 0.001 and M = 4.75 vs M = 3.86, P < 0.05, respectively); but not on the FQ Presenting Symptom subscale (Table l). In addition, the decrease on the SPAI Difference score approached significance (M = 97.63 vs M = 72.25, P < 0.06). Treatment effects were evident on the H A M A clinician rating as well, where there was a significant decrease from pre to posttreatment (M = 19.60 vs M = 7.5, P < 0.01). These results further indicate that the follow-up participants were not different from the entire sample based on their response to SET treatment. Follow -up
Correlated t-tests were used to evaluate change in patient status from posttreatment to follow-up on both clusters of outcome measures. As depicted in Table I, the posttreatment to follow-up comparisons indicated that the patients maintained their treatment gains on the SPAI Difference score, the FQ Social Phobia subscale score, the FQ Troubled by Problem subscale, the HAMA and the CGI severity index. In addition, there was a significant difference between posttreatment and follow-up on the FQ Presenting Symptom Scale (M = 8.25 vs M = 4.88, P < 0.001), indicating a further decrease in the diiliculty experienced from the primary presenting complaint. The H A M D was not administered at posttreatment. However, there was a significant decrease in depression from pretreatment to follow-up (M = 11.5 vs M = 3.00, P =0.05). Furthermore, there was no change in CGI severity rating between posttreatment and follow-up, and the overall ratings indicated that the sample was judged to be only borderline mentally
Table 1. Mean scores at pretreatment posttreatment and follow-up
Self-report lnventoriest SPAI Difference FQ Social Phobia FQ Troubled Problem FQ Presenting Symptom EPI Extraversion EPI Neuroticism Clinician Ratings~ HAMA HAMD CGI Severity
Pre-Post t
Post-FU t
68.38 (28.89) 9.88 (4.94) 3.25 (2.05) 4.88 (2.03) 7.00 (4.00) 11.63 (2.93)
2.33* 6.38"** 2.31" 1.70
0.70 0.63 2.12 2.83**
3.40 (3.05) 3.OO (4.08) 2.60 (0.58)
2.67***
Pretreatment
Posttreatment
Follow-up
97.63 (32.36) 17.75 (3.37) 4.75 (2.61) 10.00 (4.54) 5.13 (2.17) 11.13 (2.80)
72.25 (27.93) 11.25 (3.73) 3.86 (I.95) 8.25 (3.15)
19.60 (2.61) 11.50 (3.87)
7.50 (2.65)
2.80 (0.84) "tn = 8, ~n = 5, *P = 0.05: **P = 0.05; ***P = 0.01.
Pre-FU t
-2.01 -0.48 2.25 3.12" 0.34
CASE STUDIESAND SHORTER COMMUNICATIONS
555
ill. Although the EPI was not administered at posttreatment, there was a small improvement in the extraversion score but essentially no change on neuroticism. However, because these are trait measures, one might not expect a great amount of change. Three out of the 8 patients reported that they had received additional treatment during the follow-up period. Two of the three sought additional treatment for social phobia; one received 'counseling' and one an anti-hypertensive agent (Lopressor) for "the most severe 10% of his social contacts". The third patient sought treatment for difficulties associated with her divorce. DISCUSSION In the initial report of the efficacy of SET, Turner et al. (1994) reported the significant improvement of social phobia on various dimensions following a 4-month treatment program. The initial findings particularly were impressive because a norm based endstate functioning index indicated that 83% of the sample showed moderate or high endstate status at posttreatment. The data reported here provide information on how these patients fared over a 2-yr follow-up interval. The results indicate that the positive effects achieved with SET remained for this 2-yr period. Furthermore, SET treated patients continued to improve over the 2-yr period after treatment was terminated. This was reflected in significant improvement over this interval on the patient's self-report assessment of the severity of their primary complaint. In addition, although non-significant, there was continuing improvement in the level of general anxiety. Thus, patients benefited in such a way as to facilitate a continuing trend of improvement despite not being in treatment. This pattern also has been reported for other behavioral and cognitive-behavioral treatments for social phobia (Turner et al., in press). The findings reported here particularly are important because they illustrate rather enduring change in severe social phobics of the generalized subtype. Furthermore, many of the patients also had co-occurring Axis I conditions (e.g. GAD, dysthymia, simple phobia) as well as Axis II disorders (e.g. APD, OCPD). Thus, even when the condition is severe and complicated by co-occurring conditions, SET still appears to be an efficacious and durable traetment. It remains to be seen, however, whether SET will prove more efficacious than other treatments for social phobia. On the other hand, the results suggest that SET is a suitable treatment for social phobics despite level of severity and when the condition is complicated by other disorders. Like most follow-up studies, one limitation of the current report is that not all of the treatment completers participated in the follow-up, and even though there were no differences between participants and non-participants, the sample is rather small. Also, patients were not seen in person. Rather, the clinical ratings were made via telephone and self-report questionnaires were completed and returned in the mail. Nevertheless, given the sparse long-term follow-up data available on social phobia, even the results from this small sample suggest it is possible to produce enduring positive changes in patients with this disorder. REFERENCES
American Psychiatric Association (1989). Diagnostic and statistical manual of mental disorders (3rd edm Revised). Washington, DC: APA. Eysenck, H. J. & Eysenck, S. B. G. (1968). Manual: Eysenck Personality Inventory. San Diego, CA: Educational and Industrial Testing Service. Guy, W. (1976). ECDEU assessment manual for psychopharmacology. Washington, DC: DHEW. Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 32, 5~55. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56 62. Liebowitz, M. R., Gorman, J. M., Fyer, A. J. & Klein, D. F. (1985). Social phobia: Review of a neglected anxiety disorder. Archives of General Psychiatry, 42, 729 736. Marks, I. M. & Matthews, A. N. (1979). Brief standard self-rating for phobic patients. Behaviour Research and Therapy, 17, 263-267. Spitzer, R. B. & Williams, J. B. (1986). Structured Interview for DSM-R-II, Axis II. Unpublished manuscript. New York: New York State Psychiatric Institute. Turner, S. M. & Beidel, D. C. (1989). Social phobia: Clinical syndrome, diagnosis, and comorbidity. Clinical Psychology Review, 9, 3-18. Turner, S. M., Cooley-Quille, M. R. & Beidel, D. C. (in press). Behavioral and pharmacological treatment of social phobia: Long-term outcome. In Mavissakalian, M. & Prien, R. (Eds), AnxieO, disorders: Psychological and pharmacological treatments. Washington, DC: American Psychiatric Press. Turner, S. M., Beidel, D. C., Dancu, C. V. & Stanley, M. A. (1989). An empirically derived inventory to measure social fears and anxiety: The Social Phobia and Anxiety Inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology, I, 35~,0. Turner, S. M., Beidel, D. C., Cooley, M. R., Woody, S. R. & Messer, S. C. (1994). A multi-component behavioral treatment for social phobia: Social Effectiveness Therapy. Behaviour Research and Therapy, 32, 381-390. Wlazlo, A., Schroeder-Hartwig, K., Hand, I., Kaiser, G. & Munchan, N. (1990). Exposure in vivo vs social skills training for social phobia: Long-term outcome and differential effects. Behaviour Research and Therapy, 28, 181-193.
0005-7967(94)00086-7
Behav. Res. Ther. Vol. 33, No. 5, pp. 553-555, 1995 Copyright © 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0005-7967/95 $9.50 + 0.00
CASE HISTORIES AND SHORTER COMMUNICATIONS Two-year follow-up of social phobics treated with Social Effectiveness Therapy S A M U E L M. T U R N E R , l D E B O R A H C. B E I D E L 1 a n d M I C H E L E R. C O O L E Y - Q U I L L E 2 i Anxiety Prevention and Treatment Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, U.S.A. and 2Department of Psychology, George Mason University, Fairfax, VA 22030, U.S.A.
(Received 4 October 1994) Snmmary--A 2-yr follow-up assessment was conducted with patients treated with Social Effectiveness Therapy (SET), a multi-component treatment for social phobia. Eight of the 13 patients who completed the treatment study were available for the follow-up. The results indicated that treatment gains were maintained over the 2-yr follow-up interval, and there was some indication of further improvement over that attained at posttreatment. The findings are discussed in terms of the efficacy of SET and the durability of behavioral treatment of social phobia.
Social phobia is a complex clinical syndrome with a characteristic onset in adolescence and a chronic unremitting course (Liebowitz, Gorman, Fyer & Klein, 1985; Turner & Beidel, 1989). Since the diagnostic category was introduced in the third edition of the Diagnostic and Statistical Manual (DSM-III; American Psychiatric Association, 1980), a number of behavioral and cognitive-behavioral treatment studies have been reported. Although all of these studies generally report improvement as a function of treatment (Turner, Cooley-Quille & Beidel, in press), the treatments appear to be rather narrowly focused and do not in most cases address the multi-faceted syndromal features characteristic of social phobia. Turner, Beidel, Cooley, Woody and Messer (1994) reported the initial evaluation of Social Effectiveness Therapy (SET), a multi-component program designed to treat the specific deficiencies associated with social phobia. In this initial report, 17 chronic and severe social phobics were entered into a four month treatment program. At posttreatment, there was significant improvement in social phobia as assessed by a number of self-report, clinician ratings and behavioral measures. In addition, a composite index indicated that 84% of the patients showed moderate to high endstate functioning at posttreatment. Although the available follow-up data on treated social phobics show that the effects of behavioral treatment appear to be durable (e.g. Heimberg, Salzman, Holt & Blendel, 1993; Wlazlo, Schroeder-Hartwig, Hand, Kaiser & Munchan, 1990), the number of subjects evaluated to date is small, particularly for a period of time longer than 6 months posttreatment. The purpose of this report is to provide information on the status of social phobics treated with SET 2 years following the termination of treatment. METHOD
Subjects Of the 17 subjects who entered the treatment described in Turner et al. (1994), 13 completed treatment. Of that 13, 8 participated in the 2-yr (21-24 months) follow-up assessment reported here. Three were female (37.5%), 5 were male (62.5%) and all were Caucasian. The mean age was 37.5 years (SD = 13.1; range 25~52 yr), mean age of onset was 16.0 yr (SD = 4.8), mean chronicity was 25.4 yr (SD = 12.6), 5 were married (62.5%) and all were college graduates and currently employed full-time. All patients were assigned the generalized subtype. Diagnoses were made following a multi-step procedure (see Turner et al., 1994). Patients with a primary diagnosis of social phobia (DSM-III-R; APA, 1989), who had symptoms of at least moderate severity and no secondary Axis I disorder other than GAD, simple phobia or dysthymia, were included. Twenty-five percent had a concomitant Axis I diagnosis of GAD or dysthymia. Additionally, 6 patients (75.0%) had either APD, OCPD or both, based on SCID-II (Spitzer & Williams, 1986) interviews. Patients were excluded if they had an Axis II diagnosis of schizotypal, schizoid, borderline, paranoid or antisocial personality disorder. Finally, according to the 8-point rating scale of severity included in the ADIS-R, the mean social phobia severity rating was 5.3. The severity ratings and high percentage of Axis I and 1I disorders highlights the severely ill nature of the sample. Using X2 or t-tests, there were no significant demographic or diagnostic differences (gender, marital status, education, employment status, onset, chronicity, concomitant Axis I disorders, Axis II disorders, severity of social phobia at pre-treatment) between the 8 participants who participated in the follow-up assessment and the 5 who did not.
Assessment Self-report inventories. At 21-24 months posttreatment, the following subset of instruments used in the original study were administered. Self-report inventories included the Eysenck Personality Inventory (EPI; Eysenck & Eysenck, 1968), the Fear Questionnaire (FQ; Marks & Matthews, 1979), and the Social Phobia and Anxiety Inventory (SPAI; Turner, Beidel, Dancu & Stanley, 1989). 553
554
CASE HISTORIESAND SHORTER COMMUNICATIONS
Clinician ratings. Three rating scales were used: the Hamilton Rating Scale for Anxiety (HAMA; Hamilton, 1959), the Hamilton Rating Scale for Depression (HAMD; Hamilton, 1960) and the Clinical Global Impressions (CGI) Severity of illness rating (Guy, 1976). None o f the behavioral assessments were administered because patients did not come into the clinic. Treatment
Social Effectiveness Therapy (SET) is a multi-component behavioral treatment program for social phobia (Turner et al., 1994). This comprehensive treatment is designed to address the various aspects of the social phobic syndrome including maladaptive social anxiety and fear, social avoidance, limited interpersonal skills, poor self-concept and the restricted range of social functioning. The treatment consists of 4 interrelated components: education, social skills training (SST; social environment awareness, interpersonal skill enhancement, presentation skill enhancement), in vivo and/or imaginal exposure, and programmed practice (see Turner et al., 1994 for a detailed description of the treatment). Treatment implementation. SET was implemented in a combined individual and small group format (3-4 patients). Sessions were co-led by doctoral level clinical psychologists or a master's level nurse clinician. The education phase was completed in one 2-hr group session. This was followed by SST (twice per week 90 min sessions for 4 weeks). After the completion of SST, individual imaginal and/or in vivo exposure sessions were conducted twice per week for 8 weeks, averaging approximately 90 min per session. There was one individual and one group session each week. The last four SET sessions consisted of individual programmed practice sessions wherein the patient and therapist generated in vivo exposure assignments that the patient completed independently between weekly sessions. Follow-up assessment procedure
All 13 treatment completers in the original study were contacted by mail to request their participation in a follow-up assessment of the long-term effects o f SET. Participants were asked to complete the self-report instruments based on their current clinical status. Eight subjects returned the self-report battery. Additionally, subjects were asked permission to be interviewed by telephone. The 5 subjects who consented were contacted by a doctoral-level clinical psychologist who, following a general clinical interview, completed the clinician ratings. RESULTS Initially, comparisons were made on the outcome variables between those who participated in the follow-up assessment and those who did not. There were no statistically significant pre or posttreatment differences between follow-up participants and non-participants on the EPI, FQ, SPAI, H A M D or HAMA. In addition, there was no difference between the groups on the posttreatment severity of illness rating (t-tests, P > 0.05). Treatment outcome
Because those who completed follow-up represented only a sub-group of the sample reported in Turner et al. (1994), the pre and posttreatment scores for those patients who completed the follow-up assessment were examined. The EPI and H A M D were not administered at posttreatment and the CGI was not included at pretreatment. Thus, these measures were not included in this analysis. Similar to the initial sample, there were significant treatment effects on the FQ Social Phobia subscale and the FQ Troubled by Problem subscale (M = 17.75 vs M = 11.25, P < 0.001 and M = 4.75 vs M = 3.86, P < 0.05, respectively); but not on the FQ Presenting Symptom subscale (Table l). In addition, the decrease on the SPAI Difference score approached significance (M = 97.63 vs M = 72.25, P < 0.06). Treatment effects were evident on the H A M A clinician rating as well, where there was a significant decrease from pre to posttreatment (M = 19.60 vs M = 7.5, P < 0.01). These results further indicate that the follow-up participants were not different from the entire sample based on their response to SET treatment. Follow -up
Correlated t-tests were used to evaluate change in patient status from posttreatment to follow-up on both clusters of outcome measures. As depicted in Table I, the posttreatment to follow-up comparisons indicated that the patients maintained their treatment gains on the SPAI Difference score, the FQ Social Phobia subscale score, the FQ Troubled by Problem subscale, the HAMA and the CGI severity index. In addition, there was a significant difference between posttreatment and follow-up on the FQ Presenting Symptom Scale (M = 8.25 vs M = 4.88, P < 0.001), indicating a further decrease in the diiliculty experienced from the primary presenting complaint. The H A M D was not administered at posttreatment. However, there was a significant decrease in depression from pretreatment to follow-up (M = 11.5 vs M = 3.00, P =0.05). Furthermore, there was no change in CGI severity rating between posttreatment and follow-up, and the overall ratings indicated that the sample was judged to be only borderline mentally
Table 1. Mean scores at pretreatment posttreatment and follow-up
Self-report lnventoriest SPAI Difference FQ Social Phobia FQ Troubled Problem FQ Presenting Symptom EPI Extraversion EPI Neuroticism Clinician Ratings~ HAMA HAMD CGI Severity
Pre-Post t
Post-FU t
68.38 (28.89) 9.88 (4.94) 3.25 (2.05) 4.88 (2.03) 7.00 (4.00) 11.63 (2.93)
2.33* 6.38"** 2.31" 1.70
0.70 0.63 2.12 2.83**
3.40 (3.05) 3.OO (4.08) 2.60 (0.58)
2.67***
Pretreatment
Posttreatment
Follow-up
97.63 (32.36) 17.75 (3.37) 4.75 (2.61) 10.00 (4.54) 5.13 (2.17) 11.13 (2.80)
72.25 (27.93) 11.25 (3.73) 3.86 (I.95) 8.25 (3.15)
19.60 (2.61) 11.50 (3.87)
7.50 (2.65)
2.80 (0.84) "tn = 8, ~n = 5, *P = 0.05: **P = 0.05; ***P = 0.01.
Pre-FU t
-2.01 -0.48 2.25 3.12" 0.34
CASE STUDIESAND SHORTER COMMUNICATIONS
555
ill. Although the EPI was not administered at posttreatment, there was a small improvement in the extraversion score but essentially no change on neuroticism. However, because these are trait measures, one might not expect a great amount of change. Three out of the 8 patients reported that they had received additional treatment during the follow-up period. Two of the three sought additional treatment for social phobia; one received 'counseling' and one an anti-hypertensive agent (Lopressor) for "the most severe 10% of his social contacts". The third patient sought treatment for difficulties associated with her divorce. DISCUSSION In the initial report of the efficacy of SET, Turner et al. (1994) reported the significant improvement of social phobia on various dimensions following a 4-month treatment program. The initial findings particularly were impressive because a norm based endstate functioning index indicated that 83% of the sample showed moderate or high endstate status at posttreatment. The data reported here provide information on how these patients fared over a 2-yr follow-up interval. The results indicate that the positive effects achieved with SET remained for this 2-yr period. Furthermore, SET treated patients continued to improve over the 2-yr period after treatment was terminated. This was reflected in significant improvement over this interval on the patient's self-report assessment of the severity of their primary complaint. In addition, although non-significant, there was continuing improvement in the level of general anxiety. Thus, patients benefited in such a way as to facilitate a continuing trend of improvement despite not being in treatment. This pattern also has been reported for other behavioral and cognitive-behavioral treatments for social phobia (Turner et al., in press). The findings reported here particularly are important because they illustrate rather enduring change in severe social phobics of the generalized subtype. Furthermore, many of the patients also had co-occurring Axis I conditions (e.g. GAD, dysthymia, simple phobia) as well as Axis II disorders (e.g. APD, OCPD). Thus, even when the condition is severe and complicated by co-occurring conditions, SET still appears to be an efficacious and durable traetment. It remains to be seen, however, whether SET will prove more efficacious than other treatments for social phobia. On the other hand, the results suggest that SET is a suitable treatment for social phobics despite level of severity and when the condition is complicated by other disorders. Like most follow-up studies, one limitation of the current report is that not all of the treatment completers participated in the follow-up, and even though there were no differences between participants and non-participants, the sample is rather small. Also, patients were not seen in person. Rather, the clinical ratings were made via telephone and self-report questionnaires were completed and returned in the mail. Nevertheless, given the sparse long-term follow-up data available on social phobia, even the results from this small sample suggest it is possible to produce enduring positive changes in patients with this disorder. REFERENCES
American Psychiatric Association (1989). Diagnostic and statistical manual of mental disorders (3rd edm Revised). Washington, DC: APA. Eysenck, H. J. & Eysenck, S. B. G. (1968). Manual: Eysenck Personality Inventory. San Diego, CA: Educational and Industrial Testing Service. Guy, W. (1976). ECDEU assessment manual for psychopharmacology. Washington, DC: DHEW. Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 32, 5~55. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56 62. Liebowitz, M. R., Gorman, J. M., Fyer, A. J. & Klein, D. F. (1985). Social phobia: Review of a neglected anxiety disorder. Archives of General Psychiatry, 42, 729 736. Marks, I. M. & Matthews, A. N. (1979). Brief standard self-rating for phobic patients. Behaviour Research and Therapy, 17, 263-267. Spitzer, R. B. & Williams, J. B. (1986). Structured Interview for DSM-R-II, Axis II. Unpublished manuscript. New York: New York State Psychiatric Institute. Turner, S. M. & Beidel, D. C. (1989). Social phobia: Clinical syndrome, diagnosis, and comorbidity. Clinical Psychology Review, 9, 3-18. Turner, S. M., Cooley-Quille, M. R. & Beidel, D. C. (in press). Behavioral and pharmacological treatment of social phobia: Long-term outcome. In Mavissakalian, M. & Prien, R. (Eds), AnxieO, disorders: Psychological and pharmacological treatments. Washington, DC: American Psychiatric Press. Turner, S. M., Beidel, D. C., Dancu, C. V. & Stanley, M. A. (1989). An empirically derived inventory to measure social fears and anxiety: The Social Phobia and Anxiety Inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology, I, 35~,0. Turner, S. M., Beidel, D. C., Cooley, M. R., Woody, S. R. & Messer, S. C. (1994). A multi-component behavioral treatment for social phobia: Social Effectiveness Therapy. Behaviour Research and Therapy, 32, 381-390. Wlazlo, A., Schroeder-Hartwig, K., Hand, I., Kaiser, G. & Munchan, N. (1990). Exposure in vivo vs social skills training for social phobia: Long-term outcome and differential effects. Behaviour Research and Therapy, 28, 181-193.