Family Practice Vol. 17, No. 2, 114-118
© Oxford University Press 2000
The treatment of social phobia in general practice. Is exposure therapy feasible?
Department of Psychiatry, University of Bergen, 5021 Haukeland University Hospital, Bergen, Norway.
Haug TT, Hellstrøm K, Blomhoff S, Humble M, Madsbu H-P and Wold JE. The treatment of social phobia in general practice. Is exposure therapy feasible? Family Practice 2000; 17: 114–118.
Received 21 June 1999; Revised 15 October 1999; Accepted 26 October 1999.
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Abstract |
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Background. Exposure therapy is an effective treatment for generalized social phobia. Most patients with social phobia are treated in primary care, but family doctors are not usually trained to perform exposure therapy. We have conducted a study in primary care of the effect of exposure therapy alone or in combination with sertraline on generalized social phobia.
Objectives. The purpose of this article is to describe the training of GPs and the application of the treatment programme in general practice.
Method. Forty-five GPs were trained for ~30 h in assessing patients with social phobia and conducting exposure therapy. The training programme included scoring of videotaped interviews of five patients on several social phobia scales, and a videotape demonstrating different steps of an exposure therapy was used as a model for role play in group training.
Results. All of the GPs completed the training programme. The doctors expressed satisfaction with the programme and also found it useful in the treatment of patients with conditions other than social phobia. There was a significant difference in response between the treatment groups (P = 0.001), and the combination of exposure therapy and sertraline seemed to be particularly beneficial.
Keywords. Exposure, general practice, social phobia.
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Introduction |
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Social phobia is a rather new diagnostic entity; it was included as a separate condition for the first time in 1980 in DSM-III. It is characterized by a persistent and exaggerated fear of humiliation or embarrassment in social situations, leading to high levels of distress and possible avoidance of those situations. The fear may be of speaking, meeting other people, eating or writing in public, and relates to the fear of appearing nervous or foolish, making mistakes, being criticized or being laughed at. Often physical symptoms of anxiety such as blushing, trembling, sweating and tachycardia are triggered when the patient feels under evaluation or scrutiny. Recent epidemiologic studies have shown a life-time prevalence of social phobia in the general population ranging from 2.4%1 to 16%.2
Social phobia is a chronic disorder with an early, insidious onset in adolescence and a continuous, unremitting course, resulting in a substantial degree of disability and suffering.3 Both pharmacotherapy and psychological treatment have been proven effective.4–8 Exposure therapies are used commonly to treat social phobia, and treatment programmes including education and exposure instructions have been developed.9,10 Usually these programmes are applied in mental health care for individual or group treatment. There are no earlier studies of psychological treatment for social phobia by GPs. We have conducted a study of the effect of exposure therapy, either alone or in combination with medication, for patients with social phobia in primary care.
Why in general practice?
In general practice, about one-third of patients have a psychiatric disorder, mainly anxiety and depression.11 Only half of the patients with psychiatric disorders are identified by GPs mainly because primary care patients usually present somatic symptoms and only rarely mention their psychological problems.12,13 The diagnosis social phobia is almost never applied in general practice. The patients are given more general diagnoses such as anxiety or depressive conditions, sleeping problems, substance abuse or somatization such as myalgia, gastritis or cardiac neurosis.
Nearly all patients with anxiety and depressive conditions are treated by family doctors, whereas only a few are seen by psychiatrists.14,15 Given this distribution of care, it is important to ensure that GPs are well trained in psychiatric assessment, diagnosis and treatment. Valid and reliable diagnostic procedures and efficacious treatment strategies for anxiety disorders have been developed in psychiatric settings over the past two decades. Application of these diagnostic and treatment methods has not been well studied in primary care settings, although there is some indication that both presentation of illness and effective treatment interventions may differ from those in specialized psychiatric settings. There is, therefore, a need to facilitate dissemination of efficacious methodologies to primary care settings.
Recognition programmes of psychological problems in primary care have been developed where the physicians are taught skills enhancing their ability to recognize and respond to verbal and non-verbal cues, making empathic comments and using patient-directed, open-ended interviewing strategies.16 There are also several studies of brief psychological treatment for primary care patients. Barkham17 has described a three-session cognitive–behavioural intervention, and White and Keenan18 have applied a group didactic ‘course’ on anxiety management strategies. Brief problem-solving therapy has been proven to be as effective as benzodiazepine treatment of patients with anxiety,19 and Swinson et al.20 showed that panic disorder patients provided with psychoeducation and exposure instructions had a significantly better outcome than those not so informed.
Why exposure therapy?
There are now well proven efficacious treatments for social phobia using medication and psychotherapy alone and in combination.4,7,8 These treatments have not been well studied in primary care settings, and thus their effectiveness remains to be documented. The psychotherapeutic approach in this study had to meet four basic criteria: (i) it must be possible to conduct the therapy within the frame of a GP consultation; (ii) the therapy had to be standardized in such a way that a manual was available for the instruction of the therapists; (iii) only a limited number of therapeutic interventions were to be applied; and (iv) there must be some evidence of efficacy for the approach for patients with social phobia. Exposure therapy has been proven effective in the treatment of social phobia,21,22 and brief treatment programmes with structured manuals have been developed. In exposure therapy, mainly behavioral techniques such as scheduling activities, graded task assignment, distraction and relaxation are applied, while cognitive strategies for managing the problematic situation are only used to a limited degree. On the basis of these considerations, brief exposure therapy based on a self-treatment manual developed by Isaac Marks9 was chosen as the psychotherapeutic approach. We wanted to test if it was possible to describe a standard psychological treatment for social phobia which could be applied in a primary care setting and if it was feasible to train GPs to conduct this therapy at an adequate competence level within a relatively short time.
The purpose of this article is to describe the training of the GPs in the treatment programme, and its application in general practice.
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Methods |
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Design of the outcome study
Three hundred and eighty-seven patients with generalized social phobia (mean age 40 years, female/male 234/ 153) were included in the study. A total of 238 patients were recruited from general practice and 149 from advertising in newspapers. Requirements for inclusion were generalized social phobia (DSM-IV) of at least moderate severity (score
34 on the Clinical Global Impression Scale, CGI-S), lasting for at least 1 year. Exclusion criteria were other axis-I diagnoses, treatment for social phobia within the last 6 months, suicide risk, alcohol or substance abuse and expected bad compliance.
Assessments
Assessments of anamnestic data, somatic symptoms and psychological factors were made by GPs and by self-rating. Forty-three GPs and two psychiatrists participated in the study. The ratings by the physicians were tested for reliability before the study. The assessments were made in a screening interview and in a baseline interview after 1 week. Before the baseline interview, the patients performed self-ratings on several questionnaires. The following instruments were applied: Mini International Neuropsychiatric Interview (MINI-R)22 assessed DSM-IV psychiatric diagnoses, CGI-S,23 Social Phobia Scale (SPS)24 and Marks Fear Questionnaire25 measured the level of generalized social phobia.
All patients also identified 1–3 ‘target complaints' which they assumed to be important and wanted to work on in therapy, if they were selected for the therapy group. The targets covered a range of social situations where the patients feared a negative evaluation and had a substantial degree of avoidance such as attending lunch breaks, speaking up at meetings, going to parties, etc. Each of the target complaints was scored on a scale from 1 to 4 where a higher score indicated a higher degree of the problem. At the end of treatment, the patients made an evaluation where they assessed the efficacy of the therapy.
Anamnestic data were also registered and the patients had a general physical examination. All patients signed an informed consent to take part in the study.
Treatment
After the baseline interview, the patients were assigned randomly to exposure therapy or general medical care.26 In the general medical care group, the interaction with the patients was limited to discussion of clinical history, explanation of the disease and general support, such as encouragement, acceptance, ventilation and abreaction. The exposure therapy focused on the specific ‘target complaints' identified by the patients at the assessment interview. The patients also defined their own goals of treatment. A booklet containing general information about social phobia and its treatment, describing the principles of exposure therapy including graded task assignment with coping strategies such as distraction, breathing exercises and rational self-talk, was distributed. The booklet also contained a self-registration task of anxiety symptoms and coping strategies usually applied by the patients themselves and forms for registration of daily homework assignments.
The therapy included eight sessions, each lasting 15– 20 min. The first four sessions were conducted weekly, and the last four sessions every other week. The time course of the exposure therapy was 12 weeks. The aim of the exposure therapy was to let the patients expose themselves gradually to situations they usually feared and avoided and thus learn new coping strategies. They were told to stay as long as they could in the phobic situations, ideally until the anxiety decreased.
All patients did homework between sessions where they continued to expose themselves to defined anxiety-provoking situations. During homework, the patients made a written report of the training to bring with them to the next session for discussion. The task of the physician was to help the patients to identify goals of therapy and new coping strategies, collaborate with the patients in planning realistic exposure tasks and to offer guidance and support.
In the first therapy session, the patients were given general information about social phobia and exposure therapy. They were given the self-treatment booklet and the first homework assignment was to read the booklet. In the second session, the practical goals for treatment were identified and the diary was introduced. In the next sessions, the patients and physicians reviewed the homework done by the patient, discussed coping strategies and new homework was assigned. In the last session, the focus was on relapse prevention The coping strategies the patient had learned during therapy were repeated and the patients were encouraged to continue to expose themselves to feared situations.
All patients additionally were randomized to medical treatment with sertraline (50–150 mg daily) and matching placebo according to a 2 x 2 design of the study. The patients were medically treated for 24 weeks.
Follow-up
Assessments were made at 12 weeks and at 24 weeks. Social phobia, social avoidance and ‘target complaints' were assessed applying the same scales as at baseline. Outcome variables were changes in degree of social phobia rated by CGI-L, severity subscale and improvement subscale, SPS and Marks Fear Questionnaire. In addition, the effect of treatment was assessed by changes in scores on ‘target complaints'. Response was defined as a reduction of at least 50% on SPS compared with baseline, a CGI-L global improvement rating of 1–2 (markedly or moderately improved) and CGI-L overall severity in the range 1–3 (no–mild mental illness) at week 24. Non-response was defined as <25% reduction in SPS compared with baseline or CGI-L global improvement rated at least 4 (no change). Partial response was defined as all other responses.
The training programme
The goal of the training programme was to teach the GPs to carry out reliable scorings effectively on the different assessment forms and to attain a certain degree of mastery of the treatment approach. The standardization of training should ensure relatively uniform as well as adequate administration of the treatment condition across research sites.
The training programme included lectures, videotapes and group supervision. The doctors were trained in DSM-IV criteria and MINI-R interviewing to identify social phobia and co-morbid disorders. They were also trained in scoring of the CGI-S scale. Consensus ratings between five trained psychiatrists/psychologists and one GP on five videotaped patient interviews were defined as the ‘golden standard’ of severity rating. After the training programme, all doctors had to rate the CGI-S scale on 12 videotaped patient interviews to assess inter-rater reliability. An inter-rater reliability of at least 0.7 compared with the ‘golden standard’ was required to be accepted as an investigator. Thirty-nine doctors were accepted as investigators during this procedure; three withdrew during the training period. The remaining investigators were given further individual training and then rated another four videotapes. During this procedure, six additional doctors were accepted and a total of 45 GPs were included as investigators in the study.
To illustrate the different steps of the exposure therapy, an instruction video showing five of the eight sessions (first to fourth session and the last session) of therapy for a patient with social phobia was shown. The video was shown during the training sessions and each GP had a copy of the video for their own studies. In addition, the GPs were given some written material about social phobia and exposure therapy. The GPs were trained in groups of 10 for a total of 30 h during three weekend sessions. The Norwegian GPs were trained by the psychiatrists in the steering committee (SB, TTH and JEW) and the Swedish GPs were trained by a clinical psychologist (KH) and a psychiatrist (MH). During sessions, the doctors carried out role playing of different tasks in exposure therapy such as focusing the problems, planning homework, discussing coping mechanisms and giving support to the patients. The groups had supervision by the training psychiatrists and psychologist throughout the study.
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Results |
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Evaluation of the training programme
The GPs were all experienced family doctors with an average of 16 (1–30) years of experience in this position. Mean age was 48.8 years. Their main occupation was in clinical work, seeing ~90 (17–164) patients with all kinds of problems every week. Three GPs had worked in psychiatric settings previously and had taken short courses in psychotherapy/behaviour therapy.
The GPs themselves expressed satisfaction with the training programme. They pointed out the importance of learning a structured treatment of psychological problems, focusing on coping strategies of defined targets. They found the duration of exposure therapy applicable in the GP setting, adjusted to the limited time of a consultation. They also found that the techniques applied could be useful in the treatment of psychiatric patients with conditions other than generalized social phobia.
The results of the outcome study revealed that exposure therapy alone, the combination of exposure therapy and medication, and medication all were significantly superior to placebo combined with general medical care.
The target complaints identified by the patients at baseline are described in Table 1
. The most frequent targets were attending meetings, going to parties and speaking to audiences. A total of 534 of the targets were connected to performance situations such as public speaking, drinking or eating in front of others or entering a room where there are people already present, while 313 of the targets were connected to interactional situations such as speaking to strangers, going to social gatherings or interaction with the opposite sex,27 indicating that the patients had generalized social phobia covering a wide range of difficult social situations.
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There was a significant reduction in score on target complaints from baseline to week 12 and week 24 between groups (P = 0.016 and P = 0.0005, respectively) and the largest reduction was in the group with the combined treatment. The percentage of patients scoring 3 and 4 (moderate and severe problem) on intensity of target 1 over time is shown in Figure 1
. Exposure therapy alone and in combination with medication was significantly superior to general medical care at week 12 (P = 0.001). At week 24, all active treatment groups were significantly superior to placebo (P = 0.001). Similar findings emerged for targets 2 and 3.
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The patients themselves rated the active treatments to be more effective than placebo (P = 0.005), and there was a high correlation between the doctors' and the patients' evaluations of the effect of treatment (kappa 0.83).
More detailed results of the study will be described elsewhere.
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Discussion |
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In this study, there was a significant improvement in response from pre- to post-test in all four treatment groups. Exposure therapy combined with medication and medication alone were significantly superior to the combination of general medical care and pill–placebo, while exposure therapy alone approached statistical significance. The patients had generalized social phobia covering a large range of social situations and there was a significantly larger reduction in scores on target complaints from baseline to week 24 for all treatment groups compared with placebo. Brief exposure therapy administered by GPs, alone or in combination with sertraline, seemed to be an effective treatment modality. There are no other studies of psychological treatment of social phobia in general practice. Earlier studies have been conducted in mental health care settings by experienced psychiatrists or psychologists. In a study by Mattick et al.,28 exposure therapy, cognitive restructuring, a combination of these and a waiting list control group were compared. The combination and cognitive restructuring groups improved significantly on all variables, whereas the exposure therapy group showed changes on phobic avoidance. Heimberg et al.29 compared cognitive– behavioural group treatment with credible placebo control. In this study, both treatment groups improved, but the cognitive–behavioural group patients were rated as more improved than controls with less anxiety and significantly fewer negative self-statements. Gelernter et al.7 compared a cognitive behavioural group treatment programme with pharmacotherapy with phenelzine, alprazolam and pill–placebo plus directions for self-directed exposure to feared stimuli and reported a substantial improvement in all treatment groups. In another study by Heimberg,8 cognitive–behavioural group therapy, educational supportive group therapy, phenelzine and pill–placebo were compared. Cognitive therapy and phenelzine led to superior response rates and a greater change on dimensional measures than did either control condition. Based on the results from these studies, it can be concluded that GPs, after a limited training programme, are able to reach a certain competence level of exposure therapy to conduct treatment programmes which produce results as good as treatments conducted in mental health care settings.
The GPs expressed satisfaction with the training programme and found the techniques they were taught useful in treatment of patients with psychiatric conditions other than generalized social phobia. The patients found the treatment helpful and this was reinforced by the low drop-out rate. In conclusion, we can make the statement that it is possible to provide a standard short-term training programme for GPs to use exposure therapy effectively. The treatment is feasible to apply in daily practice and well accepted by both patients and family doctors.
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References |
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