Social anxiety disorder (SAD) is commonly treated with various psychotherapy approaches, including cognitive-behavioral therapy (CBT), exposure therapy, and third-wave therapies such asmindfulness-based interventions.
CBT focuses on changing negative thought patterns and behaviors, while exposure therapy gradually introduces anxiety-provoking situations. Third-wave therapies incorporate mindfulness andacceptance strategies.
Reviewing these treatments is crucial because SAD significantly impacts quality of life and social functioning for many individuals.
By synthesizing current research on psychotherapy effectiveness, clinicians can make informed decisions about treatment options, researchers can identify areas for further study, and policymakers can allocate resources effectively to improve access to evidence-based interventions for SAD.
Key Points
Rationale
Thismeta-analysisaimed to provide an updated and comprehensive examination of the efficacy of psychotherapy for social anxiety disorder (SAD) compared to control conditions.
SAD is one of the most common mental disorders, with a lifetime prevalence ranging from 4% to 15.4% worldwide (Koyuncu et al., 2019; Stein et al., 2017).
Previous meta-analyses have demonstrated positive outcomes for psychotherapies in treating SAD (Acarturk et al., 2009; Mayo-Wilson et al., 2014; Powers et al., 2008).
However, these studies are now nearly a decade old. Given the exponential growth in research on psychotherapy for SAD in recent years, there was a clear need for an updated synthesis of the evidence.
Additionally, technological advancements have led to the development of new treatment delivery formats, such as internet-based and self-guided interventions (Andersson et al., 2019; Clark et al., 2023). These formats have the potential to address barriers to treatment access and uptake.
The current meta-analysis aimed to incorporate these newer studies and delivery formats to provide a more current understanding of psychotherapy efficacy for SAD.
Understanding these factors can inform clinical decision-making and help tailor treatments to individual needs.
By conducting this comprehensive meta-analysis, the authors sought to provide the most up-to-date and robust estimates of psychotherapy efficacy for SAD, synthesize findings across various treatment types and formats, and identify factors that may influence treatment outcomes.
Method
Thissystematic reviewand meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol was pre-registered on the Open Science Framework.
Search strategy and terms:
The authors searched four bibliographic databases (PubMed, PsycINFO, Embase, and Cochrane CENTRAL) from their inception to January 1st, 2024.
They used a combination of index terms and free text related to psychotherapy and anxiety disorders, filtered for randomized controlled trials (RCTs). The specific search strings are provided in the supplementary material.
Inclusion and exclusion criteria:
Studies were included if they met the following criteria:
Statistical measures:
The authors calculated the standardized mean difference (Hedges’ g) at post-test for each comparison between a psychological intervention and a control group.
They used a random-effects model for all analyses and estimated between-study heterogeneity using restricted maximum likelihood. The I2 statistic was calculated to assess heterogeneity.
Multiple sensitivity analyses were conducted, including different pooling methods, outlier and influence analyses, and publication bias assessments.
Subgroup analyses and meta-regressions were performed to examine potential moderators of treatment effects.
Results
Study characteristics:
The meta-analysis included 66 randomized controlled trials with 98 comparisons between psychotherapy and control groups.
A total of 5,560 participants were included, with 3,573 in intervention groups and 1,987 in control groups. The mean age of participants was 33.3 years, and 56.7% were women.
Main effect of psychotherapy:
The overall effect size for psychotherapy compared to control conditions was large (g = 0.88, 95% CI: 0.76 to 1.0), with a number needed to treat (NNT) of 3.8. Heterogeneity was high (I2 = 74%, 95% CI: 69 to 79).
Sensitivity analyses:
Most sensitivity analyses yielded similar results, with effect sizes ranging from g = 0.76 to 1.00. The outlier analysis, which removed 19 outliers, reduced heterogeneity to 0% (95% CI: 0 to 27) and slightly decreased the effect size (g = 0.76, 95% CI: 0.71 to 0.81).
Publication bias:
There was evidence of significant publication bias (Egger’s test, p < 0.001). After adjusting for publication bias, the estimated effect size was reduced, ranging from g = 0.30 to 0.86, depending on the method used.
Subgroup analyses and meta-regressions:
No significant differences were found between different types of psychotherapy (p = 0.709).
In the multivariable meta-regression, several factors were significantly associated with treatment effects:
Risk of bias:
Most studies (62.1%) had a high risk of bias, with only 6.1% demonstrating a low risk of bias. The main sources of bias were related to the randomization process, missing outcome data, and selective reporting.
Insight
This meta-analysis provides a comprehensive and up-to-date synthesis of the efficacy of psychotherapy for social anxiety disorder (SAD).
The large overall effect size (g = 0.88) and relatively low number needed to treat (NNT = 3.8) suggest that psychotherapy is an effective treatment option for adults with SAD.
This finding is consistent with previous meta-analyses but provides a more current and robust estimate based on a larger pool of studies.
One of the most informative aspects of this study is the lack of significant differences in effectiveness between various types of psychotherapy, including cognitive behavioral therapy (CBT),exposure therapy, and third-wave therapies.
This suggests that clinicians and patients have multiple effective options to choose from when selecting a treatment approach for SAD.
The flexibility in treatment options may help increase treatment uptake and adherence, as individuals can select an approach that aligns with their preferences and values.
The finding that group therapy formats showed larger effects than individual therapy is particularly interesting and somewhat contradicts previous research (Mayo-Wilson et al., 2014).
This could have important implications for treatment delivery, as group formats may be more cost-effective and allow clinicians to treat more patients simultaneously.
However, the authors rightly caution that this finding should be interpreted carefully, as there may be selection bias in terms of which patients are willing to participate in group treatments.
The effectiveness of guided self-help formats is another key insight from this study. While unguidedself-helpshowed smaller effects, guided self-help performed comparably to traditional face-to-face treatments.
This finding supports the potential of internet-based and other technology-assisted interventions to increase treatment accessibility, particularly in areas with limited access to mental health professionals.
The significant associations found in the meta-regression between treatment outcomes and factors such as recruitment strategy, target group, and number of sessions provide valuable information for tailoring treatments and designing future studies.
For example, the positive association between the number of sessions and treatment effect suggests that longer treatments may be more beneficial, although this needs to be balanced with practical considerations and patient preferences.
However, the high risk of bias in many included studies, and evidence of publication bias highlight the need for more high-quality research in this area.
Future studies should focus on improving methodological rigor, including better randomization procedures, handling of missing data, and transparent reporting of outcomes.
To extend this research, future studies could:
Strengths
The study had many methodological strengths, including:
Limitations
The study had several limitations that should be considered when interpreting the results:
These limitations suggest that the results should be interpreted cautiously and highlight areas for improvement in future research on psychotherapy for SAD.
Implications
The findings of this meta-analysis have several important implications for clinical practice, research, and policy:
These implications suggest that while psychotherapy is an effective treatment for SAD, there is still room for improving access, personalizing treatments, and conducting further research to optimize outcomes.
References
Primary reference
de Ponti, N., Matbouriahi, M., Franco, P., Harrer, M., Miguel, C., Papola, D., Sicimoğlu, A., Cuijpers, P., & Karyotaki, E. (2024). The efficacy of psychotherapy for social anxiety disorder, a systematic review and meta-analysis.Journal of Anxiety Disorders, 102881.https://doi.org/10.1016/j.janxdis.2024.102881
Other references
Acarturk, C., Cuijpers, P., van Straten, A., & de Graaf, R. (2009). Psychological treatment of social anxiety disorder: a meta-analysis.Psychological medicine,39(2), 241-254.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Andersson, G., Titov, N., Dear, B. F., Rozental, A., & Carlbring, P. (2019). Internet‐delivered psychological treatments: From innovation to implementation.World Psychiatry,18(1), 20-28.https://doi.org/10.1002/wps.20610
Barrera, T. L., & Norton, P. J. (2009). Quality of life impairment in generalized anxiety disorder, social phobia, and panic disorder.Journal of anxiety disorders,23(8), 1086-1090.https://doi.org/10.1016/j.janxdis.2009.07.011
Clark, D. M., Wild, J., Warnock-Parkes, E., Stott, R., Grey, N., Thew, G., & Ehlers, A. (2023). More than doubling the clinical benefit of each hour of therapist time: a randomised controlled trial of internet cognitive therapy for social anxiety disorder.Psychological medicine,53(11), 5022-5032.
Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges.Drugs in context,8, 212573.https://doi.org/10.7573/dic.212573
Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis.The Lancet Psychiatry,1(5), 368-376.https://doi.org/10.1016/S2215-0366(14)70329-3
Powers, M. B., Sigmarsson, S. R., & Emmelkamp, P. M. (2008). A meta–analytic review of psychological treatments for social anxiety disorder.International Journal of Cognitive Therapy,1(2), 94-113.https://doi.org/10.1521/ijct.2008.1.2.94
Stein, D. J., Lim, C. C., Roest, A. M., De Jonge, P., Aguilar-Gaxiola, S., Al-Hamzawi, A., … & WHO World Mental Health Survey Collaborators. (2017). The cross-national epidemiology of social anxiety disorder: Data from the World Mental Health Survey Initiative.BMC medicine,15, 1-21.https://doi.org/10.1186/s12916-017-0889-2
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Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
