The aim of this review is to look into the effectiveness of CBT for the treatment of SAD. The report looks at the definition of SAD as per the DSM-V and looks at what the research that looked at the utilisation of CBT for those kinds of patients says about CBT for SAD. This report also looks at the various delivery channels of CBT other than one on one, such as group and online and reviewed outcomes on the success and effectiveness of treating SAD across a spectrum of people. It was found that CBT is a powerful and consistent modality for the treatment of SAD and that more research should be done moving forward with both group and online applications especially automated administration of CBT and cross-cultural matters as CBT is moved into the future.
It is generally accepted that anxiety disorders have increased amongst adults and adolescents over the last decade especially. The reasons for these can be varied and numerous with technology and social media being factors identified as possible causes and also lifestyle, work related stress, home-life and more. Anxiety can be found in a number of forms such as trauma-based anxiety, fear and phobias, obsessive compulsion, generalised anxiety. However, one form of anxiety that is fast becoming highly prevalent in society is that of social anxiety.
Anxiety is defined as a general feeling of apprehension about a possible danger (Hooley et al., 2016), and is very future oriented. Anxiety disorders are defined as the same but at unrealistic, irrational levels of fear or anxiety causing disabling, so social anxiety is anxiety linked to fears and anxieties in relation to social elements such as judgment, negative evaluation and so forth. It is one of the fastest growing mental health issues in our society and highly debilitating especially social anxiety disorder (Heimberg, 2002). Cognitive behavioural therapy (CBT) as a therapy is the go-to for treatment option (Heimberg, 2002), so it is important to investigate and review just how effective CBT is for treating this fast growing mental condition that is social anxiety disorder (SAD).
Official definition of social anxiety and when it is deemed a disorder.
The DSM-V (2013) defines social anxiety as when the individual is fearful or anxious towards or avoids social interactions and scenarios that may increase the likelihood of being scrutinized. These are inclusive of social events such as meeting new people, situations where the suffering individual may be observed eating or drinking, and other actions the individual may perform in front of people. The cognitive ideation is that of being negatively judged and scrutinised by others, leading to a poor perception of the person, causing embarrassment, humiliaton, or rejection, or offense to others.
Social anxiety disorder is the most common anxiety disorder; it can appear in a person earliest—by age 11 years in approximately half the people and by age 20 years in approximately 80% of people. It is also a risk factor as much as it is an ailment, it can lead to additional depressive illness and addictions (Stein, 2008). The DSM-V considers social anxiety to be a disorder when A) a consistent and continuous fear of a single or multiple social or performance-based situations in which the affected individual finds themselves in front of unfamiliar people or potentially under scrutiny by others.
The affected person fears that he or she will behave in a manner (or give away signs of anxiety symptoms) that will bring embarrassment and humiliation. B) Exposure to the feared situation is almost guaranteed to trigger anxiety, which may come in the form of a situationally bound or situationally pre-disposed Panic Attack. C) The individual comes to realise that their fear is unreasonable or excessive. D) The triggering situations are avoided, or the individual goes through the event with very high levels of anxiety and distress. E) The avoiding of and anxious anticipation or fearfulness in the triggering social or performance situation(s) sabotages significantly the person's normal routine, professional functioning, or social activities or relationships and there is a significant level of distress towards having the fear. F) The unwanted emotions and behaviours are consistent and menacing, and last within the person 6 or more months. G) The symptoms are not due to other physiological effects stemming from a substance (such as drugs and medications) or a medical condition not better accounted for by another mental disorder (DSM-V, 2013).
The DSM-V is deemed the authority for psychological and mental conditions and ailments, and it provides some sufficient guidelines and descriptions for diagnosis. There have been 5 versions over the decades with the fifth being the final version receiving updates in September of 2016. It is not, however, without it’s cautions, as per a report by Spitzer, First & Wakefield (2007). Spitzer and company looked at how PTSD was represented and whether its definition was complete or over expanded to include stress ailments that would be over exaggerated under the PTSD heading. They found some concerning challenges with the DSM, it raised questions such as does it adequately describe classes of stressors and the transition from stress to PTSD.
Despite attempts over the years and the different versions of the DSM, it still has a grey cloud over its ability to fully capture and adequately encompass its descriptions of the various listed conditions. This is further supported by the Social Anxiety Institute (2018) in the United States where they note that while the current definition of social anxiety is the most accurate and definitive, it is not without its challenges and view for further reviews or editions of the DSM will be considered. As great and helpful the current definition is for understanding and guidance for diagnosis; one major issue is that social anxiety disorder has only been considered as an ailment since 1980, with an adequate explanation of SAD not coming in to fruition until the version of the DSM that came out in 1987. Therefore, being a relatively new condition with more research required, it means one must also do some further exploration and research to better understand social anxiety disorder and therefore treat it more effectively (Richards, 2018).
Despite this grey cloud, the DSM-V is still as reliable a source as can be required so as to assist a practitioner to determine a diagnosis. Saxena et al., (2012) highlight that the updates and guidelines of the DSM-V are the most comprehensive and extensive of all the DSMs and the main focus of DSM-V was to make it more reliable by removing as much of the uncertainty and ambiguity of the previous versions of the DSM to make a more comprehensive and reliable reference guide for practitioners.
Cognitive Behavioural Therapy.
A noticeably common and popular treatment approach for anxiety disorders and especially social anxiety has been CBT, CBT stands for Cognitive Behavioural Therapy. Cognitive Behavioural Therapy Teaches that our emotions are mainly a creation derived mainly from our beliefs, evaluations, interpretations, and responses to life events (Corey, 2017). The first form of this therapy came about with its discovery or creation by Albert Ellis in the early nineteen hundreds where it was called REBT-Rational Emotive Behavioural Therapy where the first connection was made between our thoughts and rationale were linked with our emotions affecting our behaviour. The cognitive aspects of this were further developed giving the early form of today’s Cognitive Behavioural Therapy, when Aaron Beck further advanced the logotherapy of the process and then finally we find in the mid to late 1900’s through the work of Donald Meichenbaum an increased focus on integration between the physical behaviour and the cognitive function aspects and the formation of the ABC model that we are accustomed to today (Dobson et al., 2019).
Therapy is seen as an educational process where clients learn to identify the interplay of their thoughts, feelings and behaviours to identify and dispute irrational beliefs that are maintained by self-indoctrination. Furthermore, Cognitive Behavioural Therapy aims to replace ineffective ways of thinking with effective and rational cognitions and to stop absolutistic thinking, blaming, and repeating false beliefs (Corey, 2017).
Due to the cognitive-emotive interactivity and future based ideation of social anxiety disorder and the growing prevalence of it requiring an effective and empirical based approach for treatment, cognitive behavioural therapy very quickly became the preferred therapeutic approach. It is used as a leading, and perhaps the preferred approach, for anxiety disorders such as SAD amongst other conditions (Heimberg, 2002).
Generally speaking, cognitive behavioural therapy is one of the very few that have been empirically researched and reviewed (Goldin et al., 2014). Corey (2017) highlights that what cognitive behavioural therapy brings to the treatment of social anxiety, and indeed any condition it’s used for is a modality to aid in the changing of the subjective views a client has of themselves and the world around them. The cognitive behavioural approach looks also to weaken, in fact undermine the the sabotaging or broken assumptions and beliefs held by a client and in turn building coping skills within them. Cognitive behavioural therapy also provides the most systematic application of behavioural therapy with a defined plan of approach. The treatment sessions themselves are relatively short and quick with not a lot of complexity, which can be a benefit from a financial perspective for the client. Corey’s work comes from his widely used University text which makes this information quite accurate and clear however may also be leaning towards teaching student’s too much and providing an ideal world and short view of cognitive behavioural therapy.
However, further studies show evidence of the validity and preference of cognitive behavioural do support a lot of what Corey presents. Bryant et al., (2003) ran a 4 year longitudinal study to determine the beneficial features of CBT and comparing the effects of cognitive behavioural therapy versus basic supportive counselling and found that the re-integration and reframe processes of cognitive behavioural therapy were able to reduce and subdue intensity levels of symptoms, they assisted in helping clients cope by way of re-viewing and re-defining a situation leading to reduced frequency and reduced avoidance of triggers, significantly more so than participants who underwent basic supportive counselling.
This study would appear to show that early application, within the first month after trauma, has long-term effects and benefits for people who are at risk of developing SAD (Bryant, 2013).
The Bryant (2013) study is reliable due to its longevity of being done over 4 years, the study however has its limitations. First, the retention of participants over the four years was only 64% of treatment completers and so may not be a definitive representation of functioning of all participants who completed the process. Participants who did continue participation over the four-year process were slightly less symptomatic before starting treatment. Second, the four-year tracking nd monitoring did not look at the onset (if any) of other conditions, such as depression and addiction. Despite these limitations, the results of this experiment were significant enough to make the claim that early application of cognitive behavioural therapy leads to more successful outcomes than the application of supportive counselling in the initial early stages after an incident.
As with most things that are under scrutiny and monitored cognitive behavioural therapy as a general therapy across the board has some question marks around it. Corey (2017) highlights that cognitive behavioural therapy may have some limitations such as A) it takes a fair bit of training to practice cognitive behavioural therapy, B) therapists may misuse the influence and position of their training and job by placing their ideas of what is deemed “rational” thinking on a client C) therapists must make a special effort to guide and condition clients to act rationally as per the framework of their own value system and cultural definitions D) The strong confrontational element that can be a characteristic of cognitive behavioural therapy may be a bit much for some clients and E) Some clinicians think cognitive behavioural therapy interventions does not explore the client’s past enough and it should as done in traditional psychotherapy.
Additional studies suggest that cognitive behavioural therapy is not without limitations, Goldin (2014) in their research on Trajectories of change in emotion regulation and social anxiety during cognitive-behavioural therapy found that, despite providing structure for the therapist and the therapy application, cognitive behavioural therapy lacked some sort of trajectory tracking to determine if therapy is working, if anything else is influencing the changes in behaviour, when to alter the sessions because of improvement etc. It must be noted this can be a matter of session structure and not so much about the modality, the study by Goldin (2014) mainly concentrated on weekly changes throughout individual cognitive behavioural therapy for emotion regulation and social anxiety in clients with generalised social anxiety disorder. Due to the self-reported nature and weekly frequency and the positive outcomes of thought re-evaluation and of expressive suppression, any conclusions are confined to those exact emotions and running processes, temporal resolution, and processes of measurement. Overall studies are showing support for cognitive behavioural therapy as a highly effective modality for therapy.
CBT and SAD
CBT has been applied to social anxiety as a go to treatment of choice for the better part of the last 25 years, now this is not a great deal of time when compared to the application of other modalities which have been used for longer periods of time however CBT is the most thoroughly studied approach to psychotherapy in recent times (Heimberg, 2002). Despite this fact studies are showing significant and definitive results regarding the effectiveness of CBT on SAD. In his study Heimberg (2002) compared the effects of CBT across a number of characteristics, such as social skills training, relaxation training, cognitive restructuring and general exposure, Heimberg also looked at CBT and pharmacology and what CBT, through its effect on healing may imply about the need for pharmacological substances in the treatment process. He also looked at the effects of CBT in a group environment, which will be further looked at. In an unorthodox move Heimberg draws his conclusion not directly from his own research but as a comparison with four other meta analyses. Heimberg (2002) found that those who incorporated some level of CBT showed both significant improvement and change versus a simple exposure group undergoing supportive type counselling and also the change was sustained and maintained after a period of follow up.
This study did, however, highlight the need on the combined usage of CBT and pharmaceuticals, it also doesn’t elaborate enough on the findings of this research, its focus on comparing with the four meta analyses does draw away from Heimberg’s research. Regardless it does reflect what many other studies are reflecting in regard to CBT’s efficacy as a treatment for social anxiety.
Heimberg’s research outcomes are echoed by many such as the study by Breinholst (2011) who in looking at CBT and its effect also researched its flexibility by including others in an individual’s treatment, specifically the treatment of social anxiety in children and factoring in to the therapy the parents. This study arguably had a two-pronged effect in that it certainly supported CBT as an effective therapy for SAD however it may have uncovered an inflexibility in CBT. This therapy is very subjective and adding factors such as parents as part of the therapy may be negatively objective and counterproductive, Breinholst’s study was not extensive enough to draw firm conclusions on the flexibility of CBT, but its overall efficacy remains supported.
Group CBT and SAD
CBT however is proving flexible in other ways, CBt has transformed over the decade fom a therapy done one on one to a therapy that’s performed via a couple of channels, Group being one of those.
Goldin et al., (2016) ran a study to determine if CBGT (cognitive behavioural group therapy) had an effect on social anxiety in adults and also compared it with MBSR (mindfulness-based stress reduction) exercises. What he found was that as a group therapy CBT was significantly effective but not more effective and not more effective than MBSR exercises. Similar to Breinholst’s (2011) findings, when multiple individuals are introduced into CBT this can level out the effect of the therapy, but it does not reduce its efficacy significantly, it may vary results or timeframes as found by Goldin.
Interestingly, the only areas where CBT showed slightly better results than MBSR exercises over time was in the patient’s need for safety precautions from a potential triggering event, this is significant as it saw a slightly lower level of avoidance behaviour in CBT patients. Although slight this is still viewed as a positive and requires further investigation and review across various environments.
One thing to consider with Goldin’s study and certainly many of these studies is that they are based on western culture, and for the most part very little has been done to see if CBT translates well cross culturally. Despite some studies showing it can translate well, there needs more study and review into this matter.
Consideration must also be given to the possibility that group therapy being a social setting may make sufferers of SAD less receptive in such an environment initially, due to their SAD. More study is needed on whether time and exposure reduce any potential resistance to CBT in SAD sufferers in group environments.
Online CBT and SAD
One way that nay be avoided, and CBT propelled in to the information and technological age is CBT administered online for SAD sufferers.
The creation of the internet saw a major shift in how we live our lives and do things, on all levels, the field of psychology was no exception, specifically CBT and its practice. Although a relatively new concept as far as observing the effects of a modality on a specific ailment such as SAD, there are some informative research studies.
Anderson and Cuijper’s (2008) report highlighted that one major benefit of CBT being online as an administrable modality means it can be accessed by many people and it can be at a lower price range. They also highlight that there needs to be a distinction and protocol made around automated online programmes and therapist based online consults.
With many of the online programs, it is all based on self-reporting by the participant, there is no way of knowing for sure they are diagnosing correctly, if program taken before seeing a therapist. Automated programs are effective on certain level cases however speaking online with a therapist proved to be far more effective. There are numerous issues still to be worked out with online CBT such as motivating a client doing an online program to book with a therapist, data collection and storage and how to integrate therapist based online CBT and automated programs.
Donovan and March (2014) further support this in their study, where they found that after seeing a therapist online 70.6% of participants had symptoms severely reduced or completely resolved within 6 months. They further suggest that online programs are great for maintenance and development but not in lieu of speking with a therapist as that’s where the most effect of CBT online is found both for short term and long term results. One cautionary note with the Donovan and March study is it was done on young students, although this isn’t necessary a determining factor across many other studies.
This review found that CBT is very popular for the treatment of SAD and is the only modality to have been empirically reviewed. Due to its focus on cognitive ideation and its link to behaviour CBT has over the years become the preferred modality for treating SAD due to the patterns of cognitive processing and behaviour influencing characteristics of SAD.
CBT has evolved over the years from purely one on one to being administered as a group method of treatment and online as well.
CBT has its question marks, and as it is taken in to the future more question marks arise, such as how should it be administered online, is automation a positive or a negative, should automated courses be a pre-therapy action or post-therapy, should group based CBT be either stopped or provided later when SAD sufferers feel a bit more comfortable and the group can be a stage 1 step towards exposure. ?
One thing is becoming evidently clear, and that is, regardless of how it is administered and what it is compared with, CBT overall shows the greatest progress, promise and improvement for SAD than other modalities overall and is worth researching and expanding on further.
Andersson, G., & Cuijpers, P. (2008). Pros and cons of online cognitive–behavioural
therapy. The British Journal of Psychiatry, 193(4), 270-271.
Breinholst, S., Esbjørn, B. H., Reinholdt-Dunne, M. L., & Stallard, P. (2012). CBT for the
treatment of child anxiety disorders: A review of why parental involvement has not
enhanced outcomes. Journal of anxiety disorders, 26(3), 416-424.
Bryant, R. A., Moulds, M. L., & Nixon, R. V. (2003). Cognitive behaviour therapy of acute
stress disorder: a four-year follow-up. Behaviour research and therapy, 41(4), 489-494.
Corey, G. (2017). Theory and practice of counselling and psychotherapy. Nelson Education.
Cuijpers, P., Cristea, I. A., Karyotaki, E., Reijnders, M., & Huibers, M. J. (2016). How
effective are cognitive behavior therapies for major depression and anxiety
disorders? A meta‐analytic update of the evidence. World Psychiatry, 15(3), 245-258.
Dobson, K. S., & Dozois, D. J. (Eds.). (2019). Handbook of cognitive-behavioral therapies.
Donovan, C. L., & March, S. (2014). Online CBT for preschool anxiety disorders: a
randomised control trial. Behaviour research and therapy, 58, 24-35.
Goldin, P. R., Morrison, A., Jazaieri, H., Brozovich, F., Heimberg, R., & Gross, J. J. (2016).
Group CBT versus MBSR for social anxiety disorder: A randomized controlled
trial. Journal of Consulting and Clinical Psychology, 84(5), 427.
Goldin, P. R., Lee, I., Ziv, M., Jazaieri, H., Heimberg, R. G., & Gross, J. J. (2014).
Trajectories of change in emotion regulation and social anxiety during cognitive-
behavioral therapy for social anxiety disorder. Behaviour Research and Therapy, 56, 7-
Heimberg, R. G. (2002). Cognitive-behavioral therapy for social anxiety disorder: current
status and future directions. Biological psychiatry, 51(1), 101-108.
Richards, Dr T.R. (2018). DSM-5 Definition of Social Anxiety Disorder. Retrieved 9
May, 2019, from https://socialanxietyinstitute.org/dsm-definition-social-anxiety-
Saxena S, Esparza P, Regier DA, Saraceno B, Sartorius N: Public Health Aspects of
Diagnosis and Classification of Mental and Behavioural Disorders: Refining the
Research Agenda for DSM-5 and ICD-11. Arlington, American Psychiatric Press,
Stein, M. B., & Stein, D. J. (2008). Social anxiety disorder. The lancet, 371(9618), 1115-
Petros Galanoulis- Bach. Psych, Dip Of Life-Coaching/ Counselling