Gaps In The Evidence Base

An important issue in treatment outcome is that many clients do not achieve as much change as would be desirable, either in terms of symptoms or in terms of the impact of symptom change in other areas of life. Previous research on the clinical significance of symptom change immediately following a course of CBGT for social anxiety demonstrated a significant improvement in clients' self-perceived quality of life (Safren et al., 1997). Further, improvements from CBGT were shown to be maintained for several months after treatment (Eng et al., 2001). However, these improved ratings still fell below the normative average at post-test and follow-up.

Of major concern is the limited number of therapists who can recognize and effectively treat social anxiety disorder. Clinicians are most likely to recognize and diagnose a psychological problem in socially anxious persons who present with a comorbid condition -typically major depressive disorder or alcoholism - and are most likely to treat the comorbid condition before the social anxiety (Ballenger et al., 1998). In addition, studies have reported that, among the anxiety disorders, the most highly utilized psychosocial treatments are dynamic psychotherapy (Goisman, Warshaw & Keller, 1999) and supportive therapy (Rowa et al., 2000). There appears to be an underutilization of efficacious treatments in favour of those that have been less well studied. One promising study demonstrated that general practitioners may be trained successfully to provide brief exposure therapy (eight sessions of 15 to 20 minutes' duration) within a primary-care setting (Blomhoff et al., 2001; Haug et al., 2000; Haug et al., 2003).

One advantage of CBT for social anxiety is that its methods are manualized. However, there are not enough people who know how to administer these manuals effectively and manualized treatments are not always so simple to implement in the real world. A number of clients also have a complicated presentation that may require specific additional interventions targeted at depressive symptoms, anger management, or other adjustment difficulties. It is with these clients that there often appears to be a disconnect between the protocols described in the treatment outcome literature and the actual implementation of treatment in the real world.

Clinically relevant areas for future research also include expanding on the limited literature on treating social anxiety in children and adolescents. At the other end of the spectrum, the phenomenological experience of social anxiety in older adults has also not been adequately investigated. Mrozowski et al. (2001) found that older adults reported significantly lower levels of anxiety for most social situations but that their anxiety was less variable across situations on self-report measures in comparison to younger adults. Furthermore, Sheikh & Salzman (1995) suggest that social anxiety concerns of the elderly may be focused more on eating and writing in public because of the presence of dentures and tremors. Given the greater chance of medical problems and concurrent medications in the elderly, CBT may be an especially attractive alternative to pharmacological treatment (although the relative and combined effects of CBT and medications is another important area for research among clients of all ages). To our knowledge, there have not been studies that have investigated the effectiveness of specific treatments for social anxiety in the elderly. Similarly, we know little about the nature and treatment of social anxiety among persons who have been divorced or bereaved and who face new challenges in social interaction.

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