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Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social Anxiety Disorder: A Multicenter Randomized Controlled Trial
Falk Leichsenring, D.Sc.; Simone Salzer, D.Sc.; Manfred E. Beutel, M.D.; Stephan Herpertz, M.D.; Wolfgang Hiller, Ph.D.; Juergen Hoyer, Ph.D.; Johannes Huesing, D.rer.medic.; Peter Joraschky, M.D.; Bjoern Nolting, M.D.; Karin Poehlmann, Ph.D.; Viktoria Ritter, M.Sc.; Ulrich Stangier, D.Sc.; Bernhard Strauss, Ph.D.; Nina Stuhldreher, M.Sc.; Susan Tefikow, M.Sc.; Tobias Teismann, Ph.D.; Ulrike Willutzki, Ph.D.; Joerg Wiltink, M.D.; Eric Leibing, D.Sc.
Am J Psychiatry 2013;170:759-767. doi:10.1176/appi.ajp.2013.12081125
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Dr. Beutel has received speaking honoraria from Pfizer, Shire, and Boehringer Ingelheim. Dr. Herpertz has received speaking honoraria from Lilly Germany and Novo Nordisk Germany. Dr. Hoyer has received speaking honoraria from AstraZeneca. The other authors report no financial relationships with commercial interests.

Supported by a grant from the German Federal Ministry of Education and Research, 01GV0607.

Controlled-trials.com identifier: ISRCTN53517394.

The Social Phobia Psychotherapy Research Network was organized as follows: Steering Committee: Falk Leichsenring (Chair), Manfred E. Beutel, Eva Irle, Eric Leibing, Ulrich Stangier; statistics: Johannes Hüsing; cognitive therapy treatment implementation unit: Ulrich Stangier, Katrin von Consbruch; psychodynamic therapy treatment implementation unit: Manfred E. Beutel, Jörg Wiltink; study coordinators: Eric Leibing, Simone Salzer, Falk Leichsenring; local representatives of cognitive therapy: Wolfgang Hiller, Jürgen Hoyer, Eric Leibing, Ulrich Stangier, Ulrike Willutzki; local representatives of psychodynamic therapy: Manfred E. Beutel, Peter Joraschky, Falk Leichsenring, Björn Nolting, Bernhard Strauss.

From the Clinic of Psychosomatics and Psychotherapy, Justus-Liebig-University Giessen, Giessen, Germany; Department of Psychosomatic Medicine and Psychotherapy, University Medicine, Georg-August-University Goettingen, Goettingen, Germany; Clinic of Psychosomatic Medicine and Psychotherapy, University Medical Center and Clinical Psychology and Psychotherapy, Johannes Gutenberg University Mainz, Mainz, Germany; Clinic of Psychosomatic Medicine and Psychotherapy, LWL-University Clinic Bochum, and Clinical Psychology and Psychotherapy, Ruhr-University Bochum, Bochum, Germany; Clinical Psychology and Psychotherapy and Clinic for Psychotherapy and Psychosomatic Medicine, Technical University Dresden, Dresden, Germany; Coordination Center for Clinical Trials, University of Heidelberg, Heidelberg, Germany; Clinical Psychology and Psychotherapy, Goethe University Frankfurt, Frankfurt, Germany; Institute of Psychosocial Medicine and Psychotherapy, Jena University Hospital, Jena, Germany; and Department of Medical Sociology and Health Economics, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf.

Address correspondence to Dr. Leichsenring (falk.leichsenring@psycho.med.uni-giessen.de).

Copyright © 2013 by the American Psychiatric Association

Received August 28, 2012; Revised November 28, 2012; Revised January 08, 2013; Accepted January 18, 2013.

An erratum to this article has been published | view the erratum

Objective  Various approaches to cognitive-behavioral therapy (CBT) have been shown to be effective for social anxiety disorder. For psychodynamic therapy, evidence for efficacy in this disorder is scant. The authors tested the efficacy of psychodynamic therapy and CBT in social anxiety disorder in a multicenter randomized controlled trial.

Method  In an outpatient setting, 495 patients with social anxiety disorder were randomly assigned to manual-guided CBT (N=209), manual-guided psychodynamic therapy (N=207), or a waiting list condition (N=79). Assessments were made at baseline and at end of treatment. Primary outcome measures were rates of remission and response, based on the Liebowitz Social Anxiety Scale applied by raters blind to group assignment. Several secondary measures were assessed as well.

Results  Remission rates in the CBT, psychodynamic therapy, and waiting list groups were 36%, 26%, and 9%, respectively. Response rates were 60%, 52%, and 15%, respectively. CBT and psychodynamic therapy were significantly superior to waiting list for both remission and response. CBT was significantly superior to psychodynamic therapy for remission but not for response. Between-group effect sizes for remission and response were small. Secondary outcome measures showed significant differences in favor of CBT for measures of social phobia and interpersonal problems, but not for depression.

Conclusions  CBT and psychodynamic therapy were both efficacious in treating social anxiety disorder, but there were significant differences in favor of CBT. For CBT, the response rate was comparable to rates reported in Swedish and German studies in recent years. For psychodynamic therapy, the response rate was comparable to rates reported for pharmacotherapy and cognitive-behavioral group therapy.

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TABLE 1.Baseline Characteristics and Site Distribution of Patients With Social Anxiety Disorder Assigned to Receive Cognitive-Behavioral Therapy or Psychodynamic Therapy or to a Waiting List (Intent-to-Treat Sample)
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TABLE 2.Rates of Remission and Response, by Time, Among Patients With Social Anxiety Disorder Assigned to Receive Cognitive-Behavioral Therapy or Psychodynamic Therapy or to a Waiting List (Intention-to-Treat Sample)a
Table Footer Note

a Remission was defined as a score ≤30 on the Liebowitz Social Anxiety Scale, and response was defined as reduction of at least 31% in score on the Liebowitz Social Anxiety Scale. Scores on the Liebowitz Social Anxiety Scale range from 0 to 144, with higher scores indicating greater pathology. Assessments were not conducted for the waiting list group at weeks 8 and 15.

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TABLE 3.Outcomes for Cognitive-Behavioral Therapy, Psychodynamic Therapy, and Waiting List Among Patients With Social Anxiety Disorder (Intent-to-Treat Sample; N=495)a
Table Footer Note

a Mean scores were determined by linear-effects model analysis. Assessments with the Liebowitz Social Anxiety Scale were not conducted for the waiting list group at weeks 8 and 15. Scores on the Liebowitz Social Anxiety Scale range from 0 to 144, with higher scores indicating greater pathology. Scores on the Social Phobia and Anxiety Inventory range from 0 to 132, with higher scores indicating greater pathology. Scores on the Beck Depression Inventory range from 0 to 63, with higher scores indicating greater pathology. Scores on the Inventory of Interpersonal Problems range from 0 to 32, with higher scores indicating greater pathology.



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