Paroxetine, Cognitive Therapy or Their Combination in the Treatment of Social Anxiety Disorder with and without Avoidant Personality Disorder: A Randomized Clinical Trial

Abstract

Background: The most efficacious treatments for social anxiety disorder (SAD) are the SSRIs and cognitive therapy (CT). Combined treatment is advocated for SAD but has not been evaluated in randomized trials using CT and SSRI. Our aim was to evaluate whether one treatment is more effective than the other and whether combined treatment is more effective than the single treatments. Methods: A total of 102 patients were randomly assigned to paroxetine, CT, the combination of CT and paroxetine, or pill placebo. The medication treatment lasted 26 weeks. Of the 102 patients, 54% fulfilled the criteria for an additional diagnosis of avoidant personality disorder. Outcomes were measured at posttreatment and 12-month follow-up assessments. Results: CT was superior to paroxetine alone and to pill placebo at the end of treatment, but it was not superior to the combination treatment. At the 12-month follow-up, the CT group maintained benefits and was significantly better than placebo and paroxetine alone, whereas there were no significant differences among combination treatment, paroxetine alone, and placebo. Recovery rates at 12 months were much higher in the CT group (68%) compared to 40% in the combination group, 24% in the paroxetine group, and 4% in the pill placebo group. Conclusions: CT was the most effective treatment for SAD at both posttreatment and follow-up compared to paroxetine and better than combined treatment at the 12-month follow-up on the Liebowitz Social Anxiety Scale. Combined treatment provided no advantage over single treatments; rather there was less effect of the combined treatment compared to CT alone.

Clinical Pharmacopsychology: Conceptual Foundations and Emerging Tasks

“…Subsequent research has substantiated these conclusions in mood and anxiety disorders [72,73,74]. There are, however, some high-quality and well-designed individual studies that suggest that the addition of a benzodiazepine or an antidepressant to cognitive behavioral treatment of anxiety disorders could be detrimental compared to placebo at follow-up [75,76,77,78]. Again, clinical pharmacopsychology could be crucial for disclosing the nature of these relationships.…”

The Potential Role of Iatrogenic Comorbidity in the Interaction between Pharmacotherapy and Psychotherapy in Anxiety Disorders

“…In the literature, we can find 4 randomized placebo-controlled trials in which a combination of medication (benzodiazepine [Marks et al, 1993] or antidepressant [Barlow et al, 2000;Haug et al, 2003;Nordahl et al, 2016]) and cognitive behavioral treatment was compared with each treatment alone in the management of different forms of anxiety disorders and yielded a detrimental interaction. These studies represent only part of the randomized controlled trials (RCT) that were performed with such a combination in anxiety disorders.…”

“…Most recently, Nordahl et al [2016] conducted a comparative trial in which 102 patients with a primary diagnosis of social anxiety disorder with or without avoidant personality disorder were allocated to 4 different conditions: paroxetine and clinical management, cognitive therapy (CT), paroxetine and CT, or placebo and clinical management. The study was double-blind for the medication and placebo groups.…”

“…In most cases, the effects of the 2 interventions combined were equivalent to the effect of 1 intervention, particularly when follow-up evaluations were performed [Friedman and Thase, 2009;Forand et al, 2013;Biesheuvel-Leliefeld et al, 2015]. There are, however, some highquality and well-designed individual studies in anxiety disorders that suggested that the addition of a benzodiazepine or an antidepressant to cognitive behavioral treatment could be detrimental compared to placebo at follow-up [Marks et al, 1993;Barlow et al, 2000;Haug et al, 2003;Nordahl et al, 2016]. We will briefly describe these studies and we will then discuss a recent conceptualization, subsumed under the rubric of iatrogenic comorbidity, which needs to be adequately tested but may shed some new light on the interaction between pharmacotherapy and psychotherapy.…”

Attenuated Psychophysiological Reactivity following Single-Session Group Imagery Rescripting versus Verbal Restructuring in Social Anxiety Disorder: Results from a Randomized Controlled Trial

“…Negative self-imagery is also theorized to play a causal role in SAD [12]. Whilst verbally based cognitive behavioral therapy shows efficacy for reducing SAD symptoms [13, 14], a number of imagery-based interventions have been developed with the aim of modifying negative self-images in SAD. Imagery rescripting (IR) is one such approach, where patients are encouraged to mentally transform negative images to form new (neutral or positive) memories [15].…”