Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social Anxiety Disorder: A Multicenter Randomized Controlled Trial

Abstract

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.

Comparing Treatment Efficacy of Cognitive-Behavior Therapy and Short-Term Dynamic Psychotherapy in High-Quality Studies: A Systematic Review and Effect Size Approach

“…In anxiety disorders, with studies by Leichsenring [27][28][29][30], the results suggest that the decrease in primary symptoms from posttreatment to follow-up is greater in STDP than in CBT in social phobia, with difference in magnitude being in the small range (d = -0.30; Supplementary Figure 4, Panel A). Other differences fell into the negligible range.…”

“…In anxiety disorders, with studies by Leichsenring [27][28][29][30], CBT shows an advantage over STDP in primary symptoms in five out of the nine comparisons from pretreatment to post treatment and in two of the eight comparisons from pretreament to follow-up. In secondary symptoms, the outcome is more favorable in CBT than in STDP in one out of the five comparisons from pretreatment to post treatment, and no significant differences are observed on any of the three comparisons from pretreatment to follow-up.…”

“…In anxiety disorders, with studies by Leichsenring [27][28][29][30], CBT is associated with a large decrease in primary symptoms (ds ranging from 1.06 to 1.97; mean = 1.56) and with a moderate to large decrease in secondary symptoms (ds ranging from 0.52 to 1.12; mean = 0.85) from pretreatment to post treatment and from pretreatment to follow-up. SDPT is associated with a moderate to large decrease in primary symptoms (ds ranging from 0.65 to 1.34; mean = 1.11), and from a small to moderate decrease in secondary symptoms (ds ranging from 0.26 to 0.75; mean = 0.55).…”

“…In anxiety disorders, with studies by Leichsenring [27][28][29][30], the effect sizes suggest that the decrease in primary symptoms is greater in CBT than in STDP from pretreatment to posttreatment, and the magnitude of the difference between the two treatment modalities is moderate in the case of generalized anxiety disorder and small in the case of social phobia (ds = 0.64 and 0.42, respectively; Supplementary Figure 2 In personality disorders, with studies by Svartberg [31] and Emmelkamp [32], one study shows a small benefit of STDP over CBT in primary symptoms in Cluster C personality disorders, whereas the other shows a moderate benefit of CBT over STDP in avoidant personality disorder from pretreatment to posttreatment (ds= -0. 26 In depressive disorder, with studies by Shapiro et al [33,34] and Thompson et al [35,36] In bulimia nervosa, with a study by Garner et al [37], CBT shows a small advantage over STDP in primary symptoms (d=0.37; Supplementary Figure 2 An examination of the confidence intervals reveals that the possibility of negligible differences between CBT and STDP could not be ruled out in any of the primary and secondary symptom comparisons.…”

Affective Change in Psychodynamic Psychotherapy: Theoretical Models and Clinical Approaches to Changing Emotions

“…Lotterman's observation may help to explain our clinical experience from supervising videotaped treatments of three recent psychodynamic randomized controlled trials Leichsenring et al 2013), psychodynamic psychotherapists often did not focus on salient emotions, missed to respond to the emotional arousal of the patient in a timely manner and to maintain the level of emotional arousal conducive to change, so that the change potential of critical emotional moments got lost (Stern 1998(Stern , 2004.…”