Results of a naturalistic longitudinal study of benzodiazepine and SSRI use in the treatment of generalized anxiety disorder and social phobia. An open trial of topiramate in the treatment of generalized social phobia. Psychopharmacological treatment of social phobia; a double blind placebo controlled study with fluvoxamine Sertraline treatment of generalized social phobia: a 20-week, double-blind, placebo-controlled study. Strategy for treating selective serotonin reuptake inhibitor-resistant social anxiety disorder in the clinical setting: a randomised controlled trial protocol of cognitive behavioural therapy in combination with conventional treatment Nefazodone in the treatment of generalized social phobia: a randomized, placebo-controlled trial. The selective serotonin reuptake inhibitor paroxetine is effective in more generalized and in less generalized social anxiety disorder Paroxetine in the treatment of generalized social phobia: open-label treatment and double-blind placebo-controlled discontinuation. Guidelines for the pharmacological treatment of anxiety disorders, obsessive–compulsive disorder and posttraumatic stress disorder in primary care Prevention of relapse in generalized social phobia: results of a 24-week study in responders to 20 weeks of sertraline treatment. A double-blind placebo-controlled trial of paroxetine in the management of social phobia (social anxiety disorder) in South Africa. Pharmacotherapy of social phobia. A controlled study with moclobemide and phenelzine. Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders – First Revision A comparison of the efficacy of clonazepam and cognitive-behavioral group therapy for the treatment of social phobia. The diagnosis and treatment of generalized anxiety disorder. Cognitive-behavioral and pharmacological treatments of social phobia. A controlled study.
The past decade has brought major new developments in the psychopharmacologic management of generalized anxiety disorder and social phobia . We examined medication-prescribing patterns for the treatment of these anxiety disorders for 12 years to assess changes in patients ' anti-anxiety psychotropic medication usage during that period of evolving practice guidelines . We examined psychotropic medication use in 305 patients with generalized anxiety disorder and 232 with social phobia enrolled in the Harvard/Brown Anxiety Disorders Research Project ( HARP ) , a prospect i ve , longitudinal study of anxiety disorders .  Psychotropic treatment patterns seem to have remained relatively stable over 12 years with benzodiazepines the medications most commonly used for both generalized anxiety disorder and social phobia . Comparatively , selective serotonin reuptake inhibitor ( SSRI ) and venlafaxine usage as st and -alone medications for these disorders remained low throughout the follow-up period . At the 12-year follow-up , 24 % of patients with generalized anxiety disorder and 30 % of patients with social phobia were utilizing neither an  SSRI/selective norepinephrine reuptake inhibitor ( SNRI ) nor a benzodiazepine . Treatment recommendations for use of SSRIs and venlafaxine in the management of generalized anxiety disorder and social phobia initially promulgated in 1998 had a modest impact on changes in psychopharmacologic practice 4 - 5 years later . Difficulties in the implementation of treatment guidelines are discussed BACKGROUND Selective serotonin reuptake inhibitors ( SSRIs ) are the current gold st and ard in the pharmacologic treatment of generalized social phobia . SSRIs are only effective in approximately 50 % of individuals with generalized social phobia and can be associated with significant side effects . Based on the successful use of the anticonvulsants gabapentin and pregabalin in treating generalized social phobia , we conducted an open trial examining the efficacy of the glutamatergic and GABAergic anticonvulsant topiramate in the treatment of generalized social phobia . METHOD Twenty-three adult out patients with DSM-IV social phobia , generalized type , were entered into a 16-week open trial of topiramate , starting at 25 mg/day , and gradually titrated up to a maximum dose of 400 mg/day . RESULTS Twelve of 23 patients completed the trial . In the intent-to-treat ( ITT ) analysis , 11 ( 47.8 % ) of 23 were responders by a Clinical Global Impressions Improvement ( CGI-I ) scale rating of " much " or " very much " improved . The mean drop in the Liebowitz Social Anxiety Scale ( LSAS ) score for the ITT group was 29.4 % . The change in LSAS score from baseline to endpoint was significant for the ITT group ( F = 3.44 , df = 4,110 ; p = .01 ) . In the completers group , 9 ( 75.0 % ) of 12 were responders by CGI-I at 16 weeks , with a mean drop in LSAS score of 45.1 % . The rate of remission in the ITT sample , using a definition of an LSAS score of < /= 30 , gave a remission rate of 26.1 % ( 6/23 ) . CONCLUSION This study suggests that topiramate may be effective in the treatment of generalized social phobia . These results also suggest the possibility that the neurotransmitters glutamate and GABA may be involved in the neurobiology of generalized social phobia Previous studies have shown selective and non-selective monoamine oxidase inhibitors ( MAOIs ) to be effective in the treatment of social phobia . In this study we investigated the efficacy of selective serotonin reuptake inhibitors ( SSRIs ) in social phobia . Thirty patients with social phobia ( DSM-IIIR ) were treated with the SSRI fluvoxamine ( 150 mg daily ) using a 12-week double-blind placebo controlled design . A substantial improvement was observed in seven ( 46 % ) patients on fluvoxamine and in one ( 7 % ) on placebo . Statistically significant effects were seen on measures of social anxiety and general ( or anticipatory ) anxiety in patients treated with fluvoxamine compared with placebo . The level of phobic avoidance decreased also but the difference at endpoint between fluvoxamine and placebo failed to reach statistical significance . It is concluded that treatment with the SSRI fluvoxamine has beneficial effects in patients suffering from social phobia , suggesting that serotonergic mechanisms might be implicated in social anxiety OBJECTIVE The authors evaluated the efficacy , safety , and tolerability of sertraline , a selective serotonin reuptake inhibitor , in the treatment of generalized social phobia . METHOD Adult out patients with generalized social phobia ( N=204 ) from 10 Canadian centers were r and omly assigned to receive sertraline or placebo in a 2:1 ratio for a 20-week double-blind study following a 1-week , single-blind , placebo run-in . The initial dose of sertraline was 50 mg/day with increases of 50 mg/day every 3 weeks permitted after the fourth week of treatment ( dosing was flexible up to a maximum of 200 mg/day ) . Primary efficacy assessment s were the percentage of patients rated much or very much improved on the Clinical Global Impression ( CGI ) improvement item and the mean changes from baseline to study endpoint in total score on the social phobia subscale of the Marks Fear Question naire and total score on the Brief Social Phobia Scale . RESULTS In intent-to-treat endpoint analyses of 203 of the patients , significantly more of the 134 patients given sertraline  ( N=71 [ 53 % ] ) than of the 69 patients receiving placebo  ( N=20 [ 29 % ] ) were considered responders according to their CGI improvement scores at the end of treatment . The mean reductions in the social phobia subscale of the Marks Fear Question naire and in the total score on the Brief Social Phobia Scale were 32.6 % and 34.3 % in the sertraline group and 10.8 % and 18.6 % in the placebo group , respectively . Analysis of covariance showed superiority of sertraline over placebo on all primary and secondary efficacy measures . Sertraline was well tolerated : 103 ( 76 % ) of the 135 sertraline-treated patients and 54 ( 78 % ) of the 69 placebo-treated patients completed the study . CONCLUSIONS Sertraline is an effective treatment for patients with generalized social phobia Introduction Pharmacotherapy and cognitive behavioural therapy ( CBT ) are consistently effective as first-line treatments for  social anxiety disorders ( SADs ) . Nevertheless , pharmacotherapy is often the first choice in clinical practice . In many countries , the first line of pharmacotherapy involves the administration of a selective serotonin reuptake inhibitor ( SSRI ) . Although a significant proportion of patients with SAD fail to respond to the initial SSRI administration , there is no st and ard approach to the management of SSRI-resistant SAD . This paper describes the study protocol for a r and omised controlled trial to evaluate the clinical effectiveness of CBT as a next-step strategy , concomitant with conventional treatment , for patients with SSRI-resistant SAD . Methods and analysis This Prospect i ve R and omized Open Blinded End-point study is design ed with two parallel groups , with dynamic allocation at the individual level . The interventions for the two groups are conventional treatment , alone , and CBT combined with conventional treatment , for 16 weeks . The primary end-point of SAD severity will be assessed by an independent assessor using the Liebowitz Social Anxiety Scale , and secondary end-points include severity of other social anxieties , depressive severity and functional impairment . All measures will be assessed at weeks 0 ( baseline ) , 8 ( halfway point ) and 16 ( postintervention ) and the outcomes will be analysed based on the intent-to-treat . Statistical analyses are planned for the study design stage so that field material s can be appropriately design ed . Ethics and dissemination This study will be conducted at the academic outpatient clinic of Chiba University Hospital . Ethics approval was granted by the Institutional Review Board of Chiba University Hospital . All participants will be required to provide written informed consent . The trial will be implemented and reported in accordance with the recommendations of CONSORT . Clinical Trial Registration Number UMIN000007552 OBJECTIVE Numerous studies have demonstrated the efficacy of serotonergic antidepres-sants , particularly the selective serotonin reuptake inhibitors ( SSRIs ) , in the treatment of social phobia . We evaluated the efficacy , safety , and tolerability of nefazodone , a 5-HT(2 ) antagonist , in patients with generalized social phobia ( GSP ) . METHOD One hundred five patients with GSP ( confirmed using the Structured Clinical Interview for DSM-IV ) from 4 Canadian outpatient anxiety clinics were assigned r and omly to nefazodone ( 300 - 600 mg/day , flexible dose ) or placebo for 14 weeks of double-blind treatment . Data were collected from October 12 , 1999 , through December 8 , 2001 . Primary efficacy outcomes were the Clinical Global Impressions-Improvement scale ( CGI-I ) score and the Liebowitz Social Anxiety Scale score . RESULTS In the intent-to-treat sample , 16 ( 31.4 % ) of 51 subjects taking nefazodone and 12 ( 23.5 % ) of 51 subjects taking placebo were rated as much or very much improved on the CGI-I at endpoint ( chi(2 ) = 0.79 , p = .38 ) . With the exception of the Social Phobia Scale , no significant differences were found in measures of social phobia when comparing the nefazodone and placebo groups . CONCLUSION These findings suggest that nefazodone is not an effective agent in the treatment of GSP . These data parallel some recent findings with the use of the SSRI fluoxetine in GSP . The lack of efficacy of 2 serotonergic antidepressants in GSP suggests that serotonin reuptake inhibition may not be the only mechanism of action required for efficacy to occur in the treatment of GSP Abstract . Rationale : The DSM-IV includes the specifier " generalized " to refer to social anxiety disorder ( social phobia ) patients if the fears include " most social situations " . The focus on interventions such as the selective serotonin reuptake inhibitors ( SSRIs ) for generalized social anxiety disorder arguably runs the risk that inadequate treatment will be provided to patients with the non-generalized or discrete subtypes . There are , however , few data to address whether more generalized and less generalized subgroups of social anxiety disorder differ in response to medication . Objective : To compare response of more generalized and less generalized social anxiety disorder to pharmacotherapy . Methods : Data from three r and omized placebo-controlled double-blind multicenter trials of the SSRI paroxetine in social anxiety disorder were pooled . Response on the Clinical Global Impression Global Improvement item was analyzed using logistic regression , and change in total Liebowitz Social Anxiety Score was analyzed using analysis of variance , with both models incorporating treatment ( paroxetine vs placebo ) , subgroup ( more generalized vs less generalized ) , demographic , and clinical variables . Results : The prevalence of more generalized social anxiety disorder was higher in females than in males . However , there was no significant difference in terms of age or clinical characteristics ( duration of condition , baseline pulse , mean arterial blood pressure ) . At treatment endpoint there were significant treatment effects ( for paroxetine vs placebo ) , but no significant subgroup effects ( for more generalized vs less generalized ) . Conclusions : Although the current data base is limited insofar as few patients with discrete social anxiety disorder would have been included , it is helpful in addressing the value of medication for patients lying on the spectrum from generalized to non-generalized and discrete social anxiety disorder .  Paroxetine was effective in both more generalized and in less generalized social anxiety disorder We conducted an 11-week forced-escalation open-label study of paroxetine in the treatment of 36 patients with generalized social phobia .  At the mean dosage of 47.9 + /- 6.2 mg/day , 23 of 30 completers ( 77 % ) were deemed responders on the basis of a clinician rating of either " very much improved " or " much improved " on the Clinical Global Impressions scale . Duke Social Phobia Scale ratings declined from 35.5 + /- 13.1 at baseline to 19.7 + /- 17.4 at week 11 ( p < 0.0005 ) , and Liebowitz Social Anxiety Scale ratings declined from 75.1 + /- 25.4 at baseline to 37.2 + /- 32.5 at week 11 ( p < 0.0005 ) . Sixteen responders were r and omized to an additional 12 weeks of either paroxetine ( with no dosage change ) or placebo ( after a taper period ) on a double-blind basis . To the best of our knowledge , this is the first controlled medication-discontinuation study in social phobia . One of eight patients r and omized to continue paroxetine  relapsed versus five of eight patients r and omized to placebo . These findings call for a double-blind , placebo-controlled treatment study of paroxetine in generalized social phobia . They also suggest that relapse rates are high if medication is discontinued early and that further study is needed to determine ( 1 ) the optimal duration of maintenance pharmacotherapy for social phobia and ( 2 ) if specific psychotherapeutic interventions before medication discontinuation may prevent relapse Abstract Objective . Anxiety disorders are frequently under-diagnosed conditions in primary care , although they can be managed effectively by general practitioners . Methods . This paper is a short and practical summary of the World Federation of Biological Psychiatry ( WFSBP ) guidelines for the pharmacological treatment of anxiety disorders , obsessive – compulsive disorder ( OCD ) and posttraumatic stress disorder ( PTSD ) for the treatment in primary care . The recommendations were developed by a task force of 30 international experts in the field and are based on r and omized controlled studies . Results . First-line pharmacological treatments for these disorders are  selective serotonin reuptake inhibitors  ( for all disorders ) ,  serotonin-norepinephrine reuptake inhibitors  ( for some ) and  pregabalin  ( for generalized anxiety disorder only ) . A combination of  medication and cognitive behavior/exposure therapy  was shown to be a clinical ly desired treatment strategy . Conclusions . This short version of an evidence -based guideline may improve treatment of anxiety disorders , OCD , and PTSD in primary care The aim of this study was to evaluate the efficacy , tolerability , and effects on quality of life of sertraline , a selective serotonin reuptake inhibitor , in the prevention of relapse of generalized social phobia .  Fifty adult out patients with generalized social phobia who were rated much or very much improved on the Clinical Global Impression Scale of Improvement ( CGI-I ) after 20 weeks of sertraline treatment ( 50 - 200 mg/day ) were r and omly assigned in a one-to-one ratio to either continue double-blind treatment with sertraline or immediately switch to placebo for another 24 weeks . The initial 20-week study was placebo-controlled , and 15 responders to placebo also continued to receive double-blind placebo treatment in the continuation study . Eighty-eight percent of patients in the sertraline-continuation group and only 40 % of patients in the placebo-switch and placebo-responder groups completed the study . In intent-to-treat endpoint analyses , 1 ( 4 % ) of 25 patients in the sertraline-continuation group and 9 ( 36 % ) of 25 patients in the placebo-switch group had relapsed at study endpoint ( chi2 = 8.0 , Fisher exact test , p = 0.01 ) . The relative risk ( hazards ratio ) for relapse associated with placebo-switch relative to sertraline-continuation treatment was 10.2 ( 95 % confidence interval , 1.3 - 80.7 ) . Mean CGI-Severity , Marks Fear Question naire ( MFQ ) Social Phobia subscale , and Duke Brief Social Phobia Scale ( BSPS ) total scores were reduced by 0.07 , 0.34 , and 1.86 in the Sertraline-Continuation group and increased by 0.88 , 4.09 , and 5.99 in the Placebo-Switch group ( all F > 5.3 , p < 0.03 ) , respectively . CGI-Severity , MFQ Social Phobia subscale , and BSPS scores also increased in the Placebo-Responder group . Discontinuations because of lack of efficacy were 4 % in the sertraline-continuation group , 28 % in the placebo-switch group ( chi2 = 5.36 , Fisher exact test , p = 0.049 ) , relative to sertraline , and 27 % in the placebo-responder group . Sertraline was effective in preventing relapse of generalized social phobia . Future research should assess whether improvements may be maintained or further increased by longer periods of treatment or through the addition of cognitive-behavioral techniques BACKGROUND Social phobia , also known as social anxiety disorder , is a highly prevalent disorder with significant morbidity . Patients with social phobia frequently develop co-morbid psychiatric disorders such as depression and substance abuse , and the disorder impacts significantly on social and occupational functioning . It has been suggested that the selective serotonin reuptake inhibitors ( SSRIs ) are useful in the management of this disorder , but few controlled trials have been undertaken in this regard . There are also few data on the pharmacotherapy of social phobia in South Africa . METHODS A double-blind r and omised placebo-controlled multi-site flexible-dose trial of paroxetine was undertaken over 12 weeks among patients with a primary diagnosis of social phobia . Primary response measures were the Global Improvement item on the Clinical Global Impression scale ( CGI ) and mean change from baseline in the patient-rated Liebowitz Social Anxiety Scale ( LSAS ) total score .  Ninety-three patients participated at 9 South African sites ; their data are reported here . RESULTS There was a significant drug effect on both the CGI Global Improvement score and the LSAS at 12 weeks . In addition , there was no significant difference in overall rate of adverse experiences between those on paroxetine and those on placebo . CONCLUSIONS Paroxetine is both effective and safe in the acute treatment of social phobia . The findings here are consistent with those of previous controlled studies of the SSRIs as well as with previous work done in the USA on the use of paroxetine in the treatment of this disorder . Early diagnosis and treatment of social phobia should be encouraged . However , further research on long-term pharmacotherapy of social phobia is needed In a double-blind , parallel group trial , 78 subjects with social phobia received moclobemide ( a new reversible inhibitor of monoamine oxidase A ) phenelzine , or placebo . After eight weeks , both active drugs-phenelzine somewhat more than moclobemide -- were clinical ly and statistically significantly more effective than placebo , as assessed by rating scales . There was some further improvement between weeks 8 and 16 , particularly in the moclobemide group ; at week 16 , 82 % of the moclobemide and 91 % of the phenelzine-treated patients were almost asymptomatic .  Moclobemide was , however , much better tolerated than phenelzine . Patients withdrawn from active drugs had relapsed by week 24 , providing additional support for the efficacy of the active drugs BACKGROUND  Generalized social phobia is common , persistent , and disabling and is often treated with selective serotonin reuptake inhibitor drugs or cognitive behavioral therapy . OBJECTIVE We compared fluoxetine ( FLU ) , comprehensive cognitive behavioral group therapy ( CCBT ) , placebo ( PBO ) , and the combinations of CCBT/FLU and CCBT/PBO . DESIGN R and omized , double-blind , placebo-controlled trial . SETTING Two academic outpatient psychiatric centers . PATIENTS Subjects meeting a primary diagnosis of generalized social phobia were recruited via advertisement . Seven hundred twenty-two were screened , and 295 were r and omized and available for inclusion in an intention-to-treat efficacy analysis ; 156 ( 52.9 % ) were male , 226 ( 76.3 % ) were white , and mean age was 37.1 years . INTERVENTIONS Treatment lasted for 14 weeks . Fluoxetine and PBO were administered at doses from 10 mg/d to 60 mg/d ( or equivalent ) . Group comprehensive cognitive behavioral therapy was administered weekly for 14 sessions . MAIN OUTCOME MEASURES An independent blinded evaluator assessed response with the Brief Social Phobia Scale and Clinical Global Impressions scales as primary outcomes . A videotaped behavioral assessment served as a secondary outcome , using the Subjective Units of Distress Scale . Adverse effects were measured by self-rating . Each treatment was compared by means of chi2 tests and piecewise linear mixed-effects models . RESULTS Clinical Global Impressions scales response rates in the intention-to-treat sample were 29 ( 50.9 % ) ( FLU ) , 31 ( 51.7 % ) ( CCBT ) , 32 ( 54.2 % ) ( CCBT/FLU ) , 30 ( 50.8 % ) ( CCBT/PBO ) , and 19 ( 31.7 % ) ( PBO ) , with all treatments being significantly better than PBO . On the Brief Social Phobia Scale , all active treatments were superior to PBO . In the linear mixed-effects models analysis , FLU was more effective than CCBT/FLU , CCBT/PBO , and PBO at week 4 ; CCBT was also more effective than CCBT/FLU and CCBT/PBO . By the final visit , all active treatments were superior to PBO but did not differ from each other . Site effects were found for the Subjective Units of Distress Scale assessment , with FLU and CCBT/FLU superior to PBO at Duke University Medical Center , Durham , NC . Treatments were well tolerated . CONCLUSIONS All active treatments were superior to PBO on primary outcomes . Combined treatment did not yield any further advantage . Notwithst and ing the benefits of treatment , many patients remained symptomatic after 14 weeks In this report , which is an up date of a guideline published in 2002 ( B and elow et al. 2002 , World J Biol Psychiatry 3:171 ) , recommendations for the pharmacological treatment of anxiety disorder , obsessive-compulsive disorder ( OCD ) and post-traumatic stress disorder ( PTSD ) are presented . Since the publication of the first version of this guideline , a substantial number of new r and omized controlled studies of anxiolytics have been published . In particular , more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs . The recommendations , developed by the World Federation of Societies of Biological Psychiatry ( WFSBP ) Task Force for the Pharmacological Treatment of Anxiety , Obsessive-Compulsive and Post-traumatic Stress Disorders , a consensus panel of 30 international experts , are now based on 510 published r and omized , placebo- or comparator-controlled clinical studies ( RCTs ) and 130 open studies and case reports . First-line treatments for these disorders are selective serotonin reuptake inhibitors ( SSRIs ) , serotonin-noradrenaline reuptake inhibitors ( SNRIs ) and the calcium channel modulator pregabalin . Tricyclic antidepressants ( TCAs ) are equally effective for some disorders , but many are less well tolerated than the SSRIs/SNRIs . In treatment-resistant cases , benzodiazepines may be used when the patient does not have a history of substance abuse disorders . Potential treatment options for patients unresponsive to st and ard treatments are described in this overview . Although these guidelines focus on medications , non-pharmacological were also considered . Cognitive behavioural therapy ( CBT ) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders , OCD , and PTSD to support them being recommended either alone or in combination with the above medicines There is a growing body of evidence that social phobia may be treated effectively by either pharmacologic or cognitive-behavioral interventions . but few studies have examined the relative benefits of these treatments . In this study , we examined the relative efficacy of pharmacotherapy with clonazepam and cognitive-behavioral group therapy ( CBGT ) for treating social phobia . In addition , we examined potential predictors of differential treatment response . Out patients meeting Diagnostic and Statistical Manual of Mental Disorders ( 3rd ed . , revised ) criteria for social phobia were r and omly assigned to treatment . Clinician-rated and patient-rated symptom severity was examined at baseline and after 4 , 8 , and 12 weeks of treatment . All clinician-rated assessment s were completed by individuals blind to treatment condition . Patients in both conditions improved significantly , and differences between treatment conditions were absent , except for greater improvement on clonazepam on several measures at the 12-week assessment . Symptom severity was negatively associated with treatment success for both methods of treatment , and additional predictors-sex , comorbidity with other anxiety or mood disorders , fear of anxiety symptoms , and dysfunctional attitudes-failed to predict treatment outcome above and beyond severity measures . In summary , we found that patients r and omized to clinical care with clonazepam or CBGT were equally likely to respond to acute treatment , and pretreatment measures of symptom severity provided no guidance for the selection of one treatment over another BACKGROUND Generalized anxiety disorder  ( GAD ) is a common and serious disease with a lifetime prevalence of 4.3 % to 5.9 % . It is underdiagnosed in primary care . METHODS Recommendations on the treatment of GAD are given on the basis of all available findings from pertinent r and omized trials , retrieved by a selective search of the literature . RESULTS Among psychotherapeutic techniques , various kinds of cognitive behavioral therapy ( CBT ) have been found useful in controlled trials . The drugs of first choice include selective serotonin reuptake inhibitors ( SSRIs ) , serotonin-norepinephine reuptake inhibitors ( SNRIs ) , and the calcium-channel modulator pregabalin . Tricyclic antidepressants are also effective but have more adverse effects than SSRIs . Although benzodiazepines are effective anxiolytic agents for short-term use , they should not be given over the long term because of the danger of addiction . Buspirone , an azapirone , was found to be effective in a small number of trials , but the findings across trials are inconsistent . The response rate of GAD to CBT in published studies lies between 47 % and 75 % , while its response rate to drug treatment lies between 44 % and 81 % . CONCLUSION The treatment of GAD with CBT and drugs is evidence -based and has a good chance of improving the manifestations of the disorder Sixty-five patients with social phobia were treated in a study that compared a cognitive-behavioral group treatment program with pharmacotherapy with alprazolam , phenelzine sulfate , or pill-placebo plus instructions for self-directed exposure to phobic stimuli . Statistically significant repeated- measures effects were shown on all measures , indicating that the treatments studied were associated with substantial improvements in patients with severe and chronic social phobia . Patients who were treated with phenelzine were rated by clinicians as more improved on a measure of work and social disability than patients who were treated with alprazolam or placebo ( patients in the cognitive-behavior therapy group were not rated on this measure ) . Subjects showed positive cognitive changes from before to after treatment , and there were no differences between treatment groups on the cognitive measure . We discuss the implication s of these findings within the context of demographic and clinical predictors of response
Cognitive behavior therapy  appears to be more effective than other evidence -based psychological techniques , and its effects appear to be more enduring than those of pharmacotherapy .
There is some evidence , albeit limited to certain drug classes , that the combination of  medication and cognitive behavior therapy may be more effective than either strategy used alone .
This article proposes a number of recommendations for the treatment of  generalized social phobia  , based on a systematic literature review and meta- analysis .
For medications , selective serotonin reuptake inhibitors and dual serotonin-norepinephrine reuptake inhibitors are first-line choices based on their efficacy and tolerability profiles .
There are other medication classes with demonstrated efficacy in social phobia ( benzodiazepines , antipsychotics , alpha-2-delta lig and s ) , but due to limited published clinical trial data and the potential for dependence and withdrawal issues with benzodiazepines , it is unclear how best to incorporate these drugs into treatment regimens .