Tuesday, December 20, 2016

The Best Treatment for Social Anxiety Disorder

How effective is psychotherapy? How effective is medication for treating mental health conditions? Has one type of therapy consistently been shown to be better than others? Is it best to combine medication with one or another kind of talk therapy?

The questions are difficult and tricky. Generally speaking, cognitive and behavioral treatments have been shown to be superior to treatments that aim at insight. And yet, some studies have shown that insight-oriented treatments work well and even better than some cognitive treatments.

But this assumes that all of the clinicians were providing roughly the same treatment, and that is very difficult to know or to assess. In the great marketplace of therapy, insight oriented and psychoanalytic treatments have generally lost out to the new cognitive and even interpersonal therapies. One respects the verdict of the marketplace more than a single study.

Many of the new psychiatric treatments have addressed depression. Aaron Beck invented cognitive therapy to treat depression. Prozac and other SSRIs revolutionized the field by providing what appeared to be a better treatment for depression. As of today, most clinicians believe that a combination of medication and cognitive treatment works best.

And yet, we also know that aerobic conditioning is an effective treatment for depression. And, lest we forget, Harvard psychiatrist Richard Mollica once suggested: “The best anti-depressant is a job.”

How many of the gains we attribute to therapy have been produced by other life style changes?

When it comes to social anxiety disorders, different treatments have shown promise. I have referred to study performed by Canadian researchers, Lynn Alden and Jennifer Trew. They prescribed the performance of good deeds. They instructed their patients to get out of their minds by performing one good deed for someone else every day.

Once patients acquired this habit, without benefit of introspection, the social anxiety disorder diminished. Improved relations with other people, relationships based more on giving than on threatening diminished their anxiety.

Importantly, where cognitive treatments rely on a form of mental gymnastics-- albeit not the kind that seeks out infantile antecedents—the Trew/Alden approach involved changing habits of behavior. It did not, I hasten to add, rely directly on the stimulus/response paradigm that characterizes some behavioral treatments.

Take that as context. When evaluating psychotherapy research one does well to maintain a skeptical attitude. In truth, the same applies to all scientific experiments.

A recent study from Norway reports on the effectiveness of different treatments for social anxiety disorder. Some patients were merely given medication. Some were given medication and therapy. Some were given a placebo. And some were given cognitive talk therapy alone.

The researchers were surprised to discover that the most effective treatment was cognitive talk therapy alone. The study lasted for ten years, and thus counts as long term.

Jesse Singal reports in New York Magazine:

A research team lead by Hans Nordahl of the Norwegian University of Science and Technology found that a year after treatment, patients with social-anxiety disorders who had completed cognitive behavioral therapy (CBT) had a 68 percent recovery rate, compared with 24 percent who had taken paroxetine, an antidepressant sold under Paxil and other brand names in the U.S. The pill placebo group had just a 4 percent success rate. Tellingly, the “combination” group that used both the therapy and the drug only had a 40 percent success rate.

Obviously, the pills worked better than the placebo. And the pills combined with CBT worked better than the pills alone. But, the best results were attained  in patients who only had talk therapy.

Dr. Nordahl explained the downside of medication:

This is because, Nordahl said in a statement, patients in the combination setting rely on the drugs to make them healthier. “They become dependent on something external rather than learning to regulate themselves,” he said. 

Apparently, the same principle does not apply to the treatment of depression, but one should perhaps retain some skepticism. Does the introduction and reliance on medication cause other psychiatric patients to believe that they are powerless to control their symptoms?

For now, I would emphasize that Nordahl and his colleagues were offering a variation on standard CBT.

New York describes it:

The flavor of CBT that Nordhal and company used is called “metacognitive therapy,” meaning that therapists teach their patients to think more about their thinking, and analyze their reactions and beliefs to the thoughts that they have. This involves training patients in being able to step out of the cycles of rumination that are so much a part of debilitating, disordered anxiety. Locus of control, or whether you think your life is a result of your actions or outside forces, also seems to play a role here: “The medication camouflages a very important patient discovery: that by learning effective techniques, they have the ability to handle their anxiety themselves,” Nordhal said.

One finds it amusing that CBT—cognitive behavioral therapies—come in different flavors.

The PsyPost report also describes the kind of cognitive therapy in use:

Nordahl and the rest of the research team have also worked to improve standard cognitive therapy. They have added new processing elements, which have shown greater effectiveness.

“We’re using what’s called metacognitive therapy, meaning that we work with patients’ thoughts and their reactions and beliefs about those thoughts. We address their rumination and worry about how they function in social situations. Learning to regulate their attention processes and training with mental tasks are new therapeutic elements with enormous potential for this group of patients,” says Nordahl.

To be clear, this approach does not aim at insight and does not seek out the root causes of the social anxiety disorder. It involves taking your thoughts and your mental habits to be those of someone else. It trains you to step outside of yourself and to take your mental acts as bad habits.

Once you have identified and isolated a bad mental habit you can, I presume, replace it with a good mental habit. Such was Aristotle’s recommendation.

I note that someone who has suffered from social anxiety disorder must have missed out on learning how to function successfully in society. Beyond his bad mental habits, he must have practiced dysfunctional social behaviors.

I am intrigued by the fact that these patients did so much better with CBT. But I would also be interested in knowing how they learned new and more effective ways to interact with other people.

For that reason I still find considerable merit in the Trew/Alden approach. The Canadian researchers were more attuned to the fact that the person who was overcoming social anxiety disorder still needed to learn how to function in relationships with other people.

If you have never really known how to play the game, a new way to process your thoughts might help you to step up to the table, but it will not teach you how to play.

One understands that Norway is a homogeneous culture in a relatively small country. How well would these patients be functioning if they were living in the great funhouse of New York City, a place where social cues are consistently confused and where different people from different cultures practice different social skills?


Boggs said...

"Once you have identified and isolated a bad mental habit you can, I presume, replace it with a good mental habit. Such was Aristotle’s recommendation."

Great comment, Schneiderman.

I note for the record that Aristotle's observation was seconded by St Thomas Aquinas, the Medieval fan of The Auld Stagirite, in his analysis of habit.

Unknown said...

"One understands that Norway is a homogeneous culture in a relatively small country." And a very tight "common moral".
In Norway, winter is long and lack sunlight. Especially for the ones living up North (no real light during 4 months, dark night from 4 PM to 9 AM).The lack of light is well known to be involved in anxiety and depression. Not sure that my Beloved upthere represent a real trend (even if I love and need them for my own).
Frankly we'd all appreciate a study based on light (and sunlight effect) on mood and psychiatric deseases (or border effects such as lack of melatonin for disabled children - and adults they become).