اثر بخشی سه روش درمان نوجوانان مبتلا به اختلال اضطراب اجتماعی:ارزیابی پیگیری 5 ساله

Abstract Few studies have reported long-term follow-up data in adults and even fewer in adolescents. The purpose of this work is to report on the longest follow-up assessment in the literature on treatments for adolescents with social phobia. A 5-year follow-up assessment was conducted with subjects who originally received either Cognitive Behavioral Group Therapy for Adolescents (CBGT-A), Social Effectiveness Therapy for Adolescents—Spanish version (SET-Asv), or Intervención en Adolescentes con Fobia Social—Treatment for Adolescents with Social Phobia (IAFS) in a controlled clinical trial. Twenty-three subjects completing the treatment conditions were available for the 5-year follow-up. Results demonstrate that subjects treated either with CBGT-A, SET-Asv and IAFS continued to maintain their gains after treatments were terminated. Either the CBGT-A, SET-Asv and IAFS can provide lasting effects to the majority of adolescents with social anxiety. Issues that may contribute to future research and clinical implications are discussed.

2. Results Given that only half of subjects who completed the original study participated in the 5-year follow-up, it was important to examine if there were differences between participants and nonparticipants. Data indicated nonsignificant differences in any variable (P > .05), suggesting that the long-term follow-up participants were fully representative of the original study sample. Further, it was necessary to examine if there were pretreatment differences across treatment conditions on the measures analyzed. Variables assessed included age, comorbidity and scores in the social anxiety measures. Data revealed that patients in the three treatment packages did not differ on any demographic nor social anxiety measure (P > .05). 2.1. Statistical and clinical changes As shown in Table 1, rapid improvement was evident between the pretest and posttest, with maintenance of therapeutic gains demonstrated at 1-year and 5-year follow-ups. Considerable residual clinical social anxiety symptoms were evident at 5-year follow-up in spite of significant improvement. Although results showed a tendency toward lesser improvement on social anxiety measures at 5-year follow-up, nonstatistical differences were found. After treatment, subjects in the present study did not achieve the same level of treatment gains across treatment conditions as evident in the long-term follow-ups. At 5-year follow-up, the SET-Asv or IAFS obtained the lowest scores in all social anxiety measures. However, between-group analysis revealed absence of significant difference in any social anxiety scores at 5-year follow-up (P > .05). Table 1. Means and standard deviations for self-report measures by treatment condition SET-Asv CBGT-A IAFS M S.D. M S.D. M S.D. SPAI-SP Pretest 138.43 21.56 126.38 28.82 137.88 15.83 Posttest 61.29 25.75 65.50 26.04 69.38 52.11 1-Year follow-up 41.71 13.61 61.38 32.07 56.13 52.04 5-Year follow-up 50.57 26.14 57.63 26.29 53.38 34.93 SPAI—Difference Pretest 115.00 18.37 99.37 21.05 111.00 15.64 Posttest 50.43 19.48 50.13 21.69 54.13 39.67 1-Year follow-up 32.14 7.73 45.88 25.36 45.38 39.04 5-Year follow-up 41.71 22.16 36.50 18.77 41.00 25.20 SAS-A/Total Pretest 65.43 11.56 64.38 9.29 67.13 10.06 Posttest 45.29 15.66 40.75 9.25 42.25 13.83 1-Year follow-up 42.14 11.75 37.63 10.54 34.38 13.08 5-Year follow-up 41.86 13.52 42.25 12.97 38.63 11.65 SAS-A/FNES Pretest 30.57 5.83 30.88 8.45 32.12 4.08 Posttest 22.14 8.92 17.13 4.42 20.38 6.67 1-Year follow-up 20.29 8.38 16.00 5.78 15.50 5.63 5-Year follow-up 20.71 0.25 18.75 7.94 18.38 6.23 SAS-A/SAD-N Pretest 21.29 4.85 21.25 2.71 23.38 3.58 Posttest 13.00 3.56 15.25 5.60 13.88 5.03 1-Year follow-up 13.71 1.70 15.13 3.79 12.25 5.80 5-Year follow-up 12.71 2.14 14.88 4.64 13.13 5.25 SAS-A/SAD-G Pretest 12.43 3.55 12.25 2.37 12.38 3.77 Posttest 10.14 3.97 8.38 1.76 8.00 3.78 1-Year follow-up 8.14 2.79 8.00 2.72 6.25 2.43 5-Year follow-up 8.43 3.31 8.63 2.39 7.12 2.47 ADIS—Social Phobia section Pretest 9.14 2.41 8.63 1.68 8.50 1.41 Posttest 2.29 3.25 2.75 3.01 2.75 4.09 1-Year follow-up 0.43 0.79 2.38 2.32 1.75 2.71 5-Year follow-up 0.71 1.11 1.88 2.23 0.75 0.88 Avoidance personality disorder Pretest 1.00 0.00 1.00 0.00 1.00 0.00 Posttest 0.29 0.48 0.25 0.46 0.25 0.46 1-Year follow-up 0.14 0.39 0.25 0.46 0.13 0.35 5-Year follow-up 0.14 0.39 0.25 0.46 0.13 0.35 M: mean, S.D.: standard deviation, SET-Asv: Social Effectiveness Therapy for Adolescents—Spanish version, CBGT-A: Cognitive-Behavioral Group Therapy, IAFS: Intervención en Adolescentes con Fobia Social Gneralizada (Therapy for Adolescents with Generalized Social Phobia). Table options Table 2, Table 3 and Table 4 present data concerning within-group analyses between pretest and the other assessment times. Results demonstrate very high effect sizes, according to Cohen's (1988) criteria. The calculation of effect sizes seems to indicate high effectiveness in the three treatments across time. Estimated power ensured within-group differences. There were no significant differences in any measure among the three conditions in the remaining comparisons (between posttest and follow-ups and over the follow-up interval). Table 2. Statistical significance (SET-Asv) t P Effect size Power (%) SPAI-SP Pre/posttest 5.778 .001 3.11 96 Pre/1-year follow-up 10.171 .000 4.48 99 Pre/5-year follow-up 6.049 .001 3.54 99 SPAI-DIF Pre/posttest 6.409 .001 3.05 95 Pre/1-year follow-up 11.047 .001 3.92 99 Pre/5-year follow-up 5.761 .001 3.47 98 SAS-A/Total Pre/posttest 3.676 .010 1.51 77 Pre/1-year follow-up 5.419 .002 1.75 75 Pre/5-year follow-up 5.975 .001 1.77 71 SAS-A/FNE Pre/posttest 3.528 .012 1.44 76 Pre/1-year follow-up 4.584 .004 1.53 71 Pre/5-year follow-up 4.168 .006 1.47 70 SAS-A/SAD-N Pre/posttest 4.253 .005 1.49 69 Pre/1-year follow-up 3.958 .007 1.36 60 Pre/5-year follow-up 5.403 .002 1.53 74 SAS-A/SAD-G Pre/posttest – .244 – – Pre/1-year follow-up 3.665 .011 1.05 71 Pre/5-year follow-up 3.013 .024 0.98 70 ADIS-SP Pre/posttest 4.768 .003 2.47 94 Pre/1-year follow-up 8.774 .001 3.14 96 Pre/5-year follow-up 8.668 .001 3.04 95 Table options Table 3. Statistical significance (CBGT-A) t P Effect size Power (%) SPAI-SP Pre/posttest 4.545 .003 1.88 86 Pre/1-year follow-up 5.131 .001 2.01 75 Pre/5-year follow-up 7.618 .000 2.12 80 SPAI-DIF Pre/posttest 4.541 .003 2.08 92 Pre/1-year follow-up 4.601 .002 2.26 93 Pre/5-year follow-up 7.907 .001 2.66 96 SAS-A/Total Pre/posttest 4.746 .002 2.26 93 Pre/1-year follow-up 5.605 .001 2.56 94 Pre/5-year follow-up 3.542 .009 2.12 98 SAS-A/FNE Pre/posttest 5.536 .001 1.45 72 Pre/1-year follow-up 5.045 .001 1.57 61 Pre/5-year follow-up 3.111 .017 1.28 68 SAS-A/SAD-N Pre/posttest 2.542 .039 1.97 99 Pre/1-year follow-up 3.389 .012 2.01 98 Pre/5-year follow-up 3.147 .016 2.09 99 SAS-A/SAD-G Pre/posttest 3.307 .013 1.45 86 Pre/1-year follow-up 3.012 .020 1.59 95 Pre/5-year follow-up 3.506 .010 1.36 98 ADIS-SP Pre/posttest 6.563 .001 3.11 99 Pre/1-year follow-up 7.091 .001 3.31 99 Pre/5-year follow-up 10.003 .001 3.57 99 Table options Table 4. Statistical significance (IAFS) t P Effect size Power (%) SPAI-SP Pre/posttest 4.787 .002 3.85 99 Pre/1-year follow-up 5.453 .001 4.59 99 Pre/5-year follow-up 8.584 .000 4.75 99 SPAI-DIF Pre/posttest 3.979 .005 3.23 99 Pre/1-year follow-up 4.443 .003 3.73 99 Pre/5-year follow-up 11.209 .001 3.98 99 SAS-A/Total Pre/posttest 5.408 .001 2.20 84 Pre/1-year follow-up 9.188 .001 2.89 98 Pre/5-year follow-up 6.613 .001 2.52 93 SAS-A/FNE Pre/posttest 5.545 .001 2.56 94 Pre/1-year follow-up 11.869 .001 3.62 99 Pre/5-year follow-up 6.594 .001 2.99 98 SAS-A/SAD-N Pre/posttest 5.158 .001 2.36 89 Pre/1-year follow-up 6.733 .001 2.77 97 Pre/5-year follow-up 5.377 .001 2.55 94 SAS-A/SAD-G Pre/posttest 3.493 .010 1.03 68 Pre/1-year follow-up 4.657 .002 1.45 66 Pre/5-year follow-up 3.721 .007 1.24 61 ADIS-SP Pre/posttest 4.709 .002 3.63 99 Pre/1-year follow-up 10.003 .001 4.26 99 Pre/5-year follow-up 18.816 .001 4.89 99 Table options Based on success rate, defined as absence of social phobia DSM-IV criteria, Table 5 shows that the clinical success rates were different among the treatment conditions and assessment measures. Overall, almost half of patients evidenced total remission of social anxiety symptoms. Nevertheless, given that our sample met criteria for generalized social phobia before treatment, results displayed in Table 5 may underestimate treatment gains. Responder status was held to a very high and rigorous criterion. For instance, according to this criterion, if a patient endorsed generalized fear to nine social situations at pretest and reported anxiety to only one social situation at posttest, the patient was qualified as negative/nonresponder. However, if a subject endorsed anxiety to nine social situations at pretest and then reported no feared social situations after treatment (or follow-ups), he or she was scored as a positive/responder. In effect, to qualify as a responder, the patient could not endorse any fear. Although, as it should be noted, in both cases the reduction in fear is similar, the outcome nevertheless is different and reflects the rigorous criterion (nonresponder versus responder). In order to control this bias, we used as a clinical effectiveness criterion a 75% decrease in the number of social phobic situations endorsed at the pretest, such as is given in the ADIS-IV social phobia section. Table 6 shows that almost 9 of 10 subjects significantly reduced the number of feared social situations (partial remission) 5 years after therapy was completed. As it can be seen, success rates consolidated and generalized across time. No statistically significant differences were found among the SET-Asv, CBGT-A and IAFS. Despite of this, comparison among treatment conditions revealed that SET-Asv demonstrated the highest clinical success after treatment and at 1-year follow-up, while at 5-year follow-up the IAFS and CBGT-A displayed the highest success rates. However, our small sample size might have affected these results. Table 5. Clinical significance (100%; total remission) Result Type of treatment Total SET-Asv CBGTA IAFS Posttest Negative 4 (57%) 4 (50%) 5 (63%) 13 (57%) Positive 3 (43%) 4 (50%) 3 (37%) 10 (43%) χ2(2) = .245, P = .885 1-Year follow-up Negative 2 (29%) 6 (75%) 4 (50%) 12 (52%) Positive 5 (61%) 2 (25%) 4 (50%) 11 (48%) χ2(2) = 3,107, P = .211 5-Year follow-up Negative 4 (57%) 4 (50%) 4 (50%) 12 (52%) Positive 3 (43%) 4 (50%) 4 (50%) 11 (48%) Total 7 8 8 23 χ2(2) = 3,107, P = .211 Note. The percentages of success (denomined as positive) or failure (denomined as negative) reached in each group of treatment are shown under each frequency. Table options Table 6. Clinical significance (75%; partial remission) Result Type of treatment Total SET-Asv CBGTA IAFS Posttest Negative 0 (0%) 4 (50%) 2 (25%) 6 (26%) Positive 7 (100%) 4 (50%) 6 (75%) 17 (74%) χ2(2) = 1.218, P = .544 1-Year follow-up Negative 0 (0%) 3 (38%) 2 (25%) 5 (22%) Positive 7 (100%) 5 (62%) 6 (75%) 18 (78%) χ2(2) = 3.025, P = .220 5-Year follow-up Negative 2 (29%) 1 (13%) 0 (0%) 3 (13%) Positive 5 (71%) 7 (87%) 8 (100%) 20 (87%) Total 7 8 8 23 χ2(2) = 1.875, P = .392 Note. The percentages of success (denomined as positive) or failure (denomined as negative) reached in each group of treatment are shown under each frequency. Table options 2.2. Course of disorder over follow-up Measured as the number of social situations feared in the ADIS-SP, at pretest subjects met criteria for generalized social phobia, while qualitative data analyses revealed total or partial remission in most of patients at posttest and follow-ups. This suggests that subjects continued decreasing the number of feared social situations or maintained their therapeutic gains over the follow-up interval. As for the SET-Asv, three of seven patients (43%) did not meet DSM-IV social phobia criteria (total remission) at any stage over the follow-up period, one subject (14%) had social phobia during the follow-up interval, one (14%) fulfilled DSM-IV criteria at 1-year follow-up but evidenced total remission in the longer term, while two (29%) participants had total remission at 1-year follow-up but met social phobia criteria at 5-year follow-up. Concerning the CBGT-A, one of eight (12.5%) did not meet DSM-IV social phobia criteria (total remission) at any stage over the follow-up period, three participants (37.5%) fulfilled criteria for social phobia across the whole duration of the follow-up period, two subjects (25%) met DSM-IV criteria at 1-year follow-up but evidenced total remission in the longer term, while one of them (17.5%) evidenced total remission at 1-year follow-up but relapsed at 5-year follow-up. Regarding to the IAFS, two of eight (25%) did not meet DSM-IV social phobia criteria (total remission) at any stage over the follow-up period, while the same percentage has continued to fulfill diagnostic criteria for social anxiety disorder over the follow-up interval. Further, half of the sample was composed of subjects in remission at 1-year follow-up but who relapsed at 5-year follow-up and vice versa. Qualitative data analysis also revealed significant improvement after treatment for those participants at pretreatment who met criteria for avoidant personality disorder. Also, results indicated maintenance of the proportion of participants who did not meet avoidant personality disorder criteria at 5-year follow-up compared with the 1-year follow-up assessment. For treatment conditions, in the SET-Asv six of seven (86%) did not meet DSM-IV criteria for avoidant personality disorder over the follow-up period, while one subject did not improve at long-term. In the CBGT-A, five of eight (62.5%) maintained a complete recovery from their disorder during the whole follow-up interval, while one subject (12.5%) continued to meet diagnostic criteria for the duration of the follow-up. The remaining 25% was composed by two subjects in remission at 1-year follow-up but relapsed at 5-year follow-up and vice versa. In the IAFS, six of eight subjects (75%) did not meet the DSM-IV criteria over the follow-up period, one subject reported total remission at 1-year follow-up but relapsed at 5-year follow-up, while one subject evidenced criteria for avoidant personality disorder at 1-year follow-up but complete recovery at 5-year follow-up. As a result, these findings suggest that the SET-Asv seems to produce more stable effects over the follow-up interval, while in the CBGT-A and IAFS conditions more changes are noted in subjects who relapsed and recovered over the follow-up period.