Al-Azhar Med. J. V O ~ . 28 (3 & 4), July & October, 1999: 425 - 438.

PHARMACOLOGICAL TREATMENT VERSUS COGNITIVE BEHAVIOURAL THERAPY

IN SOCIAL PHOBIA: A COMPARATIVE STUDY BETWEEN MOCLOBEMIDE, PAROXETINE ND COGNITIVE BEHAVIOURAL THERAPY

BY MOHAMMED KHALED SALAH HELMY, MUWAFAK AL-EITHAN",

BUSSAIN ATEIA AND MOHAMMED ABD EL-FATTAH EL GAMMAL Deocsrkment of Psychiatry, Al- Azkar Facu&ty of Medicine, Cairo, Egypt

and ~ ~ ~ ~ ~ ~ ~ ~ n t of Clinical Psychology9 King Saud, University, Saudia Arabia *

ABSTRACT S ~ c i d ghobb i s among the least stu ied of major anxiety disorders. Moclobemide, Paroxetine

nitive behaviour therapy are among the new strategies in the modern treatment of social phohia. Sixty four patients with generalized social phobia were randomly assigned to Moclobe- made, Paroxetine and cognitive behavionr therapy groups for twelve weeks: The pattern of re- sponse was assessed. Resp~nsg. rate was 47.8, 50 and 23.4%for Moclobemide, paroxetine and cog- nitive behatiour therapy group respectively. Moclobemide was superior in reducing the somatic symptoms and interpersonal sensitivity, Paroxetine was superior in reducing global anxiety symp- toms and obsessive compulsive symptoms, both ~E-SUPS were superior to cognitive bebavioenr thera- py in reducing avoidance laehaviour. Cognitive behaviour therapy was superior to Paroxetine in re- ducing interpersonal sensitivity. We discussed the implication of 2hese findings within the context aF drug related dmc, period of fdiow up and clinicd predictors oh response.

Although sociaa phobia is ,"i common psychologican disorder (Stein et al., 1994; and Kessler et al,, 199iw)9 it was not unt i l 1988 that the American Psychi- atric Assoeiatiuw formally recognized SOCi2.d na as h* discrete diagnostic ectaty IGeBerntcr et a1.,1991).

According to DSMIV, socnag phobia patients experienced anxious anticipa- tion, daslress or avondance Wh1Ci-l inter- fere %vi th ~ c c u p ~ i o n a l funcamwing, so- cial activiaaes QIi- relationshaps with others, especially in generalized subtype, when the phobic situation includes most of social ~ ~ t ~ ~ ~ ~ ~ ~ ~ ~ A ~ e ~ ~ c a ~ Psychiatric Association, 1994). Investigators of this

425

social phobia subtype showed significant increase in the severity of social avoid- ance ,social anxiety as well as the level of genera9 distress, that carry with it a t rernen dou s burden s f disabi I it y (Turner et aP.,B992; and Stein, 8996),and associat- ed with reduced quality of life(Schneier et al.,1994).

This subtype typically is of the kind of patients particularly encountered in psychiatric setting, most likely to experi- ence depresive csrnorbidity ( Kessler et al., 1998).

Research has shown that social pho- bia syndrome is among the least studied of the major anxiety disorders, and have indicated the need for further research to

Mohammed Khaled Salah Helmy, et al. 426 .

address gaps in our knowledge concern- ing definition, prevalence, aetiology, pa- thophysiology assessment and treatment (Liebowitz et al., 1985).

For decades, the treatment of social phobia has traditionally been the domain of psychoanalytic therapy (Nichols, 1974). Relatively, few studies of cogni- tive behavioural therapies in clinical populations of patients with social pho- bia have been conducted with promising results for certain types of social phobia patients. The research in this area has fo- cused on the efficacy of cognitive re- structuring and exposure techniques in the treatment of social anxiety (Brady, 1984a and Heimberg et a1.,1985).

Other research has used the pharmac- ological approach to treat the disorder. Some patients, for instance,were respon- sive to beta blocking drugs such as Pro- pranolol and Metoprolol (Liebowitz et a]., 1987) or Atenolol (Liebowitz et al., 1992 ). although this was confined to specific social phobias like performance anxiety.

Data regarding the effectiveness of Benzodiazepines treatment of social phobia are minimal although some re- ports suggested that Alprazolam (Reich and Yates, 1988) and Clonazepam (Munjack et a1.,1990) are of value in re- ducing social anxiety when used in high doses, and have risk of excessive drowsi- ness and dependency; therefore their prolonged use may present some disad- vantage.

Antidepressants like Imipramine and Clomipramine were also used in reduc- ing the symptoms of social phobia in some reports but most of them were clin- ical anecdotes on the treatment of a few cases or uncontrolled studies using mixed population (Bence et al., 1986 and Pecknold et al., 1992).

Early investigators have shown that MA0 inhibitors (Phenelzine and Tranyl- cypro- mine) were effective in treating social phobia (Solyom et a1.,1981). Stud- ies which have compared the efficacy of Phenelzine to that of Imipramine or Am- itriptyline have found Phenelzine to be superior (Liebowitz et al., 1987). More recently, reversible inhibitors of Monoa- mine A (Moclobemide and Brofaromine) were used with success in some studies (Versiani et al., 1992 and Lott et al., I997), but not all (Schneier et al., 1998). These drugs are specific for both depres- sive and anxiety disorders (Baldessarini, 1989). Since Moclobemide reversible in- hibit MAO-A,the potentiation of the pressor response to Tyramine is negligi- ble (Gieschke et al., 1987).

More recently, SSRIs proved to be ef- fective with social phobia after several double blind placebo controlled studies have been published with Fluoxetine (Sternback,1990 and Black et al., 1992), Fluvoxamine (Van Vliet et al., 1994 and Stein et al., 1999), Sertraline (Katzelnick et a1.,1995) and finally, with Paroxetine (Stein et al.,1998), in a large multicentre study which demonstrated the efficacy of this agent for generalized social phobia.

It seems that none of these medica- tions are suitable for all patients. In our clinical practice, some patients do not re- spond to one treatment but surprisingly respond to the other, and the reverse is correct .

Castello (1992) has argued that re- search on symptoms may often be more fruitful than research on symptoms. With each medication, some symptoms im- proved but not always the full syndrome. Successful therapeutics require clini- cians to pay attention to the symptoms as well as to the categorical diagnosis

427 Pharmacological Treatment Versus

assuming that disturbances in neurobio- logical system causing particular symp- toms (Snaith, 1992).

The dim of the present investigation was to study the pattern of response of symptoms of social phobia (generalized type; to h e e different methods s f treat- ment, TS OUB knowledge, this Ss the first ~ ~ e ~ ~ ~ ~ ~ ~ o ~ ~ c a ~ ~ y rigorous study that comparm two recent ~ ~ ~ ~ ~ ~ ~ ~ ~ o g ~ c a ~ ~ ~ agents (Parmetine and Mocllobemide) with cognitive be'maviour psychotherapy for this disorder. %t also may be the first study on a Saudi sa p8e using such corn- paratiae approacrr; in treaiing wciail pho- I . +>Bit.

AlHEKTS ansd Patients included in this s~asdy were

daagnosed as suffering from social pho- bia (generalized type) according to DSM I\' We exc!u$ed patients with double diagnosis on axis 1, patients with a score of 12 OF higher on Hamilton de- pressive scale. those with akshol or drug abuse, those wvth physical disorders

disorder. Patients receiving psychotropic ixedicatiows within on%: ~ e e k hefore the m d y were precluded from participation. Sevety 6, i lx . patients were recruited frc~rn the outpstreni clinic of PSP ii Byehiatric

ic in Saudi Arabia, Twenty eight were treated with Moclobemide 1. '2 patiems were freated with

L>TI axis I31 awn9 pa::ents Rith personaiOity

cpeeialiaed polyeliaiic) a d A1 boostan

ri;L (group 2) and 2Q patients were n;eaied with cognitive

one of the three (GI' received kl

roups: *he fX4t

group (G2) received Pa- per day snd the third

group(G3Preceived weekly one hour in- divdbad sessions cognitive behavioural therapy, in addition to biweekly group

meeting for two hours(each group of ten patients), to help the patients to under- stand the inaccuracy of their cognitive assumptions and learn new strategies and ways to deal with their problem as social skills training (Brady, 1984b), re- laxation training and participant model-

The treatment were run according to etailled social phobia (C.B.T) treat-

ment manual {Heirnberg et aP., 1985). During treatment, all psychotropic drugs were not allowed except Bromazepam in the first week when necessary in doses not exceeding 3mg daily.

oclobemide and Parox- ethe in the first two groups was in- creased gradually to reach the previously prescribed dose by the end of the second week. Some patients received more than ane session weekly when necessary in the third group.

All patients were assessed at the pre- treatment phase (first visit) using Hamil- ton anxiety scale (HAS) (Hamilton, 19693, social avoidance and distress scale (SAD) (Watson and Friend., 1969) and Hopkin checklist 90-items (Deroga- tis et d., '1973) . HAS and SAD were re- peated at the end of weeks 1,2,4,8, and

as repeated at the end of in checklist serves basical-

ly as an outcome measure and not as a diagnostic too%. The scale contain nine subscales used to describe the diagnostic ;rsfile O F a patient, ~ ~ ~ a t ~ ~ ~ t i ~ ~ , obses- sive ~ o ~ ~ ~ ~ s ~ ~ ~ ~ hte ersonali sensitivi- ty7 anxiety, depressi phobic anxiety, anger hostility, paranoid ideation and ~ ~ y c ~ ~ t ~ ~ ~ ~ ~ . During the analysis, we neglected the last two subscaies. Ad- verse evenis were recorded by open

during the study.

DATA ANALYSIS: We used one way analysis of variance

[ANOVA] to investigate treatment re- sponse across time within the three

Mohammed Khaled Salah Helmy, et al. 428

groups and Krushall wallis [non para- metric] for sex comparison and Scheffe’s test to compare groups of une- qual sizes. t-test for paired sample was applied to compare pre- and post treat- ment scores in each group separately. The statistical package for social science (SPSS) was used for all analysis.

RESULTS Twelve patients did not complete the

study, six of them due to lack of efficacy (three patients from Moclobemide group; two patients from Paroxetine group and one patient from CBT group).Six did not return in their follow up time, leaving sixty four patients to complete the study (23 taking Moclobe- mide,24 taking Paroxetine and 17 receiv- ing CBT).

There were 17 females and 47 males, the mean age was 28.64k 4.31 years (range 19-37),the mean duration of ill- ness was 6.59+: 2.18 years (range 3-12)., There were 35 married patients(54.69%), 26 single patients(40.63%) and 3 di- vorced (4.68%). Thirty two patients (50%) were receiving college educa- tion,l2 patients ( I 8.75) had completed college education, 10 patients (1 5.63%) had completed secondary school and 10 patients( 15.63%) had some education less than secondary school. There were no statistical significant differences among treatment groups on any of these demographic variables by x test results. Six patients (26.09%) in Moclobemide group andl4 patients (58.33%) in Parox- etine group experienced at least one side effect during the first four weeks of the study. Insomnia, gastrointestinal upset and dizziness were the side effects re- corded in Moclobemide group, while in- crease anxiety symptoms ,tremors, naw sea, delayed ejaculation and anorgasmia were the side effects recorded with Pa- roxetine.

The response at the end stage of treat- ment was determined by using the clini- cal global impression scale (CGI) global improvement item, by which a response was rated either very much improvement (score=l) or much improvement (score=2). The improvement was based mainly on social phobia symptoms and not other psychiatric symptoms like anx- iety or depressive symptoms.

Eleven (47.8%) of the patients on Moclobemide, twelve (50%) of the pa- tients on Paroxetine and four (23.4%) of the patients on CBT were rated as re- sponders.

The total mean scores of HAS, SAD and total Hopkin revealed significant differences in the three groups When we compared pretreatment and pos ttreat- ment scores in Moclobemide group the mean HAS pretreatment score was 20.09 (kl.53SD) and the mean posttreatment score was 10.30 (21.26SD) [t=26.32; df=22; p<O.OOl], the mean SAD pre- treatment score was 22.96(&1.69) and the mean posttreatment score was 1 1.65 (&1.23SD) [t=28.63; df=22; p<O.OOl], the mean total Hopkin score pretreat- ment score was 101.26(+6.14SD) and the mean posttreatment score was58.91 (k4.64) [t=37.39; df=22; p c 0.0011. In Paroxetine group, the mean HAS pre- treatment score was 21.35(&1.41SD) and the mean posttreatment score was 6.88 (&1.73SD) [t=38.84; df=23; p< 0.0011, the mean SAD pretreatment score was 21.25(+1.41 SD) and the mean posttreat- ment score was12.50(+2.02SD) [t=2.27; df=23; p< 0.0011, the mean total Hopkin pretreatment score was 101.79(*7.46SD) and the mean posttreatment score was 60.13(+5.46SD) [t=48.99; df=23; p<O.OOl]. In CBT, group the mean HAS pretreatment score was 19.23(+-2.97SD) and the mean posttreatment score was 13.65(&2.9SD) [t=15.78; df=16;

429 Pharmacological Treatment Versus

pcO.OOl], the mean SAD pretreatment score was 23.29 (12.08SD) and the mean posttreatment score was 13.82 (22.24SD) [t=18.91; df=16; p<O.OOl], the total Hopkin pretreatment score was 96.67(&9.40SD) and the mean posttreat- ment score was 66.73(+7.4SD) [t=24.60; df= 16; p<O.OO 1 1.

The efficacy and pattern of response across time between the three groups over the 12 weeks were analyzed with ANOVA .All three groups showed sig- nificant pretreatment to post-treatment changes as regard SAD’S scoring as de- picted in figure (1). At the start of treat- ment, the mean SAD scoring were 22.96(+1.69SD), 2 1.25(+ 1.42SD)and 23.29(+2.08SD) respectively, with no statistical difference between the three groups with slight elevation of the score in Paroxetine group during the first week. The scores declined gradually from the second week and through all weeks of the study, with no statistical difference between the three groups ex- cept at the end of week12 ,where the mean SAD scoring were dropped to 11.62(&1.23), 12.5(+2.02) and 13.82 (k2.24) in the three groups respectively [f=6.78;df=2;p=0.002]; Scheffe test: at level of 0.05 indicated a significant dif- ference between Moclobemide(G 1) and CBT group (G3).

Global anxiety, as assessed with HAS,in pretreatment the scoring were 20.09((+1.53),21.39((+r1.41) and19.23( (k2.97) in Moclobemid, (Gl), Paroxe- tine(G2) and CBT (G3) respectively; with significant statistical difference (f=5.35; df=2; p=0.007) Scheffe test: at level of 0.05 indicated significant differ- ence between the Paroxetine(G2) and the first and third groups. HAS score in- creased slightly at end of the first week in Paroxetine group in comparison to the (GI 1 and (G3) were the scored started to decline (Fig. 2).

HAS score gradually declined in the three groups as depicted in (figure2) with no statistical difference by the end of the second week between the three groups. Statistical significant difference appeared with the end of the fourth week where the scores reduced to 16.61 (+1.37), 14.13(-e2.21) and 16.24(+3.11) in the three groups respectively [f=8.13; df=2; p=0.007];Scheffe test: indicated difference between Paroxetine (G2) and the other 2 groups. These differences in- creased by the end of the eighth week where the scores were 14.17(+1.33), 10.54(&2.2) and 15.94(&3.09) in the three groups respectively [f=30.96; df=2; p=O.OOO] and finally by the end of the twelvth week, the scores were 10.30 (+1.26), 6.88(+1.73) and 13.65(+2.9), with marked significant statistical differ- ence[f=58.39; df=2; p=O.OOO]; Scheffe test- at level of 0.05 showed significant difference between each group and the other (Table I).

The results of Hopkin checklist (total scores) showed no marked statistical dif- ference in the pretreatment phase [f=2.40; df=2; p=O.O99]. However, by the end of the study, a significant statisti- cal difference was detected [f=9.299; df=2; p=O.O003]; Scheffe test demon- strated statistical difference between CBT group(G3) and the other two groups (Table 1).

Subsequent analysis of the subscores showed no significant statistical differ- ence at pretreatment phase for all sub- scales except anxiety (Table 1). There was, however, a significant statistical difference between groups by the end of the twelfth week for the following sub- scales: somatization, obsessive compul- sive, inter-personal sensitivity, anxiety, depression but not for anger hostility and phobic anxiety (Table 1 and Figure 3).

430 Mohammed Khaled Salah Helmy, et al.

Table (1): ANOVA on different scales for the three tested groups in the pretreatment and posttreatment phase

Pharmacological Treatment Versus

20.

15.

10.

5

0.

SAD Score

43 1

20

15

10

5 .

0 -

HAS score

0 1 2 4 0 12

WEEKS OF TREATMENT

Fig. ( I ) : Mean Social Avoidance and Distress score in patients with social phobia treated with moclobemide (GI), paroxetine (G2) and cognitive behaviour therapy (G3).

0 1 2 4 8 12 WEEKS OF TREATMENT

Fig. (2): Mean Wamliton Anxiety Score in social phobia patients treated with moclobemide (GI), paroxetine (G2) and cognitive behaviour therapy ((33).

G1 G2 G3 pretreatment

G1- G2 G3 posttreatment

Fig. (3): Factor sccres of the 90 items symptom checklist in patients with social phobia treated with moclobemide, paroxetine or cognitive behaviour therapy at pretreatment phase and at the posttreatment phase (the end of week 12). key: SOM, somatization; OCD, obsessions and compulsions; IS, interpersonal sensitivity; DEP, depression: ANX anxiety; PHO phobic anxiety; HOS, hostility.

Mohammed Khaled Salah Helmy, et al. 432

DISCUSSION The present study showed that the

three groups achieved clinically signifi- cant changes. However, there was a con- siderable amount of variability in indi- vidual response in each group, i.e. some patients showed dramatic changes after treatment, while others recorded mini- mal effect if any, on the same treatment.

Although the difference found be- tween groups favoured drug therapy over CBT, the treatment of social phobia in our study was unsatisfactory. The rate of improvement was 47.8%,50% and 23.4% in Moclobemide, Paroxetine and CBT groups respectively.

The high degree of change on most outcome measures suggested some de- gree of improvement but was incomplete to satisfy patients.

The Paroxetine treated group rated themselves as significantly less anxious at the end of the study, compared to the other two groups, inspite of the higher anxiety level of this group before start- ing the treatment and the minimal eleva- tion of anxiety score at the end of the first week after Paroxetine was started which was consistent with some reports that SSRIs may induce anxiety symp- toms, arousal and agitation at the start of the therapy (Gorman et al., 1987). The amelioration of anxiety symptoms in Pa- roxetine group was found to be statisti- cally superior by the end of week four, which was consistent with other re- searches (Dunbar et a1.,1991 and Shee- han et al., 1992). Moclobemide was ef- fective in reducing anxiety from week 8 and statistically superior to CBT group by week 12, but still statistically less than Paroxetine group.

Although a significant reduction of social avoidance was observed in all groups, the reduction was nearly equal in

Moclobemide and Paroxetine groups compared to CBT group. We expected more reduction in avoidance behaviour in Paroxetine group following the marked reduction of global anxiety symptoms. Surprisingly, Moclobemide was equal or even superior to Paroxetine in reduction of avoidance behaviour. We consider social avoidance to be a sequel of anxiety which augmented in social sit- uations, and once anxiety has seased, patients will gradually learn to cope with social situations, but it seemed that Moclobemide reduces social avoidance by another mechanism.

Moclobemide has been studied with success in the treatment of social phobia in open trials (Bisserbe et al., 1994 and Versiani et al., 1996), and found to be highly efficacious in some placebo con- trolled studies (Versiani et al., 1992), and reported to be less robust in other con- trolled studies (International multicenter clinical trial group on Moclobemide 1997 and Noyes et a1.,1997) . Brofaro- mine an another Monoamine oxidaze A , differs from Moclobemide in that it have serotonin reuptake inhibitor properties (Waldmeier et a1.,1993), proved to has d good efficacy in reducing social anxiety and avoidance behaviour around week 8 in two controlled studies (Van Vliet el al., 1992 and Fahlen et al.,l995). The w- periority in the effect of Brofaromine over Moclobemide was suggestive for the efficacy of serotonin reuptake inhibi- tors in the treatment of social phobia, which was not clear in our study.

The efficacy of Fluvoxamine (other SSRI) was confined to reduction of so- cial anxiety around week 12 u i th mini- mal effect on social avoidance (VanVliet et a1.,1994). In more recent study, Flu- voxamine resulted in a significant reduc- tion of psychosocial disability around week 8 (Stein et al., 1999). We expected

433 Pharmacological Treatment Versus

in our study that Paroxetine will be more efficacious treatment for social phobia owing to its serotonin reuptake inhibitor effect which believed to be the major contribution in treatment of social pho- bia (Waldmeier et a1.,1993). The en- hancement of dopaminergic function has been suggested as a factor in the treat- ment of social phobia(Liebowitz et al., 1992), which proved to be superior com- pared to monoamine oxidaze inhibitor A Moclobemide (Versiani et al., 1992).

In our study, the reduction of interper- sonal sensitivity, which is usually aug- mented in patients with social phobia (excessive perception of and /or difficul- ty coping with criticism and rejection from others), was significantly superior in Moclobemide and CBT groups com- pared to Paroxetine group. This can ex- plain the superiority of Moclobemide to reduce social avoidance. We suggest that a reduction of global anxiety symptoms and interpersonal sensitivity can reduce social avoidance which was clear in Mo- clobemide group compared to CBT group where a reduction in interpersonal sensitivity without a clear reduction of global anxiety was unable to reduce the social avoidance significantly. Our re- sults were consistent with(VanV1iet et al., 1992), who concluded that general- ized subtype of social phobia might ben- efit more from MAOIs than the specific subtype.

Moclobemide was superior in reduc- ing somatic symptoms compared to the other two groups which can be explained by its antidepressant effect which is equal to that of Paroxetine , but the latter is associated with a variety of somatic side effects like nausea, gastrointestinal upset and headache.

Paroxetine was superior in reducing obsessive compulsive symptoms, there

was large body of evidence that the SSRIs, as well as MAOIs, were effective in treating of other anxiety disorders like OCD. Paroxetine has been licensed in UK for the symptoms of OCD at a dose of 40-60 mg and it showed to be effec- tive in OCD, including patients resistant to other SSRIs (Bazire, 1997).

Cognitive behaviour therapy group was significantly superior in reducing in- ter personal sensitivity compared to Pa- roxetine group. It seemed that Paroxetine with its good effect on reducing global anxiety symptoms, was unable to moti- vate the patients to change and to do enough effort to expose themselves to social situations during the short period of follow up ( 1 2weeks). CBT has shown, therefore, to be effective in reducing this aspect of interpersonal anxiety.

In our sample, we excluded patients with Hamilton depressive scale above 12 to exclude those patients with major de- pression and to be sure that the results in our study were not secondary to im- provement of depressive disorder. CBT group was less significant in reducing depressive symptoms compared to the other two groups. There are controversy and conflicting claims about the compar- ative efficacy of antidepressant medica- tions versus CBT (De Rubeis et al., 1999). In our study, the treatment in CBT group was tailored to treat social phobia and not depressive symptoms and a decline in depressive symptom, score may be secondary to improvement of social phobia.

Finally, we may suggest that 12 weeks period is a short period for treat- ment of social phobia, which is a chronic disorder and a longer periods needed to gain self confidence, improve self es- teem and reduce social avoidance. We wish to illustrate that all our patients were suffering from the generalized

Mohammed Khalcd ? L ~ i ~ ~ h Helmy, ct al. 434

subtype of social phobia, which is the group mostly disabled with the syn- drome.

We used the full dose of Moclobe- mide prescribed by the manufacturers which is 600 mg per day. Depending on the international multicenter clinical trial group on Moclobemide in social phobia (1997) on 578 patients, response rates of 47, 41 and 34% for Moclobemide 600mg, Moclobemide 300mg and place- bo respectively were recorded. These re- sults were quite similar to our findings with Moclobemide 47.8%.0n the other hand, we used only 30mg Paroxetine de- pending on research published by the manufacturers on depression where little additional benefit was obtained from doses above 20mg per day(Jenner, 1992). However, it is possible that pa- tients with social phobia may have bene- fited from higher doses, but a further in- crease in dose will reduc; the number of patients who complete the study due to increase the frequency of adverse events seen during the first four weeks which was experienced by 58.33% of our pa- tients with a dose 30mg per day especial- ly delayed ejaculation and anorgasmia. This may be also true for Moclobemide, in U.S. multicenter trial(Noyes et al., 1997) where the response rate(much or very much improvement) were highest at week 8 with 900 mg per day, but this difference decreased at week 12 com- pared to four doses of Moclobemide 75, 150,300,600mg per day and placebo.

We car, conclude that both Moclobe- mide and Paroxetine were efficacious in the treatment of generalized social pho- bia. Moclobemide was much better toler- ated than Paroxetine. and the good toler- ability of the formal drug is supported by results from others in social phobia(Ver- siani et al., 1992) and in depression(Ver- siani et aL.1990). Paraxetine was superi-

or in reducing global anxiety and obses- sive compulsive symptoms, while Mo- clobemide was superior in reducing so- matic and interpersonal sensitivity. In each group, a number of patients radical- ly improved while others showed mini- mal change if any, even in CBT group when the response rate was 23.4%. We suggest a combined approach of pharma- cotherapy and CBT to improve the rate of success. This study was limited by its short-term focus, and further research must be done concentrating on the time course of therapeutic gain in the three groups. Combined approaches to the treatment of social phobia should also be examined. The disability ratings with discontinuation for those who have im- proved must be examined. Further re- search must also examine the question of various treatment response in general- ized and specific social phobia subtypes.

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