Group schematherapy versus group cognitive behavioral therapy for social anxiety disorder with comorbid avoidant personality disorder

Beginning with the DSM-III (APA, 1987) and continuing in DSM-IV (APA, 1994),
individuals whose fears are manifest in most social situations are assigned to
the generalized subtype of social anxiety disorder, while individuals whose
fears are more circumscribed are grouped together as a separate category,
currently referred to as non-generalized social anxiety disorder. Since the
introduction of the generalized subtype, there is a controversy about the
differences with avoidant personality disorder (Bogels et al, 2010). While some
researchers emphasize that avoidant personality disorder is a serious form of
generalized social anxiety disorder (Holt, Heimberg, & Hope, 1992; Craske,
1999, p. 213), a growing number of studies indicate that there is a qualitative
difference between the two disorders with shortcomings in establishing
interpersonal relationships and severe feelings of inferiority as cardinal
features of the avoidant personality disorder (Bogels, et al, 2010; Carter &
Wu, 2010; Huppert, Strunk, Ledley, Davidson, & Foa, 2008; Reich, 2009). In the
DSM 5, the distinction between social phobia and avoidant personality disorder
will probably be made more explicit. In addition to limitations in (inter-)
personal functioning, two pathological personality traits have to be present to
diagnose avoidance personality disorder. The first is *detachment*,
operationalized by social withdrawal, intimacy avoidance and anhedonia. The
second is negative affectivity, characterized by anxiousness and worry in
relation to social situations (APA, 2012).
Avoidant personality disorder is associated with high societal costs because of
frequent use of somatic and mental health care, a high risk for developing
other mental disorders, and suboptimal professional functioning. Furthermore,
patients report a low quality of life and the diagnosis of a avoidant
personality disorder is often a considerable burden for the family (Kessler,
2003).
In clinical practice, there is no consensus about which treatment is indicated
for patients with diagnoses of both social phobia and avoidant personality
disorder. The multidisciplinary guidelines recommend offering prolonged
Cognitive Behavioral Therapy in case of social phobia with comorbid avoidant
personality (Trimbos Institute, 2008).
A small number of effect studies has shown that CBT and pharmacological
interventions are effective for patients with social phobia and comorbid
avoidant personality disorder. (Borge et al, 2010; Powers, Sigmarsson, &
Emmelkamp, 2008). A study of Brown, Heimberg and Juster (1995) showed APD was
not predictive of CBT treatment outcome, but several subjects who received a
diagnosis of APD before treatment no longer met criteria for APD after
treatment. Furthermore, CBT offered in a group is approximately as effective as
individual offered CBT (Hope, Heimberg, & Turk, 2006).
Furthermore, there is growing evidence that schema therapy (ST) is an effective
treatment for patients with an avoidant personality disorder (Bamelis, Evers, &
Arntz, 2012; Bamelis, Evers, Spinhoven & Arntz, 2012). Research has shown that
avoidant personality disorder is associated with emotional neglect and abuse in
the past (Johnson, Cohen, Chen, Kasen, & Brook, 2006; Lobbestael, Arntz, &
Bernstein, 2010). Within ST techniques are applied, such as imagery rescripting
that explicitly addresses these underlying problems. A new development is group
ST (GST) where specific methods and techniques are applied to use the group
process in order to facilitate the process of change (Farrell & Shaw, 2012).
The main aim of the current project is to investigate the efficacy of GST
compared to group CBT (GCBT).

To increase evidence treatment for social anxiety disorder with comorbid
avoidant personality disorder

A randomized controlled trial (RCT) with 5 repeated measurements. Effect
measurements take place at baseline (M0), mid treatment (M1), immediately after
completion (M2), six months (M3) and one year after completion of therapy (M4).
The total duration of the study for individual subjects is 2 years.

Patients who meet the inclusion criteria will be assigned to 1 of the 2
following interventions: group CBT or group ST. CBT is a complaint-oriented
approach in which exposure and cognitive techniques are central. Although
schema therapy also uses cognitive - and behavioral techniques, an important
difference in schema therapy is that experiential techniques are offered, which
can modify underlying schemas and modes (plan `s and coping processes that at
one time active in a person). Attention is also paid to how these schemas and
modes are created on the basis of past experience. Behavioral techniques will
be used to attempt to decrease avoidance behavior of patients with social
anxiety disorder and comorbid avoidant personality disorder. The rationale of
these behavioral techniques will be to increase autonomy related to individuel
needs, in stead of fear reduction.The CBT treatment will mainly focus on
exposure, as an effective method for social phobia that is also applicable to
the wide spectrum of avoidance behavior of patients with co-morbid avoidant
personality disorder. Attention will also be paid to changing negative
cognitions, but there will be no use of experiential techniques, nor will there
be attention to schema's, modes, childhood experiences, or will the group
process be handled in the way that is done in GST (such as the ability to gain
corrective emotional experience). Both GCBT and GST will be offered 30 times
weekly and last 90 minutes. Both groups will be offered semi-open to promote an
in / outflow. New patients will participate every 2 months. Each group will
participate up to 10 patients, but because of dropout, we expect an average of
7 to 8 participants.

There are no risks associated with the present study. The only inconvenience
for participating subjects could be that they have to participate in 5
assessments during the study which will take approximately 2 hours the first
time (screening) and 1 hour the following 4 times. Moreover, patients will be
asked if they can be approached to participate in the abovementioned
sub-studies 3 and 4. For study 3 participants will be invited for two sessions
on two days. The first session is at the Leiden University Medical Center. The
second session is at the Faculty of Social Sciences (FSW). Each session lasts
approximately 3.5 hours. Study 4 will take place at the participating
departments of anxiety disorders and will take approximately 1 hour.
Furthermore, patients have to be willing to adhere to the inclusion criteria
during the active treatment phase. In case of serious adverse events deviation
of the protocol is allowed. Except for therapeutic effects there will be no
direct advantages associated with participation. In general the study will lead
to more knowledge of effective treatments for social anxiety disorder and
comorbid avoidant personality disorder.