Who Gets Better and Why? Predicting the Development of a Working Alliance and its Subsequent Role in Pharmacotherapy for Social Anxiety Disorder

Abstract

Social anxiety disorder (SAD) is highly prevalent and associated with high levels of impairment and distress. Therapies for SAD leave many patients symptomatic at the end of treatment, and little is known about predictors of treatment response or the mechanisms by which these variables exert their influence on treatment outcome. This study investigated whether levels of depression, social anxiety, submissive behavior, childhood maltreatment, and suppression of anger predicted response to pharmacotherapy for SAD and whether the working alliance mediated these relationships. One hundred thirty-eight treatment-seeking individuals with a primary diagnosis of SAD received 12 weeks of open treatment with the selective serotonin reuptake inhibitor paroxetine. Higher levels of depression predicted higher levels of social anxiety symptoms at the end of treatment and higher levels of submissive behavior and childhood emotional maltreatment predicted a higher probability of attrition from treatment. The working alliance mediated response to pharmacotherapy for individuals who self-reported a history of emotional maltreatment. These results identify variables that predict pharmacotherapy treatment outcome and emphasize the importance of the psychiatrist-assessed working alliance as a mechanism of treatment response for those with a history of emotional maltreatment. Implications for person-specific treatment selection are discussed.