Treatment specific competence predicts outcome in cognitive therapy for social anxiety disorder

Several studies have demonstrated a positive relationship between competence and outcome in CBT for depression but studies of CBT for anxiety disorders are lacking. The present study explores the relationship between competence and outcome in cognitive therapy (CT) for social anxiety disorder, using hierarchical linear modeling analyses (HLM). Data were drawn from a multicenter randomized controlled trial. Five trained raters evaluated videotapes of two therapy sessions per patient using the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP). Overall adherence to the treatment manual and patient difficulty were also assessed. Patient outcome was rated by other assessors using the Clinical Global Impression Improvement Scale (CGI-I) and the Liebowitz Social Anxiety Scale (LSAS). Results indicated that competence significantly predicted patient outcome on the CGI-I (β = .79) and LSAS (β = .59). Patient difficulty and adherence did not further improve prediction. The findings support the view that competence influences outcome and should be a focus of training programs. Further research is needed to compare different ways of assessing competence and to understand the complex relationships between competence and other therapy factors that are likely to influence outcome.     

Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder

Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in several controlled trials, but the mechanisms of change are largely unknown. Therapeutic alliance is a factor that has been studied in many psychotherapy trials, but the role of therapeutic alliance in ICBT is less well known. The present study investigated early alliance ratings in three separate samples. Participants from one sample of depressed individuals (N = 49), one sample of individuals with generalized anxiety disorder (N = 35), and one sample with social anxiety disorder (N = 90) completed the Working Alliance Inventory (WAI) modified for ICBT early in the treatment (weeks 3-4) when they took part in guided ICBT for their conditions. Results showed that alliance ratings were high in all three samples and that the WAI including the subscales of Task, Goal and Bond had high internal consistencies. Overall, correlations between the WAI and residualized change scores on the primary outcome measures were small and not statistically significant. We conclude that even if alliance ratings are in line with face-to-face studies, therapeutic alliance as measured by the WAI is probably less important in ICBT than in regular face-to-face psychotherapy.     

Mediators in psychological treatment of social anxiety disorder: Individual cognitive therapy compared to cognitive behavioral group therapy

According to cognitive-behavioral models of social anxiety disorder (SAD), four of the important maintaining mechanisms are avoidance, self-focused attention, anticipatory processing and post-event cognitive processing. Individual cognitive therapy (ICT) and cognitive behavioral group therapy (CBGT) both have substantial empirical support. However, it is unclear whether they achieve their effects by similar or different mechanisms. The aim of this study was to investigate whether changes in the four maintenance processes mediate clinical improvement in ICT and CBGT for SAD. We analyzed data from participants (N = 94) who received either ICT or CBGT in two separate RCTs. The results showed that ICT had larger effects than CBGT on social anxiety and each of the four potential mediators. More pertinently, moderated mediation analyses revealed significant between-treatment differences. Whereas improvement in ICT was mainly mediated by reductions in avoidance and self-focused attention, improvement in CBGT was mediated by changes in self-focused attention and in anticipatory and post-event processing. These results support the importance of the putative mediators, but suggest that their relative weights are moderated by treatment type.     

Perfectionism: A contributor to social anxiety and its cognitive processes

The present study aimed to examine how perfectionism is contributing to social anxiety and its cognitive processes of post‐event rumination and self‐perception of performance following a speech task. Forty‐eight undergraduate students completed measures of perfectionism and trait social anxiety prior to performing a 3‐min impromptu speech task. Immediately following the speech task, participants rated their state anxiety and self‐perception of performance, and 24 hr later, their level of post‐event rumination was measured. Structural equation modelling revealed that perfectionism, in the form of socially prescribed perfectionism and doubts about actions, directly influences trait social anxiety, and indirectly influences post‐event rumination and self‐perception of performance through its relationship with trait social anxiety and state anxiety. This is the first study to investigate how perfectionism is contributing to social anxiety and its cognitive processes. The findings of this study provide evidence in support of the potential predictive role of perfectionism in social anxiety.     

A follow-up study of cognitive bias in generalized anxiety disorder

Patients with generalized anxiety disorder (GAD) without concurrent depression (n = 11) and normal controls (n = 17) were tested twice, about 2 months apart, on a modified Stroop colour-naming task, which presented anxiety-related, depression-related and neutral words in masked and unmasked exposure conditions. GAD patients received cognitive behaviour therapy in the test-retest interval, and were also retested at follow-up, about 20 months after initial testing. GAD patients showed interference in colour-naming negative words across both masked and unmasked conditions before treatment, but not post-treatment, compared with controls. Reduced interference effects of masked threat words over time correlated with reduced ratings of anxious thoughts at post-treatment, and at follow-up, in GAD patients. Thus, the preconscious bias for threat information in GAD appears to vary over time in association with changes in anxious thoughts and worries.     

Habituation of cognitive and physiological arousal and social anxiety

This study examined differences in habituation between high and low socially anxious Ss. Participants gave three impromptu speeches, each separated by a brief rest interval. Skin conductance and heart rate were monitored during the speeches. Following each speech participants completed self-ratings of nervousness, heart rate, and palmar sweat activity as well as a modified Social Interaction Self Statement Test. Low anxious controls showed significant reduction of negative expectations and self-reported nervousness, heart rate, and sweat activity across the three trials. Actual heart rate of low-anxious subjects also decreased significantly across trials. In contrast, high anxious subjects did not evidence significant decreases in any of the above measures of anxiety and stress across the three trials. Skin conductance measures increased across trials for both groups, but increased more for the high anxious group than low-anxious controls. Results indicate that high anxiety participants are slow to decrease cognitive and autonomic responsiveness to stressful social situations.     

Social anxiety and cognitive expectancy of aversive outcome in avoidance conditioning

Fear conditioning studies have shown that social anxiety is associated with enhanced expectancy of aversive outcome. However, the relation between cognitive expectancy and social anxiety has never been tested in avoidance conditioning paradigms. We compared 48 low (LSA) and high socially anxious individuals (HSA) on subjective expectancy of aversive outcome during an avoidance conditioning task. Displays of neutral faces were coupled with an aversive outcome (US): a shout and a shock. Participants could avoid the US by pressing a correct button from a button box. First, HSA showed higher US expectancy than LSA during the initial phase of avoidance conditioning, supporting the view that socially anxious individuals have an expectancy bias when social situations are ambiguous. Second, when the avoidance response became unavailable, LSA showed lower US expectancy than HSA, suggesting that low socially anxious individuals are prone to a positive bias when perceived threat is high. A lack of such positive bias in socially anxious individuals may lead to higher susceptibility to safety behavior interpretations. Together, these findings support the role of cognitive processes in avoidance conditioning and underscore the relevance to encounter avoidance learning when studying social anxiety.     

Predictors of outcome in Internet-based cognitive behavior therapy for severe health anxiety

Internet-based cognitive behavior therapy (CBT) for severe health anxiety can be effective, but not all patients achieve full remission. Under these circumstances, knowledge about predictors is essential for the clinician in order to make reliable treatment recommendations. The primary aim of this study was to investigate clinical, demographic, and therapy process-related predictors of Internet-based CBT for severe health anxiety. We performed three types of analyses on data from a sample comprising participants (N = 81) who had received Internet-based CBT in a randomized controlled trial. Outcomes were a) end state health anxiety, b) improvement in health anxiety (continuous change scores), and c) clinically significant improvement. Outcomes were assessed at six-month follow-up. The results showed that the most stable predictors of both end state health anxiety and improvement were baseline health anxiety and depressive symptoms. Treatment adherence, i.e. the number of completed treatment modules, also significantly predicted outcome. Notably, health anxiety at baseline was positively associated with symptom improvement while depressive symptoms was negatively related to improvement. Demographic factors were largely without significant impact on end state symptoms or improvement. We conclude that baseline symptom burden and adherence to treatment have strong predictive effects in Internet-based CBT for severe health anxiety.     

Self-focused attention and safety behaviors across group therapies for social anxiety disorder

Background: Self-focused attention (SFA) and safety behaviors are two variables implicated in the maintenance of social anxiety disorder (SAD).

Design: The present study examined SFA and safety behaviors across two therapies for SAD, cognitive behavioral group therapy (CBGT) and mindfulness and acceptance-based group therapy (MAGT).

Method: Participants with symptoms meeting criteria for SAD (N?=?137) were randomly assigned to the 12-week-treatment groups (n?=?53 for each condition) or a waitlist control (n?=?31). Variables were assessed at baseline, midtreatment, posttreatment, and a 3-month follow-up.

Results: Both treatment conditions reported significantly lower SFA and safety behaviors compared to control, but did not differ from one another at posttreatment. Mediation analyses supported the following models: (1) safety behaviors mediating the relationship between SFA and social anxiety, and (2) SFA mediating the relationship between safety behaviors and social anxiety. These models were supported for both treatment groups.

Conclusions: Both treatments may have the potential to reduce the SFA and safety behaviors that serve to maintain SAD.     

Generalised anxiety: A controlled treatment study

The effects of anxiety management training were evaluated by allocating 66 generally anxious clients to either a wait list condition, non-directive counselling, or a combination of relaxation and brief cognitive therapy. Anxiety management was significantly more effective than the wait list condition on a number of relevant measures at post-treatment, but there were relatively few differencs between anxiety management and non-directive counselling, either at post-treatment or at 6 months follow-up. Those differences which were found could plausibly be explained in terms of the demand characteristics of training in relaxation or cognitive therapy. It was concluded that anxiety management is clearly better than a non-treatment control condition, but that its superiority to plausible alternatives which lack the specific components thought to be responsible for improvement has yet to be demonstrated.     

A comparative study of rodent social behavior in a seminatural enclosure

Social behavior, aggression, and copulation were studied in six groups of two males and two females each in seven species of muroid rodents (Clethrionomys gapperi, Microtus montanus, M ochrogaster, M pennsylvanicus, Peromyscus eremicus, P leucopus, and P polionotus) in a seminatural enclosure. Data were compared to those from an earlier study with P maniculatus tested under identical conditions. There were appreciable species differences in levels of both aggressive and sexual behavior; the two were not significantly correlated. Although levels of aggression did not appear well correlated with reports of social structure in the field, patterns of weight loss and litter production during the study did appear correlated. In general, levels of copulatory behavior appeared weakly correlated with factors previously proposed as predictors of polygamous mating systems; levels of aggressive behavior were better correlated with taxonomy.     

Sleep quality and treatment of social anxiety disorder

Background and Objectives: Poor sleep is prevalent among individuals with social anxiety disorder (SAD) and may affect treatment outcome. We examined whether: (1) individuals with SAD differed from healthy controls (HCs) in sleep quality, (2) baseline sleep quality moderated the effects of treatment (Cognitive–behavioral group therapy [CBGT] vs. mindfulness-based stress reduction [MBSR] vs. waitlist [WL]) on social anxiety, (3) sleep quality changed over treatment, and (4) changes in sleep quality predicted anxiety 12-months post-treatment.

Design: Participants were 108 adults with SAD from a randomized controlled trial of CBGT vs. MBSR vs. WL and 38 HCs.

Methods: SAD and sleep quality were assessed pre-treatment and post-treatment; SAD was assessed again 12-months post-treatment.

Results: Participants with SAD reported poorer sleep quality than HCs. The effect of treatment condition on post-treatment social anxiety did not differ as a function of baseline sleep quality. Sleep quality improved in MBSR, significantly more than WL, but not CBGT. Sleep quality change from pre- to post-treatment in CBGT or MBSR did not predict later social anxiety.

Conclusions: MBSR, and not CBGT, improved sleep quality among participants. Other results were inconsistent with prior research; possible explanations, limitations, and implications for future research are discussed. ClinicalTrials.gov identifier: NCT02036658.     

Intensive cognitive behavioural group treatment for social phobia: a pilot study

The aim of this pilot study was to examine the effectiveness of an intensive form of cognitive behavioural group treatment practised routinely in a psychiatric clinic. A total of 27 outpatients with social phobia of long duration were assigned to a 41-hour treatment administered over 2 periods of 3.5 and 4.5 days, 1 week apart. Four groups, each comprising 6-8 patients, participated in the study. All except 1 patient (26/27) completed the treatment and 20 patients participated in all follow-up sessions after 3, 6 and 12 months. Treatment significantly reduced fear and avoidance of social interaction and performance, anticipatory anxiety and symptoms' influence on daily life. Follow-up assessments indicated maintained or increased improvement from post-test to 1 year and large sensitivity to treatment at both post-test and 1 year. Of the patients in the study, 85% were taking a prescribed drug, and 70% had taken medication for at least 1 year before they entered the treatment. At 1-year follow-up 52% had discontinued medication.     

Changes in EEG cross-frequency coupling during cognitive behavioral therapy for social anxiety disorder

Coupling between EEG delta and beta oscillations is enhanced among anxious and healthy individuals during anticipatory anxiety. EEG coupling patterns associated with psychotherapy have not yet been quantified in socially anxious individuals. In this study, we used a double baseline, repeated measures design, in which 25 adults with a principal diagnosis of social anxiety disorder completed 12 weekly sessions of standardized group cognitive behavioral therapy and four EEG assessments: two at pretreatment, one at midtreatment, and one at posttreatment. Treatment was associated with reductions in symptom severity across multiple measures and informants, as well as reductions in delta-beta coupling at rest and during speech anticipation. Moreover, the clinical group exhibited greater coupling at pretreatment than did post hoc control participants with low social anxiety. The EEG cross-frequency profiles in the clinical group normalized by the posttreatment assessment. These findings provide evidence of concomitant improvement in neural and behavioral functioning among socially anxious adults undergoing psychotherapy.