Long-Term Improvements in Probability and Cost Biases Following Brief Cognitive Behavioral Therapy for Social Anxiety Disorder

Brief scales for the measurement of target variables and processes of change in cognitive behaviour therapy for major depression, panic disorder and social anxiety disorder

BACKGROUND

The measurement of process variables derived from cognitive behavioural theory can aid treatment development and support the clinician in following treatment progress. Self-report process measures are ideally brief, which reduces the burden on patients and facilitates the implementation of repeated measurements.

AIMS

To develop 13 brief versions (3-6 items) of existing cognitive behavioural process scales for three common mental disorders: major depression, panic disorder, and social anxiety disorder.

METHOD

Using data from a real-world teaching clinic offering internet-delivered cognitive behavior therapy (n=370), we drafted brief process scales and then validated these scales in later cohorts (n=293).

RESULTS

In the validation data, change in the brief process scales significantly mediated change in the corresponding domain outcomes, with standardized coefficient point estimates in the range of -0.53 to -0.21. Correlations with the original process scales were substantial (r=.83-.96), internal consistency was mostly adequate (α=0.65-0.86), and change scores were moderate to large (|d|=0.51-1.18). For depression, the brief Behavioral Activation for Depression Scale-Activation subscale was especially promising. For panic disorder, the brief Agoraphobic Cognitions Questionnaire-Physical Consequences subscale was especially promising. For social anxiety disorder, the Social Cognitions Questionnaire, the Social Probability and Cost Questionnaire, and the Social Behavior Questionnaire-Avoidance and Impression Management subscales were all promising.

CONCLUSIONS

Several brief process scales showed promise as measures of treatment processes in cognitive behaviour therapy. There is a need for replication and further evaluation using experimental designs, in other clinical settings, and preferably in larger samples.

Cognitive Benefits of Sodium-Glucose Co-Transporters-2 Inhibitors in the Diabetic Milieu

Patients with diabetes are at higher risk of cognitive impairment and memory loss than the normal population. Thus, using hypoglycemic agents to improve brain function is important for diabetic patients. Sodium-glucose cotransporters-2 inhibitors (SGLT2i) are a class of therapeutic agents used in the management of diabetes that has some pharmacologic effects enabling them to fight against the onset and progress of memory deficits. Although the exact mediating pathways are not well understood, emerging evidence suggests that SGLT2 inhibition is associated with improved brain function. This study reviewed the possible mechanisms and provided evidence suggesting SGLT2 inhibitors could ameliorate cognitive deficits.

Virtual reality interventions for the treatment of anxiety disorders: A scoping review

BACKGROUND

& Objectives: Virtual Reality (VR) refers to an artificial, immersive three-dimensional environment with interactive sensory stimuli. VR is typically incorporated into the psychotherapeutic process as a means of providing exposure therapy. The objectives of this scoping review were to synthesize the most up-to-date evidence on the outcomes, acceptability, and side effects of VR interventions for treating anxiety disorders in adults.

METHODS

This scoping review is grounded in the methodological framework of Arksey and O'Malley (2005). The databases searched were PubMed, EMBASE, Web of Science, PsycINFO, and ProQuest Dissertations and Theses.

RESULTS

The search process identified 112 unique citations. 52 (46%) of the eligible articles examined participants with specific phobias, 25 (22%) with PTSD, 21 (19%) with social anxiety disorder, 12 (10%) with panic disorder with or without agoraphobia, and 3 (3%) with generalized anxiety disorder. VR interventions often led to statistically significant and meaningful reductions in symptoms for people with anxiety disorders. Additionally, they were acceptable to clients and associated with minimal side effects for all types of anxiety disorders, except for Combat-Related PTSD in Vietnam veterans.

LIMITATIONS

Limitations included the fact that the studies in this review were of varying quality, and that articles in languages other than English and French were excluded.

CONCLUSION

VR interventions appeared to be a viable alternative to conventional exposure therapy. Future research should include more male participants and have a stronger emphasis on acceptability and side effects. Increased traction for VR interventions for generalized anxiety disorder and panic disorder is also important.

Internet-Based Cognitive Behavioral Therapy and Virtual Reality Exposure Therapy for Social Anxiety Disorder: Protocol for a Randomized Controlled Trial in Hong Kong

BACKGROUND

Social anxiety disorder (SAD), also known as social phobia, is one of the most common mental disorders worldwide. In Hong Kong, the prevalence of SAD is high, but its treatment rate is low. SAD has immense impact on academic or work performance, social life, career development, and quality of life. One of the most effective treatments for SAD is cognitive behavioral therapy (CBT), with internet-based CBT (iCBT) and virtual reality exposure therapy (VRET) showing promise in treating SAD. However, internet interventions are underdeveloped in Chinese communities including Hong Kong.

OBJECTIVE

This study aims to develop an iCBT program that includes VRET, called "Ease Anxiety in Social Event Online" (Ease Online), for Hong Kong adults with SAD in a randomized controlled trial.

METHODS

The 14-week Ease Online program is a guided self-help iCBT program with a blended mode of service delivery. The program comprises 9 web-based modules and 5 individual counseling sessions (including 2 VRET sessions) conducted remotely or face-to-face with a therapist to provide therapist support, as guided iCBT shows superior effects than unguided iCBT. Other program components include therapist feedback on assignments, internal messages, forums, client portfolios, web-based questionnaires, reminders, and web-based bookings. The program can be accessed either through a mobile app or program website through a PC with an internet connection. The participants are openly recruited and screened using a questionnaire and through an intake interview. Eligible participants are randomized by placing them into a web-based iCBT group, app-based iCBT group, or a waitlist control (WLC) group. Participants in the WLC group are assigned to the app-based program upon completion of the service of the 2 experimental groups. Measurements of social anxiety, depression and anxiety symptoms, psychological distress, automatic thoughts, and quality of life are administered at pretest, posttest, and 3- and 6-month follow-ups. Multivariate ANOVA with repeated measures will be performed to determine the intervention effectiveness on the continuous variables over time.

RESULTS

Participant recruitment commenced in January 2021. As of February 2023, a total of 1811 individuals applied for the Ease Online program. In total, 401 intake interviews have been completed, and 329 eligible participants have joined the program, among whom 166 have completed the service. Data collection is still ongoing, which is expected to be completed in March 2024.

CONCLUSIONS

This study is the first of its kind in combining iCBT and VRET for the treatment of SAD in Hong Kong. At a theoretical level, this study contributes to the development and evaluation of internet-based psychological interventions in Hong Kong. At a practical level, the Ease Online program may serve as an alternative service option for SAD clients in Hong Kong if proven effective.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04995913; https://clinicaltrials.gov/study/NCT04995913.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48437.

A follow-up study on treatment effects of cognitive-behavioral therapy on social anxiety disorder: Impact of COVID-19 fear during post-lockdown period

There is a paucity of research on the role of COVID-19 related fear and lockdown on social anxiety disorder (SAD). In a follow-up study during post-lockdown period, we compared social anxiety of individuals with SAD who received cognitive-behavioral therapy (CBT) versus psychoeducational-supportive therapy (PST) before the COVID-19 pandemic, and the impact of COVID-19 related fear. Social anxiety severity was rated by the Social Phobia Inventory (SPIN) at pre-intervention, post-intervention, and post-lockdown periods. Fear of COVID-19 was assessed during the post-lockdown period. The treatment effects in the CBT group (n = 33) were significantly better than the PST group (n = 32) at post-intervention; this was maintained at 14-months following intervention despite COVID-related lockdown. In the PST group, there was no change following the intervention; and the social phobia increased after lockdown. The CBT group had significantly less COVID-19 related fear than the PST group. Social anxiety was positively correlated with fear of COVID-19; and individuals with comorbidities had significantly more fear. Using the hierarchical multiple regression, SPIN post-intervention, COVID-19 fear, and duration of SAD predicted social anxiety severity during the post-lockdown period. In conclusion, the effect of CBT for SAD was maintained through lockdown and was associated with significantly less COVID-19 related fear.

Biased probability estimates in trait anxiety and trait depression are unrelated to biased availability

BACKGROUND AND OBJECTIVES

People high in trait anxiety or depression overestimate the probability of negative events, and underestimate the probability of positive events, relative to people low in trait anxiety and depression. Although this probability bias may be fundamental to some emotional disorders, its causes are not well understood. The dominant explanations are based on the availability heuristic: people relatively high in anxiety or depression find it relatively easy to imagine reasons why bad things might happen to them, and this affects their probability estimates. We tested, for the first time, whether individual differences in the availability of such reasons mediate the relationships between trait anxiety or depression and probability bias, in a nonclinical sample.

METHODS

Two hundred and seventy-eight undergraduates generated reasons why a set of positive and negative events might vs. might not happen to them, before rating those events' probability and potential impact on their lives.

RESULTS

Individual differences in the availability of reasons why good and bad events might vs. might not happen did not mediate the sizeable relationships between trait anxiety and probability bias, and between trait depression and probability bias; these relationships remained significant when availability was controlled. Results for the impact of events ('cost bias') were less clear.

LIMITATIONS

Replication with patient groups would be invaluable; different operationalisations of availability may change the results.

CONCLUSIONS

Availability can influence probability estimates, but it does not explain why we see probability bias in people with high trait anxiety or depression.

Homework Compliance and Quality in Cognitive Behavioral Therapies for Anxiety Disorders and Obsessive-Compulsive Disorder

Homework assignments are an integral part of cognitive behavioral therapy, providing patients with opportunities to practice skills between sessions. Generally, greater homework compliance is associated with better treatment outcomes. However, fewer studies have examined the effect of homework quality on treatment outcomes. This study examined homework compliance and quality as predictors of outcome and attrition across five CBT protocols. A sample of 179 individuals with principal diagnoses of generalized anxiety disorder, panic disorder, social anxiety disorder, or obsessive-compulsive disorder were randomized to receive a transdiagnostic CBT protocol (the Unified Protocol) or a single-diagnosis CBT protocol corresponding to their principal diagnosis. The Unified Protocol had a lower homework burden than the majority of the single-diagnosis protocols, which varied in degree of assigned homework. Despite this, there were no differences in average homework compliance or quality across principal diagnosis, treatment condition, or their interaction. Homework quality was significantly related to all symptom outcomes (self-reported and clinician-rated anxiety and depressive symptoms, clinician-rated clinical severity). Homework compliance was significantly related to clinician-rated anxiety symptom outcomes. Additionally, greater homework quality and compliance were both significantly associated with increased odds of completing treatment, suggesting homework variables can be useful and easily obtainable predictors of treatment retention.

Virtual Reality Therapy in Mental Health

Initially designed for the treatment of phobias, the use of virtual reality in phobic disorders has expanded to other mental health disorders such as posttraumatic stress disorder, substance-related disorders, eating disorders, psychosis, and autism spectrum disorder. The goal of this review is to provide an accessible understanding of why this approach is important for future practice, given its potential to provide clinically relevant information associated with the assessment and treatment of people suffering from mental illness. Most of the evidence is available for the use of virtual reality exposure therapy in anxiety disorders and posttraumatic stress disorder. There is hardly any evidence that virtual reality therapy is effective in generalized anxiety disorder and obsessive-compulsive disorder. There is increasing evidence that cue exposure therapy is effective in addiction and eating disorders. Studies into the use of virtual reality therapy in psychosis, autism spectrum disorder, and attention deficit hyperactivity disorder (ADHD) are promising.

Virtual Reality Therapy in Social Anxiety Disorder

PURPOSE OF REVIEW

This review provides an overview of current methods and important aspects to consider when applying virtual worlds in the treatment of social anxiety disorder (SAD).

RECENT FINDINGS

Different aspects such as dialogs between avatars and patients have been investigated as well as virtual audiences, emotional facial expression, and verbal interaction with avatars. Results of these studies are promising. Few randomized controlled trials (RCTs) have investigated the efficacy of virtual reality exposure therapy (VRET) in SAD. Unfortunately, most RCTs into the efficacy of VRET in comparison with exposure in vivo in SAD have been conducted with a combination of cognitive interventions and VRET. No differences between these conditions were found, but the pure effect of VRET as a stand-alone treatment has only been investigated in one RCT, wherein VRET was not superior to exposure in vivo. Current research into different facets of SAD and VRET has produced promising results with respect to technological aspects. No differences in efficacy between cognitive behavior therapy and VRET were found, but there is a clear need for studies investigating the efficacy of VRET as a stand-alone treatment and the therapeutic processes involved before this therapy can be disseminated in routine clinical practice.

Virtual Reality for Anxiety Disorders: Rethinking a Field in Expansion

The principal aim to this chapter is to present the latest ideas in virtual reality (VR), some of which have already been applied to the field of anxiety disorders, and others are still pending to be materialized. More than 20 years ago, VR emerged as an exposure tool in order to provide patients and therapists with more appealing ways of delivering a technique that was undoubtedly effective but also rejected and thus underused. Throughout these years, many improvements were achieved. The first section of the chapter describes those improvements, both considering the research progresses and the applications in the real world. In a second part, our main interest is to expand the discussion of the new applications of VR beyond its already known role as an exposure tool. In particular, VR is enabling the materialization of numerous ideas that were previously confined to a merely philosophical discussion in the field of cognitive sciences. That is, VR has the enormous potential of providing feasible ways to explore nonclassical ways of cognition, such as embodied and situated information processing. Despite the fact that many of these developments are not fully developed, and not specifically designed for anxiety disorders, we want to introduce these new ideas in a context in which VR is experiencing an enormous transformation.

Attentional control and estimation of the probability of positive and negative events

People high in negative affect tend to think negative events are more likely than positive events ("probability bias"). Studies have found that weak attentional control exaggerates another negative affect-related cognitive bias - attentional bias - but it is not clear why this might be. We therefore wanted to know whether weak attentional control would be related to probability bias too. Four studies, with predominantly female student samples (N = 857), revealed correlations of around -.38 between attentional control and probability bias. This remained significant when trait anxiety and depression were controlled; there were no interactions between attentional control and negative affect. Studies 3 and 4 found that attentional control's relationship with probability bias was partly mediated by emotion regulation ability. These results suggest attentional control is important for regulating affect-related cognitive biases, and for emotion regulation in general. Furthermore, because cognitive biases are thought to be important for maintaining emotional disorders, these results are also consistent with weak attentional control being a risk factor for these disorders.