Cognitive Behavioral Therapy for Social Anxiety Disorder: Predictors of Treatment Outcome in a Quasi-Naturalistic Setting

Effectiveness and predictors of group cognitive behaviour therapy outcome for generalised anxiety disorder in an out-patient hospital setting

BACKGROUND

Cognitive behavioural therapy (CBT) is an empirically supported treatment for generalized anxiety disorder (GAD). Little is known about the effectiveness of CBT for GAD in real-world treatment settings.

AIM

This study investigated the effectiveness of group CBT and predictors of treatment response in an out-patient hospital clinic.

METHOD

Participants (n = 386) with GAD participated in 12 sessions of group CBT at an out-patient clinic. Of those who provided at least partial data (n = 326), 84.5% completed treatment. Most questionnaires were completed at pre- and post-treatment; worry severity was assessed weekly.

RESULTS

Group CBT led to improvements in chronic worry (d = -0.91, n = 118), depressive symptoms (d = -1.22, n = 172), GAD symptom severity (d = -0.65, n = 171), intolerance of uncertainty (IU; d = -0.46, n = 174) and level of functional impairment (d = -0.35, n = 169). Greater pre-treatment GAD symptom severity (d = -0.17, n = 293), chronic worry (d = -0.20, n = 185), functional impairment (d = -0.12, n = 292), and number of comorbid diagnoses (d = -0.13, n = 299) predicted greater improvement in past week worry over treatment. Biological sex, age, depression symptom severity, number of treatment sessions attended, and IU did not predict change in past week worry over time.

DISCUSSION

These findings provide support for the effectiveness of group CBT for GAD and suggest the outcomes are robust and are either not impacted or are slightly positively impacted by several demographic and clinical factors.

Sociodemographic representation in randomized controlled trials for anxiety-related disorders in the U.S.: A systematic review (1993-2023)

Cognitive behavioral therapies have been identified as evidence-based treatments for anxiety-related disorders. However, data supporting the effectiveness of these treatments have been largely collected from participants with majoritized identities, potentially limiting the extent to which they can be considered "evidence-based" for clients from minoritized groups. The current review examined sociodemographic representation and quality of sociodemographic reporting in randomized controlled trials for anxiety-related disorders in the U.S. between 1993 and 2023. We conducted a systematic literature review of U.S.-based randomized controlled trials of cognitive behavioral therapies for anxiety-related disorders, extracted data on sociodemographic variables, and rated quality of reporting. Data from 55 eligible studies (N = 4492) indicated that white and female identities were overrepresented relative to the U.S. population, with variables like disability status, sexual orientation, and religious identification consistently ignored. In addition, quality of reporting was generally poor (mean = 3.6 out of 10), with many studies failing to account for demographic variables in their analyses or description of study limitations. Publication year, sample size, and NIH funding status did not significantly predict gender representation (% women), ethnoracial representation (% white), or quality of reporting. These findings underscore the importance of critically evaluating to whom "evidence-based" treatments apply and increasing diversity of clinical samples, to ensure that evidence-based treatments are inclusive. Recommendations for future research, clinical implications, and limitations are discussed.

Internet-Based Versus Face-to-Face Cognitive-Behavioral Therapy for Social Anxiety Disorder: A Randomized Control Trial

During the COVID-19 epidemic, face-to-face mental health services faced obstacles. Using Internet-based interventions was a good solution and had the potential to overcome these treatment barriers. However, there is no strong research evidence about the effectiveness of these methods for social anxiety disorder in different cultures and developing countries. Therefore, the present study aimed to investigate the effectiveness and application of Internet-based cognitive-behavioral therapy for social anxiety disorder in Iran. The current study was a pretest-posttest follow-up experimental design. Fifty-four adolescents with social anxiety disorder were selected from Lorestan province (Iran) by cluster sampling method and randomly assigned to three groups: face-to-face, internet-based, and wait-list control. At the beginning and end of the study and 3-month follow-up, three groups were interviewed and answered questionnaires related to the primary and secondary symptoms of social anxiety disorder. Two experimental groups were treated with the same therapeutic intervention during 10 weekly sessions. ANCOVA analysis showed that both forms of intervention effectively reduced social phobia, fear of negative evaluation and social interaction anxiety and increased emotion regulation. Also, a significant decrease in secondary outcomes, including physical symptoms, insomnia, social dysfunction, and depression symptoms, was observed in both groups. The treatment effects were stable during a 3-month follow-up. Our findings showed that although Internet-based cognitive-behavioral therapy for adolescents with social anxiety disorder can be effective, several clinical, cultural, and implementation weaknesses should be considered.

The Course of Anxiety-Specific Cognitive Bias Following Daycare/Inpatient Treatment in Youths with Social Phobia and School Absenteeism

Social phobia (SP) is a common mental disorder in youth often accompanied by absence from school, which may require daycare or inpatient intervention (DC/IN). Objective: The present explorative study investigates changes in anxiety-specific implicit assumptions and interpretation bias following DC/IN. Methods: The study included 16 youths with SP (M age = 15.8 [SD = 1.24], females: 62.5 %) participating in DC/IN. We assessed the main outcomes using the Implicit Association Test and Affective Misattribution Procedure. Results: A large effect was shown for reducing implicit assumptions of feeling anxious (p = .142; η2p = .171) and for reducing the implicit interpretation bias (p = .137; η2p = .162). No change was indicated by effect size in implicit assumptions of feeling socially rejected (p = .649; η2p = .016). Social phobia symptoms initially correlated with changes in implicit assumptions of feeling anxious (r = .45). Conclusion: Effect sizes indicate that implicit anxiety-specific assumptions and interpretation bias descriptively improved following DC/IN. Thus, DC/IN may lead to meaningful improvements of anxiety-specific cognition in some individuals with high SP symptoms, emphasizing the relevance of cognitive behavioral approaches in the treatment of SP. Several limitations are discussed.

The Effects of Repeated Attachment Security Priming on Social Anxiety and Attention Bias: A Randomized Controlled Trial

BACKGROUND

Although the clinical utility of attachment security priming has been suggested in recent years, the effect of attachment security priming on social anxiety and its core symptoms (i.e., attention bias) remains unspecified. Therefore, the present study explored the potential effectiveness of repeated attachment security priming in alleviating social anxiety and attention bias among Chinese college students.

METHODS

Fifty-six college students with high social anxiety were randomly assigned to the attachment security priming group (n = 30) or control group (n = 26). The priming group completed seven attachment security priming sessions over 2 weeks (every 2 days), and the control group was assigned to a waitlist for 2 weeks.

RESULTS

The results revealed that individuals in the priming group reported less social anxiety after 2 weeks of security attachment priming, and those in the control group did not change significantly. The results also showed that there was no significant change in the attention bias of individuals with social anxiety before and after the intervention.

CONCLUSIONS

Our findings indicate that attachment security priming is a promising alternative intervention option for social anxiety. The potential clinical implications of security attachment priming are discussed.

Developing Transdiagnostic Internalizing Disorder Prognostic Indices for Outpatient Cognitive Behavioral Therapy

A growing literature is devoted to understanding and predicting heterogeneity in response to cognitive behavioral therapy (CBT), including using supervised machine learning to develop prognostic models that could be used to inform treatment planning. The current study developed CBT prognostic models using data from a broad dimensionally oriented pretreatment assessment (324 predictors) of 1,210 outpatients with internalizing psychopathology. Super learning was implemented to develop prognostic indices for three outcomes assessed at 12-month follow-up: principal diagnosis improvement (attained by 65.8% of patients), principal diagnosis remission (56.8%), and transdiagnostic full remission (14.3%). The models for principal diagnosis remission and transdiagnostic remission performed best (AUROCs = 0.71-0.73). Calibration was modest for all three models. Three-quarters (77.3%) of patients in the top tertile of the predicted probability distribution achieved principal diagnosis remission, compared to 35.0% in the bottom tertile. One-third (35.3%) of patients in the top two deciles of predicted probabilities for transdiagnostic complete remission achieved this outcome, compared to 2.7% in the bottom tertile. Key predictors included principal diagnosis severity, social anxiety diagnosis/severity, hopelessness, temperament, and global impairment. While additional work is needed to improve performance, integration of CBT prognostic models ultimately could lead to more effective and efficient treatment of patients with internalizing psychopathology.

The Integrated Behavior Therapy for Children with Selective Mutism: Findings from an open pilot study in a naturalistic setting

To test the hypothesis that the Integrated Behavior Therapy for Children with Selective Mutism (IBTSM), administered in a naturalistic setting, is (a) a feasible and acceptable treatment, (b) effective in reducing children's selective mutism (SM) and social anxiety (SA) symptoms, and (c) effective in reducing parents' accommodation behaviors to their children's anxiety. This was an open, uncontrolled trial with assessments at baseline, first session, and post-treatment. The study treated 30 children aged 4-13, using the IBTSM protocol. The diagnosis of SM was established by psychologists using a structured interview. The parents reported levels of SM, SA, and parental accommodation on questionnaires, and the level of children's global functioning was rated by clinicians. Feasibility and acceptability of the IBTSM were assessed using dropout rates, protocol adherence, adverse events, and therapist's acceptability ratings. The IBTSM had acceptable dropout rates, with no adverse events and high acceptability rates. Following IBTSM, children's SM and SA levels, and parents' accommodation, significantly decreased. 75% of children were rated by clinicians as treatment responders. IBTSM is a feasible, acceptable, and efficacious treatment for children with SM, utilized in clinical settings. The results of this open trial must be replicated in randomized controlled studies.

When emotions cannot be efficiently used to guide attention: Flexible, goal-relevant utilization of facial emotions is hindered by social anxiety

In order to achieve optimal outcomes in diverse situations, emotional information can be used to initiate novel, goal-directed processes that are not inherently related to the emotional meaning. Demonstrating this goal-dependent flexibility, in a recent study, we presented facial emotions as informative spatial cues: Participants could direct their attention to the probable target location based on the expressed emotion with a remarkable efficiency (Folyi, Rohr, & Wentura, 2020). However, as inherent motivational aspects of threat-related facial expressions can be particularly salient to socially anxious individuals (e.g., Staugaard, 2010), they might not be able to use this information flexibly in the pursuit of a context-specific goal. The present study tested this assumption in an endogenous cueing task with anger and fear expressions as informative central cues. Indeed, in Experiment 1 (N = 174), higher social anxiety was associated with reduced cueing at a 600 ms cue-target asynchrony, and this deficit was specific to social as opposed to general anxiety. Furthermore, this effect occurred only when faces were presented upright (Experiment 1), and not under inverted presentation (Experiment 2, N = 90), ruling out a general deficit in attentional control. The results suggest that flexible utilization of threat-related emotional information is sensitive to participants' social anxiety, suggesting an imbalance between using emotional information in the pursuit of a context-dependent goal on the one hand, and processes intrinsically related to the emotional meaning on the other.

No evidence that gaze anxiety predicts gaze avoidance behavior during face-to-face social interaction

Eye contact is an indispensable social signal, yet for some individuals it is also a source of discomfort they fear and avoid. However, it is still unknown whether gaze anxiety actually produces avoidant gaze behavior in naturalistic, face-to-face interactions. Here, we relied on a novel dual eye-tracking setup that allows us to assess interactive gaze behavior. To investigate the effect of gaze anxiety on gaze behavior, we a priori created groups of participants reporting high or low levels of gaze anxiety. These participants (n = 51) then performed a semi-standardized interaction with a previously unknown individual reporting a medium level of gaze anxiety. The gaze behavior of both groups did not differ in either classical one-way, eye-tracking parameters (e.g. unilateral eye gaze), or interactive, two-way ones (e.g. mutual gaze). Furthermore, the subjective ratings of both participants' interaction did not differ between groups. Gaze anxious individuals seem to exhibit normal gaze behavior which does not hamper the perceived quality of interactions in a naturalistic face-to-face setup. Our findings point to the existence of cognitive distortions in gaze anxious individuals whose exterior behavior might be less affected than feared by their interior anxiety.

Optimized short-forms of the Cognitive Distortions Questionnaire

INTRODUCTION

The Cognitive Distortions Questionnaire (CD-Quest) is a self-report questionnaire that assesses common cognitive distortions. Although the CD-Quest has excellent psychometric properties, its length may limit its use.

METHODS

We attempted to develop short-forms of the CD-Quest using RiskSLIM - a machine learning method to build short-form scales that can be scored by hand. Each short-form was fit to maximize concordance with the total CD-Quest score for a specified number of items based on an objective function, in this case R², by selecting an optimal subset of items and an optimal set of small integer weights. The models were trained in a sample of US undergraduate students (N = 906). We then validated each short-form on five independent samples: two samples of undergraduate students in Brazil (Ns = 182, 183); patients with depression in Brazil (N = 62); patients with social anxiety disorder in the US (N = 198); and psychiatric outpatients in Turkey (N = 269).

RESULTS

A 9-item short-form with integer scoring was created that reproduced the total 15-item CD-Quest score in all validation samples with excellent accuracy (R² = 90.4-93.6%). A 5-item ultra-short-form had good accuracy (R² = 78.2-85.5%).

DISCUSSION

A 9-item short-form and a 5-item ultra-short-form of the CD-Quest both reproduced full CD-Quest scores with excellent to good accuracy. These shorter versions of the full CD-Quest could facilitate measurement of cognitive distortions for users with limited time and resources.

Social Anxiety Disorder: Associated Conditions and Therapeutic Approaches

Social anxiety disorder (SAD) is a highly distressing chronic psychiatric disorder characterized by persistent fear of social situations in anticipation of being judged negatively by others. As shyness mimics some of the symptoms of SAD, people suffering from this debilitating disease are often underdiagnosed. It can have a devastating impact on all areas of life including academic performance, social growth, relationship status, and work performance. In recent years, research on anxiety and related disorders has proliferated due to the increased use of cognitive-behavioral models. The understanding of SAD has evolved greatly from distinguishing it from shyness to implementing modalities to comprehend the sophisticated underlying mechanism of disease prevalence and progression as well as methods to treat it. This review summarizes the concept of SAD, its epidemiology, symptoms, and diagnostic tools. Frequent comorbidities including other psychiatric disorders are also discussed. Additionally, we examine the latest evidence related to treatment options including psychotherapy and pharmacotherapy as well as recommendations for managing SAD.

The Use of Dynamic Cognitive Behavioural Therapy (DCBT) in Social Anxiety Disorder (SAD): A Theoretical Integration Initiative

Psychotherapy theorists can often become fervent advocates of the schools they follow and place the doctrines of the theories they adopt above all else. This situation can sometimes turn into a war of theories between researchers as well. However, therapists should not aim to shape therapy sessions according to their methods but to use them in line with clients' needs. Although it is emphasised that the integration of both psychoanalytic and cognitive behavioural therapy techniques, which is going to be named dynamic cognitive behavioural therapy (DCBT) in this case report, will provide more effective and permanent treatment, a discernible gap exists regarding the integration of these theories and their use in psychotherapy. Taking into account this gap, it is considered important to use this approach with a client who has a social anxiety disorder (SAD). Therefore, this study aims to describe the almost forgotten DCBT approach step by step through a case report and reveal the effectiveness of this approach. As a result, DCBT seems to be effective in the treatment of SAD.

Brief Report: The Influence of Autism Severity and Depression on Self-Determination Among Young Adults with Autism Spectrum Disorder

Self-determination (SD) is linked to autonomy and better adult outcomes. Adults with autism spectrum disorder (ASD) are often less independent than cognitively matched peers. Given the frequency with which depression co-occurs in ASD and the established association between depression and SD, we sought to evaluate the influence of both ASD severity and depression on SD among cognitively able emerging adults with ASD. Emerging adults (n = 59) with ASD completed measures of SD, ASD severity, and depression. Both ASD severity and depression were moderately correlated with SD (r = - 0.473; - 0.423, respectively) and with each other (r = 0.625). After controlling for ASD severity, depression did not significantly predict SD. Strengthening SD should be considered in programming to promote independence.

Correlates of Quality of Life in Anxiety Disorders: Review of Recent Research

PURPOSE OF REVIEW

Anxiety disorders are highly prevalent conditions that have a detrimental impact on quality of life (QOL), particularly when left untreated. In the present review, we summarize recent literature, published within the last 3 years, on QOL in anxiety disorders, with a focus on factors that may play a role in the relationship between anxiety and QOL.

RECENT FINDINGS

We organize our findings into four categories: (1) subjective distress, (2) behavioral responses, (3) functional impairment, and (4) clinical factors. Results indicate that greater anxiety symptom severity is linked with poorer QOL, and cognitive behavioral therapies for anxiety yield positive effects on QOL. Additional transdiagnostic mechanisms are highlighted, including anxiety sensitivity, distress tolerance, emotion regulation, and avoidant coping. We examine the role of functional impairment, and we discuss factors related to treatment, including comorbidity and longitudinal effects. We also consider early research from the COVID-19 pandemic. Understanding the underlying factors that contribute to QOL detriments provides important insight into the impact of anxiety disorders and identifies targets for enhancing QOL through treatment.