Imagery-enhanced cognitive behavioural group therapy for social anxiety disorder: A pilot study

Experiences of imagery-based treatment for anxiety in bipolar disorder: A qualitative study embedded within the image based emotion regulation feasibility randomised controlled trial

OBJECTIVES

Intrusive mental imagery is associated with anxiety in bipolar disorder (BD) and presents a novel treatment target. Imagery-based treatments show promise in targeting anxiety and improving mood instability. This qualitative study explored experiences of receiving up to 12 sessions of a brief structured psychological intervention: Image-Based Emotion Regulation (IBER), which targets maladaptive mental imagery in the context of BD with an aim to modify the emotional impact of these images.

DESIGN

A qualitative study embedded within the Image Based Emotion Regulation (IBER) feasibility randomised controlled trial.

METHODS

Semi-structured interviews were conducted with 12 participants in the treatment arm of the trial who received IBER + treatment as usual. Data were analysed using thematic analysis.

RESULTS

Despite some initial scepticism about imagery-focused treatment, all participants expressed broadly positive accounts of treatment experiences. High levels of engagement with imagery modification techniques, beneficial use of techniques post treatment and improvements in anxiety management and agency were described by some. Three sub-groups were identified: those who reported a powerful transformative impact of treatment; those who embedded some new techniques into their daily lives, and those who felt they had techniques to use when needed. No participants reported overall negative experiences of the IBER treatment.

CONCLUSIONS

Findings from this study highlight the value for treatment recipients of modifying the underlying meanings associated with maladaptive imagery, and the personalised skills development to manage anxiety within bipolar disorders. Findings can inform treatment refinements and further trial-based evaluations.

Self-guided imagery rescripting for worry images: A preliminary experimental investigation

BACKGROUND

Mental images of feared events are overactive and intrusive in generalized anxiety disorder (GAD). Imagery rescripting involves integration of positive or neutral imagery and corrective information into images to facilitate emotional processing, reduce imagery intrusions, and re-structure underlying schema. Yet only one known study has applied the technique to treatment of worry. The present study aimed first to examine the relationship between trait worry and properties of future-oriented worry images, and second to examine the efficacy of a self-guided imagery rescripting intervention in improving individuals' response to their worries.

METHODS

Participants recruited through Amazon Mechanical Turk (N = 365) identified their major worry and wrote the script of a worst-case scenario mental image. Participants were randomized to three conditions: re-writing the same worry image script (exposure), or writing scripts of either one or three positive alternative future-oriented images (rescripting conditions).

RESULTS

In preliminary analyses, trait worry negatively predicted participants' ratings of worry images, including valence and ability to cope, and positively predicted distress, anticipated cost, and belief in their negative meaning. In experimental analyses, linear mixed-effects models revealed anxious response and cognitive appraisal of the threat were significantly lower among participants allocated to rescripting relative to exposure. There was no effect of rescripting type.

CONCLUSIONS

This investigation demonstrated the impact of a future-oriented imagery rescripting task on anxiety and cognitive biases associated with real worries in an unselected sample. Results may contribute to the development of imagery rescripting interventions for GAD.

Neurocognitive Model of Schema-Congruent and -Incongruent Learning in Clinical Disorders: Application to Social Anxiety and Beyond

Negative schemas lie at the core of many common and debilitating mental disorders. Thus, intervention scientists and clinicians have long recognized the importance of designing effective interventions that target schema change. Here, we suggest that the optimal development and administration of such interventions can benefit from a framework outlining how schema change occurs in the brain. Guided by basic neuroscientific findings, we provide a memory-based neurocognitive framework for conceptualizing how schemas emerge and change over time and how they can be modified during psychological treatment of clinical disorders. We highlight the critical roles of the hippocampus, ventromedial prefrontal cortex, amygdala, and posterior neocortex in directing schema-congruent and -incongruent learning (SCIL) in the interactive neural network that comprises the autobiographical memory system. We then use this framework, which we call the SCIL model, to derive new insights about the optimal design features of clinical interventions that aim to strengthen or weaken schema-based knowledge through the core processes of episodic mental simulation and prediction error. Finally, we examine clinical applications of the SCIL model to schema-change interventions in psychotherapy and provide cognitive-behavior therapy for social anxiety disorder as an illustrative example.

Internet videoconferencing delivered cognitive behavioral therapy for social anxiety disoder: Protocol for a randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) is characterized by a fear of scrutiny in social or performance situations. Due to a number of barriers, many individuals do not seek treatment for SAD, resulting in a chronic and debilitating course. Cognitive behaviour therapy (CBT), and more recently Imagery Rescripting (ImR), have been found to be efficacious in the treatment of SAD when delivered face-to-face. However, the efficacy of these treatment approaches when delivered remotely, have not yet been examined in controlled trials.

METHODS

The authors propose a two-group randomized controlled trial comparing the efficacy of videoconferencing delivered CBT (vCBT) for SAD against a waitlist control group. The study will recruit 78 adults in total with a primary diagnosis of SAD of at least moderate severity. The manualised high-intensity vCBT intervention will be delivered weekly over an 8-week period. After treatment completion, the waitlist participants will receive a high-intensity videoconferencing delivered ImR (vImR) intervention also delivered weekly over an 8-week period. Treatment for both groups will be delivered in real time via an online videoconferencing platform. Outcome measures will be administered at baseline, mid-treatment, post-treatment, and 3-month follow-up.

CONCLUSION

This trial will report findings on the efficacy of a remote synchronous high-intensity vCBT and vImR intervention for SAD and benchmark the two different treatment methodologies against standard face-to-face CBT. The results have the potential to inform best-practice remote psychological treatment for SAD.

TRIAL REGISTRATION

The trial was registered on the Australian New Zealand Clinical Trials Registry; ACTRN12623000313639 (5 April 2023).

What explains the failure to identify replicable moderators of symptom change in social anxiety disorder?

Trials of cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) have struggled to identify replicable moderators of treatment outcome. This could be due to a genuine lack of effects, or a spurious finding caused by methodological factors such as inadequate testing of theory-driven moderators, use of small homogenous samples, failure to model non-linear relationships, and over-reliance on significance testing. We probed explanations for the field's failure to detect moderators by testing whether 15 theory-driven and atheoretical variables moderated treatment outcome in a large heterogeneous sample treated with group CBT for SAD. Moderation was not assessed by only using p-values for linear models, but also by considering effect sizes, plots, and non-linear relationships. Despite using a comprehensive approach to assess moderation, only two variables - the baseline severity of SAD symptoms and fear of negative evaluation (FNE) - were found to moderate social anxiety symptom trajectories. FNE had a non-linear relationship with symptom change that would have been missed using common research methods. Our findings suggest both a genuine lack of effects and limitations of research methods have contributed to the field's inability to identify moderators. We provide suggestions that may increase the likelihood of future researchers detecting genuine effects.

Developing a Psychological Intervention for Decreasing Bedtime Procrastination: The BED-PRO Study

INTRODUCTION

Bedtime Procrastination (BP) is defined as the behavior of going to bed later than intended, without having external reasons for doing so. Previous studies have shown that BP has a negative effect on sleep and health, emphasizing the need to develop interventions to decrease BP. This intervention development study is a proof-of-concept study for a psychological intervention designed for decreasing bedtime procrastination, namely BED-PRO.

MATERIAL AND METHOD

The intervention was developed based on behavioral modification principles and motivational interviewing techniques. The final intervention was a weekly three-session intervention, with one additional booster call. Twenty individuals with high BP participated in the study, and data was collected for pre- and post-intervention, and one-month follow-up. Individuals completed the Bedtime Procrastination Scale, Epworth Sleepiness Scale, Fatigue Severity Scale, Morningness-Eveningness Questionnaire, Insomnia Severity Index, and a sleep diary.

RESULT

Significant changes were found for BPS scores, bedtime procrastination duration (Δ51 mins, 63.8% reduction compared to baseline), wake after sleep onset, sleep efficiency and feeling refreshed upon awakening measured by sleep diaries following the intervention. In addition, changes in BPS, ISI, and ESS scores, wake after sleep onset, sleep efficiency and feeling refreshed upon awakening were maintained or continued to improve at 1-month follow-up.

CONCLUSION

This study verified the feasibility and acceptability of the BED-PRO intervention and the potential for being the first intervention to target bedtime procrastination. Considering the research about negative implications of BP, we expect that this intervention could be a step forward in considering BP as a serious health behavior.

An Investigation of Cognitive and Affective Changes During Group Imagery Rescripting for Social Anxiety Disorder

Recurrent, negative self-imagery is common in social anxiety disorder (SAD). Imagery rescripting (ImRs) is an effective therapeutic technique that aims to target past aversive memories to modify their associated meanings, and update the encapsulated negative schematic beliefs. The current study aimed to extend previous research by investigating the cognitive and affective shifts during each phase of ImRs delivered within a group cognitive behavioral therapy protocol. Participants (N = 32) retrieved an aversive memory associated with social anxiety and were guided through brief cognitive restructuring, prior to completing ImRs. Core beliefs associated with the memory (strength and valence) and fear of negative evaluation were assessed before and after ImRs and affect was assessed following each phase. Strength and affective valence of encapsulated core beliefs about the self, others, the world, and the image itself significantly reduced following ImRs, and core beliefs were updated to become more positive. Participants reported large affective shifts early in the process, with smaller shifts in the later stages. Fear of negative evaluation did not significantly reduce following ImRs. Outcomes provide some support for cognitive and affective changes during group ImRs for SAD and suggest future research directions to investigate longer-term impacts and to better understand the underlying mechanisms of the technique.

Imagery-enhanced v. verbally-based group cognitive behavior therapy for social anxiety disorder: a randomized clinical trial

BACKGROUND

Cognitive behavior therapy (CBT) is effective for most patients with a social anxiety disorder (SAD) but a substantial proportion fails to remit. Experimental and clinical research suggests that enhancing CBT using imagery-based techniques could improve outcomes. It was hypothesized that imagery-enhanced CBT (IE-CBT) would be superior to verbally-based CBT (VB-CBT) on pre-registered outcomes.

METHODS

A randomized controlled trial of IE-CBT v. VB-CBT for social anxiety was completed in a community mental health clinic setting. Participants were randomized to IE (n = 53) or VB (n = 54) CBT, with 1-month (primary end point) and 6-month follow-up assessments. Participants completed 12, 2-hour, weekly sessions of IE-CBT or VB-CBT plus 1-month follow-up.

RESULTS

Intention to treat analyses showed very large within-treatment effect sizes on the social interaction anxiety at all time points (ds = 2.09-2.62), with no between-treatment differences on this outcome or clinician-rated severity [1-month OR = 1.45 (0.45, 4.62), p = 0.53; 6-month OR = 1.31 (0.42, 4.08), p = 0.65], SAD remission (1-month: IE = 61.04%, VB = 55.09%, p = 0.59); 6-month: IE = 58.73%, VB = 61.89%, p = 0.77), or secondary outcomes. Three adverse events were noted (substance abuse, n = 1 in IE-CBT; temporary increase in suicide risk, n = 1 in each condition, with one being withdrawn at 1-month follow-up).

CONCLUSIONS

Group IE-CBT and VB-CBT were safe and there were no significant differences in outcomes. Both treatments were associated with very large within-group effect sizes and the majority of patients remitted following treatment.

Imagery rescripting and negative self-imagery in social anxiety disorder: a systematic literature review

BACKGROUND

Imagery rescripting (IR) is an effective intervention for social anxiety disorder (SAD) that targets memories of distressing formative events linked to negative self-imagery (NSI). IR is thought to update unhelpful schema by addressing the needs of the younger self within the memory. An accumulating body of evidence indicates that by modifying NSI, IR can significantly affect distressing imagery, memory appraisal, and beliefs about the self.

AIMS

This systematic review aims to critically evaluate and synthesise literature investigating the existing research on the effects IR has on NSI in SAD.

METHOD

A systematic electronic search of Academic Search Complete, ProQuest, Medline, Scopus and PubMed was performed in February 2021 using pre-defined criteria. Ten studies met the inclusion criteria and were selected for review.

RESULTS

Analysis of the reviewed articles' findings identified three main themes: Changes to negative self-images, Memories linked to images and Encapsulated beliefs. IR was associated with significant decreases in image distress, image vividness, memory vividness, memory distress, and encapsulated beliefs. Although reductions were found with image frequency, they were non-significant. Interpretation of results is limited by the small number of studies.

CONCLUSIONS

IR appears to effectively alter images, memories and beliefs in SAD in as little as a single session. The findings indicate that IR could be utilised as a cost-effective intervention for SAD. However, additional studies and longer-term follow-ups are needed.

The efficacy of incorporating mental imagery in cognitive restructuring techniques on reducing hostility: A randomized controlled trial

BACKGROUND AND OBJECTIVES

Cognitive restructuring (CR) is an effective intervention for hostility. However, the number of patients who fail to benefit suggest that the efficacy of CR can be further improved. The present study investigated whether enhancing CR with mental imagery techniques can increase its efficacy.

METHODS

A high hostility sample (28% male, and 72% female) was randomized over one session of imagery enhanced CR (I-CR) (n = 34), traditional CR (n = 32) or an active control session (AC) (n = 21). Changes in hostile beliefs, aggressive tendencies, state anger and hostility traits were assessed pre- and post-treatment, and at one-week follow-up.

RESULTS

Results showed that both I-CR and CR efficaciously reduced hostile beliefs, aggressive tendencies and anger, to a stronger degree than AC. I-CR was more efficacious and sustainable over time than both CR and AC in reducing hostile beliefs and aggressive tendencies.

LIMITATIONS

This study was conducted using a small, non-treatment seeking sample.

CONCLUSIONS

Findings suggest that implementing imagery techniques in CR for hostile beliefs enhances its' efficacy.

Self-image and self-focused attention in a social interaction situation: what is relevant for social anxiety?

BACKGROUND

According to Clark and Wells' cognitive model (Clark and Wells, 1995), social anxiety is maintained by both a negative self-image and self-focused attention (SFA). Although these maintaining factors were investigated extensively in previous studies, the direction of this relationship remains unclear, and so far, few studies have investigated self-image and SFA together within a current social interaction situation.

AIMS

The aim of this experiment is to investigate the influence of a negative versus positive self-image on social anxiety and on SFA during a social interaction.

METHOD

High (n = 27) and low (n = 36) socially anxious participants, holding a manipulated negative versus positive self-image in mind, had a real-time video conversation with a confederate. Social anxiety, SFA and state anxiety before and during the conversation were measured with questionnaires.

RESULTS

An interaction between negative self-image and social anxiety showed that high socially anxious individuals with a negative self-image in mind were more anxious than those with a positive self-image in mind during the conversation. They were also more anxious compared with low socially anxious individuals. Furthermore, high socially anxious individuals reported higher SFA; however, SFA was not affected by negative or positive self-image.

CONCLUSION

The present results confirm once again the strong influence of self-image and SFA on social anxiety, highlighting that a negative self-image has more impact on socially anxious individuals. Moreover, the present results suggest that SFA is not necessarily affected by a negative self-image, indicating that therapies should focus on both.

Imagery Rescripting Versus Cognitive Restructuring for Social Anxiety: Treatment Effects and Working Mechanisms

Background

Negative mental images in social anxiety are often linked to memories of distressing social experiences. Imagery Rescripting (ImRs) has been found to be a promising intervention to target aversive memories, but mechanisms underlying ImRs are largely unknown. The present study aimed (a) to investigate the effects of ImRs compared to cognitive restructuring (CR) on social anxiety symptoms and (b) to extend previous research by examining whether ImRs works by fostering reappraisal of negative emotional self-beliefs.

Method

Highly socially anxious individuals (N = 77) were randomly allocated to ImRs, CR, or no intervention control (NIC). A speech task was performed at baseline and at 1-week follow-up.

Results

Only CR significantly reduced social anxiety symptoms from baseline to follow-up. Decreases in negative appraisals and emotional distress in response to the speech task did not differ between conditions. Regarding working mechanisms, ImRs led to stronger increases in positive emotions than CR and NIC. Both CR and ImRs yielded short-term reductions in emotionally anchored idiosyncratic self-beliefs, but CR was superior to ImRs at follow-up.

Conclusions

The present study provides evidence for the efficacy of a single-session of CR for social anxiety symptoms. As one specific version of ImRs was applied, it is conceivable that other or optimized versions of ImRs might be more effective.

Mental Imagery in the Science and Practice of Cognitive Behaviour Therapy: Past, Present, and Future Perspectives

Mental imagery has a long history in the science and practice of cognitive behaviour therapy (CBT), stemming from both behavioural and cognitive traditions. The past decade or so has seen a marked increase in both scientific and clinical interest in mental imagery, from basic questions about the processes underpinning mental imagery and its roles in everyday healthy functioning, to clinical questions about how dysfunctions in mental imagery can cause distress and impairment, and how mental imagery can be used within CBT to effect therapeutic change. This article reflects on the current state of mental imagery in the science and practice of CBT, in the context of past developments and with a view to future challenges and opportunities. An ongoing interplay between the various strands of imagery research and the many clinical innovations in this area is recommended in order to realise the full therapeutic potential of mental imagery in CBT.

Can words be worse than stones? Understanding distressing social events and their relationship with social anxiety

Research on the relationship between distressing social events and social anxiety has focused on antagonistic social events (i.e., peer victimization, cyberbullying) in adolescent samples. There is little research examining such relationships in adults, and less examining the relationship between non-antagonistic distressing social events (i.e., accidental embarrassing events) and social anxiety. The current investigation utilized a retrospective design to examine how different distressing social events may be associated with posttraumatic stress-like reactions, which may relate to social anxiety in early adulthood. Characteristics of distressing social events (i.e., betrayal, presence of an antagonist) were explored as possible influences on the severity of stress responses. Community participants (n = 271; ages 18-25) completed online questionnaires measuring social anxiety and reactions to distressing social events. Antagonistic and non-antagonistic distressing social events were both related to social anxiety. Relationships between the frequencies of any distressing social events and social anxiety were mediated by reactions akin to posttraumatic stress. Responses to distressing social events were not influenced by the presence of an antagonist or betrayal. The results suggest that non-antagonistic distressing social events can be as distressing as antagonistic distressing social events and contribute to expanding evidence that reactions to distressing social events may resemble reactions to life-threatening events.

Imagery Rescripting for Anxiety Disorders and Obsessive-Compulsive Disorder: Recent Advances and Future Directions

PURPOSE OF REVIEW

This review describes imagery rescripting (ImRs) and its clinical application to anxiety disorders and obsessive-compulsive disorder (OCD). Variations in ImRs delivery, clinical evidence, and theories of potential mechanisms of change are also reviewed. Finally, we propose a future research agenda.

RECENT FINDINGS

There is some evidence that ImRs affects memory processes and schemas. ImRs is associated with reductions in cognitive-affective, physiological and behavioural symptoms of social anxiety disorder and reductions in OCD-related distress and OCD symptoms. ImRs for other anxiety disorders has not been evaluated. While ImRs appears to be an effective intervention for social anxiety disorder and OCD, more research is needed to (a) systematically compare ImRs to established interventions, (b) evaluate ImRs for other anxiety disorders, (c) test theorized mechanisms of change, and (d) evaluate the impact of moderating factors and treatment variations on therapeutic outcomes.

Effectiveness of cognitive behavioural group therapy for social anxiety disorder: long-term benefits and aftercare

BACKGROUND

Empirical research demonstrates the short- to medium-term efficacy and effectiveness of cognitive behavioural group therapy (CBGT) for social anxiety disorder (SAD). Little is known about the durability of gains beyond 1 year following treatment in real-life clinical settings. Literature regarding the impact of aftercare programs as an adjunct to CBGT treatment on SAD is scarce.

AIMS

To evaluate the long-term effectiveness of CBGT for SAD in a community sample and to explore the relationship between long-term treatment outcomes and aftercare support group attendance.

METHOD

A longitudinal cohort design evaluated changes in standardized psychological measures assessing aspects of SAD, anxiety and depression. Questionnaires were completed before the program (time 1, N = 457), after the program (time 2, n = 369) and at an average of 4.6 years follow-up (time 3, n = 138).

RESULTS

Large treatment effect sizes at post-intervention were maintained at long-term follow-up on measures of SAD, anxiety and depression. There was no statistically significant relationship between frequency of attendance at an aftercare support group and degree of improvement from post-treatment severity on any measure.

CONCLUSIONS

CBGT is an effective intervention in the long-term in a routine clinical setting and should be considered a viable treatment option for SAD. Recommendations for future research, treatment implications and study limitations are considered.

Attenuated Psychophysiological Reactivity following Single-Session Group Imagery Rescripting versus Verbal Restructuring in Social Anxiety Disorder: Results from a Randomized Controlled Trial

BACKGROUND

The effectiveness of psychotherapies for social anxiety disorder (SAD) is typically evaluated using self- and clinician-reported symptom change, while biomarkers of treatment response are rarely measured. The current study aimed to compare biomarkers of response following two brief group interventions for SAD.

METHODS

This randomized controlled trial evaluated the effectiveness of single-session group interventions for SAD (n = 58) - imagery rescripting (IR) and verbal restructuring (VR) versus waitlist control (WC). The IR intervention guided participants to rescript autobiographical memories through visualization whilst the VR intervention focused on thought challenging. Trial outcomes included change in psychophysiological reactivity (heart rate variability (HRV) and electrodermal responding) to social stress, and symptom-based measures (social interaction anxiety, negative self-portrayal, cognitive avoidance, repetitive negative thinking, memory modification, anxious behaviors).

RESULTS

Psychophysiological reactivity was selectively attenuated following IR treatment, compared to VR and WC groups. The specific influence of the imagery-based intervention in modulating autonomic reactivity was evident across HRV parameters, including the standard deviation of intervals between heartbeats (IR vs. WC, d = 0.67, p = 0.021; IR vs. VR, d = 0.58, p = 0.041), and high frequency power - an indicator of parasympathetically mediated emotion regulation (IR vs. WC, d = 0.75, p = 0.034; IR vs. VR, d = 0.95, p = 0.006). Few group differences were observed across self-report measures.

CONCLUSION

The current study highlights the specificity of brief imagery-based interventions in influencing psychophysiological reactivity in SAD and establishes the sensitivity of objective markers of treatment response in quantifying change over symptom-based measurements.

Out of my league: Appraisals of anxiety and confidence in others by individuals with and without social anxiety disorder

Forty participants with social anxiety disorder (SAD) and 42 healthy controls (HCs) were randomized to watch a confederate deliver a speech in either a visibly anxious or confident manner. Participants rated their perception of the presenter's desirability across five attributes and compared themselves to the presenter along these same dimensions. Participants then delivered their own speeches, and were rated in a similar manner by trained research assistants who were naïve to participants' group status and study objectives. Results demonstrated that all participants, irrespective of group status, judged the visibly anxious presenter as being less desirable and the confident presenter as more desirable. Socially anxious participants tended to view themselves as inferior to confident others. Coders also rated participants with SAD, based on their speeches, as being less interpersonally desirable than HCs. These results suggest that individuals who appear visibly anxious may be objectively disadvantaged in their ability to make a positive first impression on others. We discuss these findings in relation to theoretical models of social anxiety and explore how to address such interpersonal factors in psychological interventions for SAD.

Changes in perceived centrality of anxious events following cognitive behavioral therapy for social anxiety disorder and panic disorder

BACKGROUND AND OBJECTIVE

The purpose of the present study was to explore the association between reductions in symptoms of psychopathology and perceived centrality of negative autobiographical memories in participants with social anxiety disorder (SAD) or panic disorder (PD).

METHODS

Thirty-nine individuals with SAD or PD recalled and rated four negative autobiographical memories before and after ten sessions of cognitive behavioral therapy (CBT) over a three-month period. Twenty-eight healthy controls did the same before and after a three-month period.

RESULTS

As hypothesized, results showed a decrease in perceived centrality following CBT. This decrease in perceived centrality was larger, although at the trend level, for individuals who experienced reliable change on disorder-specific symptoms.

LIMITATIONS

The correlational nature of the study prevents establishing the causal relationship between changes in perceived centrality and psychopathology, and future studies should explore such mechanisms.

CONCLUSIONS

The present study adds to the emerging body of literature, investigating changes in centrality of event following psychotherapy.

Transportability of imagery-enhanced CBT for social anxiety disorder

Pilot and open trials suggest that imagery-enhanced group cognitive behaviour therapy (CBT) is highly effective for social anxiety disorder (SAD). However, before being considered reliable and generalisable, the effects of the intervention need to be replicated by clinicians in a setting that is independent of the protocol developers. The current study compared outcomes from clients with a principal diagnosis of SAD at the Australian clinic where the protocol was developed (n = 123) to those from an independent Canadian clinic (n = 46) to investigate whether the large effects would generalise. Trainee clinicians from the independent clinic ran the groups using the treatment protocol without any input from its developers. The treatment involved 12 2-h group sessions plus a one-month follow-up. Treatment retention was comparable across both clinics (74% vs. 78%, ≥9/12 sessions) and the between-site effect size was very small and non-significant on the primary outcome (social interaction anxiety, d = 0.09, p = .752). Within-group effect sizes were very large in both settings (ds = 2.05 vs. 2.19), and a substantial minority (41%-44%) achieved clinically significant improvement at follow-up. Replication of treatment effects within an independent clinic and with trainee clinicians increases confidence that outcomes are generalisable.

Combined Audience and Video Feedback With Cognitive Review Improves State Anxiety and Self-Perceptions During Speech Tasks in Socially Anxious Individuals

This study investigated the effects of combined audience feedback with video feedback plus cognitive preparation, and cognitive review (enabling deeper processing of feedback) on state anxiety and self-perceptions including perception of performance and perceived probability of negative evaluation in socially anxious individuals during a speech performance. One hundred and forty socially anxious students were randomly assigned to four conditions: Cognitive Preparation + Video Feedback + Audience Feedback + Cognitive Review (CP+VF+AF+CR), Cognitive Preparation + Video Feedback + Cognitive Review (CP+VF+CR), Cognitive Preparation + Video Feedback only (CP+VF), and Control. They were asked to deliver two impromptu speeches that were evaluated by confederates. Participants' levels of anxiety and self-perceptions pertaining to the speech task were assessed before and after feedback, and after the second speech. Compared to participants in the other conditions, participants in the CP+VF+AF+CR condition reported a significant decrease in their state anxiety and perceived probability of negative evaluation scores, and a significant increase in their positive perception of speech performance from before to after the feedback. These effects generalized to the second speech. Our results suggest that adding audience feedback to video feedback plus cognitive preparation and cognitive review may improve the effects of existing video feedback procedures in reducing anxiety symptoms and distorted self-representations in socially anxious individuals.

Association between Social Anxiety and Visual Mental Imagery of Neutral Scenes: The Moderating Role of Effortful Control

According to cognitive theories, verbal processing attenuates emotional processing, whereas visual imagery enhances emotional processing and contributes to the maintenance of social anxiety. Individuals with social anxiety report negative mental images in social situations. However, the general ability of visual mental imagery of neutral scenes in individuals with social anxiety is still unclear. The present study investigated the general ability of non-emotional mental imagery (vividness, preferences for imagery vs. verbal processing, and object or spatial imagery) and the moderating role of effortful control in attenuating social anxiety. The participants (N = 231) completed five questionnaires. The results showed that social anxiety was not necessarily associated with all aspects of mental imagery. As suggested by theories, social anxiety was not associated with a preference for verbal processing. However, social anxiety was positively correlated with the visual imagery scale, especially the object imagery scale, which concerns the ability to construct pictorial images of individual objects. Further, it was negatively correlated with the spatial imagery scale, which concerns the ability to process information about spatial relations between objects. Although object imagery and spatial imagery positively and negatively predicted the degree of social anxiety, respectively, these effects were attenuated when socially anxious individuals had high effortful control. Specifically, in individuals with high effortful control, both object and spatial imagery were not associated with social anxiety. Socially anxious individuals might prefer to construct pictorial images of individual objects in natural scenes through object imagery. However, even in individuals who exhibit these features of mental imagery, effortful control could inhibit the increase in social anxiety.

Emotional cascade theory and non-suicidal self-injury: the importance of imagery and positive affect

Grounded in Emotional Cascade Theory, we explored whether rumination and multisensory imagery-based cognitions moderated the relationships between affect and both odds of non-suicidal self-injury (NSSI), and frequency of the behaviour. A sample of 393 university students completed self-report questionnaires assessing the constructs of interest. Contrary to expectations, rumination did not emerge as a significant moderator of the affect-NSSI relationship. However, the relationship between affect and frequency of NSSI was moderated by the use of imagery. Further, the relationship between negative affect and NSSI was moderated by positive affect, underscoring the need to consider both negative and positive affect in models of NSSI. Most youth who self-injured reported thinking in images while the urge to self-injure was strong, with 53% thinking in images at least half the time. Future work is needed to explore how positive and negative affect work in concert to govern NSSI, and how imagery might either exacerbate or reduce risk of NSSI.

Cognitive behavioural therapy attenuates the enhanced early facial stimuli processing in social anxiety disorders: an ERP investigation

Background

Previous studies of patients with social anxiety have demonstrated abnormal early processing of facial stimuli in social contexts. In other words, patients with social anxiety disorder (SAD) tend to exhibit enhanced early facial processing when compared to healthy controls. Few studies have examined the temporal electrophysiological event-related potential (ERP)-indexed profiles when an individual with SAD compares faces to objects in SAD. Systematic comparisons of ERPs to facial/object stimuli before and after therapy are also lacking. We used a passive visual detection paradigm with upright and inverted faces/objects, which are known to elicit early P1 and N170 components, to study abnormal early face processing and subsequent improvements in this measure in patients with SAD.

Methods

Seventeen patients with SAD and 17 matched control participants performed a passive visual detection paradigm task while undergoing EEG. The healthy controls were compared to patients with SAD pre-therapy to test the hypothesis that patients with SAD have early hypervigilance to facial cues. We compared patients with SAD before and after therapy to test the hypothesis that the early hypervigilance to facial cues in patients with SAD can be alleviated.

Results

Compared to healthy control (HC) participants, patients with SAD had more robust P1–N170 slope but no amplitude effects in response to both upright and inverted faces and objects. Interestingly, we found that patients with SAD had reduced P1 responses to all objects and faces after therapy, but had selectively reduced N170 responses to faces, and especially inverted faces. Interestingly, the slope from P1 to N170 in patients with SAD was flatter post-therapy than pre-therapy. Furthermore, the amplitude of N170 evoked by the facial stimuli was correlated with scores on the interaction anxiousness scale (IAS) after therapy.

Conclusions

Our results did not provide electrophysiological support for the early hypervigilance hypothesis in SAD to faces, but confirm that cognitive-behavioural therapy can reduce the early visual processing of faces. These findings have potentially important therapeutic implications in the assessment and treatment of social anxiety.

Trial registration HEBDQ2014021

Transdiagnostic versus diagnosis specific cognitive behavioural therapies for anxiety: A meta-analysis

Research evaluating transdiagnostic CBT (tCBT) demonstrates its efficacy. Some evidence suggests equivalence between tCBT and diagnosis-specific CBT (dxCBT), however more investigations are necessary to clarify any difference in efficacy. This meta-analysis was conducted to compare tCBT and dxCBT, and to investigate the differential impact of comorbidity on effect sizes. Pre and post scores from primary anxiety measures in 83 treatment conditions, taken from studies primarily targeting anxiety disorders, were summarised and compared. Meta-regression analyses were then used to test the effects of comorbidity. DxCBT and tCBT meta-effects were found to be large, where g=0.951, 95% CI: 0.874-1.027, and g=1.059, 95% CI: 0.876-1.242, respectively. While statistically different (p=0.008), overlap of confidence intervals indicated a lack of clinical significance. Furthermore, no relationship between comorbidity rate and tCBT outcome was observed. These results were discussed in the context of previous findings in the transdiagnostic CBT literature.

The search for universal transdiagnostic and trans-therapy change processes: Evidence for intolerance of uncertainty

The search for universal processes associated with symptom change across emotional disorders and different forms of psychotherapy offers hope of increased theoretical parsimony and treatment efficiencies. This study investigated whether intolerance of uncertainty (IU) is a universal process by examining whether changes in IU were associated with changes in symptoms across three different cognitive behavior therapy protocols for depression (n=106), social anxiety disorder (n=88), or generalized anxiety disorder (n=62) in a community mental health clinic. IU was associated with reductions in repetitive negative thinking in all treatments, which is consistent with IU being a transdiagnostic and 'trans-therapy' process of change. Changes in IU were also associated with symptom relief in the social anxiety disorder and generalized anxiety disorder groups, but not in the depression group. Implications of these findings are discussed within the broader literature of transdiagnostic approaches to emotional disorders.

Early memories in social anxiety: A meaningful and enduring collaboration with my Dad

In this short paper in honour of my father's Festschrift, I describe a recent collaboration with him in which we joined forces to investigate the nature of autobiographical images and memories in social anxiety. I outline our work together and the unique insights that were gleaned from our interactive contributions. Then, I reflect on how this collaboration has helped to lay the foundation for subsequent work in my lab and illuminate new directions in my program of research, enhance my career as a scientist-practitioner, and ultimately, enrich both my personal and professional identities. In so doing, I aim to highlight one of the most important and enduring aspects of my father's legacy: the profound positive impact he has on the people with whom he has worked.

The impact of imagery rescripting on memory appraisals and core beliefs in social anxiety disorder

Negative mental images in social anxiety disorder (SAD) are often rooted in autobiographical memories of formative, distressing life events. In the present study, 25 participants with SAD retrieved an idiosyncratic negative mental image and associated autobiographical memory. Participants were then randomly assigned either to a single-session of imagery rescripting (IR) targeting the retrieved autobiographical memory or to a non-intervention control condition (no-IR). Outcomes were assessed one week later. Compared to control participants, those who received IR experienced substantial reduction in SAD symptoms accompanied by more positive and less negative appraisals of their autobiographical memories. Moreover, IR relative to no-IR participants reported marked shifts in the content, validity, and accuracy of their memory-derived negative core beliefs about self and others, but not about the world. Results support the promise of IR as a stand-alone intervention for SAD and suggest important directions for future research to enhance our understanding of the cognitive mechanisms that underlie its effects.