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Wojtaszek JA, Koch EI, Arble E, Loverich TM. Cognitive behavioral group therapy for social anxiety disorder - A critical review of methodological designs. J Anxiety Disord 2024; 107:102928. [PMID: 39303446 DOI: 10.1016/j.janxdis.2024.102928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 08/16/2024] [Accepted: 09/11/2024] [Indexed: 09/22/2024]
Abstract
Social anxiety disorder (SAD) is highly prevalent with significant lifetime impacts, especially when left untreated. Cognitive behavioral therapy is the current gold standard treatment with successful patient outcomes. Cognitive behavioral group therapy (CBGT) is one form that provides unique benefits to participants including normalization of symptoms and social support, as well as providing increased access to treatment at a lower per-session cost. Research on this mode of treatment has been ongoing for over 20 years, but we still have much to learn about its overall efficacy. The goals of this critical review were to summarize and evaluate the most current research, including an analysis of the overall methodological design quality, and provide recommendations for the enhancement of future studies based on best practices. Recent studies included some best practice design elements used in measuring efficacy such as the use of comparison groups, masking procedures, fidelity assessments, and consideration of clinical significance in outcomes. However, many gaps exist such as a lack of consensus around measures and therapy manuals, as well as baseline competencies of facilitators. Future studies should consider incorporating additional best practice elements aligning with study goals to strengthen designs and provide the field with even more confidence in this mode of treatment.
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Affiliation(s)
| | - Ellen I Koch
- Department of Psychology, Eastern Michigan University, USA
| | - Eamonn Arble
- Department of Psychology, Eastern Michigan University, USA
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Cohen ZD, Barnes-Horowitz NM, Forbes CN, Craske MG. Measuring the active elements of cognitive-behavioral therapies. Behav Res Ther 2023; 167:104364. [PMID: 37429044 DOI: 10.1016/j.brat.2023.104364] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 06/09/2023] [Accepted: 07/02/2023] [Indexed: 07/12/2023]
Abstract
Understanding how and for whom cognitive-behavioral therapies work is central to the development and improvement of mental health interventions. Suboptimal quantification of the active elements of cognitive-behavioral therapies has hampered progress in elucidating mechanisms of change. To advance process research on cognitive-behavioral therapies, we describe a theoretical measurement framework that focuses on the delivery, receipt, and application of the active elements of these interventions. We then provide recommendations for measuring the active elements of cognitive-behavioral therapies aligned with this framework. Finally, to support measurement harmonization and improve study comparability, we propose the development of a publicly available repository of assessment tools: the Active Elements of Cognitive-Behavioral Therapies Measurement Kit.
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Affiliation(s)
- Zachary D Cohen
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, United States.
| | | | - Courtney N Forbes
- Department of Psychology, University of California, Los Angeles, United States
| | - Michelle G Craske
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, United States; Department of Psychology, University of California, Los Angeles, United States
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Laposa JM, Katz DE, Lisi DM, Hawley LL, Quigley L, Rector NA. Longitudinal changes in intolerance of uncertainty and worry severity during CBT for generalized anxiety disorder. J Anxiety Disord 2022; 91:102623. [PMID: 35994883 DOI: 10.1016/j.janxdis.2022.102623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 06/17/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
Abstract
Intolerance of uncertainty (IU) is a key construct in generalized anxiety disorder (GAD), but little is known about the concurrent and temporal patterns of associations between IU and GAD symptom severity during treatment. In addition, most of the extant literature focuses on IU as a unidimensional construct, whereas some researchers conceptualize IU as being comprised of two dimensions, inhibitory and prospective IU. Ninety individuals with GAD completed measures of IU and worry severity at pre-treatment, session 4, session 8, and end of treatment (session 12), during group-based cognitive behavior therapy (CBT) for GAD. Longitudinal multilevel modeling showed that IU predicted worry severity concurrently, but not prospectively over time; this pattern of associations was found with the total IUS score and the inhibitory (but not prospective) subscale score. Further, the relationship between IU total scores and worry severity became stronger over time. The relationship between inhibitory (but not prospective) IU and worry also became stronger over time. When the order of the variables in the model was reversed, worry severity also predicted concurrent but not future IU. Therefore, change in IU is associated with change in worry throughout the course of CBT, particularly as treatment progresses, though its directional association as a cause and/or effect remains unclear.
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Affiliation(s)
- Judith M Laposa
- Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, 100 Stokes St., Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario, Canada.
| | - Danielle E Katz
- Forest Hill Centre for Cognitive Behavioural Therapy, 439 Spadina Road, Toronto, Ontario, Canada
| | - Diana M Lisi
- Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, Canada
| | - Lance L Hawley
- Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, Canada
| | - Leanne Quigley
- Ferkauf Graduate School of Psychology, 1165 Morris Park Ave, The Bronx, NY, United States
| | - Neil A Rector
- Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, Canada
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Hawley LL, Rector NA, Segal ZV. The Relative Impact of Cognitive and Behavioral Skill Comprehension and Use During CBT for Obsessive Compulsive Disorder. COGNITIVE THERAPY AND RESEARCH 2021. [DOI: 10.1007/s10608-020-10117-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Change Processes in Cognitive Therapy for Social Anxiety Disorder Delivered in Routine Clinical Practice. CLINICAL PSYCHOLOGY IN EUROPE 2020; 2. [PMID: 34870201 PMCID: PMC7612064 DOI: 10.32872/cpe.v2i2.2947] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Most studies examining processes of change in psychological therapy for social anxiety disorder (SAD) have analysed data from randomised controlled trials in research settings. Method To assess whether these findings are representative of routine clinical practice, we analysed audit data from two samples of patients who received Cognitive Therapy for SAD (total N = 271). Three process variables (self-focused attention, negative social cognitions, and depressed mood) were examined using multilevel structural equation models. Results Significant indirect effects were observed for all three variables in both samples, with negative social cognitions showing the strongest percent mediation effect. ‘Reversed’ relationships, where social anxiety predicted subsequent process variable scores, were also supported. Conclusion The findings suggest the processes of change in this treatment may be similar between research trials and routine care. The three process variables examined showed significant indirect effects on subsequent social anxiety. There was evidence of a bidirectional relationship between process and outcome. Results are consistent with the theoretical model underpinning the treatment. The change processes of this treatment in routine practice may be similar to those found in research trials.
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Peters L, Romano M, Byrow Y, Gregory B, McLellan LF, Brockveld K, Baillie A, Gaston J, Rapee RM. Motivational interviewing prior to cognitive behavioural treatment for social anxiety disorder: A randomised controlled trial. J Affect Disord 2019; 256:70-78. [PMID: 31158718 DOI: 10.1016/j.jad.2019.05.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/28/2019] [Accepted: 05/24/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND We examined whether providing three sessions of treatment based on motivational interviewing (MI) prior to Cognitive Behavioral Therapy (CBT) for Social Anxiety Disorder (SAD) improved outcomes. METHODS Participants diagnosed with SAD (N = 186) were randomly allocated to receive three sessions of MI (MI+CBT; n = 85) or supportive counselling (SC+CBT; n = 101) prior to a 12-week group CBT program. Assessments occurred at baseline, after preparatory treatment, after CBT, and at 6-months follow-up. Outcomes were expectations for change, number of CBT sessions attended, self- and clinician-rated CBT homework completion, and self- and clinician-rated social anxiety severity. RESULTS Conditions did not differ significantly on expectations for change, number of CBT sessions attended, or clinician-rated homework completion. Self-rated homework completion was greater in MI+CBT than in SC+CBT. Change over time in social anxiety severity did not differ between conditions overall, however, this outcome was significantly moderated by two variables; those in MI+CBT, as compared to SC+CBT, showed significantly poorer outcomes on self-reported social anxiety severity if they were higher in change readiness and significantly better outcomes on clinician-rated social anxiety severity if they were higher in functional impairment. LIMITATIONS Although therapists in MI sessions were rated as behaving more consistently with MI than therapists in SC sessions, some MI consistent behaviors occurred in the SC sessions. CONCLUSIONS Addition of a MI-based discussion prior to evidence-based CBT appears to benefit people with SAD who have high functional impairment but may interfere with outcomes for those higher in readiness for change.
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Affiliation(s)
- Lorna Peters
- Centre for Emotional Health, Department of Psychology, Macquarie University, NSW 2109, Australia.
| | - Mia Romano
- Centre for Emotional Health, Department of Psychology, Macquarie University, NSW 2109, Australia
| | - Yulisha Byrow
- Centre for Emotional Health, Department of Psychology, Macquarie University, NSW 2109, Australia
| | - Bree Gregory
- Centre for Emotional Health, Department of Psychology, Macquarie University, NSW 2109, Australia
| | - Lauren F McLellan
- Centre for Emotional Health, Department of Psychology, Macquarie University, NSW 2109, Australia
| | - Keila Brockveld
- Centre for Emotional Health, Department of Psychology, Macquarie University, NSW 2109, Australia
| | - Andrew Baillie
- Centre for Emotional Health, Department of Psychology, Macquarie University, NSW 2109, Australia
| | - Jonathan Gaston
- Centre for Emotional Health, Department of Psychology, Macquarie University, NSW 2109, Australia
| | - Ronald M Rapee
- Centre for Emotional Health, Department of Psychology, Macquarie University, NSW 2109, Australia
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Ay DS, Kühne F, Weck F. The assessment of cognitive-behavioral therapy skills in patients diagnosed with health anxiety: Development and pilot study on an observer-based rating scale. Clin Psychol Psychother 2019; 26:639-649. [PMID: 31218759 DOI: 10.1002/cpp.2387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 11/07/2022]
Abstract
Cognitive-behavioral therapy is a highly effective treatment of health anxiety, but it remains unclear through which mechanisms treatment effects prevail. Some evidence suggests that patients acquire skills-understood as techniques helping them reach therapy goals-through psychotherapy. In the current study, an observer-based rating scale for the skills assessment of patients with health anxiety (SAPH) was developed and validated in a pilot study. Based on 177 videotapes, four independent raters evaluated the frequency of skills acquired during cognitive and exposure therapy among 66 patients diagnosed with health anxiety with the SAPH. Predictive validity was evaluated by the Yale-Brown Obsessive-Compulsive Scale for Hypochondriasis. The SAPH demonstrated good interrater reliability (ICC(1,2) = .88, p < .001, 95% CI [.81, .92]) and internal consistency (α = .94). Although patient skills did not significantly increase during three sessions, they significantly predicted a reduction in health anxiety symptoms at the end of treatment (R2 = .35). Patients' skills are highly important within the treatment of health anxiety. By providing external ratings of patients' skills with good psychometric properties, our pilot data suggest that the SAPH may complement current tools for the assessment of skills, specifically in targeting health anxiety.
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Affiliation(s)
- Destina Sevde Ay
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Potsdam, Germany
| | - Franziska Kühne
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Potsdam, Germany
| | - Florian Weck
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Potsdam, Germany
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Zainal NH, Newman MG. Relation between cognitive and behavioral strategies and future change in common mental health problems across 18 years. JOURNAL OF ABNORMAL PSYCHOLOGY 2019; 128:295-304. [PMID: 31045412 PMCID: PMC6707366 DOI: 10.1037/abn0000428] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Major depressive disorder (MDD), generalized anxiety disorder (GAD), and panic disorder (PD), constitute common mental disorders that may have chronic and disabling courses. Cognitive and behavioral theories posit that lack of engagement in certain strategies (goal persistence, self-mastery, positive reappraisal) increases vulnerability toward these disorders. Further, scar effect theories assert that experiencing more of these disorders may diminish engagement in such strategies within individuals across time. However, dynamic longitudinal associations between cognitive-behavioral strategies (CBS) and disorder counts across adulthood are not well understood. Using bivariate latent difference score models, this study aimed to test the dynamic trajectories between disorder counts and each CBS across 18 years. Participants were 3,294 community-dwelling adults ages 45.62 years (SD = 11.41, range = 20-74; 54.61% female) who took part in 3 waves of measurement spaced 9 years apart. Self-mastery, disorder counts, and their change were not significantly related. However, higher within-subject increase in goal persistence (but not self-mastery or positive reappraisal) led to greater future decline in disorder counts, but not vice versa. Last, within individuals, greater prior levels of goal persistence and positive reappraisal predicted larger subsequent reduction in disorder counts, and vice versa. The reciprocal, bidirectional associations between specific CBS (goal persistence, positive reappraisal) and disorder counts support both vulnerability and scar models of depression and anxiety. Treatments for MDD, GAD, and PD should attempt to enhance perseverance and optimism. Theoretical and clinical implications are further discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Felsman P, Seifert CM, Himle JA. The use of improvisational theater training to reduce social anxiety in adolescents. ARTS IN PSYCHOTHERAPY 2019. [DOI: 10.1016/j.aip.2018.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Olivares-Olivares PJ, Ortiz-González PF, Olivares J. Role of social skills training in adolescents with social anxiety disorder. Int J Clin Health Psychol 2018; 19:41-48. [PMID: 30619496 PMCID: PMC6300857 DOI: 10.1016/j.ijchp.2018.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 11/16/2018] [Indexed: 12/18/2022] Open
Abstract
Background/Objective: Social skills training (SST) is frequently included in the treatment of social anxiety disorder (SAD) in both children and adolescents, although there is no empirical evidence to support it. Consequently, our objective is to study the role and effects of SST in the treatment of a sample of adolescents with SAD. Method: A total of 108 adolescents diagnosed with generalized social phobia were randomly assigned to two treatment conditions (with and without SST) and a control group waiting list (WLCG). The evaluation included self-report measures, observational tests and blind evaluators. Results: Both interventions significantly reduced the number of social situations feared/avoided with respect to the WLCG, which worsened. Likewise, both interventions were effective but the group with SST obtained better results in the post-test and follow-ups, as well as a lower dropout rate (6:1). Conclusions: The use of SST reduces the dropout rate of treated adolescents and increases the effectiveness of the Intervention Program for Adolescents with Social Phobia.
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Social Anxiety and Fear of Causing Discomfort to Others: Diagnostic Specificity, Symptom Correlates and CBT Treatment Outcome. Behav Cogn Psychother 2017; 45:382-400. [PMID: 28260554 DOI: 10.1017/s135246581700008x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background: Patients with social anxiety disorder (SAD) report fear content relating to the perceived aversive consequences of their anxiety for others in their social environment. However, no studies to date have examined the diagnostic specificity of these fears to SAD as well as predictors to treatment response of these fears. Aims: To examine relative specificity of fears related to causing discomfort to others, as measured by Social Anxiety–Fear of Causing Discomfort to Others (SA-DOS), among patients with anxiety disorders, obsessive compulsive disorder (OCD) and major depressive disorder (MDD), in addition to relation between dysfunctional attitudes and treatment response among patients with SAD. Method: In study 1, a large (n=745) sample of DSM diagnosed OCD, MDD and anxiety disorder participants completed the SA-DOS. In study 2, patient participants with SAD (n=186) participated in cognitive behavioural group therapy (CBGT) and completed measures of social anxiety symptoms and dysfunctional attitudes. Results: In study 1, the SAD group demonstrated significantly elevated SA-DOS scores compared with participants with generalized anxiety disorder (GAD), OCD and panic disorder with or without agoraphobia (PD/A), but not the MDD group. In study 2, CBGT treatment was found to lead to significant reductions in SA-DOS scores. Need for approval (NFA) but not perfectionism, predicted treatment response to fears related to causing discomfort to others, with greater change in NFA relating to greater change in SA-DOS scores. Conclusions: These findings extend previous research linking allocentric fears to the phenomenology and treatment of SAD.
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Hawley LL, Padesky CA, Hollon SD, Mancuso E, Laposa JM, Brozina K, Segal ZV. Cognitive-Behavioral Therapy for Depression Using Mind Over Mood: CBT Skill Use and Differential Symptom Alleviation. Behav Ther 2017; 48:29-44. [PMID: 28077219 DOI: 10.1016/j.beth.2016.09.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 07/15/2016] [Accepted: 09/08/2016] [Indexed: 11/24/2022]
Abstract
Cognitive-behavioral therapy (CBT) for depression is highly effective. An essential element of this therapy involves acquiring and utilizing CBT skills; however, it is unclear whether the type of CBT skill used is associated with differential symptom alleviation. Outpatients (N = 356) diagnosed with a primary mood disorder received 14 two-hour group sessions of CBT for depression, using the Mind Over Mood protocol. In each session, patients completed the Beck Depression Inventory and throughout the week they reported on their use of CBT skills: behavioral activation (BA), cognitive restructuring (CR), and core belief (CB) strategies. Bivariate latent difference score (LDS) longitudinal analyses were used to examine patterns of differential skill use and subsequent symptom change, and multigroup LDS analyses were used to determine whether longitudinal associations differed as a function of initial depression severity. Higher levels of BA use were associated with a greater subsequent decrease in depressive symptoms for patients with mild to moderate initial depression symptoms relative to those with severe symptoms. Higher levels of CR use were associated with a greater subsequent decrease in depressive symptoms, whereas higher levels of CB use were followed by a subsequent increase in depressive symptoms, regardless of initial severity. Results indicated that the type of CBT skill used is associated with differential patterns of subsequent symptom change. BA use was associated with differential subsequent change as a function of initial severity (patients with less severe depression symptoms demonstrated greater symptom improvement), whereas CR use was associated with symptom alleviation and CB use with an increase in subsequent symptoms as related to initial severity.
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Affiliation(s)
- Lance L Hawley
- Sunnybrook Health Sciences Centre, Frederick Thompson Anxiety Disorders Centre, and University of Toronto.
| | | | | | | | - Judith M Laposa
- University of Toronto and Centre for Addiction and Mental Health
| | | | - Zindel V Segal
- University of Toronto and Centre for Addiction and Mental Health
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