A pilot randomized clinical trial of cognitive behavioral therapy versus attentional bias modification for social anxiety disorder: An examination of outcomes and theory-based mechanisms

Body image and social anxiety in hemifacial spasm: Examining self-esteem and fear of negative evaluation as mediators

BACKGROUND

Individuals diagnosed with hemifacial spasm (HFS) frequently undergo noticeable alterations in their facial appearance. Such changes can detrimentally influence both their physical and psychological well-being. While prior studies have identified self-esteem and fear of negative evaluation (FNE) as key elements in social anxiety, their role in studies concerning body image and its correlation with social anxiety has been seldom explored. This research seeks to explore how self-esteem and FNE concurrently mediate the relationship between body image and social anxiety among Chinese individuals with HFS.

METHODS

Chinese patients with HFS (n=151) completed a cross-sectional questionnaire on the first day of admission that assessed body image, social anxiety, self-esteem, and FNE over the past week. Path analysis was used to test the hypothesis of the mediation model.

RESULTS

The hypothesized model showed that FNE was positively correlated with body image and social anxiety, while negative associations were found among body image, self-esteem and social anxiety. Self-esteem and FNE play a mediating role between body image and social anxiety.

CONCLUSION

Our findings suggest that self-esteem and FNE may be important psychological pathways that affect body image and social anxiety in Chinese patients with HFS. Supplementing mental health services that help increase self-esteem and reduce FNE should be considered to improve the psychological quality of patients with HFS.

Reliability (or lack thereof) of smartphone ecological momentary assessment of visual dot probe attention bias toward threat indices

BACKGROUND AND OBJECTIVES

Cognitive bias theories posit that generalized anxiety disorder (GAD) and social anxiety disorder (SAD) are entwined with attention bias toward threats, commonly indexed by faster response time (RT) on threat-congruent (vs. threat-incongruent) trials on the visual dot probe. Moreover, although smartphone ecological momentary assessment (EMA) of the visual dot probe has been developed, their psychometric properties are understudied. This study thus aimed to assess the reliability of 8 smartphone-delivered visual dot probe attention bias and related indices in persons with and without GAD and SAD.

METHODS

Community-dwelling adults (n = 819; GAD: 64%; SAD: 49%; Mixed GAD and SAD: 37%; Non-GAD/SAD Controls: 24%) completed a five-trial smartphone-delivered visual dot probe for a median of 60 trials (12 sessions x 5 trials/session) and an average of 100 trials (20 sessions x 5 trials/session).

RESULTS

As hypothesized, Global Attention Bias Index, Disengagement Effect, and Facilitation Bias had low-reliability estimates. However, retest-reliability and internal reliability were good for Trial-Level Bias Scores (TLBS) (Bias Toward Treat: intra-class correlation coefficients (ICCs) = 0.626-0.644; split-half r = 0.640-0.670; Attention Bias Variability: ICCs = 0.507-0.567; split-half r = 0.520-0.580) and (In)congruent RTs. Poor retest-reliability and internal reliability estimates were consistently observed for all traditional attention bias and related indices but not TLBS.

LIMITATIONS

Our visual dot probe EMA should have administered ≥320 trials to match best-practice guidelines based on similar laboratory studies.

CONCLUSIONS

Future research should strive to examine attention bias paradigms beyond the dot-probe task that evidenced meaningful test-retest reliability properties in laboratory and real-world naturalistic settings.

Self-processing characteristics from first-person and third-person perspectives in individuals with social anxiety disorder: insights into negative bias

Background

As one of the most common psychological problems, social anxiety disorder (SAD) has lots of negative effects on the physical and mental development of individuals, such as decreasing the quality of interpersonal relationships, and even causing depression, suicidal ideation, etc., as well as leads individuals to generate mental illness stigma. The mental illness stigma that individuals perceive affects not only how they perceive themselves (first-person perspective) but also how they perceive others' appraisals of them (third-person perspective), which further exacerbates their anxiety symptoms.

Objective

The study aims to explore the self-processing characteristics of individuals with social anxiety disorder from the first-person perspective and the third-person perspective.

Methods

This study adopted the self-referential paradigm to conduct the recognition memory test on individuals with social anxiety disorder (30 participants in experiment 1) and individuals without social anxiety disorder (31 participants in experiment 2) in the two experiments.

Results

In experiment 1, the recognition rate of individuals with social anxiety disorder under the self-appraisals condition was significantly higher than that under the condition of appraisals on mothers; in the three conditions of self-appraisals, appraisals on mothers and mothers' reflected appraisals, the recognition rate of negative trait adjectives was significantly higher than that of positive trait adjectives. In experiment 2, there was no significant difference in recognition rate of individuals without social anxiety disorder under the three conditions, and the recognition rate of positive trait adjectives was significantly higher than that of negative trait adjectives under the three conditions.

Conclusion

Individuals with social anxiety disorder have a negative bias in self-processing and are more likely to focus on self-information, which is different from the self-positive bias of individuals without social anxiety disorder. This study can be beneficial to know the self-cognitive characteristics of individuals with social anxiety disorder, help them get rid of negative cognitive patterns, and remove the mental illness stigma.

Effects of attention bias modification for anxiety: Neurophysiological indices and moderation by symptom severity

OBJECTIVE

Attention bias modification (ABM) aims to decrease anxiety symptom severity through the reduction of threat-related attention bias (AB). Individual differences in treatment response and poor measurement reliability of AB have called its clinical promise into question. The current study examined whether individual differences in anxiety severity at baseline moderated treatment response, and employed both behavioral and neurophysiological metrics of AB.

METHODS

Participants (N = 99) were randomly assigned to four weeks of ABM or placebo control training (PT). Self-reported anxiety symptom severity, and AB metrics and ERPs generated during the dot probe task were collected at baseline (Time 1), one-week post-intervention (Time 5), and at a three-month follow-up (Time 6).

RESULTS

ABM, relative to PT, reduced ERPs indexing attention discrimination (N170) and increased ERPs indexing salience tracking (P3). Increases in P3 were associated with ABM-related reductions in anxiety. Anxiety severity was reduced following ABM, but only among those with higher baseline anxiety symptom severity.

CONCLUSIONS

ABM effectively reduced symptom severity among those with higher levels of anxiety, and modulated neurophysiological indices of AB.

SIGNIFICANCE

Results provide evidence for attention-relevant ERPs as outcomes of ABM treatment responsivity and suggest that ABM may be most beneficial for those with more severe anxiety symptoms.

The alliance in mental health care: conceptualization, evidence and clinical applications

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.

Metacognition, cognition and social anxiety: A test of temporal and reciprocal relationships

Cognitive models of social anxiety give prominence to dysfunctional schemas about the social self as the key underlying factors in maladaptive self-processing strategies and social anxiety symptoms. In contrast, the metacognitive model argues that beliefs about cognition represent a central belief domain underlying psychopathology and cognitive schemas as products of a thinking style regulated by metacognition. The present study therefore evaluated the temporal and reciprocal relations between metacognitive beliefs, social self-beliefs, and social anxiety symptoms to shed light on possible causal relationships among them. Eight hundred and sixty-eight individuals gathered at convenience participated in a four-wave online survey with each measurement wave 6 weeks apart. Using autoregressive cross-lagged panel models, we found significant temporal and reciprocal relations between metacognition, social self-beliefs (schemas), and social anxiety. Whilst social self-beliefs prospectively predicted social anxiety this relationship was reciprocal. Metacognitive beliefs prospectively predicted both social interaction anxiety and social self-beliefs, but this was not reciprocal. The results are consistent with metacognitive beliefs causing social anxiety and social self-beliefs and imply that negative social self-beliefs might be a product of metacognition. The clinical implications are that metacognitive beliefs should be the central target in treatments of social anxiety.

Does attention bias modification reduce anxiety in socially anxious college students? An experimental study of potential moderators and considerations for implementation

According to cognitive models, preferential attention to social threat contributes to maintenance of social anxiety. Socially anxious individuals are known to show attention biases to threatening stimuli, although there is inconsistency in the literature with regards to the type of attentional biases they present. This study examines the effect of attention bias modification (ABM) for social anxiety in non-treatment-seeking college students meeting social anxiety disorder criteria, taking into consideration previous mixed results regarding its effectiveness. Attention bias levels and types (i.e. vigilance vs avoidance) at baseline were examined and considered as potential moderators of ABM effects. Sixty-eight socially anxious individuals were randomly allocated to ABM vs placebo groups. A structured interview and self-report assessment were completed at pre-treatment and post-treatment. Results showed half of the participants presented few attention biases at baseline, and the rest presented either vigilance or avoidance. Participants with low attention biases scored higher in social anxiety than those showing avoidance and there was no difference between those showing vigilance vs avoidance. No significant effects from pre to post treatment were observed in attention biases, self-report or structured interview of anxiety in the ABM group. Baseline attention biases did not moderate these effects. Results are discussed with regards to implications for future research towards the creation of more effective protocols, based on the needs of heterogeneous social anxiety sub-groups.

The use of trial-level bias scores to examine attention bias and attention bias variability among people with and without social anxiety disorder

BACKGROUND

Cognitive models of anxiety propose that people with anxiety disorders show elevated levels of attention bias toward threat, but the most commonly used index of attention bias, which measures the construct with an aggregate score of multiple trials across an experimental session, shows poor test-retest reliability. Newer indices that measure attention bias dynamically on a trial-to-trial basis show good reliability and enable researchers to measure not only overall attention bias toward threat, but also attention bias variability.

METHODS

The current study tested the hypothesis that people diagnosed with social anxiety disorder would show higher attention bias variability and higher attention bias toward threat when calculated dynamically and when calculated using the traditional aggregate index. Participants diagnosed with social anxiety disorder (n = 47) and controls (n = 57) completed a 160-trial version of the dot-probe task using emotional and neutral images of faces as stimuli.

RESULTS

Relative to controls, participants diagnosed with social anxiety disorder showed higher mean bias toward threat, but only when calculated using trial-level bias scores. There were no differences between groups on attention bias variability.

DISCUSSION

This is the first study to examine differences in attention bias and attention bias variability between people with and without social anxiety disorder using trial-level bias scores. Results suggest that attention bias, but not attention bias variability, is a feature of social anxiety psychopathology and that trial-level bias scores may be more sensitive than aggregated mean scores to detect it. These findings have implications for clinical interventions such as attention bias modification programs, which require precise measures of attention bias to accurately assess treatment outcomes.

Patterns of alliance development in cognitive behavioral therapy versus attention bias modification for social anxiety disorder: Sawtooth patterns and sudden gains

OBJECTIVES

We examined patterns in alliance development in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). We focused on the occurrence of sawtooth patterns (increases within- and decreases between-sessions) and sudden gains and their association with outcome.

METHODS

Clients received CBT (n = 33) or ABM (n = 17). Client-rated alliance was measured before and after each session. Self-reported and clinician-rated anxiety were measured weekly and monthly, respectively.

RESULTS

The alliance increased in CBT in a sawtooth pattern and did not change in ABM. When examining individual clients, sawtooths were more common in CBT (61% clients) than in ABM (6%) and predicted worse outcome in CBT. Sudden gains were equally frequent (CBT, 18%; ABM, 18%) and did not predict outcome.

CONCLUSION

The alliance in CBT is dynamic and important for outcome. Sawtooths are common in CBT and may mark worse outcome.

Exploring the temporal associations between avoidance behavior and cognitions during the course of cognitive behavioral therapy for clients with symptoms of social anxiety disorder

OBJECTIVES

In cognitive behavioral therapy (CBT) for social anxiety disorder (SAD), avoidance behavior (AB) and cognitions (COG) are two important targets of intervention, but so far no studies have directly examined their relative importance. By means of cross-lagged panel models (CLPM), we examined their temporal associations and impacts on outcome in clients with symptoms of SAD while addressing typical methodological challenges.

METHOD

We used data from the first six therapy sessions in a sample of 428 primary care clients (mean [SD] age = 34.6 [12.2], 34.3% men), participating in the Prompt Mental Health Care trial. Session-by-session data was collected on AB, COG, depression and general anxiety. Competing multiple indicator CLPMs were tested.

RESULTS

The Random Intercept-CLPM provided best fit, and indicated that AB predicted COG at subsequent time points (.39 ≤ β  ≤ .42 for T2-T5, p  < .05), but not vice versa. In addition, AB, but not COG, predicted clients' general anxiety score at subsequent time points. Results were both robust to the inclusion of depressive symptoms as a within-level covariate, and sensitivity tests for stationarity and missing data assumptions.

CONCLUSION

Targeting avoidance behavior for primary care clients with symptoms of SAD may be more vital for the optimal effect of CBT than targeting cognitions. Methodological considerations and limitations of the study are discussed.Trial registration: ClinicalTrials.gov identifier: NCT03238872.

The role of expressive suppression and cognitive reappraisal in cognitive behavioral therapy for social anxiety disorder: A study of self-report, subjective, and electrocortical measures

BACKGROUND

Contemporary models of cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) emphasize emotion dysregulation as a core impairment whose reduction may play a causal role in psychotherapy. The current study examined changes in use of emotion regulation strategies as possible mechanisms of change in CBT for SAD. Specifically, we examined changes in expressive suppression and cognitive reappraisal during CBT and whether these changes predict treatment outcome.

METHODS

Patients (n = 34; 13 females; Mean age = 28.36 (6.97)) were allocated to 16-20 sessions of CBT. An electrocortical measure of emotion regulation and a clinician-rated measure of SAD were administered monthly. Self-report measures of emotion regulation and social anxiety were administered weekly. Multilevel models were used to examine changes in emotion regulation during treatment and cross-lagged associations between emotion regulation and anxiety.

RESULTS

CBT led to decreased suppression frequency, increased reappraisal self-efficacy, and decreased unpleasantness for SAD-related pictures (ps < .05). At post-treatment, patients were equivalent to healthy controls in terms of suppression frequency and subjective reactivity to SAD-related stimuli. Gains were maintained at 3-months follow-up. Decreases in suppression frequency and electrocortical reactivity to SAD-related pictures predicted lower subsequent anxiety but not the other way around (ps < .05). Lower anxiety predicted greater subsequent increases in reappraisal self-efficacy.

LIMITATIONS

The lack of a control group precludes conclusions regarding mechanisms specificity.

CONCLUSIONS

Decreased frequency of suppression is a potential mechanism of change in CBT for SAD.

The alliance mediates outcome in cognitive-behavioral therapy for social anxiety disorder, but not in attention bias modification

Objective: The aim of the current study was to examine changes in the therapeutic alliance and its role as a mediator of treatment outcome in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). Method: Patients were randomized to 16-20 sessions of CBT (n = 33) or 8 sessions of ABM (n = 17). Patient-rated alliance and self-reported social anxiety were measured weekly and evaluator-rated social anxiety was measured monthly. Results: Early alliance predicted greater subsequent anxiety reduction in CBT but not in ABM. The alliance increased and weekly improvements in alliance predicted weekly contemporaneous and subsequent decreases in anxiety only in CBT. Decreases in anxiety did not predict subsequent improvements in alliance. Both treatments were effective in reducing anxiety, but treatment effects were mediated by stronger early alliance and stronger cross-lagged effects of alliance on outcome in CBT compared to ABM. Conclusions: The results highlight the importance of the alliance in CBT for SAD. Further studies should examine the role of alliance alongside additional mediators to better understand differential mechanisms in CBT and ABM.

Seeking neutral: A VR-based person-identity-matching task for attentional bias modification - A randomised controlled experiment

BACKGROUND

Attentional bias modification (ABM) aims to reduce anxiety by attenuating bias towards threatening information. The current study incorporated virtual reality (VR) technology and 3-dimensional stimuli with a person-identity-matching (PIM) task to evaluate the effects of a VR-based ABM training on attentional bias and anxiety symptoms.

METHODS

One hundred participants with elevated social anxiety were randomised to four training groups. Attentional bias was assessed at pre- and post-training, and anxiety symptoms were assessed at pre-training, post-training, 1-week follow-up, and 3-month follow-up.

RESULTS

Change in anxiety did not correlate with change in bias (r = -0.08). A repeated-measures ANOVA showed no significant difference in bias from pre- to post-ABM, or between groups. For anxiety symptoms, a linear mixed-effects model analysis revealed a significant effect of time. Participants showed reduction in anxiety score at each successive assessment (p < .001, Nagelkerke's pseudo r ² = 0.65). However, no other significant main effect or interactions were found. A clinically significant change analysis revealed that 4% of participants were classified as 'recovered' at 3-month follow-up.

CONCLUSIONS

A single session of VR-based PIM task did not change attentional bias. The significant reduction in anxiety was not specific to active training, and the majority of participants remained clinically unchanged.

Are individuals diagnosed with social anxiety disorder successful in regulating their emotions? A mixed-method investigation using self-report, subjective, and event-related potentials measures

BACKGROUND

Models of social anxiety emphasize the role of emotion dysregulation, but the nature of these impairments needs clarification.

METHODS

We utilized a mixed-method approach to examine impairments in cognitive reappraisal and expressive suppression in social anxiety disorder. Forty nine treatment-seeking individuals diagnosed with social anxiety disorder and 35 healthy controls completed self-reports and a lab-based task of suppression and reappraisal. Unpleasantness ratings and event-related potentials (ERPs) were collected while participants regulated their emotions in response to shame-arousing pictures. ERP analyses focused on the late positive potential, a measure of increased attention to emotional stimuli that is reduced during emotion regulation.

RESULTS

Participants with social anxiety reported less frequent and effective use of reappraisal and more frequent and effective use of suppression than controls. Counter to most models and our hypotheses, participants with social anxiety were more successful than controls in lab-based reappraisal as measured by unpleasantness ratings, but no differences emerged for ERPs. No differences were found in measures of lab-based suppression.

LIMITATIONS

Use of standardized, and not participant-generated, materials in the lab-based task of emotion regulation may limit the generalizability of the findings.

CONCLUSIONS

Subjective appraisals of self-efficacy and frequency suggest strong impairments in emotion-regulation in social anxiety that are not revealed in the laboratory. Models and treatment protocols should specify the exact nature of emotion dyregulation in social anxiety, highlighting difficulties in implementation of potentially intact emotion regulation abilities.

Attention and interpretation bias modification treatment for social anxiety disorder: A randomized clinical trial of efficacy and synergy

BACKGROUND AND OBJECTIVES

Attention bias modification treatment (ABMT) and cognitive bias modification of interpretation (CBM-I) both have demonstrated efficacy in alleviating social anxiety, but how they compare with each other, their combination, and with a combined control condition has not been studied. We examined their relative and combined efficacy compared to control conditions in a randomized controlled trial (RCT).

METHODS

Ninety-five adults diagnosed with social anxiety disorder (SAD), were randomly allocated to 4 groups: ABMT + CBM-I control (hereafter ABMT; n = 23), CBM-I + ABMT control (hereafter CBM-I; n = 24), combined ABMT + CBM-I (n = 23), and combined control (n = 25). Treatment included eight sessions over four weeks. Clinician-rated and self-reported measures of social anxiety symptoms, functional impairment, and threat-related attention and interpretive biases were evaluated at baseline, post-treatment, and 3-month follow-up.

RESULTS

ABMT yielded greater symptom reduction as measured by both clinician-ratings (Cohen's ds = 0.57-0.70) and self-reports (ds = 0.70-0.85) compared with the CBM-I, the combined ABMT + CBM-I, and the combined control conditions. Neither of the other conditions demonstrated superior symptom change compared to the control condition. No group differences were found for functioning or cognitive biases measures.

LIMITATIONS

Limitations mainly include the mix of active and control treatments applied across the different groups. Therefore, the net effect of each of the treatments by itself could not be clearly tested.

CONCLUSIONS

Results suggest superiority of ABMT compared to CBM-I and their combination in terms of symptom reduction. Possible interpretations and methodological issues underlying the observed findings are discussed.