Social skills training augments the effectiveness of cognitive behavioral group therapy for social anxiety disorder

Examining trauma, anxiety, and depression as predictors of dropout from residential treatment for substance use disorders

Substance use disorders (SUDs) are highly prevalent and have deleterious effects on one's health and well-being. Inpatient treatment for SUDs reduces patient relapse, which subsequently ameliorates these negative effects on the individual and society. Additionally, those who complete treatment are less likely to relapse compared to those who do not complete treatment. Thus, maintaining patient engagement in treatment and reducing the rates of those leaving against medical advice (AMA) is particularly important. Examining the factors and comorbidities that may contribute to treatment dropout has the potential to identify at-risk patients in need of additional individualized intervention. The current study aimed to examine comorbid anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms as predictors of dropout AMA in a residential substance use treatment population. Results showed that patients with social anxiety were more likely to leave treatment AMA, while those with PTSD were more likely to complete treatment. Findings suggest that PTSD-specific treatment, as offered in this facility, may help with patient retention, while group focused therapy may be distressing to those with social anxiety. Clinical implications of this research may include incorporating evidence-based practice for social anxiety early during inpatient treatment to reduce anxiety such that patients may better engage with SUDs treatment.

Effectiveness of cognitive behavioral group therapy, psychodrama, and their integration for treatment of social anxiety disorder: A randomized controlled trial

BACKGROUND AND OBJECTIVES

Although cognitive behavioral group therapy (CBGT) is an effective treatment for social anxiety disorder, many socially anxious patients are still symptomatic after treatment. A possible improvement for CBGT could come from the more experiential group psychotherapy, psychodrama (PD). The integration of CBGT and PD (labeled CBPT) might offer an even more effective treatment than CBGT or PD alone. With the present study, we investigated first whether three kinds of group therapy (CBGT, PD, and CBPT) are superior to a waitlist (WL). Second, we investigated whether CBPT is more effective than CBGT or PD alone.

METHODS

One hundred and forty-four social anxiety patients were randomly assigned to three active conditions or a WL. After wait, WL-participants were randomized over the active treatment conditions.

RESULTS

The results of a multilevel analysis showed that all treatments were superior to WL in reducing social anxiety complaints. Only CBGT and CBPT differed significantly from WL in reducing fear of negative evaluations. There were no significant differences between active conditions in any of the variables after treatment and after six-month follow up, neither were there significant differences in treatment dropout.

LIMITATIONS

First there is the lack of a long-term follow-up. Second, because of loss of participants, we did not reach the planned numbers in the active treatment groups in comparison to WL. Moreover, this study was not designed as a non-inferiority or equivalence trial.

CONCLUSIONS

Although the integrative CBPT showed good results, it was not more effective than the other treatments.

Perceived interpersonal competence as a predictor of clinical outcomes in a randomized controlled trial for social anxiety and employment

This study explored relationships among perceived interpersonal competence and demographic and work history variables in a randomized control trial for social anxiety disorder (SAD) that compared work-related group cognitive behavioral therapy plus vocational services (WCBT+VSAU) to vocational services only (VSAU-alone). Intervention effects of perceived interpersonal competence on treatment outcomes over 12 weeks were also examined. Data from 250 job seekers with SAD (59.2% Female; 40.8% Black/African American; 82.4% Non-Hispanic/non-Latino/a) were analyzed. We predicted negative relationships between perceived interpersonal competence and symptoms/impairment and that individuals with lower perceived interpersonal competence would benefit more quickly in WCBT+VSAU relative to VSAU-alone. Results indicated that perceived interpersonal competence did not vary by gender, race, ethnicity, homeless status, or employment history. There were no intervention effects of perceived interpersonal competence regarding social anxiety or overall functional impairment, but results supported negative relationships between perceived interpersonal competence and lower social anxiety and overall functional impairment in both conditions. Separately, perceived interpersonal competence moderated effects in the depression model such that there were faster declines in depression at lower perceived interpersonal competence levels in WCBT+VSAU, but not in VSAU-alone. Results indicate the value of attending to perceived interpersonal competence in interventions, which may result in mood benefits.

Combinatorial approaches for treating neuropsychiatric social impairment

Social behaviour is an essential component of human life and deficits in social function are seen across multiple psychiatric conditions with high morbidity. However, there are currently no FDA-approved treatments for social dysfunction. Since social cognition and behaviour rely on multiple signalling processes acting in concert across various neural networks, treatments aimed at social function may inherently require a combinatorial approach. Here, we describe the social neurobiology of the oxytocin and endocannabinoid signalling systems as well as translational evidence for their use in treating symptoms in the social domain. We leverage this systems neurobiology to propose a network-based framework that involves pharmacology, psychotherapy, non-invasive brain stimulation and social skills training to combinatorially target trans-diagnostic social impairment. Lastly, we discuss the combined use of oxytocin and endocannabinoids within our proposed framework as an illustrative strategy to treat specific aspects of social function. Using this framework provides a roadmap for actionable treatment strategies for neuropsychiatric social impairment. This article is part of the theme issue 'Interplays between oxytocin and other neuromodulators in shaping complex social behaviours'.

Youth social functioning interacts with treatment arm, diagnosis, and gender to predict anxiety treatment outcome

Research has uncovered a wide range of predictors of youth anxiety treatment outcome (i.e., symptom severity and diagnostic remission). Youth's social functioning is one predictor that has been rarely studied, however, which is a significant gap given its importance to development and clinical functioning. We address this gap by examining two aspects of youth's social functioning as predictors of anxiety treatment outcome: (1) positive social interactions and (2) social skills. We further examined the moderating roles of treatment arm (child- or parent-based treatment), diagnosis (presence or absence of social anxiety disorder), and youth gender, between each of the two predictors and treatment response and remission. Participants were 96 youths with anxiety disorders (6-16 years; 54% girls) and their mothers, who completed diagnostic interviews and questionnaires at baseline and posttreatment. Multiple regression models revealed that higher baseline parent-reports of their child's social skills predicted lower posttreatment anxiety symptom severity for youth with social anxiety disorder. Modified linear probability models revealed that baseline youth-reports of their social skills predicted remission from anxiety diagnoses for youths assigned to the parent-based treatment. Baseline youth-reports of their positive social interactions and parent-reports of youth social skills predicted remission from anxiety diagnoses for girls. Results contribute to the predictor literature by highlighting the importance of youth social functioning to anxiety treatment outcome.

Five Approaches to Understanding Interpersonal Competence: A Review and Integration

Social connectedness has been linked to beneficial outcomes across domains, ages, and cultures. However, not everyone receives these benefits, as there are large individual differences in the capacities required to create and sustain functional interpersonal relationships. A great deal of research has been devoted to assessing and understanding these differences, often focusing on how competent interpersonal behavior renders it more likely that one will succeed interpersonally. The current paper examines five relevant approaches that have emerged from personality (global traits), social (social cognition), clinical (social skills interventions), developmental (social information processing), and industrial/organizational (situation judgment) areas of psychology. A comparison of these approaches highlights important considerations related to bandwidth and fidelity, whether the focus should be on overt behavior or underlying processes, and whether to emphasize tendencies or their effectiveness. The review concludes with calls for greater integration efforts, which can capitalize on strengths inherent to different approaches.

Secret Agent Society: A Randomized Controlled Trial of a Transdiagnostic Youth Social Skills Group Treatment

Group programs are key for targeting social skills (SS) for children with developmental disorders and/or mental illness. Despite promising evidence regarding efficacy of group treatments, there are several limitations to current research regarding generalizability and effectiveness across diagnoses. This randomized control trial assessed whether the Secret Agent Society (SAS) group program was superior to treatment as usual (TAU) in improving social-emotional functioning for children with Attention Deficit-Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), and/or anxiety. Eighty-nine youth (8-12) with ADHD, ASD, and/or an anxiety disorder receiving treatment at hospital-based outpatient clinics were randomized to receive SAS (n = 47) or TAU (n = 42) over a three-month period, at which point TAU participants were offered the SAS intervention. Parent report showed significant improvement in Emotion Regulation (ER) and Social Skills (SS) for youth in SAS vs. TAU (Fs ≥ 6.79, ps ≤ 01). Gains for the SAS condition were maintained at 6-months. Intent-to-treat analysis of teacher report indicated youth in SAS had positive gains in SS (F = 0.41, p = 0.475) and ER (F = 0.99, p = 0.322), though not significantly better than youth in TAU. Clinically reliable improvement rates were significantly higher for SAS participants than TAU for parent and teacher reported SS and ER. Improvements were significant for youth with single and comorbid diagnoses. Results suggest that SAS was superior to TAU in improving SS and ER for youth aged 8-12 with ADHD, ASD, and/or anxiety. Gains maintained in the medium-term. Trial registration number NCT02574273, registered 10/12/2015.

TREINAMENTO DE HABILIDADES SOCIAIS EM ALUNOS DE GRADUAÇÃO: UMA REVISÃO SISTEMÁTICA

RESUMO Os programas de intervenção baseados em Treinamento de Habilidades Sociais têm sido pesquisados em diferentes populações, entre elas, a universitária. Este estudo teve como objetivo realizar uma revisão da literatura sobre programas de THS com universitários, publicados em periódicos nacionais e internacionais, enfatizando os instrumentos e delineamentos utilizados, além dos principais resultados e limitações, a partir de 1980. Utilizaram-se as palavras-chave em inglês “social skills training”, “undergraduate”, “graduate students” e “higher education” em seis bases de dados (Capes, ERIC, PHS/RIHS, DOAJ, EBSChost, LILACS, IBICT, WEB OF SCIENCE). Foram encontrados 13 artigos e estes analisados quanto às variáveis de interesse aplicando-se o Protocolo PRISMA. Os resultados mostraram que nove estudos utilizaram o Inventário de Habilidades Sociais como principal instrumento de coleta de dados e tiveram o delineamento experimental. O número de sessões mostrou-se variável entre as intervenções e, em todos os estudos, ocorreu a melhora no repertório de habilidades sociais dos participantes das pesquisas. O presente artigo contribui para a literatura da área ao discutir implicações para a pesquisa e a prática de promoção de habilidades sociais na formação universitária bem como direções para futuras pesquisas que devem considerar o conceito de competência social.

SOCIAL SKILLS TRAINING IN UNDERGRADUATE STUDENTS: A SYSTEMATIC REVIEW

ABSTRACT Intervention programs based on Social Skills Training have been researched in different populations, including university students. This study aimed to review the literature about HST programs with university students, published in national and international journals, emphasizing the instruments and designs used, in addition to the main results and limitations, from 1980 onwards. The keywords in English “social skills training”, “undergraduate”, “graduate students” and “higher education” were used in six databases (Capes, ERIC, PHS/RIHS, DOAJ, EBSChost, LILACS, IBICT, WEB OF SCIENCE). Thirteen articles were found and they were analyzed regarding the variables of interest by applying the PRISMA Protocol. The results showed that nine studies used the Social Skills Inventory as the main data collection instrument and had an experimental design. The number of sessions was variable among the interventions and, in all studies, there was an improvement in the social skills repertoire of the research participants. This article contributes to the literature in the area by discussing implications for research and practice in promoting social skills in university education, as well as directions for future research that should consider the concept of social competence.

The Importance of Learning Style in Case Formulation–Driven Cognitive Behavioral Therapy: A Case Study

Rather than structuring treatment based on diagnoses, case formulation–driven cognitive behavior therapy (CF-CBT) focuses on building an individualized formulation or map of how a patient’s presenting problems are being maintained and uses this formulation to guide treatment planning. A case formulation can include comorbid diagnoses, underlying mechanisms, relevant historical, biological, and social factors, and problems unrelated to a diagnosis (e.g., unemployment). Therapy is also a learning context, and clients vary in their learning styles and preferences. The success of treatment depends not only on what a client learns but also on how a client learns. Frequently, learning style is not considered when developing a case formulation or providing CBT. The present case study, based on a man with social anxiety disorder who was treated using CF-CBT, demonstrates the importance of including learning style to target both what and how the client learns.

An exploration of group cognitive analytic therapy for anxiety and depression

OBJECTIVES

Cognitive analytic therapy has been shown to be an effective psychological treatment for a range of differing presentations but little research to date has focused on the use of Group CAT (GCAT). The aim of this study was to explore the acceptability, feasibility, and preliminary effectiveness of GCAT for clients with mood and anxiety disorders in primary care.

DESIGN

This study utilized a mixed method design.

METHOD

A 12-session GCAT programme was developed covering key CAT concepts. The structure reflected the three phases of CAT - reformulation, recognition, and revision. Participants completed outcome measures pre- and post-treatment and at 3-month follow-up. Acceptability was reported using session attendance and participant feedback in addition to asking clients to rank the utility of CAT treatment components. A therapist interview was also completed.

RESULTS

Fifty-five per cent of clients completed the treatment, and feedback suggests that GCAT is an acceptable and feasible intervention for a primary care population. Clients also reported on the utility of specific CAT treatment components. Clients demonstrated positive change on a number of outcome measures.

CONCLUSIONS

Group cognitive analytic therapy shows promise as an acceptable and feasible treatment for clients with mood and anxiety disorders presenting to primary care services. Further larger and more controlled studies are indicated.

PRACTITIONER POINTS

The study supports the idea that GCAT is an acceptable and feasible treatment for clients with mood and anxiety disorders in a primary care setting. Clients indicated the utility of various aspects of GCAT The study provides tentative evidence for the effectiveness of GCAT in ameliorating symptoms of stress, anxiety, and depression in primary care.

The Fears of Evaluation About Performance (FEAP) Task: Inducing Anxiety-Related Responses to Direct Exposure to Negative and Positive Evaluations

Fears of negative and positive evaluation (i.e., evaluative fears) manifest within performance-based situations (e.g., public speaking, group presentations), particularly among those experiencing social anxiety. Within these performance-based situations, individuals experiencing such evaluative fears frequently display a variety of impairments (e.g., avoidance, nervousness) that might manifest within and across various settings (e.g., employment, school). How do those who experience these fears react to in-the-moment feedback about their performance? We constructed the Fear of Evaluation About Performance (FEAP) task to examine ecologically valid experiences with anxiety when reacting to positive and negative feedback. During the task, participants gave a speech, and subsequent to this and in counterbalanced order, received positive and negative feedback about their speech, with continued assessment of anxiety-related arousal throughout the task. We tested the FEAP task among 127 adults, who provided self-reports of fears of positive and negative evaluation before completing the task. Fears of positive evaluation uniquely predicted arousal following receipt of positive feedback, whereas fears of negative evaluation uniquely predicted arousal following receipt of negative feedback. Relative to participants receiving positive feedback first, those receiving negative feedback first experienced elevated post-feedback arousal, followed by a steep decline in arousal post-positive feedback. Conversely, participants receiving positive feedback first experienced a buffer effect whereby arousal post-negative feedback remained low, relative to the arousal experienced post-negative feedback among those who received negative feedback first. We expect the FEAP task to inform basic science on fears of negative and positive evaluation, as well as treatment planning in applied clinical settings.

Do depressive symptoms affect the outcome of treatments for SAD? A meta analysis of randomized controlled trials

Individuals with social anxiety disorder (SAD) typically have elevated depressive symptoms. In the present meta-analysis, we reviewed the treatment outcome literature in SAD and examined whether depressive symptoms predict treatment outcome. We focused on randomized controlled trials of cognitive behavior therapy (individual face-to-face, group format, and internet-delivered format) and randomized controlled trials of pharmacotherapy. After implementing exclusion criteria, 108 studies with 133 treatment conditions (n = 12,913 participants) were included in the meta-analysis. Our findings indicated that treatments for SAD were efficacious and significantly reduced social anxiety symptoms across all treatment modalities. Exclusion of individuals with MDD or high levels of depression did not affect outcome at post-treatment or at follow-up. However, we found that elevated depressive symptoms were associated with greater reductions in social anxiety symptoms from pre-treatment to post-treatment. Importantly, this effect was above and beyond pre-treatment levels of social anxiety. Finally, analyzing treatment modalities separately, we found that depressive symptoms were associated with better post-treatment outcomes in individual face-to-face CBT but not in other modalities. Clinical and research implications of these findings are discussed.

Inpatient treatment decreases depression but antidepressants may not contribute. A prospective quasi-experimental study

OBJECTIVE

The aim of the study is the evaluation of psychiatric-psychotherapeutic inpatient treatment utilizing a naturalistic design.

METHODS

In a sample of 574 consecutively admitted patients, depression (64.5%), personality disorders (19.5%), schizophrenia (4.2%), bipolar disorder (3.3%), obsessive-compulsive disorder (2.3%) or other mental disorders (6.4%) were diagnosed. All patients were treated with psychotherapy, most with antidepressants. Depression was measured using the Beck Depression Inventory-II (BDI-II). 180 patients formed a waiting list control group. The regularly discharged patients (N = 489) were asked to participate in a six-month follow-up, with 62.6% taking part.

RESULTS

From the time of admission to discharge, there was a strong decline in depression (31.5 vs. 13.2 points on the BDI-II), as well as from admission to follow-up (31.2 vs. 18.3 points). In the control group, there was a weak symptom decline (34.6 vs. 32.1 points) until admission, which was independent of the waiting period duration. For the success of treatment, it did not matter whether the patients received antidepressants. In the follow-up, 81.0% of patients retrospectively considered psychotherapy to be important for treatment outcome, only 2.3% considered medications to be important.

CONCLUSIONS

Psychiatric inpatient treatment reduces depression significantly at discharge and follow-up; the decrease in depression is rather due to psychotherapy than to antidepressants.

Assessing Social Affiliative Behavior: A Comparison of in Vivo and Video Tasks

Social affiliation, or engagement in positive social interactions, is often profoundly impaired in individuals with schizophrenia. Valid measures of social affiliation are needed to understand these impairments and their symptom and functional correlates; however, such measures are limited and have not been validated. This pilot study evaluated one such measure-the video-based Social Affiliation Interaction Task (SAIT)-and a novel in vivo behavioral measure, the Affiliative Conversation Task (ACT). Twenty participants with schizophrenia or schizoaffective disorder (SZ) and 35 nonpsychiatric controls (CT) completed both tasks and measures of negative symptoms and functioning. We explored group differences in social affiliation skills; convergent validity between social affiliation skill ratings from the two tasks; and concurrent validity with social affiliation skill ratings, negative symptoms, and functioning. SZ evidenced lower affiliation skill ratings than CT on the video SAIT, but not on the ACT, and the tasks displayed moderate convergent validity for affiliation skill ratings. Less affiliation skill in the SAIT was correlated with more negative symptoms and less functioning in the SZ group with medium effects, though the results were not significant. Findings suggest that the SAIT may be more sensitive to individual differences in skill level. Future research should continue to examine the SAIT for use in measuring affiliation skills.

In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy

OBJECTIVE

Three recent meta-analyses have made the claim, albeit with some caveats, that cognitive-behavioral treatments (CBT) are superior to other psychotherapies, in general or for specific disorders (e.g., social phobia).

METHOD

The purpose of the present article was to examine four issues in meta-analysis that mitigate claims of CBT superiority: (a) effect size, power, and statistical significance, (b) focusing on disorder-specific symptom measures and ignoring other important indicators of psychological functioning, (c) problems inherent in classifying treatments provided in primary studies into classes of treatments, and (d) the inclusion of problematic trials, which biases the results, and the exclusion of trials that fail to find differences among treatments.

RESULTS

When these issues are examined, the effects demonstrating the superiority of CBT are small, nonsignificant for the most part, limited to targeted symptoms, or are due to flawed primary studies.

CONCLUSION

Meta-analytic evidence for the superiority of CBT in the three meta-analysis are nonexistent or weak.

A framework for treating DSM-5 alternative model for personality disorder features

Despite its demonstrated empirical superiority over the DSM-5 Section 2 categorical model of personality disorders for organizing the features of personality pathology, limitations remain with regard to the translation of the DSM-5 Section 3 alternative model of personality disorders (AMPD) to clinical practice. The goal of this paper is to outline a general and preliminary framework for approaching treatment from the perspective of the AMPD. Specific techniques are discussed for the assessment and treatment of both Criterion A personality dysfunction and Criterion B maladaptive traits. A concise and step-by-step model is presented for clinical decision making with the AMPD, in the hopes of offering clinicians a framework for treating personality pathology and promoting further research on the clinical utility of the AMPD. Copyright © 2018 John Wiley & Sons, Ltd.

Adherence to a web-based pre-treatment for phobias in outpatient clinics

BACKGROUND

Non-adherence in Internet interventions is a persistent and multifaceted issue and potentially limits the applicability and effectiveness of these interventions. Factors that influence non-adherence are poorly understood, especially in outpatient samples with more complex symptoms.

OBJECTIVE

The current study is a secondary analysis of data from a randomised controlled trial that examined the cost-effectiveness of offering an Internet-based exposure treatment to phobic outpatients on a wait-list to receive face-to-face psychotherapy.

METHODS

We collected baseline demographic and clinical information, and adherence data of the Internet-based intervention and conducted regression analyses to predict non-adherence to the intervention.

RESULTS

The adherence to the intervention was low, with only 13.3% of 105 patients completing all five lessons of the intervention. The median number of exercises completed (out of a possible 8) was 3. In a multi-predictor model, a higher baseline score of anxiety (OR = 0.94, 95% CI 0.90-0.99) was a risk factor for low adherence. Higher age (OR = 1.05, 95% CI 1.00-1.09) was a protective factor against non-adherence. Participants who adhered to the intervention were more likely to complete post-test assessments, further biasing results. However, overall participant attrition was high. The results are based on a small subset of participants and should be interpreted with caution.

CONCLUSIONS

Poor baseline clinical status and age are factors to consider when deciding whether to offer an Internet-based intervention to outpatients. Low adherence among those patients might be related to intrinsic motivation and might even be lower in outpatient settings where participants expect to receive face-to-face treatment. It might be worthwhile to develop a concise instrument to assess intrinsic motivation and treatment expectations for using Internet-based interventions, and for the therapist to review the range of possible (Internet-based) intervention options to suit personal preferences and expectations.

TRIAL REGISTRATION

Netherlands Trial Register, NTR2233.

The new transdiagnostic cognitive behavioral treatments: Commentary for clinicians and clinical researchers

Recognition of the limitations of the current categorical diagnostic system and increased understanding of commonalities across clinical problems associated with negative emotion, including anxiety and depression, has led to the development of transdiagnostic psychological interventions. This new approach holds promise in shifting our emphasis from diagnostic categories to treating core construct that cut across disorders. This paper identifies some of the similarities and differences across various cognitive-behavioral transdiagnostic protocols and key challenges in assessment and case conceptualization for clinicians wishing to use this approach. Some key needs in the research literature that would be particularly helpful to clinicians are also identified.

The Effects of a Brief Acceptance-Based Behavioral Treatment Versus Traditional Cognitive-Behavioral Treatment for Public Speaking Anxiety

Individuals with public speaking anxiety (PSA) experience fear and avoidance that can cause extreme distress, impaired speaking performance, and associated problems in psychosocial functioning. Most extant interventions for PSA emphasize anxiety reduction rather than enhancing behavioral performance. We compared the efficacy of two brief cognitive-behavioral interventions, a traditional cognitive-behavior treatment (tCBT) and an acceptance-based behavior treatment (ABBT), on public speaking performance and anxiety in a clinical sample of persons with PSA. The effects of treatment on prefrontal brain activation were also examined. Participants ( n = 21) were randomized to 90 min of an ABBT or a tCBT intervention. Assessments took place at pre- and post-treatment and included self-rated anxiety and observer-rated performance measures, a behavioral assessment, and prefrontal cortical activity measurements using functional near-infrared spectroscopy (fNIRS). Exploratory results indicated that participants in the ABBT condition experienced greater improvements in observer-rated performance relative to those in the tCBT condition, while those in the tCBT condition experienced greater reductions in subjective anxiety levels. Individuals in the ABBT condition also exhibited a trend toward greater treatment-related reductions in blood volume in the left dorsolateral prefrontal cortex relative to those who received tCBT. Overall, these findings preliminarily suggest that acceptance-based treatments may free more cognitive resources in comparison with tCBT, possibly resulting in greater improvements in objectively rated behavioral performances for ABBT interventions.

Acceptance and Commitment Therapy for Generalized Social Anxiety Disorder

Despite the demonstrated efficacy of cognitive-behavior therapy (CBT) for social anxiety disorder (SAD), many individuals do not respond to treatment or demonstrate residual symptoms and impairment posttreatment. Preliminary evidence indicates that acceptance-based approaches (e.g., acceptance and commitment therapy; ACT) can be helpful for a variety of disorders and emphasize exposure-based strategies and processes. Nineteen individuals diagnosed with SAD participated in a 12-week program integrating exposure therapy and ACT. Results revealed no changes across a 4-week baseline control period. From pretreatment to follow-up, significant improvements occurred in social anxiety symptoms and quality of life, yielding large effect size gains. Significant changes also were found in ACT-consistent process measures, and earlier changes in experiential avoidance predicted later changes in symptom severity. Results suggest the acceptability and potential efficacy of ACT for SAD and highlight the need for future research examining both the efficacy and mechanisms of change of acceptance-based programs for SAD.

Avoidant Personality Disorder: a Current Review

This review focuses on recent research on diagnostic aspects, etiology, and treatment of avoidant personality disorder (AVPD). Current studies stress the close relation between AVPD and social anxiety disorder, the influence of genetic factors in the development of AVPD, and the relative stability of symptoms. Treatment approaches should target the pervasive patterns of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Empirical evidence for cognitive-behavior and schema therapy is promising. Few other therapeutic approaches have been developed, but until now, these have only been investigated in case studies. We conclude that AVPD qualifies as a neglected disorder and that more research specifically on avoidant personality disorder symptoms and its treatment is needed.

Family and friendship informal support networks and social anxiety disorder among African Americans and Black Caribbeans

BACKGROUND

This study explores relationships between Social Anxiety Disorder (SAD) and quality and frequency of involvement with family and friends.

METHODS

Data are from a nationally representative sample of African American and Black Caribbean adults (n = 5191), the National Survey of American Life. SAD was assessed using the DSM-IV World Mental Health Composite International Diagnostic Interview.

RESULTS

Findings indicated that among both populations, close supportive ties with family members and friends are protective against meeting criteria for SAD. Negative interactions with family (e.g., conflicts), however, are a risk factor for SAD among both African Americans and Black Caribbeans. For African Americans, an interaction indicates that the relationship between negative interaction and social anxiety is much stronger among African Americans who are not emotionally close to their families. For Caribbean Blacks, an interaction suggests that the odds of meeting criteria for SAD were higher among Black Caribbeans who had high negative interaction with family as well as low levels of friendship closeness.

LIMITATIONS

The cross-sectional nature of the study does not allow for causal attributions for findings.

CONCLUSIONS

This study demonstrates that SAD may impact black ethnic subgroups differently, which has important implications for understanding the nature, etiology, and treatment of this disorder.

Validity and reliability of the Chinese version of the Sheehan Disability Scale (SDS-C)

INTRODUCTIONS

This study aims to evaluate the validity and reliability of the Chinese version of the Sheehan Disability Scale (SDS-C) among depression patients in Taiwan.

METHODS

To validate the SDS-C, two samples were selected: Sample 1 (n = 78) consisted of patients diagnosed with Depressive Disorder, while sample 2 (n = 63) consisted of a nondepressive population. Sample 1 was evaluated with SDS twice with 7-14 days interval to measure test-retest reliability. Both samples were also evaluated with The Centre for Epidemiologic Studies Depression Scale (CESD), Family APGAR (adaptation, partnership, growth, affection, resolve) score, the Global Assessment of Functioning (GAF), and brief questionnaire of the World Health Organization Quality of Life instrument (WHOQOL-BREF) and by a psychiatrist. The two samples were combined to measure validity.

RESULTS

In concurrent validity, SDS-C scores were significantly correlated with the total score of GAF. The discriminative validity was carried out by comparing the score of SDS-C between subjects with and without current depressive disorder (t = 12.32, df = 139, P < 0.001). Another discriminative validity by receiver-operating characteristic analysis showed the optimal cut-point was >11 (sensitivity: 82.1, specificity: 93.7). The area under the curve was 0.93 (±0.02). For the factor validity, principal components analysis showed that a single factor solution was the best solution accounting for 88.9% of the variance. Regarding the construct validity, SDS-C scores were significantly correlated with CESD, WHOQOL-BREF, and the Family APGAR score. For test-retest reliability, the intra-class correlation coefficient for the total SDS-C score was 0.89 (95% confidence interval 0.82-0.93) and internal consistency Cronbach's alpha was 0.94.

DISCUSSION

The SDS-C was found to be a valid and reliable instrument for current depressive disorder patients in Taiwan.

The impact of social skills training for social anxiety disorder: a randomized controlled trial

OBJECTIVE

Social anxiety disorder (SAD) impacts social, occupational and academic functioning. Although many interventions report change in social distress, improvement in social behavior remains under-addressed. This investigation examined the additive impact of social skills training (SST) for the treatment of SAD.

METHOD

Using a sample of 106 adults who endorsed SAD across numerous social settings, participants were randomized to exposure therapy (imaginal and in vivo) alone, a combination of SST and exposure therapy known as Social Effectiveness Therapy (SET), or a wait list control. The assessment strategy included self-report measures, blinded clinical ratings and blinded assessment of social behavior.

RESULTS

Both interventions significantly reduced distress in comparison to the wait list control and at post-treatment, 67% of patients treated with SET and 54% of patients treated with exposure therapy alone no longer met diagnostic criteria for SAD, a difference that was not statistically significant. When compared to exposure therapy alone, SET produced superior outcomes (p<.05) on measures of social skill and general clinical status. In addition to statistical significance, participants treated with SET or exposure reported clinically significant decreases on two measures of self-reported social anxiety and several measures of observed social behavior (all ps<.05).

CONCLUSIONS

Both interventions produced efficacious treatment outcome, although SET may provide additional benefit on measures of social distress and social behavior.

Stereotype confirmation concerns predict dropout from cognitive behavioral therapy for social anxiety disorder

BACKGROUND

There are high attrition rates observed in efficacy studies for social anxiety disorder, and research has not identified consistent nor theoretically meaningful predictors of dropout. Pre-treatment symptom severity and demographic factors, such as age and gender, are sometimes predictive of dropout. The current study examines a theoretically meaningful predictor of attrition based on experiences associated with social group membership rather than differences between social group categories--fear of confirming stereotypes.

METHODS

This is a secondary data analysis of a randomized controlled trial comparing two cognitive behavioral treatments for social anxiety disorder: virtual reality exposure therapy and exposure group therapy. Participants (N = 74) with a primary diagnosis of social anxiety disorder who were eligible to participate in the parent study and who self-identified as either "African American" (n = 31) or "Caucasian" (n = 43) completed standardized self-report measures of stereotype confirmation concerns (SCC) and social anxiety symptoms as part of a pre-treatment assessment battery.

RESULTS

Hierarchical logistic regression showed that greater stereotype confirmation concerns were associated with higher dropout from therapy--race, age, gender, and pre-treatment symptom severity were not. Group treatment also was associated with higher dropout.

CONCLUSIONS

These findings urge further research on theoretically meaningful predictors of attrition and highlight the importance of addressing cultural variables, such as the experience of stereotype confirmation concerns, during treatment of social anxiety to minimize dropout from therapy.

An Integrated, Acceptance-Based Behavioral Approach for Depression With Social Anxiety: Preliminary Results

Depression and social anxiety disorder (SAD) are highly comorbid, resulting in greater severity and functional impairment compared with each disorder alone. Although recently transdiagnostic treatments have been developed, no known treatments have addressed this comorbidity pattern specifically. Preliminary support exists for acceptance-based approaches for depression and SAD separately, and they may be more efficacious for comorbid depression and anxiety compared with traditional cognitive-behavioral approaches. The aim of the current study was to develop and pilot test an integrated acceptance-based behavioral treatment for depression and comorbid SAD. Participants included 38 patients seeking pharmacotherapy at an outpatient psychiatry practice, who received 16 individual sessions of the therapy. Results showed significant improvement in symptoms, functioning, and processes from pre- to post-treatment, as well as high satisfaction with the treatment. These results support the preliminary acceptability, feasibility, and effectiveness of this treatment in a typical outpatient psychiatry practice, and suggest that further research on this treatment in larger randomized trials is warranted.

Feedback versus no feedback in improving patient outcome in group psychotherapy for eating disorders (F-EAT): protocol for a randomized clinical trial

BACKGROUND

Continuous feedback on patient improvement and the therapeutic alliance may reduce the number of dropouts and increase patient outcome. There are, however, only three published randomized trials on the effect of feedback on the treatment of eating disorders, showing inconclusive results, and there are no randomized trials on the effect of feedback in group therapy. Accordingly the current randomized clinical trial, initiated in September 2012 at the outpatient clinic for eating disorders at Stolpegaard Psychotherapy Centre, aims to investigate the impact of continuous feedback on attendance and outcome in group psychotherapy.

METHODS/DESIGN

The hypothesis is that continuous feedback to both patient and therapist on treatment progress and alliance will increase attendance and treatment outcome. The trial is set up using a randomized design with a minimum of 128 patients allocated to either an experimental or control group at a ratio of 1:1. The experimental group will receive standard treatment (systemic and narrative group psychotherapy) with feedback intervention, whereas the control group will receive standard treatment only. The participants are diagnosed with bulimia nervosa, binge eating disorder, or an eating disorder not otherwise specified, according to the DSM-IV. In the experimental group feedback to the participants, based on the Outcome Rating Scale (ORS) and the Group Session Rating Scale (GSRS), is actively added to standard treatment. The ORS assesses areas of life functioning known to change as a result of therapeutic intervention. The GSRS assesses key dimensions of effective therapeutic relationships. In the control group, the patients fill out the Outcome Rating Scale only, and feedback is not provided.The primary outcome is the rate of attendance to treatment sessions. The secondary outcome is the severity of eating disorder symptoms. Exploratory outcomes are the level of psychological and social functioning, and suicide or self-harm. This is measured with the ORS, Symptom Check List, WHO-Five Wellbeing Index, Sheehan Disability Scale and a modified version of the Self-Harm Inventory.

DISCUSSION

If the results will confirm the hypothesis, this trial will support feedback as a way to improve group treatment attendance for outpatients with eating disorders.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01693237.

Effect of Comorbid Depression on Cognitive Behavioural Group Therapy for Social Anxiety Disorder

Many individuals seeking treatment for social anxiety disorder (SAD) also meet criteria for a comorbid depressive disorder. Little is known, however, about how a comorbid depressive disorder affects social anxiety treatment. This study examined 61 participants with SAD and 72 with SAD and a comorbid depressive disorder (SAD+D) before and after 12 weeks of cognitive behavioural group therapy (CBGT) for social anxiety. Although patients with SAD+D reported more severe symptoms of social anxiety and depression at pretreatment, treatment was similarly effective for individuals with SAD and SAD+D. However, individuals with SAD+D continued to report higher symptom severity at post-treatment. Interestingly, CBGT for social anxiety also led to improvements in depressive symptoms despite the fact that depression was not targeted during treatment. Improvement in social anxiety symptoms predicted 26.8% of the variance in improvement in depressive symptoms. Results suggest that depressive symptoms need not be in remission for individuals to benefit from CBGT for social anxiety. However, more than 12 sessions of CBGT may be beneficial for individuals with comorbid depression.

Clinical experiences in conducting cognitive-behavioral therapy for social phobia

Several authors have identified a disconnect between psychotherapy research, including research on cognitive behavioral therapy (CBT), and real-world psychotherapy practice. This disconnect has several negative consequences, potentially including less-than-optimal practice standards as well as a lack of input from practicing psychotherapists on how research can be improved and made more relevant in their day-to-day clinical work. As part of an ongoing effort to engage practicing psychotherapists in a feedback loop with psychotherapy researchers, this study reports the results of a survey of CBT therapists who have used CBT in the treatment of social phobia (SP). The survey was designed primarily to document how often certain potential problems, identified by expert researchers and CBT manuals, actually act as barriers to successful treatment when CBT is employed in nonresearch environments. The participants were 276 psychotherapists responding to email, online, and print advertisements completing the online survey. Participants varied considerably in psychotherapy experience, work environment, experience in using CBT for SP, and in some ways varied in their usual CBT techniques when treating SP. Among the most prominent barriers identified by many of the participants were patient motivation, comorbidity, logistical problems (especially with exposures), patient resistance, and severity and chronicity of SP symptoms. These findings may be useful for psychotherapy researchers as areas for potential study. The results may also suggest topics requiring clinical guidelines, innovations within CBT, and dissemination of successful techniques to address the barriers identified here.

Exploring frontal asymmetry using functional near-infrared spectroscopy: a preliminary study of the effects of social anxiety during interaction and performance tasks

Preliminary studies examining brain function associated with social anxiety suggest the possibility of right-sided prefrontal activation associated with phobic stimulation. Although most existing neuroimaging techniques preclude participants from engaging in ecologically valid social tasks during assessment, functional near-infrared spectroscopy (fNIRS) is a promising new technique that permits such assessment. The present study investigated the utility of the fNIRS procedure and explored frontal asymmetry during in vivo social challenge tasks among female undergraduate students who scored in top and bottom percentiles on a social anxiety screening measure. Results revealed that participants in both groups experienced a significant increase in concentration of blood volume and oxygenated hemoglobin in the right hemisphere compared to the left hemisphere while giving a speech. Non-hemispheric effects were also observed. In addition, the high anxiety group showed a non-significant trend toward greater right frontal activity than the low anxiety group. This study highlights the utility of the fNIRS device in successfully assessing real-time changes in cerebrovascular response as a function of naturalistic social behavior, and supports the potential utility of this technology in the study of the neurophysiology of social anxiety.

A randomized trial of attention training for generalized social phobia: does attention training change social behavior?

The use of attention training protocols for the treatment of generalized social anxiety disorder (SAD) is undergoing increased examination. Initial investigations were positive but more recent investigations have been less supportive of the treatment paradigm. One significant limitation of current investigations is overreliance on self-report. In this investigation, we expanded on initial investigations by using a multimodal assessment of patient functioning (i.e., including behavioral assessment). Patients with a primary diagnosis of SAD (n=31) were randomly assigned to eight sessions of attention training (n=15) or placebo/control (n=16). Participants were assessed at pre- and posttreatment via self- and clinician-report of social anxiety as well as anxious and behavioral response to two in vivo social interactions. Results revealed no differences between groups at posttreatment for all study outcome variables, suggesting a lack of effect for the attention training condition. The results are concordant with recent investigations finding a lack of support for the use of attention training as an efficacious treatment for patients with SAD.

Discrepancies in therapist and client ratings of global improvement following cognitive behavioral therapy for social phobia and their differential relations with symptom improvement at post-treatment and 12-month follow-up

OBJECTIVE

This study aimed to examine discrepancies in client and therapist ratings of global improvement and their relations to symptom improvement at post-treatment and 12-month follow-up.

METHOD

Participants (N = 59) with social phobia received eight sessions of cognitive behavioral therapy (CBT). Participants and therapists rated improvement following each session. Participants also rated improvement at follow-up. Participants completed symptom severity self-reports at post-treatment and follow-up.

RESULTS

Clients consistently rated themselves as more improved than therapists. Relative to client ratings, therapist post-treatment ratings of improvement were related to more indices of symptom change at both timepoints.

CONCLUSIONS

RESULTS suggest that therapist ratings have good predictive utility of client-reported change in symptoms.

Psychological group-treatments of social anxiety disorder: a meta-analysis

Background

A few meta-analyses have examined psychological treatments for a social anxiety disorder (SAD). This is the first meta-analysis that examines the effects of cognitive behavioural group therapies (CBGT) for SAD compared to control on symptoms of anxiety.

Method

After a systematic literature search in PubMed, Cochrane, PsychINFO and Embase was conducted; eleven studies were identified that met the inclusion criteria. The studies had to be randomized controlled studies in which individuals with a diagnosed SAD were treated with cognitive-behavioural group therapy (CBGT) and compared with a control group. The overall quality of the studies was moderate.

Results

The pooled effect size indicated that the difference between intervention and control conditions was 0.53 (96% CI: 0.33–0.73), in favour of the intervention. This corresponds to a NNT 3.24. Heterogeneity was low to moderately high in all analyses. There was some indication of publication bias.

Conclusions

It was found that psychological group-treatments CBGT are more effective than control conditions in patients with SAD. Since heterogeneity between studies was high, more research comparing group psychotherapies for SAD to control is needed.

The feasibility and acceptability of virtual environments in the treatment of childhood social anxiety disorder

Two significant challenges for the dissemination of social skills training programs are the need to assure generalizability and provide sufficient practice opportunities. In the case of social anxiety disorder, virtual environments may provide one strategy to address these issues. This study evaluated the utility of an interactive virtual school environment for the treatment of social anxiety disorder in preadolescent children. Eleven children with a primary diagnosis of social anxiety disorder between 8 to 12 years old participated in this initial feasibility trial. All children were treated with Social Effectiveness Therapy for Children, an empirically supported treatment for children with social anxiety disorder. However, the in vivo peer generalization sessions and standard parent-assisted homework assignments were substituted by practice in a virtual environment. Overall, the virtual environment programs were acceptable, feasible, and credible treatment components. Both children and clinicians were satisfied with using the virtual environment technology, and children believed it was a high-quality program overall. In addition, parents were satisfied with the virtual environment augmented treatment and indicated that they would recommend the program to family and friends. Findings indicate that the virtual environments are viewed as acceptable and credible by potential recipients. Furthermore, they are easy to implement by even novice users and appear to be useful adjunctive elements for the treatment of childhood social anxiety disorder.

Mediators in psychological treatment of social anxiety disorder: individual cognitive therapy compared to cognitive behavioral group therapy

According to cognitive-behavioral models of social anxiety disorder (SAD), four of the important maintaining mechanisms are avoidance, self-focused attention, anticipatory processing and post-event cognitive processing. Individual cognitive therapy (ICT) and cognitive behavioral group therapy (CBGT) both have substantial empirical support. However, it is unclear whether they achieve their effects by similar or different mechanisms. The aim of this study was to investigate whether changes in the four maintenance processes mediate clinical improvement in ICT and CBGT for SAD. We analyzed data from participants (N = 94) who received either ICT or CBGT in two separate RCTs. The results showed that ICT had larger effects than CBGT on social anxiety and each of the four potential mediators. More pertinently, moderated mediation analyses revealed significant between-treatment differences. Whereas improvement in ICT was mainly mediated by reductions in avoidance and self-focused attention, improvement in CBGT was mediated by changes in self-focused attention and in anticipatory and post-event processing. These results support the importance of the putative mediators, but suggest that their relative weights are moderated by treatment type.

Acceptance based behavior therapy for social anxiety disorder through videoconferencing

Most individuals with social anxiety disorder (SAD) do not receive any type of treatment. Reasons include logistical barriers (e.g., geographic location, travel time), fear of stigmatization, and fear of the social interactions associated with seeking treatment. Videoconferencing technology holds great promise in the widespread delivery of evidence-based treatments to those who would otherwise not receive treatment. This pilot study assessed the feasibility, acceptability, and initial efficacy of an acceptance-based behavioral intervention using Skype videoconferencing to treat adults with generalized SAD. Twenty-four participants received 12 sessions of weekly therapy and were assessed at pre-treatment, mid-treatment, post-treatment, and 3-month follow-up. Participants and therapists rated the intervention as acceptable and feasible. Analyses revealed significant pre-treatment to follow-up improvements in social anxiety, depression, disability, quality of life, and experiential avoidance, with effect sizes comparable to or larger than previously published results of studies delivering in-person CBT for SAD. Implications and future directions are discussed.