Therapeutic strategies for social anxiety disorder: where are we now?

Pharmacotherapy and cognitive bias modification for the treatment of anxiety disorders

INTRODUCTION

Anxiety disorders are characterized by widespread and persistent anxiety or recurrent panic attacks. As a result of their high prevalence, chronicity, and comorbidity, patients' quality of life and functioning are severely compromised. However, several patients do not receive treatment.

AREAS COVERED

This review discusses the effectiveness, safety, and limitations of major medications and cognitive bias modification (CBM) for treating anxiety disorders. The possibility of combined treatment is also discussed in the literature. Furthermore, drawing on Chinese cultural perspectives, the authors suggest that anxiety can be recognized, measured, and coped with at three levels of skill (), vision (), and Tao ().

EXPERT OPINION

The combination of pharmacotherapy and CBM is possibly more effective in treating anxiety disorders than either treatment alone. However, clinicians and patients should participate in the joint decision-making process and consider comprehensive factors. Moderate anxiety has adaptive significance. In the coming years, by combining the downward analytical system of western culture with the upward integrative system of Chinese culture, a comprehensive understanding of anxiety and anxiety disorders should be established, rather than focusing only on their treatment.

Social anxiety of the citizens of Kazakhstan: The dynamics of change and its impact on public consciousness

The purpose of the study is to analyze the factors associated with the formation of social anxiety and to explore trends in their impact on society in the Republic of Kazakhstan. The authors have used comparative, descriptive, and deductive methods to achieve the research goals. The results of the study determined that anxiety phenomena have become increasingly common over time and social anxiety is one of the most dangerous due to its degree of limitation. The vast majority of people experience some form of social anxiety, which occurs when distorted reality intervenes and certain moments signalize as dangerous. As a product of individual experience and sociopolitical construct, fear becomes the element organizing the state order. The social aspects are notably relevant to the process when the common sense of public consciousness puts security in the foreground as a matter of the greatest importance and urgency.

The effects of a dual orexin receptor antagonist on fear extinction memory and sleep in mice: Implications for exposure therapy

Extinction of conditioned fear is considered a fundamental process in the recovery from posttraumatic stress disorder and anxiety disorders. Sleep, especially rapid-eye-movement (REM) sleep, has been implicated in promoting extinction memory. The orexin system contributes to the regulation of sleep and wakefulness and emotional behaviors. In rodents, administrations of an orexin receptor antagonist following fear extinction training enhanced consolidation of extinction memory. Although orexin antagonists increase sleep, including REM sleep, the possible contribution of sleep to the effects of orexin antagonists on extinction memory has not been examined. Therefore, this study examined the effects of suvorexant, a dual orexin receptor antagonist, on extinction memory and sleep and their associations in mice. C57BL/6 mice underwent sleep recording for 24 h before and after contextual fear conditioning with footshocks and extinction learning during the early light phase or early dark phase. Mice were systemically injected with either 25 mg/kg of suvorexant or vehicle immediately after the extinction session. We found that suvorexant neither altered sleep nor improved extinction memory recall compared with vehicle. The higher percentages of REM sleep during the post-extinction dark phase were associated with lower extinction memory recall and greater freezing responses to the fear context. Results also indicate that animals did not reach complete extinction of fear with the fear extinction training protocol used in this study. These findings suggest that promoting REM sleep may not enhance fear extinction memory when extinction of fear is incomplete.

Neural evidence of face processing in social anxiety disorder: A systematic review with meta-analysis

Numerous previous studies have used event-related potentials (ERPs) to examine facial processing deficits in individuals with social anxiety disorder (SAD). However, researchers still need to determine whether the deficits are general or specific and what the dominant factors are behind different cognitive stages. Meta-analysis was performed to quantitatively identify face processing deficits in individuals with SAD. Ninety-seven results in 27 publications involving 1032 subjects were calculated using Hedges' g. The results suggest that the face itself elicits enlarged P1 amplitudes, threat-related facial expressions induce larger P2 amplitudes, and negative facial expressions lead to enhanced P3/LPP amplitudes in SAD individuals compared with controls. That is, there is face perception attentional bias in the early phase (P1), threat attentional bias in the mid-term phase (P2), and negative emotion attentional bias in the late phase (P3/LPP), which can be summarized into a three-phase SAD face processing deficit model. These findings provide an essential theoretical basis for cognitive behavioral therapy and have significant application value for the initial screening, intervention, and treatment of social anxiety.

Fear of positive evaluation differentially predicts social anxiety: a six-month longitudinal panel study

This study investigated whether (a) fear of negative evaluation (FNE) and fear of positive evaluation (FPE) prospectively predict the other, (b) FPE predicts social anxiety controlling for FNE, and (c) FPE predicts social anxiety symptoms but not general anxiety and depression. Data were collected from a student sample at two time points over six months. The cross-lagged structural equation modeling results revealed that FNE and FPE do not prospectively predict the other, FPE positively predicts social anxiety symptoms controlling for FNE, and FPE does not significantly predict general anxiety or depression. These results confirmed that FNE and FPE are distinctively related to social anxiety. Moreover, the study findings indicated that FPE may be a factor unique to social anxiety.

Long-term outcomes of cognitive behavioural therapy for social anxiety disorder: A meta-analysis of randomised controlled trials

Cognitive Behavioural Therapy (CBT) is effective in treating Social Anxiety Disorder (SAD). However, less is known about whether gains achieved in disorder-specific and secondary outcomes (e.g., depression, general anxiety, quality of life, and self-esteem) are maintained 12 months or longer. A systematic literature search yielded 25 relevant studies that administered CBT to participants with SAD. Multivariate meta-analyses of post-treatment assessments, found that CBT was superior to control conditions in reducing social anxiety (g =.74), depression (g =.52), general anxiety (g =.69) and improving quality of life (g =.39). The within-groups effect sizes revealed that 12 months or more after CBT treatment, symptoms continued to improve for social anxiety (g_av =.23) and quality of life (g_av =.17), and gains were maintained for depressive (g_av =.06) and general anxiety symptoms (g_av =.03). However, meta-analyses of long-term outcomes lack comparison groups. Moderation was non-significant for the treatment model, format, number of sessions, treatment duration, or inclusion of booster sessions. Future research may investigate what drives improvement after treatment cessation and how CBT affects other co-occurring symptomatology. Taken together, CBT produces many benefits for SAD and individuals with co-occurring symptoms can benefit from extant SAD-focused treatments.

Therapeutic Implications of microRNAs in Depressive Disorders: A Review

MicroRNAs are hidden players in complex psychophysical phenomena such as depression and anxiety related disorders though the activation and deactivation of multiple proteins in signaling cascades. Depression is classified as a mood disorder and described as feelings of sadness, loss, or anger that interfere with a person’s everyday activities. In this review, we have focused on exploration of the significant role of miRNAs in depression by affecting associated target proteins (cellular and synaptic) and their signaling pathways which can be controlled by the attachment of miRNAs at transcriptional and translational levels. Moreover, miRNAs have potential role as biomarkers and may help to cure depression through involvement and interactions with multiple pharmacological and physiological therapies. Taken together, miRNAs might be considered as promising novel therapy targets themselves and may interfere with currently available antidepressant treatments.

Preliminary Study of Efficacy and Safety of Self-Administered Virtual Exposure Therapy for Social Anxiety Disorder vs. Cognitive-Behavioral Therapy

Social anxiety disorder (SAD) is one of the most frequent mental disorders. Exposure to virtual reality can be a solution complementing standard CBT (cognitive-behavioral therapy) or can be used as an independent therapeutic tool. The study’s objective was to assess the safety and efficacy of using self-administered virtual reality exposure vs. CBT and CBT with virtual exposure. We assessed the efficacy of the applied intervention with the Leibowitz Social Anxiety Scale (LSAS). We compared three groups: CBT (n = 25), CBT + VR (n = 29), and self-administered therapy without aid of a therapist (n = 19). The results indicated that all three groups showed changes on the LSAS. The simple effect analysis showed that there were no differences between experimental conditions at T0 (session 1) and T1 (session 9) and that the only significant difference occurred at T2 (session 14). The pairwise comparisons showed that the participants in the VR condition scored higher on the LSAS score during the measurement at T2 than participants in CBT condition. Our study has several limitations. The presented initial study shows that the methods of CBT for social anxiety used so far are also effective, while the VR tool for self-therapy requires further research.

Social Fear Affects Limbic System Neuronal Activity and Gene Expression

Social anxiety disorder (SAD) is a highly prevalent and comorbid anxiety disorder with rather unclear underlying mechanisms. Here, we aimed to characterize neurobiological changes occurring in mice expressing symptoms of social fear and to identify possible therapeutic targets for SAD. Social fear was induced via social fear conditioning (SFC), a validated animal model of SAD. We assessed the expression levels of the immediate early genes (IEGs) cFos, Fosl2 and Arc as markers of neuronal activity and the expression levels of several genes of the GABAergic, serotoninergic, oxytocinergic, vasopressinergic and neuropeptide Y (NPY)-ergic systems in brain regions involved in social behavior or fear-related behavior in SFC+ and SFC− mice 2 h after exposure to a conspecific. SFC+ mice showed a decreased number and density of cFos-positive cells and decreased expression levels of IEGs in the dorsal hippocampus. SFC+ mice also showed alterations in the expression of NPY and serotonin system-related genes in the paraventricular nucleus of the hypothalamus, basolateral amygdala, septum and dorsal raphe nucleus, but not in the dorsal hippocampus. Our results describe neuronal alterations occurring during the expression of social fear and identify the NPY and serotonergic systems as possible targets in the treatment of SAD.

Alter Game: A Study Protocol on a Virtual "Serious Game" for Relapse Prevention in Patients With Gambling Disorder

Cognitive behavioral therapy (CBT) is the most successful protocol in gambling disorder (GD) treatment. However, it presents some weaknesses, especially concerning relapse prevention (RP). RP is one of the most important therapeutic steps, aiming at managing cravings and to avoid future relapse increasing perceived self-efficacy. Encouraging results come from the blending of psychotherapy and virtual reality (VR), containing gambling cues. The goal of Alter Game (approved by the Ethical Commission, Prot. No. 69346) is verifying the efficacy of an innovative psychological treatment for GD based on the integration of traditional CBT therapy and an immersive VR cue exposure therapy using a serious virtual game, which is a game designed for purposes other than entertainment. RP in virtual cue-exposure therapy allows pathological gamblers to manage the urge to gamble and to avoid relapse by becoming aware of which internal and external triggers are related to craving. We hypothesize that the integrated intervention will be more effective than simple CBT with regard to self-efficacy, craving, and gambling-related distortions. Four virtual ecological environments were developed, and a virtual app, Exludo, interfaced with a computerized multiparametric acquisition system for biofeedback, was created. A sample of about 60 patients aged between 18 and 65 with GD referring to the Addiction Medicine Unit of Verona (Rossi Hospital) will be recruited. Patients will be randomly assigned to the CBT group (16 CBT sessions) or the CBT + VR group (8 CBT sessions + 8 VR cue-exposure therapy sessions). The MCMI-III, the BIS-11, and the SOGS will be used to evaluate inclusion and exclusion criteria, while the Gambling Related Cognitions Scale and the Multidimensional Gambling Self-Efficacy Scale will be used to verify changes as a function of the treatment. Craving will be evaluated through VAS, and psychophysiological variables will be assessed through biofeedback. A pre-test/post-test experimental design with a 1-month follow-up will be conducted. This study will examine an innovative psychotherapeutic protocol for GD treatment, and it will help in identifying new virtual tools to increase the efficacy of traditional therapeutic approaches that could also be applied to treat other addictions.

Look at the Audience? A Randomized Controlled Study of Shifting Attention From Self-Focus to Nonsocial vs. Social External Stimuli During Virtual Reality Exposure to Public Speaking in Social Anxiety

Background: Enhanced self-focused attention plays a central role in the maintenance and treatment of Social Anxiety and is targeted in contemporary cognitive behavioral therapy. Actual developments use Virtual Reality (VR) for behavioral training. However, no VR attention training combining exposure to public speaking with shifting attention from self-focus to external focus has been investigated, and no experimental evidence exists on different kinds of external cues as targets of attention. Therefore, we investigated the effects of an attention training during public speaking in VR and examined differential effects of an external focus on nonsocial vs. social stimuli. Methods: In this randomized controlled study, highly socially anxious participants were instructed to focus on either objects or the audience within a virtual speech task. We assessed the pre-post effects on affective reactions, self-perception, and attentional processes during public speaking as well as general Social Anxiety using subjective, physiological, and eye-tracking measures. Repeated-measures analyses of variance (ANOVAs) were calculated to detect changes from pretest to posttest over both groups, and time × group interaction effects. Results: Within the analysis sample (n = 41), anxiety during public speaking and fear of negative evaluation significantly decreased, with no significant differences between groups. No significant time effect, but a significant time × group effect, was found for the looking time proportion on the audience members' heads. Follow-up tests confirmed a significant increase in the social-focus group and a significant decrease in the nonsocial-focus group. For all other variables, except external focus and fear of public speaking, significant improvements were found over both groups. Further significant time x group effects were found for positive affect during public speaking, with a significant increase in the social focus, and no significant change in the nonsocial-focus group. Conclusion: Our findings suggest that attention training to reduce self-focus can be successfully conducted in VR. Both training versions showed positive short-term effects in the highly socially anxious, with particular advantages of an external social focus concerning eye contact to the audience and positive affect. Further research should investigate whether social focus is even more advantageous long term and if reinterpretations of dysfunctional beliefs could be achieved by not avoiding social cues.

Exploring the Relationship Between Interpersonal Emotion Regulation and Social Anxiety Symptoms: The Mediating Role of Negative Mood Regulation Expectancies

Background

This study aimed to investigate the relationship between interpersonal emotion regulation (IER) and social anxiety symptoms and the mediating role of negative mood regulation expectancies (NMRE). We hypothesised that IER is positively associated with social anxiety symptoms, controlling for depression and intrapersonal emotion regulation strategies of suppression and reappraisal, and NMRE mediate this relationship.

Methods

Study 1 was conducted with a student sample (N = 400) and Study 2 included a community sample with 271 participants.

Results

Study 1 showed that, of four IER strategies, soothing and social modeling were positively, and perspective-taking was negatively related to social anxiety symptoms controlling for depression, suppression and reappraisal. Study 2 replicated these findings and extended them by showing the mediated relationship between the two IER strategies (i.e. enhancing positive affect and soothing) and social anxiety symptoms through NMRE.

Conclusions

The results contribute to the limited research on IER by portraying its relationship with social anxiety symptoms and revealing the mediating role of NMRE in this relationship.

Initial Maintenance of Attention to Threat in Children with Social Anxiety Disorder? Findings from an Eye-Tracking Experiment

Background

Attentional biases are assumed to be a core feature in the etiology and maintenance of clinical anxiety. The present study focuses on initial maintenance of attention to threat, one of three attentional components investigated the least, particularly in child anxiety.

Methods

Angry and neutral facial expressions were presented in a free-viewing task, while eye-movements were recorded. Participants were N = 96 school-aged children, with n = 50 children with a clinical social anxiety disorder (SAD) and n = 46 healthy control children (HC). Prior to the task, social stress was induced in half of participating children to investigate the impact of increased levels of distress on initial attention allocation.

Results

The length of first fixation to angry faces in children with SAD neither differed from the length of first fixation to neutral faces nor the length of first fixation to angry faces in HC children. Furthermore, this variable was not affected by a stress induction procedure. However, children with SAD initially fixated longer on faces than HC children.

Conclusion

Our findings provide evidence for difficulties disengaging attention from faces. This may indicate that attention allocation is determined by the social nature of the stimuli rather than by the specific emotional valence.

The Prevalence of Generalised Anxiety Disorder Among Prisoners of the Penitentiary Institution in North-Eastern Poland

Introduction: Generalised anxiety disorder (GAD) is one of the most common mental disorders. The psychosocial factors that may lead to generalised anxiety disorders include stress, traumatic events, conscious and unconscious internal conflicts, and low social and economic status. Imprisonment and forced isolation may favour the development of depression or anxiety disorders in inmates. Thus, this study aimed to analyse the prevalence of generalised anxiety disorder (GAD) in the population of inmates detained in one of the largest penitentiary units in north-eastern Poland. Materials and Methods: The data comes from 2017 and includes information on 635 male inmates incarcerated at the Czerwony Bór Prison. The information comes from the health records of individual inmates, kept by the prison outpatient clinician, and documented consultations with doctors of units outside the prison. The classification of generalised anxiety disorders (F41.1) was made in accordance with the 10th Revision of the International Statistical Classification of Diseases and Health Problems and the clinical diagnosis made by a psychiatrist. The Mann-Whitney test was used to compare quantitative data without normal distribution, chi-squared test or Fisher exact test for comparing qualitative data. A one-dimensional and multi-dimensional logistic regression model was used to examine the impact of the prison type on the prevalence of generalised anxiety disorder. Results: Generalised anxiety disorder was observed among 44 prisoners (6.9%), most often in the age range 30-39 years and among men younger than 30 years, respectively 40.9 and 31.8% of all diagnosed. The average age of patients was 34.6 years. The least number of prisoners with GAD was in the age group 50-59 (2.3%). Nearly 66% of patients were prisoners detained in a closed type prison; the chance of generalised anxiety disorder was three times higher than among the prisoners in a half-open and open type facility. Generalised anxiety disorder was diagnosed significantly more often with those currently serving a prison sentence than those before incarceration. Conclusions: In Polish conditions, the importance of the problem associated with GAD is evidenced by a significant increase in its prevalence in the prison environment and a three times higher chance of developing generalised anxiety disorder among prisoners in a closed type institution, which calls for highly organised psychiatric care and increased availability of psychological assistance for prisoners.

Impact of changes in social anxiety on social functioning and quality of life in outpatients with schizophrenia: A naturalistic longitudinal study

The prevalence of comorbid social anxiety disorder among patients with schizophrenia is currently attracting attention, and symptoms of social anxiety are reportedly associated with various clinical features. However, the contribution of social anxiety to social functioning and quality of life (QOL) over time remains obscure. The aim of this study was to examine the impact of changes in social anxiety symptoms on social functioning and QOL among outpatients with schizophrenia. Of the 207 outpatients who were eligible at baseline, 118 patients agreed with and completed a follow-up investigation at least 1 year (695.8 days on average) after the baseline study. Stepwise multiple regressions examining the change in social functioning using demographic data and changes in clinical variables as explanatory variables demonstrated that the changes in social anxiety and general psychopathology contributed to the change in the Social Functioning Scale, while the changes in clinical severity and negative symptoms contributed to the change in the Global Assessment of Functioning scale. Stepwise multiple regressions for the change in QOL demonstrated that the changes in social anxiety and depression contributed to the change in the World Health Organization QOL scale, Brief version, and the changes in social anxiety and positive symptoms contributed to the Subjective Well-being Under Neuroleptic Drug Treatment, Short Form. The results revealed that the changes in social anxiety symptoms were significantly associated with the change in functional outcome among patients with schizophrenia. Treatments targeting social anxiety seem to be key to achieving a full recovery in patients with schizophrenia.

Virtual Reality Therapy in Social Anxiety Disorder

PURPOSE OF REVIEW

This review provides an overview of current methods and important aspects to consider when applying virtual worlds in the treatment of social anxiety disorder (SAD).

RECENT FINDINGS

Different aspects such as dialogs between avatars and patients have been investigated as well as virtual audiences, emotional facial expression, and verbal interaction with avatars. Results of these studies are promising. Few randomized controlled trials (RCTs) have investigated the efficacy of virtual reality exposure therapy (VRET) in SAD. Unfortunately, most RCTs into the efficacy of VRET in comparison with exposure in vivo in SAD have been conducted with a combination of cognitive interventions and VRET. No differences between these conditions were found, but the pure effect of VRET as a stand-alone treatment has only been investigated in one RCT, wherein VRET was not superior to exposure in vivo. Current research into different facets of SAD and VRET has produced promising results with respect to technological aspects. No differences in efficacy between cognitive behavior therapy and VRET were found, but there is a clear need for studies investigating the efficacy of VRET as a stand-alone treatment and the therapeutic processes involved before this therapy can be disseminated in routine clinical practice.

Treatment Options for Fear of Blushing

PURPOSE OF REVIEW

To review mechanisms of blushing and fear of blushing from physiological, neuropharmacological and psychological viewpoints, and to evaluate current forms of treatment for blushing-related fear.

RECENT FINDINGS

Blushing appears to be driven primarily by sympathetic adrenomedullary and neural vasodilator discharge, possibly in association with secondary neurovascular inflammation. Psychological risk factors for fear of blushing include social anxiety, coupled with heightened self-focused attention and inflated beliefs about the likelihood and social costs of blushing. In addition, schemas of emotional inhibition, social isolation and alienation may underlie blushing-related fears. Established psychological treatments for fear of blushing include task concentration training, exposure, cognitive therapy, social skills training, psychoeducation and applied relaxation. More novel approaches include mindfulness and mindful self-compassion, video feedback and imagery rescripting. There are no established pharmacological treatments specifically for fear of blushing. However, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are effective treatments for social anxiety disorder and may thus help some patients manage their fear of blushing. A reactive sympathetic nervous system may interact with psychological predispositions to intensify fear of blushing. These physiological and psychological risk factors could be promising targets for treatment.