Intensive group cognitive treatment and individual cognitive therapy vs. treatment as usual in social phobia: a randomized controlled trial

The efficacy of psychotherapy for social anxiety disorder, a systematic review and meta-analysis

BACKGROUND

Given the growth in research examining the effects of psychotherapy on social anxiety disorder (SAD), an up-to-date comprehensive meta-analysis in this field is needed.

METHODS

We selected studies from a database of randomized trials (RCTs) on psychotherapies for anxiety disorders (last updated search of PubMed, PsycINFO, Embase, and Cochrane (CENTRAL): 1 January 2024) We included RCTs comparing psychotherapy to a control condition for adults with SAD and conducted random effects meta-analyses to examine the efficacy of psychotherapy compared to control conditions at post-treatment.

RESULTS

Sixty-six RCTs were included with 5560 participants and 98 comparisons between psychotherapy and control groups. Psychotherapy was effective in reducing SAD symptoms, with a large effect size (g = 0.88; 95 % CI: 0.76 to 1.0; I2 = 74 %; 95 % CI: 69 to 79, NNT = 3.8). Effects remained robust across sensitivity analyses. However, there was evidence for significant risk of bias in the included trials. The multivariable meta-regression indicated significant differences in treatment delivery formats, type of recruitment strategy, target group, and number of sessions.

CONCLUSION

Psychotherapy is an effective treatment for SAD, with moderate to large effect sizes across all treatment types and formats. Future research is needed to determine the long-term effects.

The Bergen 4-day treatment for social anxiety disorder: a pilot study

BACKGROUND

Few studies have examined the use of concentrated and intensified cognitive behaviour therapy for treating social anxiety disorder (SAD). The aim of this study was to examine the feasibility of the Bergen 4-Day Treatment (B4DT) for treating SAD.

METHODS

This study adopted an open trial design without a control group. Thirty consecutively referred patients who were diagnosed with SAD were treated and assessed at pre-treatment, at post-treatment, and at the 3-month follow-up. The Liebowitz Social Anxiety Scale was used to assess symptoms of SAD; the Generalized Anxiety Disorder-7 scale was used to assess anxiety symptoms; and the Patient Health Questionnaire-9 was used to assess symptoms of anxiety and depression. The Client Satisfaction Questionnaire-8 was administered posttreatment.

RESULTS

Overall, patients reported a high level of satisfaction with the B4DT. Large effect sizes were observed for symptoms of SAD (d = 1.94-2.66) and for the secondary outcomes, i.e., generalized anxiety (d = 0.86-0.99) and depression (d = 0.62-0.83). The remission rate was 55.2% at follow-up, while the treatment response rate was 89.7%.

CONCLUSIONS

The B4DT is a promising treatment approach for patients with SAD. In the future, controlled trials should be performed to compare the efficacy of this treatment approach with standard outpatient treatment. Practical consequences, policy implications, and suggestions for future research are discussed herein.

Cognitive behavioural therapy for social anxiety disorder in people with bipolar disorder: a case series

BACKGROUND

Social anxiety disorder increases the likelihood of unfavourable outcomes in people with bipolar disorder. Cognitive behavioural therapy (CBT) is the first-line treatment for social anxiety disorder. However, people with bipolar disorder have been excluded from the studies that this recommendation is based on.  METHOD: We completed a case series to obtain initial data on whether CBT is an acceptable, safe, and effective treatment for social anxiety disorder in people with bipolar disorder.

RESULTS

Eleven euthymic participants with bipolar disorder attended up to sixteen treatment and three follow-up sessions of CBT for social anxiety disorder. Participants attended on average 95% of the offered CBT sessions. No adverse events were reported. Participants' mean score on the Social Phobia Inventory decreased from 46.5 (SD 6.6) before the treatment to 19.8 (SD 11.9) at the end of the sixteen-session intervention and further to 15.8 (SD 10.3) by the end of the 3-month follow-up. This degree of improvement is equivalent to the effect observed in studies of CBT for social anxiety disorder in people without severe mental illness.

CONCLUSIONS

This case series provides preliminary evidence that CBT is acceptable, safe, and effective for treating social anxiety disorder in people with bipolar disorder during euthymia. A randomized controlled trial is needed to confirm these findings, and to establish whether treatment for social anxiety disorder improves the course of bipolar disorder.

More than doubling the clinical benefit of each hour of therapist time: a randomised controlled trial of internet cognitive therapy for social anxiety disorder

BACKGROUND

Cognitive therapy for social anxiety disorder (CT-SAD) is recommended by NICE (2013) as a first-line intervention. Take up in routine services is limited by the need for up to 14 ninety-min face-to-face sessions, some of which are out of the office. An internet-based version of the treatment (iCT-SAD) with remote therapist support may achieve similar outcomes with less therapist time.

METHODS

102 patients with social anxiety disorder were randomised to iCT-SAD, CT-SAD, or waitlist (WAIT) control, each for 14 weeks. WAIT patients were randomised to the treatments after wait. Assessments were at pre-treatment/wait, midtreatment/wait, posttreatment/wait, and follow-ups 3 & 12 months after treatment. The pre-registered (ISRCTN 95 458 747) primary outcome was the social anxiety disorder composite, which combines 6 independent assessor and patient self-report scales of social anxiety. Secondary outcomes included disability, general anxiety, depression and a behaviour test.

RESULTS

CT-SAD and iCT-SAD were both superior to WAIT on all measures. iCT-SAD did not differ from CT-SAD on the primary outcome at post-treatment or follow-up. Total therapist time in iCT-SAD was 6.45 h. CT-SAD required 15.8 h for the same reduction in social anxiety. Mediation analysis indicated that change in process variables specified in cognitive models accounted for 60% of the improvements associated with either treatment. Unlike the primary outcome, there was a significant but small difference in favour of CT-SAD on the behaviour test.

CONCLUSIONS

When compared to conventional face-to-face therapy, iCT-SAD can more than double the amount of symptom change associated with each therapist hour.

Sudden gains in face-to-face and internet-based cognitive therapy for social anxiety disorder

Sudden gains are large and stable decreases in clinical symptoms between consecutive therapy sessions. This work examined the frequency and possible determinants of sudden gains in Cognitive Therapy for Social Anxiety Disorder, comparing face-to-face (CT) and internet-based (iCT) formats of treatment delivery. Data from 99 participants from a randomised controlled trial were analysed. The frequency of sudden gains was high: 64% and 51% of participants experienced a sudden gain in CT and iCT respectively. Having a sudden gain was associated with lower social anxiety symptoms at posttreatment and follow-up. There was evidence of reductions in negative social cognitions and self-focused attention immediately prior to the sudden gain, contrasting with no prior reductions in depression symptoms. Ratings of session videotapes in CT showed that clients' statements indicated greater generalised learning in sessions immediately prior to gains, compared to control sessions. This may suggest a role for generalised learning in facilitating these large symptom reductions. There were no significant differences in results between the CT and iCT treatment formats, suggesting that the therapy content appears to play a more important role in determining participants' large symptom improvements than the medium of treatment delivery.

Preliminary Evaluation of Translated and Culturally Adapted Internet-Delivered Cognitive Therapy for Social Anxiety Disorder: Multicenter, Single-Arm Trial in Japan

BACKGROUND

Internet-delivered cognitive therapy for social anxiety disorder (iCT-SAD), which is a therapist-guided modular web-based treatment, has shown strong efficacy and acceptability in English-language randomized controlled trials in the United Kingdom and Hong Kong. However, it is not yet known whether iCT-SAD can retain its efficacy following linguistic translation and cultural adaptation of treatment contents and implementation in other countries such as Japan.

OBJECTIVE

This study aimed to examine the preliminary efficacy and acceptability of the translated and culturally adapted iCT-SAD in Japanese clinical settings.

METHODS

This multicenter, single-arm trial recruited 15 participants with social anxiety disorder. At the time of recruitment, participants were receiving usual psychiatric care but had not shown improvement in their social anxiety and required additional treatment. iCT-SAD was provided in combination with usual psychiatric care for 14 weeks (treatment phase) and for a subsequent 3-month follow-up phase that included up to 3 booster sessions. The primary outcome measure was the self-report version of the Liebowitz Social Anxiety Scale. The secondary outcome measures examined social anxiety-related psychological processes, taijin kyofusho (the fear of offending others), depression, generalized anxiety, and general functioning. The assessment points for the outcome measures were baseline (week 0), midtreatment (week 8), posttreatment (week 15; primary assessment point), and follow-up (week 26). Acceptability was measured using the dropout rate from the treatment, the level of engagement with the program (the rate of module completion), and participants' feedback about their experience with the iCT-SAD.

RESULTS

Evaluation of the outcome measures data showed that iCT-SAD led to significant improvements in social anxiety symptoms during the treatment phase (P<.001; Cohen d=3.66), and these improvements were maintained during the follow-up phase. Similar results were observed for the secondary outcome measures. At the end of the treatment phase, 80% (12/15) of participants demonstrated reliable improvement, and 60% (9/15) of participants demonstrated remission from social anxiety. Moreover, 7% (1/15) of participants dropped out during treatment, and 7% (1/15) of participants declined to undergo the follow-up phase after completing the treatment. No serious adverse events occurred. On average, participants completed 94% of the modules released to them. Participant feedback was positive and highlighted areas of strength in treatment, and it included further suggestions to improve suitability for Japanese settings.

CONCLUSIONS

Translated and culturally adapted iCT-SAD demonstrated promising initial efficacy and acceptability for Japanese clients with social anxiety disorder. A randomized controlled trial is required to examine this more robustly.

In the moment social experiences and perceptions of children with social anxiety disorder: A qualitative study

OBJECTIVES

Childhood social anxiety disorder (SAD) is a common and disabling condition. General forms of cognitive behavioural treatments have demonstrated poorer efficacy for childhood SAD when compared to other childhood anxiety disorders and further understanding of the psychological factors that contribute to the maintenance of childhood SAD is warranted. Examining the social experiences of children with SAD may help to identify relevant psychological factors and increase our understanding of what keeps childhood SAD going.

METHODS

The current study used reflexive thematic analysis to analyse the transcripts of interviews with 12 children aged 8-12 years with SAD who had been interviewed about their 'in the moment' social experiences during a social stress induction task. The interview topic guide included factors hypothesized to maintain SAD in adult cognitive models of the disorder.

RESULTS

The interviews revealed both variety and commonalities in the experiences and interpretations of social events in children with SAD, captured in three related main themes: (i) Discomfort being the centre of attention, (ii) (Lack of) awareness of cognitions and (iii) Managing social fears. Findings indicated likely developmental influences on which maintenance mechanisms apply at which point in time.

CONCLUSIONS

There is variation in the psychological mechanisms that children with SAD endorse and developmental factors are likely to influence when specific mechanisms are relevant. We now need further studies that take a developmentally informed approach to understand the nature of the association between the factors identified in this study and social anxiety in childhood to inform the development of more effective interventions for childhood SAD.

Feasibility of an Intensive, Disorder-Specific, Group-Based Cognitive Behavioural Therapy Intervention for Adolescents with Social Anxiety Disorder

This study examined the preliminary acceptability and efficacy of an intensive, group-based, disorder-specific cognitive behavioural therapy (CBT) intervention for adolescents with social anxiety disorder (SAD). Fourteen Australian adolescents with SAD (78.6% female, M age = 13.93 years) and their parents completed the program plus measures of treatment satisfaction, and provided feedback. Clinical interviews and surveys were administered pre-treatment, post-treatment, and at 6-month follow-up to determine diagnostic status and assess related variables. Post-treatment satisfaction scores were very high for adolescents and parents. Post-treatment, 32.3% of participants no longer met criteria for SAD diagnosis, increasing to 42.9% at follow-up. Participants showed sizeable reductions in comorbid diagnoses, significant improvements in global functioning, social anxiety symptoms, and internalising symptoms from pre- to post-treatment (maintained at follow-up), and significant improvements in social skills and social competence from pre-treatment to follow-up. This study supports the use of an intensive CBT program for adolescents with SAD.

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.

Group cognitive behavioural therapy with virtual reality exposure versus group cognitive behavioural therapy with in vivo exposure for social anxiety disorder and agoraphobia: a protocol for a randomised clinical trial

INTRODUCTION

Anxiety disorders have a high lifetime prevalence, early-onset and long duration or chronicity. Exposure therapy is considered one of the most effective elements in cognitive behavioural therapy (CBT) for anxiety, but in vivo exposure can be challenging to access and control, and is sometimes rejected by patients because they consider it too aversive. Virtual reality allows flexible and controlled exposure to challenging situations in an immersive and protected environment.

AIM

The SoREAL-trial aims to investigate the effect of group cognitive behavioural therapy (CBT-in vivo) versus group CBT with virtual reality exposure (CBT-in virtuo) for patients diagnosed with social anxiety disorder and/or agoraphobia, in mixed groups.

METHODS AND ANALYSIS

The design is an investigator-initiated randomised, assessor-blinded, parallel-group and superiority-designed clinical trial. Three hundred two patients diagnosed with social anxiety disorder and/or agoraphobia will be included from the regional mental health centres of Copenhagen and North Sealand and the Northern Region of Denmark. All patients will be offered a manual-based 14-week cognitive behavioural group treatment programme, including eight sessions with exposure therapy. Therapy groups will be centrally randomised with concealed allocation sequence to either CBT-in virtuo or CBT-in vivo. Patients will be assessed at baseline, post-treatment and 1-year follow-up by treatment blinded researchers and research assistants. The primary outcome will be diagnosis-specific symptoms measured with the Liebowitz Social Anxiety Scale for patients with social anxiety disorder and the Mobility Inventory for Agoraphobia for patients with agoraphobia. Secondary outcome measures will include depression symptoms, social functioning and patient satisfaction. Exploratory outcomes will be substance and alcohol use, working alliance and quality of life.

ETHICS AND DISSEMINATION

The trial has been approved by the research ethics committee in the Capital Region of Denmark. All results, positive, negative as well as inconclusive, will be published as quickly as possible and still in concordance with Danish law on the protection of confidentially and personal information. Results will be presented at national and international scientific conferences. The trial has obtained approval by the Regional Ethics Committee of Zealand (H-6-2013-015) and the Danish Data Protection Agency (RHP-2014-009-02670). The trial is registered at ClinicalTrial.gov as NCT03845101. The patients will receive information on the trial both verbally and in written form. Written informed consent will be obtained from each patient before inclusion in the trial. The consent form will be scanned and stored in the database system and the physical copy will be destroyed. It is emphasised that participation in the trial is voluntary and that the patient can withdraw his or her consent at any time without consequences for further and continued treatment.

TRIAL REGISTRATION NUMBER

NCT03845101.

Group autonomy enhancing treatment versus cognitive behavioral therapy for anxiety disorders: A cluster-randomized clinical trial

BACKGROUND

Although cognitive behavioral therapy (CBT) is effective in the treatment of anxiety disorders, few evidence-based alternatives exist. Autonomy enhancing treatment (AET) aims to decrease the vulnerability for anxiety disorders by targeting underlying autonomy deficits and may therefore have similar effects on anxiety as CBT, but yield broader effects.

METHODS

A multicenter cluster-randomized clinical trial was conducted including 129 patients with DSM-5 anxiety disorders, on average 33.66 years of age (SD = 12.57), 91 (70.5%) female, and most (92.2%) born in the Netherlands. Participants were randomized over 15-week groupwise AET or groupwise CBT and completed questionnaires on anxiety, general psychopathology, depression, quality of life, autonomy-connectedness and self-esteem, pre-, mid-, and posttreatment, and after 3, 6, and 12 months (six measurements).

RESULTS

Contrary to the hypotheses, effects on the broader outcome measures did not differ between AET and CBT (d = .16 or smaller at post-test). Anxiety reduction was similar across conditions (d = .059 at post-test) and neither therapy was superior on long term.

CONCLUSION

This was the first clinical randomized trial comparing AET to CBT. The added value of AET does not seem to lie in enhanced effectiveness on broader outcome measures or on long term compared to CBT. However, the study supports the effectiveness of AET and thereby contributes to extended treatment options for anxiety disorders.

Examining the relationship between shame and social anxiety disorder: A systematic review

This paper is the first systematic review of the literature on the relationship between shame and social anxiety (SA). We reviewed a total of 60 peer-reviewed empirical articles that met criteria for inclusion. We begin by summarizing literature investigating the empirical association between shame and SA and review literature on whether this association is impacted by cultural or diagnostic differences. Next, we briefly describe the updated version of Rapee and Heimberg's (1997) cognitive-behavioral model of social anxiety disorder (SAD; Heimberg, Brozovich, & Rapee, 2014) and propose how shame may interact with five processes described therein: environmental experiences, observations/images of the self, perceived negative evaluation by others, post-event cognitive processes, and behavioral manifestations of SA. We review the current literature on shame and SA as it relates to each of these domains. Thereafter, we discuss existing research on the role of shame in the treatment of SAD and the implications of the research discussed in this review. Finally, we conclude with a discussion of some key limitations in the existing literature and areas for future research.

Delivering cognitive therapy for adolescent social anxiety disorder in NHS CAMHS: a clinical and cost analysis

BACKGROUND

Cognitive therapy, based on the Clark and Wells (1995) model, is a first-line treatment for adults with social anxiety disorder (SAD), and findings from research settings suggest it has promise for use with adolescents (Cognitive Therapy for Social Anxiety Disorder in Adolescents; CT-SAD-A). However, for the treatment to be suitable for delivery in routine clinical care, two questions need to be addressed.

AIMS

Can therapists be trained to achieve good outcomes in routine Child and Adolescent Mental Health Services (CAMHS), and what are the costs associated with training and treatment?

METHOD

CAMHS therapists working in two NHS trusts received training in CT-SAD-A. They delivered the treatment to adolescents with SAD during a period of supervised practice. We examined the clinical outcomes for the 12 patients treated during this period, and estimated costs associated with treatment and training.

RESULTS

Treatment produced significant improvements in social anxiety symptoms, general anxiety and depression symptoms, and reductions in putative process measures. Seventy-five per cent (9 out of 12) patients showed a reliable and clinically significant improvement in social anxiety symptoms, and 64% (7/11) lost their primary diagnosis of SAD. The total cost to the NHS of the CT-SAD-A treatment was £4047 (SD = £1003) per adolescent treated, of which £1861 (SD = £358) referred to the specific estimated cost of face-to-face delivery; the remaining cost was for training and supervising therapists who were not previously familiar with the treatment.

CONCLUSIONS

This study provides preliminary evidence that clinicians can deliver good patient outcomes for adolescents with SAD in routine CAMHS during a period of supervised practice after receiving a 2-day training workshop. Furthermore, the cost of delivering CT-SAD-A with adolescents appeared to be no more than the cost of delivering CT-SAD with adults.

Individual vs. Group Cognitive Behavior Therapy for Anxiety Disorder in Children and Adolescents: A Meta-Analysis of Randomized Controlled Trials

Background: Anxiety disorder is the most prevalent mental disorder in children and adolescents. However, evidence for efficacy and acceptability between individual cognitive behavior therapy (I-CBT) and group cognitive behavior therapy (G-CBT) in anxiety disorders in children and adolescents remains unclear. Methods: Eight electronic databases (PubMed, Embase, Cochrane, Web of Science, CINAHL, PsycINFO, ProQuest, and LILACS) were searched from inception to October 2019. Randomized controlled trials comparing I-CBT with G-CBT for anxiety disorders in children and adolescents were included. The primary outcomes were efficacy (mean change in anxiety symptom scores) at post-treatment and acceptability (all-cause discontinuation). The secondary outcome was remission at post-treatment. Subgroup analyses were also conducted to examine whether the result would be influenced by age, number of treatment sessions, parental involvement, male/female sex, and number of participants. Results: Nine studies were selected in this meta-analysis. The pooled analyses indicated no significant difference between I-CBT and G-CBT for efficacy at post-treatment [standardized mean difference (SMD), -0.14; 95% confidence interval (CI), -0.37 to 0.09], acceptability [odds ratio (OR), 1.30; 95% CI, 0.61-2.77], and remission at post-treatment (OR, 1.15; 95% CI, 0.79-1.66). In the subgroup analysis of age, I-CBT was significantly more effective than G-CBT in adolescents at post-treatment (SMD, -0.77; 95% CI, -1.51 to -0.02), but not in children (SMD, 0.00; 95% CI, -0.02 to 0.20). However, the findings were not materially different from those of the efficacy subgroup analysis of number of treatment sessions, parental involvement, male/female sex, and number of participants. Conclusions: Based on those current evidence, I-CBT was shown to be more beneficial than G-CBT for anxiety disorders in adolescents, but not in children. However, further well-designed clinical studies should be performed to confirm these findings. Systematic Review Registration:http://osf.io/xrjkp, identifier: 10.17605/OSF.IO/XRJKP.

Are young people with primary social anxiety disorder less likely to recover following generic CBT compared to young people with other primary anxiety disorders? A systematic review and meta-analysis

Background:

Social anxiety disorder (SoAD) in youth is often treated with a generic form of cognitive behavioural therapy (CBT). Some studies have suggested that primary SoAD is associated with lower recovery rates following generic CBT compared with other anxiety disorders.

Aims:

This systematic review and meta-analysis investigated recovery rates following generic CBT for youth with primary SoAD versus other primary anxiety disorders.

Method:

Five databases (PsycINFO, Web of Science, PubMed, Embase, Medline) were searched for randomised controlled trials of generic CBT for child and/or adolescent anxiety.

Results:

Ten trials met criteria for inclusion in the systematic review, six of which presented sufficient data for inclusion in the meta-analysis. Sixty-seven did not report data on recovery rates relative to primary diagnosis. While most individual studies included in the systematic review were not sufficiently powered to detect a difference in recovery rates between diagnoses, there was a pattern of lower recovery rates for youth with primary SoAD. Across the trials included in the meta-analysis, the post-CBT recovery rate from primary SoAD (35%) was significantly lower than the recovery rate from other primary anxiety disorders (54%).

Conclusions:

Recovery from primary SoAD is significantly less likely than recovery from any other primary anxiety disorder following generic CBT in youth. This suggests a need for research to enhance the efficacy of CBT for youth SoAD.

The Relationship between Symptoms and Social Functioning over the Course of Cognitive Behavioral Therapy for Social Anxiety Disorder

Background

The present study is aimed at investigating the relationship between changes in symptoms and changes in social functioning during cognitive behavioral therapy (CBT) for social anxiety disorder (SAD).

Methods

Ninety-six patients with SAD were treated with manualized group CBT. Measures of social anxiety symptoms, depression symptoms, cognition, and social functioning were administered at baseline and endpoint. Using multiple regression analysis, we examined the associations between the changes in four aspects (work, home management, social leisure activities, and private leisure activities) of social functioning as dependent variables and the changes in four factors (social interaction, public speaking, observation by others, and eating and drinking in public) in social anxiety symptoms, depression symptoms, and cognition as independent variables.

Results

The changes in work functioning were predicted by the changes in the public speaking factor in social anxiety symptoms. The changes in depression symptoms predicted the changes in home management. The significant predictors of changes in social leisure activities were the changes in the social interaction factor and depression symptoms. The changes in private leisure activities were predicted by the changes in the observation by others factor. The changes in cognition predicted nothing.

Conclusion

The present study suggested that the changes in social anxiety or depression symptoms may predict several aspects of social functioning changes in patients with SAD over the course of CBT. In order to improve social functioning, our results may be useful for selecting the fear or feared situation in CBT for SAD. Trial Registration. The clinical study registration number in the Japanese trials registry is UMIN CTR 000031147.

Treating social anxiety disorder remotely with cognitive therapy

Remote delivery of evidence-based psychological therapies via video conference has become particularly relevant following the COVID-19 pandemic, and is likely to be an on-going method of treatment delivery post-COVID. Remotely delivered therapy could be of particular benefit for people with social anxiety disorder (SAD), who tend to avoid or delay seeking face-to-face therapy, often due to anxiety about travelling to appointments and meeting mental health professionals in person. Individual cognitive therapy for SAD (CT-SAD), based on the Clark and Wells (1995) model, is a highly effective treatment that is recommended as a first-line intervention in NICE guidance (NICE, 2013). All of the key features of face-to-face CT-SAD (including video feedback, attention training, behavioural experiments and memory-focused techniques) can be adapted for remote delivery. In this paper, we provide guidance for clinicians on how to deliver CT-SAD remotely, and suggest novel ways for therapists and patients to overcome the challenges of carrying out a range of behavioural experiments during remote treatment delivery.

Condensing parent training: A randomized trial comparing the efficacy of a briefer, more intensive version of Parent-Child Interaction Therapy (I-PCIT)

OBJECTIVE

The current study examined the comparative efficacy of a more intensive version of Parent-Child Interaction Therapy (I-PCIT; 5 days/week over 2 weeks) versus a time-limited weekly PCIT format (1 day/week over 10 weeks) in treating early childhood externalizing behavior problems.

METHOD

Using a randomized trial design, 60 young children (mean age [Mage] = 4.33 years; 65% male; 85% Latinx) with clinically elevated levels of externalizing behavior problems and their parents were assigned to either I-PCIT (n = 30) or time-limited PCIT (n = 30). Families completed pre-, post-, and follow-up assessments 6-9 months following treatment completion. Parents completed measures of child behavior, discipline practices, and parenting stress. Observational data on child behavior and parenting were also collected.

RESULTS

Noninferiority and multivariate repeated-measures analyses indicated comparable improvements across 6 out of 7 observed and parent-reported outcomes, including parenting skills, discipline practices, and child externalizing behavior problems at posttreatment. Comparable treatment gains remained at follow-up, with the caveat that parents in time-limited PCIT reported lower externalizing behavior problems compared with I-PCIT, although both groups were still significantly better compared with pretreatment. Lastly, moderation analyses indicated that parents experiencing high levels of stress benefited more from I-PCIT in terms of decreasing child externalizing behavior compared with time-limited PCIT.

CONCLUSIONS

I-PCIT appears to be a viable treatment option for families, especially those experiencing high levels of stress, in terms of targeting early externalizing behavior problems within a short period of time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

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.

Efficacy of Behavioral Experiments in Cognitive Therapy for Social Anxiety Disorder: Study protocol for a randomized controlled trial

Background

While the efficacy of cognitive therapy (CT) has been well established for social anxiety disorder (SAD) in several randomized controlled trials, there are still large differences between trials with respect to effect sizes. The present study investigates the question of whether enhanced training and the use of behavioral experiments (BEs) increases the efficacy of traditional CT, based on verbal methods of cognitive restructuring.

Methods/design

A mixed within/between conditions design will be applied, with therapists and patients being randomly allocated to one of two conditions: (1) training of CT plus BEs, (2) training of CT “as usual”.

Sixty patients with the primary diagnosis of SAD will be recruited and treated in the outpatient clinic of the Department of Psychology, University of Frankfurt. To ensure adherence to therapist protocols, all therapists will be trained and supervised by the project coordinators. In addition, videotaped treatment sessions will be independently evaluated to guarantee both adherence to protocols and the quality of the intervention. Treatment effects will be assessed by independent SAD symptom ratings using the Liebowitz Social Anxiety Scale as the primary outcome measure and self-report measures as secondary outcome measures.

Discussion

The present cognitive behavioral therapy (CBT) trial will be the first to clarify the contribution of BEs to the efficacy of CT in a randomized controlled design. Study results are relevant to clinical training and implementation of evidence-based treatments.

Trial registration

German Clinical Trials Register International Clinical Trials Registry Platform (ICTRP) identifier: DRKS00014349. Trial status: recruiting.

Sub-types of safety behaviours and their effects on social anxiety disorder

Cognitive models suggest that social anxiety disorder (SAD) is maintained through the use of safety behaviours. Previous reports propose that these safety behaviours can be subdivided into two main categories: avoidance and impression management. Study 1 investigates whether certain safety behaviours are specific to SAD. The social behaviour questionnaire was administered to individuals with SAD (N = 106), post-traumatic stress disorder (N = 28) and non-patient controls (N = 59). A factor analysis (N = 164) replicated the previously reported avoidance and impression management subtypes. Scores for both subtypes were significantly higher in individuals with SAD than in individuals with post-traumatic stress disorder or non-patient controls. Study 2 investigated the causal role of such safety behaviours using an experimental design in a non-clinical population (N = 96). Pairs of participants each engaged in two conversations. In one of the conversations, a randomly selected participant performed either avoidance or impression management safety behaviours. In the other conversation, neither participant was instructed to use safety behaviours. Each participant rated their own anxiety and performance as well as rating the other person. Videos of the conversations were also rated. Both types of safety behaviour increased anxiety in the person performing the safety behaviour. The avoidance subtype also had broader effects on the other person that were largely absent from the impression management subtype. Taken together the studies provide support for the distinction between safety behaviour subtypes and have implications for the treatment of SAD.

Internet-Based Cognitive Therapy for Social Anxiety Disorder in Hong Kong: Therapist Training and Dissemination Case Series

BACKGROUND

Guided internet-based psychological interventions show substantial promise for expanding access to evidence-based mental health care. However, this can only be achieved if results of tightly controlled studies from the treatment developers can also be achieved in other independent settings. This dissemination depends critically on developing efficient and effective ways to train professionals to deliver these interventions. Unfortunately, descriptions of therapist training and its evaluation are often limited or absent within dissemination studies.

OBJECTIVE

This study aimed to describe and evaluate a program of therapist training to deliver internet-based Cognitive Therapy for social anxiety disorder (iCT-SAD). As this treatment was developed in the United Kingdom and this study was conducted in Hong Kong with local therapists, an additional objective was to examine the feasibility, acceptability, and initial efficacy of iCT-SAD in this cultural context, based on data from a pilot case series.

METHODS

Training in iCT-SAD was provided to 3 therapists and included practice of the face-to-face format of therapy under clinical supervision, training workshops, and treating 6 patients with the iCT-SAD program. Training progress was evaluated using standardized and self-report measures and by reviewing patient outcomes. In addition, feedback from patients and therapists was sought regarding the feasibility and acceptability of the program.

RESULTS

The training program was effective at increasing therapists' iCT-SAD knowledge and skills, resulting in levels of competence expected of a specialist Cognitive Behavioral Therapy practitioner. The 6 patients treated by the trainees all completed their treatment and achieved a mean pre- to posttreatment change of 53.8 points (SD 39.5) on the primary patient outcome measure, the Liebowitz Social Anxiety Scale. The within-group effect size (Cohen d) was 2.06 (95% CI 0.66-3.46). There was evidence to suggest that the patients' clinical outcomes were sustained at 3-month follow-up. These clinical results are comparable to those achieved by UK patients treated by the developers of the internet program. Patient and therapist feedback did not identify any major cultural barriers to implementing iCT-SAD in Hong Kong; some modest language suggestions were made to assist understanding.

CONCLUSIONS

The therapist training implemented here facilitated the successful dissemination of an effective UK-developed internet intervention to Hong Kong. The treatment appeared feasible and acceptable in this setting and showed highly promising initial efficacy. A randomized controlled trial is now required to examine this more robustly. As therapist training is critical to the successful dissemination of internet interventions, further research to develop, describe, and evaluate therapist training procedures is recommended.

Inflated sense of responsibility, explanatory style and the cognitive model of social anxiety disorder: a brief report of a case control study

We sought to investigate situation-specific inflated sense of responsibility and explanatory style in social anxiety disorder (SAD) according to the cognitive model. Participants aged 17–68 years (mean = 31.9, SD = 11.1) included waiting list patients referred to a primary care mental health service for cognitive behavioural therapy for SAD (n = 18) and non-anxious control participants (n = 65). A battery of psychometric measures, including a bespoke measure of responsibility beliefs, was used. Compared with controls, participants with SAD were more likely to demonstrate an inflated sense of responsibility (p ≤ 0.001), and to adopt a negative explanatory style specific to social interaction (p ≤ 0.01). Inflated sense of responsibility was found to correlate with SAD symptomatology (r = 0.47, p ≤ 0.05), and with increased usage of safety behaviours (r = 0.47, p ≤ 0.05). Caseness (β = 1.45, p ≤ 0.01) and stability of causal attribution (β = 0.25, p ≤ 0.001) were found to predict inflated responsibility in our sample. To our knowledge this study represents the first attempt to investigate inflated responsibility within the context of SAD. Our results support the notion of inflated responsibility as a feature of SAD.

Key learning aims

(1)

Understanding Social Anxiety Disorder in Adolescents and Improving Treatment Outcomes: Applying the Cognitive Model of Clark and Wells (1995)

Social anxiety disorder is a condition characterised by a marked and persistent fear of being humiliated or scrutinised by others. Age-of-onset data point to adolescence as a developmentally sensitive period for the emergence of the condition, at a time when the peer group becomes increasingly important. Social anxiety in adolescence is associated with considerable impairment that persists through to adulthood. There are clear potential benefits to delivering effective interventions during adolescence. However, there is limited evidence on the specific efficacy of available therapies. This is in contrast to adults, for whom we have interventions with very specific treatment effects. One such treatment is individual cognitive therapy. Cognitive therapy is based on the cognitive model of social anxiety proposed by Clark and Wells (in: Heimberg, Leibowitz, Hope, Scheiber (eds) Social phobia: diagnosis, assessment and treatment, The Guilford Press, New York, 1995). The present review examines the potential application of this adult cognitive model to the understanding of adolescent social anxiety and considers additional adolescent-specific factors that need to be accommodated. It is suggested that a developmentally sensitive adoption of the cognitive model of social anxiety disorder (Clark and Wells 1995) for adolescents may lead to better treatment outcomes.

Imagery rescripting of traumatic memories for panic disorder: an exploratory study

Imagery rescripting (ImRs) is a psychological intervention designed to change the meaning of images and associated memories and reduce emotional distress. Recent studies have shown that ImRs can be successfully applied to many psychological problems and disorders; however, little has been reported on the application of ImRs for panic disorder (PD). Consequently, we explored the therapeutic effects of ImRs on patients with PD. Fifteen patients with PD received 16 individual cognitive behavioural therapy (CBT) sessions weekly, including one ImRs session. Early traumatic memories associated with recurrent images in panic situations were identified and rescripted to alleviate maladaptive encapsulated beliefs. ImRs ratings (vividness and distress of the images and memories and conviction degree of encapsulated beliefs) were measured prior to and after ImRs. Self-negative contents not directly related to symptoms of panic attack were observed as common themes in the worst meaning of the image, the memory, and in the encapsulated belief. Whilst five (33%) patients had anticipatory anxiety, 10 (67%) patients had other self-negative beliefs. ImRs significantly reduced distress from images, memories and encapsulated beliefs; however, it did not change the vividness of images and memories. There was no significant correlation between the reduction in PD severity over the CBT program and the change in each ImRs rating. The results of this study are promising for certain aspects of panic disorder. However, further research is needed to overcome the limitations of this study.

Accelerated Outpatient Individual Cognitive Behavioural Therapy for Social Anxiety Disorder: A Preliminary Pilot Study

Background: Social anxiety disorder (SAD) is a common and chronic mental health condition. Given the significant prevalence and impairment caused by SAD, it is important to investigate novel ways to improve the efficacy of cognitive behavioural therapy (CBT) for SAD. One approach may be to provide CBT in an accelerated fashion, which involves multiple sessions per week. Such accelerated treatments have been shown to be effective in other anxiety disorders, but in SAD this accelerated treatment has only been studied in a group treatment format. Aims: The aim of this study was to provide a preliminary investigation of the efficacy of individual accelerated CBT (aCBT) in the treatment of SAD. Method: The studied utilized an open trial design. Seventeen participants commenced the treatment, which consisted of 12 sessions delivered over 4 weeks. Results: The results indicated that participants obtained moderate to large effect sizes on measures of SAD at post-treatment (range d = 0.76–0.92) and 3-month follow-up (range d = 1.31–1.79). In addition, at post-treatment, 59% of participants no longer met criteria for SAD, and this number increased to 71% at 3-month follow-up. Conclusions: The results provide preliminary evidence to suggest that individual aCBT may be an important treatment option for individuals with SAD.

Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions

This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.

Pharmacotherapy for social anxiety disorder (SAnD)

BACKGROUND

Recognition is growing that social anxiety disorder (SAnD) is a chronic and disabling disorder, and data from early trials demonstrate that medication may be effective in its treatment. This systematic review is an update of an earlier review of pharmacotherapy of SAnD.

OBJECTIVES

To assess the effects of pharmacotherapy for social anxiety disorder in adults and identify which factors (methodological or clinical) predict response to treatment.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR-Studies and CCMDCTR-References) to 17 August 2015. The CCMDCTR contains reports of relevant RCTs from MEDLINE (1950-), Embase (1974-), PsycINFO (1967-) and CENTRAL (all years). We scanned the reference lists of articles for additional studies. We updated the search in August 2017 and placed additional studies in Awaiting Classification, these will be incorporated in the next version of the review, as appropriate.

SELECTION CRITERIA

We restricted studies to randomised controlled trials (RCTs) of pharmacotherapy versus placebo in the treatment of SAnD in adults.

DATA COLLECTION AND ANALYSIS

Two authors (TW and JI) assessed trials for eligibility and inclusion for this review update. We extracted descriptive, methodological and outcome information from each trial, contacting investigators for missing information where necessary. We calculated summary statistics for continuous and dichotomous variables (if provided) and undertook subgroup and sensitivity analyses.

MAIN RESULTS

We included 66 RCTs in the review (> 24 weeks; 11,597 participants; age range 18 to 70 years) and 63 in the meta-analysis. For the primary outcome of treatment response, we found very low-quality evidence of treatment response for selective serotonin reuptake inhibitors (SSRIs) compared with placebo (number of studies (k) = 24, risk ratio (RR) 1.65; 95% confidence interval (CI) 1.48 to 1.85, N = 4984). On this outcome there was also evidence of benefit for monoamine oxidase inhibitors (MAOIs) (k = 4, RR 2.36; 95% CI 1.48 to 3.75, N = 235), reversible inhibitors of monoamine oxidase A (RIMAs) (k = 8, RR 1.83; 95% CI 1.32 to 2.55, N = 1270), and the benzodiazepines (k = 2, RR 4.03; 95% CI 2.45 to 6.65, N = 132), although the evidence was low quality. We also found clinical response for the anticonvulsants with gamma-amino butyric acid (GABA) analogues (k = 3, RR 1.60; 95% CI 1.16 to 2.20, N = 532; moderate-quality evidence). The SSRIs were the only medication proving effective in reducing relapse based on moderate-quality evidence. We assessed tolerability of SSRIs and the serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine on the basis of treatment withdrawal; this was higher for medication than placebo (SSRIs: k = 24, RR 2.59; 95% CI 1.97 to 3.39, N = 5131, low-quality evidence; venlafaxine: k = 4, RR 3.23; 95% CI 2.15 to 4.86, N = 1213, moderate-quality evidence), but there were low absolute rates of withdrawal for both these medications classes compared to placebo. We did not find evidence of a benefit for the rest of the medications compared to placebo.For the secondary outcome of SAnD symptom severity, there was benefit for the SSRIs, the SNRI venlafaxine, MAOIs, RIMAs, benzodiazepines, the antipsychotic olanzapine, and the noradrenergic and specific serotonergic antidepressant (NaSSA) atomoxetine in the reduction of SAnD symptoms, but most of the evidence was of very low quality. Treatment with SSRIs and RIMAs was also associated with a reduction in depression symptoms. The SSRIs were the only medication class that demonstrated evidence of reduction in disability across a number of domains.We observed a response to long-term treatment with medication for the SSRIs (low-quality evidence), for the MAOIs (very low-quality evidence) and for the RIMAs (moderate-quality evidence).

AUTHORS' CONCLUSIONS

We found evidence of treatment efficacy for the SSRIs, but it is based on very low- to moderate-quality evidence. Tolerability of SSRIs was lower than placebo, but absolute withdrawal rates were low.While a small number of trials did report treatment efficacy for benzodiazepines, anticonvulsants, MAOIs, and RIMAs, readers should consider this finding in the context of potential for abuse or unfavourable side effects.

Social anxiety in pre-adolescent children: What do we know about maintenance?

The cognitive theory of social anxiety disorder (SAD) is one of the most widely accepted accounts of the maintenance of the disorder in adults, yet it remains unknown if, or to what extent, the same cognitive and behavioral maintenance mechanisms that occur in adult SAD also apply to SAD among pre-adolescent children. In contrast to the adult literature, current models of SAD in children mostly account for etiology and maintenance processes are given limited attention. Consequently, their clinical utility for the treatment of SAD in children may be limited. This narrative review, first, critically examines the different theoretical conceptualizations of the maintenance of social anxiety in the child and adult literature and illustrates how these have resulted in different treatment approaches and clinical understanding. Second, it reviews the available evidence relating to hypotheses about the maintenance of SAD in children as derived from adult cognitive and etiological models. Third, it highlights the need to attend directly to child specific maintenance mechanisms in SAD, to draw on cognitive theory, and to account for the influence of childhood-specific contextual (e.g. family and school-based interactions) and developmental factors on children's social experiences.

Cognitive Behavioral Therapy for Patients with Social Anxiety Disorder Who Remain Symptomatic following Antidepressant Treatment: A Randomized, Assessor-Blinded, Controlled Trial

BACKGROUND

Although antidepressants are still a commonly used treatment for social anxiety disorder (SAD), a significant proportion of patients fail to remit following antidepressants. However, no standard approach has been established for managing such patients. This study aimed to examine the effectiveness of cognitive behavioral therapy (CBT) as an adjunct to usual care (UC) compared with UC alone in SAD patients who remain symptomatic following antidepressant treatment.

METHODS

This was a prospective randomized open-blinded end-point study with two parallel groups (CBT + UC, and UC alone, both for 16 weeks) conducted from June 2012 to March 2014. SAD patients who remain symptomatic following antidepressant treatment were recruited, and a total sample size of 42 was set based on pilot results.

RESULTS

Patients were randomly allocated to CBT + UC (n = 21) or UC alone (n = 21). After 16 weeks, adjusted mean reduction in the Liebowitz Social Anxiety Scale from baseline for CBT + UC and UC alone was -40.87 and 0.68, respectively; the between-group difference was -41.55 (-53.68 to -29.42, p < 0.0001). Response rates were 85.7 and 10.0% for CBT + UC and UC alone, respectively (p < 0.0001). The corresponding remission rates were 47.6 and 0.0%, respectively (p = 0.0005). Significant differences were also found in favor of CBT + UC for social anxiety symptoms, depressive symptoms, and functional impairment.

CONCLUSIONS

Our results suggest that in SAD patients who have been ineffectively treated with antidepressants, CBT is an effective treatment adjunct to UC over 16 weeks in reducing social anxiety and related symptoms.

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

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

Factor solutions of the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS) in a Swedish population

Culturally validated rating scales for social anxiety disorder (SAD) are of significant importance when screening for the disorder, as well as for evaluating treatment efficacy. This study examined construct validity and additional psychometric properties of two commonly used scales, the Social Phobia Scale and the Social Interaction Anxiety Scale, in a clinical SAD population (n = 180) and in a normal population (n = 614) in Sweden. Confirmatory factor analyses of previously reported factor solutions were tested but did not reveal acceptable fit. Exploratory factor analyses (EFA) of the joint structure of the scales in the total population yielded a two-factor model (performance anxiety and social interaction anxiety), whereas EFA in the clinical sample revealed a three-factor solution, a social interaction anxiety factor and two performance anxiety factors. The SPS and SIAS showed good to excellent internal consistency, and discriminated well between patients with SAD and a normal population sample. Both scales showed good convergent validity with an established measure of SAD, whereas the discriminant validity of symptoms of social anxiety and depression could not be confirmed. The optimal cut-off score for SPS and SIAS were 18 and 22 points, respectively. It is concluded that the factor structure and the additional psychometric properties of SPS and SIAS support the use of the scales for assessment in a Swedish population.

Changes in the self during cognitive behavioural therapy for social anxiety disorder: A systematic review

A consistent feature across cognitive-behavioural models of social anxiety disorder (SAD) is the central role of the self in the emergence and maintenance of the disorder. The strong emphasis placed on the self in these models and related empirical research has also been reflected in evidence-based treatments for the disorder. This systematic review provides an overview of the empirical literature investigating the role of self-related constructs (e.g., self-beliefs, self-images, self-focused attention) proposed in cognitive models of SAD, before examining how these constructs are modified during and following CBT for SAD. Forty-one studies met the inclusion criteria. Guided by Stopa's (2009a, b) model of self, most studies examined change in self-related content, followed by change in self-related processing. No study examined change in self-structure. Pre- to post-treatment reductions were observed in self-related thoughts and beliefs, self-esteem, self-schema, self-focused attention, and self-evaluation. Change in self-related constructs predicted and/or mediated social anxiety reduction, however relatively few studies examined this. Papers were limited by small sample sizes, failure to control for depression symptoms, lack of waitlist, and some measurement concerns. Future research directions are discussed.

A feasibility study of the clinical effectiveness and cost-effectiveness of individual cognitive behavioral therapy for panic disorder in a Japanese clinical setting: an uncontrolled pilot study

Background

In Japan, cognitive behavioral therapy (CBT) for panic disorder (PD) is not well established. Therefore, a feasibility study of the clinical effectiveness and cost-effectiveness of CBT for PD in a Japanese clinical setting is urgently required. This was a pilot uncontrolled trial and the intervention consisted of a 16-week CBT program. The primary outcome was Panic Disorder Severity Scale (PDSS) scores. Quality of life was assessed using the EuroQol’s EQ-5D questionnaire. Assessments were conducted at baseline, 8 weeks, and at the end of the study. Fifteen subjects completed outcome measures at all assessment points.

Results

At post-CBT, the mean reduction in PDSS scores from baseline was −6.6 (95 % CI 3.80 to −9.40, p < 0.001) with a Cohen’s d = 1.77 (95 % CI 0.88–2.55). Ten (66.7 %) participants achieved a 40 % or greater reduction in PDSS. By calculating areas under the curve for EQ-5D index changes, we estimated that patients gained a minimum of 0.102 QALYs per 1 year due to the CBT.

Conclusions

This study demonstrated that individual CBT for PD may be useful in Japanese clinical settings but further randomized control trials are needed.

Trial registration: UMIN-CTR UMIN000022693 (retrospectively registered)

How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence

We report the current best estimate of the effects of cognitive behavior therapy (CBT) in the treatment of major depression (MDD), generalized anxiety disorder (GAD), panic disorder (PAD) and social anxiety disorder (SAD), taking into account publication bias, the quality of trials, and the influence of waiting list control groups on the outcomes. In our meta-analyses, we included randomized trials comparing CBT with a control condition (waiting list, care-as-usual or pill placebo) in the acute treatment of MDD, GAD, PAD or SAD, diagnosed on the basis of a structured interview. We found that the overall effects in the 144 included trials (184 comparisons) for all four disorders were large, ranging from g=0.75 for MDD to g=0.80 for GAD, g=0.81 for PAD, and g=0.88 for SAD. Publication bias mostly affected the outcomes of CBT in GAD (adjusted g=0.59) and MDD (adjusted g=0.65), but not those in PAD and SAD. Only 17.4% of the included trials were considered to be high-quality, and this mostly affected the outcomes for PAD (g=0.61) and SAD (g=0.76). More than 80% of trials in anxiety disorders used waiting list control groups, and the few studies using other control groups pointed at much smaller effect sizes for CBT. We conclude that CBT is probably effective in the treatment of MDD, GAD, PAD and SAD; that the effects are large when the control condition is waiting list, but small to moderate when it is care-as-usual or pill placebo; and that, because of the small number of high-quality trials, these effects are still uncertain and should be considered with caution.

Preliminary Investigation of a Mindfulness-Based Intervention for Social Anxiety Disorder That Integrates Compassion Meditation and Mindful Exposure

OBJECTIVES

This study evaluated the feasibility and initial efficacy of a 12-week group mindfulness-based intervention tailored for persons with social anxiety disorder (MBI-SAD). The intervention includes elements of the standard mindfulness-based stress reduction program, explicit training in self-compassion aimed at cultivating a more accepting and kinder stance toward oneself, and use of exposure procedures to help participants practice responding mindfully to internal experiences evoked by feared social situations.

METHODS

Participants were randomly assigned to the MBI-SAD (n = 21) or a waitlist (WL) (n = 18) control group. Feasibility was assessed by the number of participants who completed at least 75% of the 12 weekly group sessions. Primary efficacy outcomes were clinician- and self-rated measures of social anxiety. Other outcomes included clinician ratings of illness severity and self-rated depression, social adjustment, mindfulness, and self-compassion.

RESULTS

The MBI-SAD was acceptable and feasible, with 81% of participants attending at least 75% of sessions. The MBI-SAD fared better than WL in improving social anxiety symptom severity (p ≤ 0.0001), depression (p ≤ 0.05), and social adjustment (p ≤ 0.05). The intervention also enhanced self-compassion (p ≤ 0.05), and facets of mindfulness (observe and aware; p ≤ .05). MBI-SAD treatment gains were maintained at 3-month follow-up.

CONCLUSIONS

These preliminary findings suggest that an MBI that integrates explicit training in self-compassion and mindful exposure is a feasible and promising intervention for social anxiety disorder. The next step is to compare the MBI-SAD to the gold standard of cognitive-behavior therapy to determine equivalence or noninferiority and to explore mediators and moderators of treatment outcome.

Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized-controlled trials

Group psychotherapy for social anxiety disorder (SAD) is an established treatment supported by findings from primary studies and earlier meta-analyses. However, a comprehensive summary of the recent evidence is still pending. This meta-analysis investigates the efficacy of group psychotherapy for adult patients with SAD. A literature search identified 36 randomized-controlled trials examining 2171 patients. Available studies used mainly cognitive-behavioral group therapies (CBGT); therefore, quantitative analyses were done for CBGT. Medium to large positive effects emerged for wait list-controlled trials for specific symptomatology: g=0.84, 95% CI [0.72; 0.97] and general psychopathology: g=0.62, 95% CI [0.36; 0.89]. Group psychotherapy was also superior to common factor control conditions in alleviating symptoms of SAD, but not in improving general psychopathology. No differences appeared for direct comparisons of group psychotherapy and individual psychotherapy or pharmacotherapy. Hence, group psychotherapy for SAD is an efficacious treatment, equivalent to other treatment formats.

New Developments in Cognitive-Behavioral Therapy for Social Anxiety Disorder

Social anxiety disorder (SAD) is a highly prevalent and chronic disorder that causes considerable psychosocial impairment. This article reviews recent changes in the definition of SAD in DSM-5 and summarizes the current evidence for effective cognitive-behavioral treatments in adults, children, and adolescents. Current data suggests that cognitive-behavioral therapy (CBT) is efficacious in the treatment of this condition. Among different CBT approaches, individual cognitive therapy may be associated with the largest effect sizes. In this review, interventions targeting dysfunctional cognitive processes that contribute to the effective treatment of SAD are discussed. Some recent findings from neuroimaging research and studies on the augmentation of CBT using neuroenhancers indicate that changes in emotion regulation as well as fear extinction are important psychological mediators of positive outcome. Furthermore, internet-delivered CBT is a promising field of technological innovation that may improve access to effective treatments. Despite the availability of effective treatments, treatment-resistant SAD remains a common problem in clinical practice that requires more research efforts. Finally, potential areas for further development of CBT as well as its dissemination in health care are summarized.

Internet-delivered cognitive-behavioral therapy for social anxiety disorder in Romania: a randomized controlled trial

Background and Aims

Internet-based cognitive-behavioral therapy (iCBT) for social anxiety disorder has been found effective, as attested by independently conducted randomized controlled trials in four languages. The study aim is to test the efficacy of an iCBT program in a culture where it was not tested before (i.e. Romania).

Methods

Participants (n = 76) were recruited, screened and randomized to either a nine-week guided iCBT or a wait-list control group in April and May 2012. Self-report measures were collected before (April 2012) and after the intervention (July 2012), as well as six months later (January 2013). Although social anxiety was assessed with multiple measures, the Liebowitz Social Anxiety Scale - Self Report version (LSAS-SR) and Social Phobia Inventory (SPIN) were used as the primary outcome measures.

Results

A significant difference with a large between-group effect size in favor of iCBT was found (Cohen´s d = 1.19 for LSAS-SR and d = 1.27 for SPIN). Recovery rates show that 36.8% (n = 14) in the treatment group score below the SPIN clinical cut-off compared to only 2.6% (n = 1) in the wait-list control group. Post-intervention clinical interviews also revealed that 34.2% (n = 13) of the treatment group was completely recovered (full remission) while additionally 36.8% (n = 14) retained some social anxiety symptoms (partial remission). However, an important study limitation is that post-intervention interviewers were not blinded to the study conditions. The program also effectively reduced depression and dysfunctional thinking (between-group Cohen´s d = 0.84 for depression and d = 0.63 for dysfunctional thinking). Moreover, the iCBT intervention appears to have a long-term impact for participants’ functioning, as the treatment gains were maintained six months later.

Conclusions

Internet-delivered interventions display a high potential to quickly and widely disseminate effective evidence-based programs around the world. This study provides support for guided iCBT as a promising treatment approach in Romania.

Trial Registration

ClinicalTrials.gov NCT01557894

Intensive group-based CBT for child social phobia: a pilot study

OBJECTIVE

Although CBT has proven efficacious in the treatment of child social phobia (SP), most children do not present for treatment and child SP may be less responsive to treatment than other anxiety disorders. Intensive, group-based, SP-specific CBT may improve the efficacy of, and access to, treatment for child SP. The aim of this study was to provide a preliminary examination of such a program.

METHOD

Forty Australian children aged 7-12 years (15 male and 25 female) were allocated into treatment and waitlist groups. Clinical interviews to determine diagnostic status were conducted prior to treatment, following treatment and at 6-month follow-up. Parent and child questionnaire measures of child anxiety symptoms, internalizing symptoms, depression, social skills, social competence, and parental social anxiety were administered at the same time points. Treatment was delivered in 4 separate 3-hour sessions conducted over 3 consecutive weekends.

RESULTS

At postassessment, 52.4% of children in the treatment group and 15.8% of children in the waitlist group were free of their SP diagnosis. At postassessment, compared to waitlist children, treatment group children demonstrated a greater drop in clinical severity, a greater increase in overall functioning, and held fewer clinical diagnoses. Treatment group children also reported a greater reduction in SP symptoms compared to waitlist children, and treatment group parents reported a greater reduction in child internalizing and anxiety symptoms, a greater increase in child social competence, and a greater decrease in parental SP symptoms, compared to parents of children in the waitlist group. By 6-month follow-up, 76.9% of the treatment group were free of their SP diagnosis and gains on all other measures were maintained.

CONCLUSIONS

The results of this study are encouraging, and suggest that brief, intensive, group CBT for children with social anxiety is beneficial for many youngsters.

Treatment-as-usual (TAU) is anything but usual: a meta-analysis of CBT versus TAU for anxiety and depression

OBJECTIVES

There were three aims of this study, the first was to examine the efficacy of CBT versus treatment-as-usual (TAU) in the treatment of anxiety and depressive disorders, the second was to examine how TAU is defined in TAU control groups for those disorders, and the third was to explore whether the type of TAU condition influences the estimate of effects of CBT.

METHOD

A systematic search of Cochrane Central Register of Controlled Trials, PsycINFO, and CINAHL was conducted.

RESULTS

48 studies of CBT for depressive or anxiety disorders (n=6926) that specified that their control group received TAU were identified. Most (n=45/48) provided an explanation of the TAU group however there was significant heterogeneity amongst TAU conditions. The meta-analysis showed medium effects favoring CBT over TAU for both anxiety (g=0.69, 95% CI 0.47-0.92, p<0.001, n=1318) and depression (g=0.70, 95% CI 0.49-0.90, p<0.001, n=5054), with differential effects observed across TAU conditions.

CONCLUSIONS

CBT is superior to TAU and the size of the effect of CBT compared to TAU depends on the nature of the TAU condition. The term TAU is used in different ways and should be more precisely described. The four key details to be reported can be thought of as "who, what, how many, and any additional treatments?"