A Randomized Controlled Trial in Routine Clinical Practice Comparing Acceptance and Commitment Therapy with Cognitive Behavioral Therapy for the Treatment of Major Depressive Disorder

Effectiveness of group acceptance and commitment therapy in treating depression for acute stroke patients

OBJECTIVES

To date, the effectiveness of acceptance and commitment therapy (ACT) for acute stroke patients has not been well recognized. The study aimed to discover the effectiveness of group-based ACT in treating depression for acute stroke patients.

METHODS

We conducted a randomized controlled trial with 140 acute stroke patients with depression. The ACT intervention comprised seven sessions, of 45-60 min over 4 weeks. Data were collected pre- and post-intervention and at 3-month follow-up, assessing depression, health-related quality of life (HRQoL), psychological flexibility, cognitive fusion, sleep quality, and confidence.

RESULTS

Overall, 99.3% of the included patients were assessed as having mild depression. The ACT intervention significantly reduced depression in acute stroke patients in comparison with the control group post-intervention and at 3 months (partialη 2 = . 306 $\eta^{2}=.306$ ). Additionally ACT significantly improved HRQoL-mental component summary, sleep quality, psychological flexibility, cognitive fusion, and confidence compared with control group.

CONCLUSIONS

ACT is effective in treating acute stroke patients with depression, and the efficacy was maintained at 3-month follow-up.

Effect of acceptance and commitment therapy for depressive disorders: a meta-analysis

OBJECTIVE

To systematically evaluate the effect of Acceptance and Commitment Therapy (ACT) on depressive disorders.

METHODS

The electronic databases of Web of Science Core Collection, Pubmed, EMBASE, Cochrane Library, PsycInfo, CNKI, Wanfang and Weipu were used to select relevant publications. Screening, data extraction, and quality assessment were undertaken following PRISMA guidelines for preferred reporting of systematic reviews and meta-analysis. RevMan5.4 was used for meta-analysis.

RESULTS

11 studies with a total of 962 patients were included. Random-effects model analysis showed that ACT could effectively reduce the level of depressive symptoms in patients with depressive disorders (SMD = - 1.05, 95% CI: - 1.43-- 0.66, P < 0.00001), improve psychological flexibility (MD = 4.84, 95% CI: 2.70-6.97, P < 0.00001), and have good maintenance effect (SMD = - 0.70, 95% CI: - 1.15-- 0.25, P = 0.002). All differences were statistically significant.

CONCLUSIONS

ACT not only improves depressive symptoms and psychological flexibility, but also has a good maintenance effect, and it is particularly effective in Chinese patients. Large randomized controlled trials are needed to validate the findings from this meta-analysis.

Acceptance and commitment therapy and its unacknowledged influences: Some old wine in a new bottle?

Recently, Goldfried suggested that one main reason for the underdevelopment of psychotherapy as a scientific enterprise was the lack of acknowledgment of past contributions. In this article, this issue is illustrated by analysing the particular case of acceptance and commitment therapy (ACT). ACT has clear overlaps with therapies from the systemic tradition, such as strategic therapy in the line of the Mental Research Institute in Palo Alto and with the more recent models of solution-focused therapy and narrative therapy. This article analyses theoretical overlaps with these models (e.g. the paradoxical nature of human problems and the nature of language) as well as examples of similarities in therapeutic strategies (externalization and the miracle question). It concludes by suggesting that this practice of inadvertently obliterating the past does not favour the development of the field or the creation of consensus but rather contributes to the ongoing proliferation of 'new' psychotherapy models. Trends that may contribute to circumventing this problem are discussed.

Adolescents' experiences of acceptance and commitment therapy for depression: An interpretative phenomenological analysis of good-outcome cases

Introduction

Acceptance and commitment therapy (ACT) has been shown to help treat depression. However, little is known about the patient's experiences with ACT. This study aimed to learn how it was used in adolescents with major depressive disorder who have achieved good treatment outcomes.

Methods

Five adolescents with major depressive disorder with good treatment outcomes of ACT were enrolled in the semi-structured qualitative interview and analyzed using systematic textual condensation and interpretative phenomenological analysis.

Results

Four primary themes emerged from the investigation. "Therapist relationships and characteristics" describes the therapist's receptiveness and respect for adolescents with depression and having a trustworthy and sincere therapist. "Spaces to explore and experience" describes the ongoing process and content of acceptance of negative emotions and mindfulness practices in the healing process. "Do important things" refers to values and committed action. The "time settings" include the frequency and duration of treatment.

Conclusion

Adolescents make positive changes with a receptive and respectful therapist by exploring themselves in a genuine and trusting therapeutic relationship. Improvement seems to come from being open to all thoughts and feelings and developing the ability to live in the present moment. Teenagers attach great importance to value-oriented behaviour. Therefore, treatment should target the critical areas of depressed adolescents to guide them towards recovery effectively.

A meta-analysis of CBT efficacy for depression comparing adults and older adults

INTRODUCTION

This meta-analysis investigates CBT treatment efficacy fordepression, and compares outcomes between adults (young and middle aged) and older adults (OA).

METHODOLOGY

Effect sizes (Hedges' g) were obtained from 37 peer-reviewed RCTs, 25 adult papers (participant n = 2948) and 12 OA papers (participant n = 551), and analysed with the random effects model.

RESULTS

No significant difference between age groups is reported in terms of CBT efficacy for depression compared to other treatments (Q_between (1) = 0.06, p = .89), with the overall effect favouring CBT over any other treatments (g = 0.48, 95 % CI = 0.29-0.68). The same pattern of results was found when restricting studies to those which used active control conditions (Q_between (1) = 0.03, p = .86) or passive control conditions (Q (1) = 2.45, p = .12).

DISCUSSION

No significant differences in efficacy for CBT treatment for depression are found when comparing adults and OA. CBT is as efficacious with OA as with adults.

The effects of acceptance and commitment therapy on psychosocial impact and adherence of MDR-TB patients

Background: The Worldwide resistance prevalence of the first-line tuberculosis drug, rifampicin, in 2017 was 7.4 per 100,000 population, and 82% of them experienced multidrugresistant tuberculosis (MDR-TB). Indonesia is the top 20 country with an MDR-TB burden, and its prevalence is 8.8 per 100,000 population. MDR-TB requires a long-time treatment and has accompanying side effects: biological and psychosocial effects. However, efforts to overcome the psychosocial impacts have not been conducted. This study aims to determine the effect of acceptance and commitment therapy (ACT) on anxiety, depression, suicidal ideation, and treatment adherence in MDR-TB patients.

Design and methods: This research employed a quasi-experimental design with a pre-test three post-tests using total sampling. The pre-test was conducted before the standard nursing intervention, post-test 1 was after the standard nursing intervention, posttest 2 was after ACT session 1, and post-test 3 was after ACT session 2. Data were collected by the Hamilton Rating Scale for Anxiety, Beck Hopelessness Scale, a Scale for Suicide Ideation, and Morisky Medication Adherence Scale.

Results: The standard nursing action and ACT reduce anxiety (p=0.002), reduced depression (p=0.0001), reduced suicidal ideation (p=0.008), and increased treatment adherence (p=0.0001).

Conclusions: The standard nursing action and ACT reduce anxiety, depression, and suicidal ideation. They increase treatment adherence recommended for use in MDR-TB patients.

Group-based acceptance and commitment therapy interventions for improving general distress and work-related distress in healthcare professionals: A systematic review and meta-analysis

BACKGROUND

A large proportion of the healthcare workforce reports significant distress and burnout, which can lead to poor patient care. Several psychological interventions, such as Acceptance and Commitment Therapy (ACT), have been applied to improve general distress and work-related distress in healthcare professionals (HCPs). However, the overall efficacy of ACT in this context is unknown. This review and meta-analysis aimed to: 1) test the pooled efficacy of ACT trials for improving general distress and reducing work-related distress in HCPs; 2) evaluate the overall study quality and risk of bias; and 3) investigate potential moderators of intervention effectiveness.

METHOD

Four databases (Ovid MEDLINE, EMBASE, PsycINFO, CINHAL) were searched, with 22 pre-post design and randomised controlled trial (RCTs) studies meeting the inclusion criteria. 10 RCTs studies were included in the meta-analysis.

RESULTS

Two random effects meta-analyses on general distress and work-related distress found that ACT outperformed pooled control conditions with a small effect size for general distress at post-intervention (g = 0.394, CIs [.040; .748]) and for work-related distress (g = 0.301, CIs [.122; .480]) at follow-up. However, ACT was more effective than controls. The number of treatment sessions was a moderator of intervention efficacy for general distress. ACT process measures (psychological flexibility) did not show significantly greater improvements in those who received the intervention.

LIMITATIONS

The methodological quality of studies was poor and needs to be improved.

CONCLUSIONS

Overall, ACT interventions are effective in improving general distress and work-related distress in HCPs. These findings have implications for policymakers, healthcare organisations and clinicians.

Blinding in randomised clinical trials of psychological interventions: a retrospective study of published trial reports

OBJECTIVES

To study the extent of blinding in randomised clinical trials of psychological interventions and the interpretative considerations if randomised clinical trials are not blinded.

DESIGN

Retrospective study of trial reports published in six high impact factor journals within the field of psychiatry in 2017 and 2018.

SETTING

Trial reports published in World Psychiatry, JAMA Psychiatry, Lancet Psychiatry, American Journal of Psychiatry, British Journal of Psychiatry, or Psychotherapy and Psychosomatics.

MAIN OUTCOME MEASURES

Blinding status of participants, treatment providers, outcome assessors, data managers, the data safety and monitoring committee, statisticians and conclusion makers, if trialists rejected the null hypothesis on the primary outcome measure, and if trialists discussed the potential bias risk from lack of blinding in the published trial report.

RESULTS

63 randomised clinical trials of psychological interventions were identified. None (0%; 95% CI 0% to 5.75%) of the trials reported blinding of all possible key persons. 37 (58.7%; 95% CI 46.42% to 70.04%) trials reported blinding of outcome assessors. Two (3.2%; 95% CI 0.87% to 10.86%) trials reported blinding of participants. Two (3.2%; 95% CI 0.87% to 10.86%) trials reported blinding of data managers. Three (4.8%; 95% CI 1.63% to 13.09%) trials reported blinding of statisticians. None of the trials reported blinding of treatment providers, the data safety and monitoring committee, and conclusion makers. 45 (71.4%; 95% CI 59.30% to 81.10%) trials rejected the null hypothesis on the primary outcome(s). 13 (20.7%; 95% CI 12.48% to 32.17%) trials discussed the potential bias risk from lack of blinding in the published trial report.

CONCLUSIONS

Blinding of key persons involved in randomised clinical trials of psychological interventions is rarely sufficiently documented. The possible interpretative limitations are only rarely considered. There is a need of randomised clinical trials of psychological interventions with documented blinding attempts of all possible key persons.

Acceptance and commitment therapy in adult cancer survivors: a systematic review and conceptual model

PURPOSE

People with cancer experience significant physical and psychological symptoms, during as well as after primary treatment. Acceptance and Commitment Therapy (ACT), a psychological intervention, reduces both types of symptoms among individuals with chronic pain and emotional distress. Due to the unique challenges of cancer survivorship, this systematic review critically evaluates and synthesizes the literature on the context, mechanisms, and effect of ACT among adult cancer survivors.

METHODS

Articles were retrieved from the CINAHL, MEDLINE via Ovid, Web of Science, PsycInfo, Scopus, Embase, Google Scholar, and Cochrane databases. Selected grey literature portals, clinical trial registries, and conference proceedings were also searched. The NIH tools were used to assess study quality and the revised Cochrane Risk-of-Bias tool to assess risk of bias RESULTS: Thirteen articles, reporting on 537 cancer survivors with various cancer types, were included. ACT significantly reduced anxiety, depression, and fear of cancer recurrence and improved psychological flexibility and quality of life. Outcomes such as pain and insomnia were understudied. Lack of participant blinding and non-random assignment were the most common methodological issues. A conceptual model is proposed that describes the possible influencing factors of an ACT-based intervention in cancer survivors.

CONCLUSION

Review findings suggest that ACT is an effective intervention to improve some of the common concerns among cancer survivors. While all the studies in the review were recent (published 2015-2019), they examined only a limited number of outcomes. Hence, more methodologically rigorous studies which examine the effect of ACT on other troubling symptoms among cancer survivors are warranted.

IMPLICATIONS FOR CANCER SURVIVORS

Incorporating ACT into comprehensive post-treatment survivorship care can enhance psychological flexibility and reduce anxiety, depression, and fear.

Mindfulness-Based Cognitive Therapy, Acceptance and Commitment Therapy, and Positive Psychotherapy for Major Depression

OBJECTIVE

In the past two decades, newer psychotherapy treatments have emerged for the treatment of major depression. This review aimed to comprehensively synthesize the evidence for mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), and positive psychotherapy (PPT) in treating a current episode of major depression.

METHODS

A systematic search of the Ovid MEDLINE, Embase, PsycINFO, and Cochrane databases was conducted for randomized controlled trials of MBCT, ACT, and PPT for major depression. Standardized mean differences were calculated with Hedges' g to complete random-effects meta-analysis. Heterogeneity was assessed with the Cochran Q statistic and I² statistic. Subgroup analysis was conducted to further investigate heterogeneity.

RESULTS

A random-effects meta-analysis of 15 studies (MBCT, N=7; ACT, N=4; PPT, N=4) revealed that all three therapies showed efficacy in reducing symptoms of depression with a small favorable effect, compared with all control conditions (N=946; Hedges' g=0.34; 95% confidence interval=0.14, 0.54; p<0.001). Cochrane's Q statistic (Q=32, df=15, p=0.007) suggested significant heterogeneity (I²=53%). A mixed-effects model test for subgroup differences showed significant differences between active controls and treatment-as-usual controls (χ²=15.3, df=1, p<0.001). Overall quality of evidence and publication bias were low.

CONCLUSIONS

Meta-analysis shows that MBCT and ACT may be superior to inactive or treatment-as-usual controls and that PPT may be comparable to active controls for reducing symptoms of major depression after an acute course of therapy. However, the quality of the evidence was low. High-quality studies are needed to confirm the efficacy of these interventions.

One year follow-up and mediation in cognitive behavioral therapy and acceptance and commitment therapy for adult depression

BACKGROUND

Existing therapies for depression are effective, but many patients fail to recover or relapse. To improve care for patients, more research into the effectiveness and working mechanisms of treatments is needed. We examined the long-term efficacy of Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) for Major Depressive Disorder (MDD), testing the hypothesis that CBT outperforms ACT and that both therapies work through their designated mechanisms of change.

METHODS

We conducted a randomized controlled trial with 82 patients suffering from MDD. Data were collected before, during and after treatment, and at 12-month follow-up, assessing symptoms of depression, quality of life, dysfunctional attitudes, decentering, and experiential avoidance.

RESULTS

Patients in both conditions reported significant and large reductions of depressive symptoms (d = - 1.26 to - 1.60) and improvement in quality of life (d = 0.91 to - 1.28) 12 months following treatment. Our findings indicated no significant differences between the two interventions. Dysfunctional attitudes and decentering mediated treatment effects of depressive symptoms in both CBT and ACT, whereas experiential avoidance mediated treatment effects in ACT only.

CONCLUSIONS

Our results indicate that CBT is not more effective in treating depression than ACT. Both treatments seem to work through changes in dysfunctional attitudes and decentering, even though the treatments differ substantially. Change in experiential avoidance as an underlying mechanism seems to be an ACT-specific process. Further research is needed to investigate whether ACT and CBT may work differently for different groups of patients with depression.

TRIAL REGISTRATION

clinicaltrials.gov; NCT01517503 . Registered 25 January 2012 - Retrospectively registered.

A clinical effectiveness trial comparing ACT and CBT for inpatients with depressive and mixed mental disorders

Abstract Objective: Meta-analyses show that Acceptance and Commitment Therapy (ACT) is an efficacious treatment for a wide range of mental health problems. However, few studies have examined the effectiveness of ACT in naturalistic inpatient settings and in direct comparison to Cognitive Behavior Therapy (CBT). The aim of this study was to investigate the effectiveness of ACT and CBT with regard to depression, general symptom strain and life satisfaction. Method: 177 inpatients in a psychiatric ward were included in the study and assigned to either ACT or CBT group intervention. All patients were assessed with the SCID-I interview and disorder-specific questionnaires as well as with a satisfaction with life scale. To control for confounding variables, amongst others, treatment integrity was evaluated. Results: Both the ACT and CBT intervention showed a large, statistically significant and stable symptom reduction over six months across all outcomes. Both approaches led to small improvement in life satisfaction. With regards to depressive symptoms, more than half of the patients reliably recovered due to therapy. Conclusion: ACT and CBT were similarly effective in treating patients with depressive and other mental disorders in a routine clinical setting. ACT is a viable alternative to CBT for treating inpatients.

Piloting a New Model for Treating Music Performance Anxiety: Training a Singing Teacher to Use Acceptance and Commitment Coaching With a Student

Thus far, treatments for music performance anxiety (MPA) have focused primarily on interventions administered by psychologists and mental health clinicians with training and education in psychotherapy. While these interventions are promising or even efficacious, many musicians prefer not to work with a psychotherapist due to stigma and lack of time/access. Student musicians are particularly vulnerable to developing MPA, and while they may prefer consulting with their teachers about MPA over psychotherapists, many teachers feel unqualified to help. Here, we investigated an alternative intervention model, in which a clinical psychologist with MPA expertise trained a singing teacher with no training or education in psychotherapy to use an evidence-based coaching model, Acceptance and Commitment Coaching (ACC), with a student vocalist with problematic MPA, in a single-subject design format. ACC is a version of Acceptance and Commitment Therapy (ACT) that has been used under various names with non-clinical populations to help enhance psychological flexibility, e.g., with athletes, at the workplace, with undergraduates, and others. The teacher received approximately seven hours of ACC training via Skype. In turn, she provided six one-hour ACC sessions to a university student vocalist. Materials for the training and coaching sessions were taken from an ACC book and an ACT-based self-help book for musicians, and the teacher also adhered to a GROW model of coaching. The student made clinically significant improvements in two ACT-based processes believed to correlate with improved psychological flexibility in previous ACT for MPA psychotherapy research, i.e., acceptance of MPA-related discomfort and defusion from MPA-related thoughts. The student also reported a significant shift had occurred in his thinking: he became more willing to have his MPA, and so he volunteered to sing in classes early in the upcoming semester, and he auditioned for & won a lead role in a musical, both of which he previously avoided doing. ACC appears to be a promising MPA intervention that can be administered by a music teacher without training or education in psychotherapy, and it may help schools who do not employ psychologists and are therefore unable to follow best practice guidelines for treating MPA.

Explicit and implicit attachment and the outcomes of acceptance and commitment therapy and cognitive behavioral therapy for depression

BACKGROUND

Attachment theory predicts that patients who are not securely attached may benefit less from psychological treatment. However, evidence on the predictive role of attachment in the effectiveness of treatment for depression is limited.

METHODS

Explicit attachment styles, levels of attachment anxiety and attachment avoidance, as well as implicit relational self-esteem and implicit relational anxiety were assessed in 67 patients with major depressive disorder (MDD) receiving Acceptance and Commitment Therapy (ACT) or Cognitive Behavioral Therapy (CBT). ANOVA and hierarchical regression analyses were performed to investigate the predictive power of explicit and implicit attachment measures on treatment outcome.

RESULTS

Explicit attachment avoidance at pre-treatment significantly predicted reduction of depressive symptoms following treatment. Reductions in attachment anxiety and avoidance from pre- to post-treatment predicted better treatment outcomes. Neither one of the implicit measures, nor change in these measures from pre- tot post-treatment significantly predicted treatment outcome.

CONCLUSIONS

Our findings show that attachment avoidance as well as reductions in avoidant and anxious attachment predict symptom reduction after psychological treatment for depression. Future research should use larger sample sizes to further examine the role of attachment orientation as moderator and mediator of treatment outcome.

TRIAL REGISTRATION

clinicaltrials.gov; NCT01517503.

Psychological Flexibility in Depression Relapse Prevention: Processes of Change and Positive Mental Health in Group-Based ACT for Residual Symptoms

Relapse rates following a depressive episode are high, with limited treatments available aimed at reducing such risk. Acceptance and commitment therapy (ACT) is a cognitive-behavioral approach that has gained increased empirical support in treatment of depression, and thus represents an alternative in relapse prevention. Psychological flexibility (PF) plays an important role in mental health according to the model on which ACT is based. This study aimed to investigate the role of PF and its subprocesses in reducing residual symptoms of depression and in improving positive mental health following an 8-week group-based ACT treatment. Adult participants (75.7% female) with a history of depression, but currently exhibiting residual symptoms (N = 106) completed measures before and after intervention, and at 6 and 12-month follow-up. A growth curve model showed that positive mental health increased over 12-months. Multilevel mediation modeling revealed that PF significantly mediated these changes as well as the reduction of depressive symptoms, and that processes of acceptance, cognitive defusion, values and committed action, in turn, mediated increased PF.

Acceptance and Commitment Therapy (ACT) to reduce depression: A systematic review and meta-analysis

OBJECTIVES

The aim of this study is to investigate the effectiveness of ACT on depression reduction and further examine the relationship between different follow-up periods, different degree of depression, and different age of patients through subgroup analysis.

METHODS

Relevant electronic databases were searched from Jan 2010 to Aug 2018, including CNKI, WANFANG, PubMed, EMBASE, Cochrane Library, PsycINFO. Two reviewers independently screened for eligible studies, extracted data, and assessed risk of bias of the included studies. The Cochrane Collaboration's bias assessment tool was used to evaluate the risk of bias for included studies, and Review Manager 5.3 Software for the meta-analysis RESULTS: 18 studies with 1,088 participants were included in the review. Four studies were rated as high-quality studies, and the remaining 14 studies were rated as moderate quality studies. ACT significantly reduced depression as compared with the control group [SMD = 0.59, 95% CI (0.38, 0.81)]. The subgroup analysis found a significant difference between ACT and control group after post-intervention, three months follow up, mild depression group and adults group, [SMD= 0.62, 95% CI (0.35, 0.90), [SMD= 0.55, 95% CI (0.23, 0.87)], [SMD= 0.65, 95% CI (0.40, 0.91)], [SMD= 0.52, 95% CI (0.33, 0.71)] respectively.

LIMITATIONS

The heterogeneity between included studies results in heterogeneity of the results. Most of the specific methods for random sequence generation and allocation concealment were not clear. The search results had limitations since only the published studies in Chinese and English were searched and lacked a search for gray and paper documents.

CONCLUSIONS

The current study suggested that ACT was significantly for reducing depressive symptoms compared with the control group, especially at three months of follow-up, adult group and mild depression. More research is needed to investigate the difference effects for minor group, moderate and severe depression and long-term follow-up.

Acceptance and Commitment Therapy Preceded by Attention Bias Modification on Residual Symptoms in Depression: A 12-Month Follow-Up

Depression is a highly recurrent disorder with limited treatment alternatives for reducing risk of subsequent episodes. Acceptance and commitment therapy (ACT) and attention bias modification (ABM) separately have shown some promise in reducing depressive symptoms. This study investigates (a) if group-based ACT had a greater impact in reducing residual symptoms of depression over a 12-month follow-up than a control condition, and (b) if preceding ACT with ABM produced added benefits. This multisite study consisted of two phases. In phase 1, participants with a history of depression, currently in remission (N = 244), were randomized to either receive 14 days of ABM or a control condition. In phase 2, a quasi- experimental design was adopted, and only phase-1 participants from the Sørlandet site (N = 124) next received an 8-week group-based ACT intervention. Self-reported and clinician-rated depression symptoms were assessed at baseline, immediately after phase 1 and at 1, 2, 6, and 12 months after the conclusion of phase 1. At 12-month follow-up, participants who received ACT exhibited fewer self-reported and clinician-rated depressive symptoms. There were no significant differences between ACT groups preceded by ABM or a control condition. There were no significant differences between ACT groups preceded by ABM or a control condition. Group-based ACT successfully decreased residual symptoms in depression over 12 months, suggesting some promise in preventing relapse.

Cognitive predictors of treatment outcome for exposure therapy: do changes in self-efficacy, self-focused attention, and estimated social costs predict symptom improvement in social anxiety disorder?

BACKGROUND

Cognitions play an important role in the development and maintenance of social anxiety disorder (SAD).

METHODS

To investigate whether changes in cognitions during the first six sessions of exposure therapy are associated with treatment outcome, we assessed reported self-focused attention, self-efficacy in social situations, and estimated social costs in 60 participants (M_age = 36.9 years) diagnosed with SAD who received in vivo or virtual reality exposure therapy.

RESULTS

Patients demonstrating a greater decrease in estimated social costs during treatment reported greater improvement of their social anxiety symptoms following both forms of exposure therapy. While changes in self-focused attention and social self-efficacy during treatment were significantly associated with treatment outcome when examined individually, these changes did not significantly predict symptom improvement beyond social costs.

CONCLUSIONS

Changes in estimated social costs during treatment are associated with improvement of social anxiety symptoms after exposure therapy. Future research needs to further investigate estimated social costs as a predictor in relation to other cognitive variables.

TRIAL REGISTRATION

NCT01746667 ; www.clinicaltrials.gov, November 2012, retrospectively registered.