Psychological treatments for social phobia

Physical Activity as a Treatment for Social Anxiety in Clinical and Non-clinical Populations: A Systematic Review and Three Meta-Analyses for Different Study Designs

The fear of being in the focus of attention in social situations can develop into a social anxiety disorder (SAD). The classical treatment for SAD is cognitive behavioral therapy, which is in many cases accompanied by drug treatments. A promising alternative treatment is physical activity (PA) interventions, because regular PA has been shown to be suitable for reducing anxiety in general. We conducted a pre-registered systematic review and meta-analysis (PROSPERO registration no. CRD42020191181) as well as two additional searches. Our aim was to investigate whether PA interventions are a suitable treatment for SAD and whether PA is suitable for reducing social anxiety (SA) in general. For studies with randomized controlled trial designs, a not statistically significant effect of medium size toward lower general SA symptomatology was found in the PA group in comparison with the control group (d = -0.24, p = 0.377). For studies with longitudinal designs, significantly lower SA symptoms were found after PA treatments (d = -0.22, p = 0.001). The effect of PA on SA was stronger for adults than for children and adolescents (p = 0.003). For cross-sectional studies, a small negative association between SA symptoms and the amount of PA was found, i.e., lower SA was found for people who were more physically active (r = -0.12, p = 0.003). We conclude that PA is a promising means for the (additional) treatment of SAD or to reduce SA in general in non-clinical samples, but more research in which high-quality studies with randomized controlled trial designs are used is needed. Furthermore, open questions with respect to moderating variables (e.g., age, sex, BMI, type of intervention, stress, amount of regular PA before the intervention, and comorbidities) remain still open.

Treatments for Anxiety Disorders in Malaysia

This current study aims to systematically review the treatments for anxiety disorders in Malaysia. PsycINFO, MEDLINE databases, and 28 local journals were used to search published papers in this area. Eight articles were subjected to review after excluding 273 papers that did not meet the inclusion criteria. A total of 598 participants with various types of anxiety disorders were included in the review. Based on the findings, the combination of pharmacotherapy and psychotherapy provided better treatment outcomes if compared to psychotherapy or pharmacotherapy alone. The combination of selective serotonin reuptake inhibitors and cognitive behaviour therapy was considered as one of the most effective treatment to treat patients with anxiety disorders in Malaysia. This is in line with the clinical practice guidelines from the Ministry of Health Singapore and Canada. Even though there were some limitations in the methodology and reporting of the results, it can be concluded that efforts have been taken to conduct studies related to treatments for patients with anxiety disorders in Malaysia. Future studies are suggested to make conscious efforts to overcome these limitations.

Asperger syndrome and anxiety disorders (PAsSA) treatment trial: a study protocol of a pilot, multicentre, single-blind, randomised crossover trial of group cognitive behavioural therapy

INTRODUCTION

A number of studies have established that children, adolescents and adults with Asperger syndrome (AS) and high functioning autism (HFA) have significant problems with anxiety. Cognitive behavioural therapy (CBT) is an effective treatment for anxiety in a variety of clinical populations. There is a growing interest in exploring the effectiveness of CBT for people with AS who have mental health problems, but currently there are no known clinical trials involving adults with AS or HFA. Studies with children who have AS have reported some success. The current study aims to examine whether modified group CBT for clinically significant anxiety in an AS population is likely to be efficacious.

METHODS AND ANALYSIS

This study is a randomised, single-blind crossover trial. At least 36 individuals will be recruited and randomised into a treatment arm or a waiting-list control arm. During treatment, individuals will receive 3 sessions of individual CBT, followed by 21 sessions of group CBT. Primary outcome measures focus on anxiety. Secondary outcome measures focus on everyday social and psychiatric functioning, additional measures of anxiety and fear, depression, health-related quality of life and treatment cost. Assessments will be administered at pregroup and postgroup and at follow-up by researchers who are blinded to group allocation. The trial aims to find out whether or not psychological treatments for anxiety can be adapted and used to successfully treat the anxiety experienced by people with AS. Furthermore, we aim to determine whether this intervention represents good value for money.

ETHICS AND DISSEMINATION

The trial received a favourable ethical opinion from a National Health Service (NHS) Research Ethics Committee. All participants provided written informed consent. Findings will be shared with all trial participants, and the general public, as well as the scientific community.

TRIAL REGISTRATION

ISRCTN 30265294 (DOI: 10.1186/ISRCTN30265294), UKCRN 8370.

A pilot study examining the effects of Kouk Sun Do on university students with anxiety symptoms

The effects of Kouk Sun Do (KSD), a mind-body exercise on mental health in university students, were investigated in this pilot study. University students (N = 30) with self-reported anxiety symptoms were randomly assigned to either the treatment group or the waiting list control group. Eighteen participants (N = 18; seven in the treatment group and 11 in the waiting list control group) completed a pre-test and a post-test, and 12 participants dropped out before or during the intervention. Ten 70-min KSD exercise sessions were conducted three times per week over a 4-week period. Trait anxiety, depressive symptoms and general self-efficacy in coping with stress were measured with the pre-test and the post-test. Qualitative data were collected using open-ended questions regarding benefits of KSD at the last session. A two (group) by two (time) repeated-measure analysis of variance was used to analyse the data. Trait anxiety and depressive symptoms decreased whereas general self-efficacy increased over a 4-week period. The treatment group had significantly reduced trait anxiety and depressive symptoms compared with the control group across time. Qualitative data provided support that the self-induced relaxation effects of KSD may lead to reduced anxiety.

High preoperative depression, phobic anxiety, and binge eating scores and low medium-term weight loss in sleeve gastrectomy obese patients: a preliminary cohort study

OBJECTIVE

Although depression, anxiety, and binge eating are prevalent in candidates for bariatric surgery, their impact on weight loss is unknown following sleeve gastrectomy. This study assesses the associations between weight loss and preoperative depression, anxiety, and binge eating scores in patients undergoing sleeve gastrectomy for morbid obesity.

METHOD

This cohort study included 34 patients who underwent sleeve gastrectomy for morbid obesity between May 2006 and February 2010 in a French tertiary referral center. We assessed preoperative depression (using the Beck depression inventory and the SCL-90-R depression subscale), anxiety (using the Hamilton anxiety rating scale and the SCL-90-R anxiety subscales), and binge eating (using the bulimic investigatory test, Edinburgh). The primary outcome was the percentage of excess weight loss at 12 months (PEWL).

RESULTS

The preoperative mean body mass index (BMI) was 55.3 kg/m2 ± 10.2 kg/m2 and 41.7 kg/m2 ± 8.7 kg/m2 at the 12-month follow-up visit. The mean PEWL was 46.8% ± 15.8%. After adjusting for the preoperative BMI, the PEWL was negatively associated with preoperative scores for depression (β= -0.357; P < 0.05), phobic anxiety (β = -0.340; P < 0.05), interpersonal sensitivity (β = -0.328; P < 0.05), and binge eating (β = -0.315; P = 0.05). Other forms of anxiety were not correlated with the PEWL.

CONCLUSIONS

Higher preoperative depression, phobic anxiety, interpersonal sensitivity, and binge eating scores are associated with low postoperative weight loss in patients undergoing sleeve gastrectomy. Future studies should assess the preoperative prevalence of syndromal or subsyndromal atypical depression and its relationship to postoperative weight loss in bariatric surgery candidates.

A systematic review of the impact of adherence on the effectiveness of e-therapies

Background

As the popularity of e-therapies grows, so too has the body of literature supporting their effectiveness. However, these interventions are often plagued by high attrition rates and varying levels of user adherence. Understanding the role of adherence may be crucial to understanding how program usage influences the effectiveness of e-therapy interventions.

Objective

The aim of this study was to systematically review the e-therapy literature to (1) describe the methods used to assess adherence and (2) evaluate the association of adherence with outcome of these interventions.

Methods

A systematic review of e-therapy interventions was conducted across disease states and behavioral targets. Data were collected on adherence measures, outcomes, and analyses exploring the relationship between adherence measures and outcomes.

Results

Of 69 studies that reported an adherence measure, only 33 (48%) examined the relationship between adherence and outcomes. The number of logins was the most commonly reported measure of adherence, followed by the number of modules completed. The heterogeneity of adherence and outcome measures limited analysis. However, logins appeared to be the measure of adherence most consistently related to outcomes in physical health interventions, while module completion was found to be most related to outcomes in psychological health interventions.

Conclusions

There is large variation in the reporting of adherence and the association of adherence with outcomes. A lack of agreement about how best to measure adherence is likely to contribute to the variation in findings. Physical and psychological outcomes seem influenced by different types of adherence. A composite measure encompassing time online, activity completion, and active engagements with the intervention may be the best measure of adherence. Further research is required to establish a consensus for measuring adherence and to understand the role of adherence in influencing outcomes.

Mortality hazard associated with anxiolytic and hypnotic drug use in the National Population Health Survey

OBJECTIVE

Although widely used in the general population, sleeping pills and minor tranquilizers, also known as antianxiety agents, have been associated with undesirable outcomes. Reports about the association of these drugs with an elevated mortality rate are inconsistent and controversial. This study was designed to assess the mortality hazard associated with anxiolytic and hypnotic drug use in the National Population Health Survey in Canada. It was hypothesized that anxiolytic and hypnotic drug use would be associated with an elevated mortality hazard.

METHOD

A population-based sample of 14 117 people aged 18 to 102 years participated in a longitudinal panel survey, with data collected every second year from 1994 to 2007. The primary outcome measures reported in this study are self-report use of anxiolytic and hypnotic drugs, and death.

RESULTS

For respondents who reported anxiolytic or hypnotic drug use in the past month the odds of mortality were 3.22 times more (95% CI 2.70 to 3.84) than for those who did not use anxiolytic or hypnotic drugs in the past month. After controlling for confounding sociodemographic, lifestyle, and health factors (including depression), the odds ratio was reduced to 1.36 (95% CI 1.09 to 1.70) but remained significant.

CONCLUSION

Sedative drug use is associated with a small but significant increase in mortality risk. Further research is required to confirm the mechanisms by which sedative drug use increases mortality risk. Where possible, physicians should systematically consider possibilities for nonpharmacological treatment of sleep disturbances and anxiety.

Functional neural correlates of mindfulness meditations in comparison with psychotherapy, pharmacotherapy and placebo effect. Is there a link?

Chiesa A, Brambilla P, Serretti A. Functional neural correlates of mindfulness meditations in comparison with psychotherapy, pharmacotherapy and placebo effect. Is there a link?

OBJECTIVE

Mindfulness meditations (MM) are a group of meditation practices which are increasingly receiving attention. The aim of the present work is to review current findings about the neural correlates of MM and compare such findings with other specific and non-specific treatments.

METHODS

A literature search was undertaken using MEDLINE, ISI web of knowledge, the Cochrane database and references of retrieved articles. Studies which focused on the functional neural correlates of MM, psychotherapy, pharmacotherapy and placebo published up to August 2009 were screened in order to be considered for the inclusion.

RESULTS

Main findings suggest that long-term MM practice allows a more flexible emotional regulation by engaging frontal cortical structures to dampen automatic amygdala activation. A large overlap exists between cerebral areas activated during MM, psychotherapy, pharmacotherapy and those activated by placebo. However, while MM, psychotherapy and placebo seem to act through a top-down regulation, antidepressants seem to act through a bottom-up process.

CONCLUSION

MM seem to target specific brain areas related to emotions and emotional regulation. Similar mechanisms have been observed also in other interventions, particularly psychotherapy.

Pre-treatment patient variables as predictors of drop-out and treatment outcome in cognitive behavioural therapy for social phobia: A systematic review

BACKGROUND

Although cognitive behavioural therapy (CBT) has been shown to be an efficacious treatment for social phobia (SP), many patients drop out or achieve little or no benefit from treatment. This fact is generally considered an argument for the importance of studies of predictor variables.

AIMS

This paper systematically reviews pre-treatment patient variables as predictors of drop-out from and outcome of CBT for SP.

METHOD

A structured literature search was conducted in PsycINFO, Embase and PubMed.

RESULTS

28 published studies with n>or=60 were located. No pre-treatment patient variables were found to predict drop-out. Consistently across studies, higher levels of pre-treatment symptomatic severity predicted higher levels of end-state symptomatic severity, but not degree of improvement. There was some evidence that comorbid depression and avoidant personality disorder before treatment negatively influenced post-treatment end-state functioning, but not consistently improvement. No other patient variables consistently predicted outcome across studies.

CONCLUSIONS

Generally, the results are in line with the conclusion that more disturbed patients with SP both begin and end treatment at a higher symptomatic level but with a similar degree of improvement. There is, however, little clinically or theoretically relevant knowledge to be gained from existing studies of pre-treatment patient variables as predictors of drop-out and treatment outcome in CBT for patients with SP. The field is in need of conceptual and methodological improvements if more solid findings should be hoped for.

Does the form or the amount of exposure make a difference in the cognitive-behavioral therapy treatment of social phobia?

Exposure is considered to be an essential ingredient of cognitive-behavioral therapy treatment of social phobia and of most anxiety disorders. To assess the impact of the amount of exposure on outcome, 30 social phobic patients were randomly allocated to 1 of 2 group treatments of 8 weekly sessions: Self-Focused Exposure Therapy which is based essentially on prolonged exposure to public speaking combined with positive feedback or a more standard cognitive and behavioral method encompassing psychoeducation, cognitive work, working through exposure hierarchies of feared situations for exposure within and outside the group. The results show that the 2 methods led to significant and equivalent symptomatic improvements which were maintained at 1-year follow-up. There was a more rapid and initially more pronounced decrease in negative cognitions with the Self-Focused Exposure Therapy, which included no formal cognitive work, than with the more standard approach in which approximately a third of the content was cognitive. In contrast, decrease in social avoidance was more persistent with standard cognitive-behavior therapy which involved less exposure. The results indicate that positive cognitive change can be achieved more rapidly with non cognitive methods while avoidance decreases more reliably with a standard approach rather than an approach with an exclusive focus on exposure.

Cognitive behavioral group therapy for social phobia with or without attention training: a controlled trial

The Self-Regulatory Executive Function model [S-REF; Wells, A., & Matthews, G. (1996). Modelling cognition in emotional disorder: the S-REF model. Behaviour Research and Therapy, 34, 881-888] proposes that metacognitive beliefs, inflexible self-focused attention, and perseverative thinking (rumination and worry) play an important role in maintaining emotional dysfunction. Attention training [ATT; Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: an attentional training approach to treatment. Behavior Therapy, 21, 273-280] is a technique designed to increase attentional control and flexibility, and thereby lessen the impact of these maintaining factors. The main aim of this study was to determine whether or not supplementing cognitive behavioral group therapy (CBGT) with ATT could potentiate greater changes in social anxiety, depression, attentional control, metacognitive beliefs, and anticipatory and post-event processing in a clinical sample with social phobia. Patients (N=81) were allocated to CBGT with ATT or relaxation training (RT). ATT did not potentiate greater change on any outcome variable, with both groups achieving significant improvements on all measures. Exploratory correlational analyses (pre-treatment and changes scores) showed that some metacognitive beliefs were associated with attentional control, anticipatory processing, and symptoms of social anxiety and depression. However, attentional control was more consistently associated with anticipatory processing, post-event processing, and symptoms of social anxiety and depression, than with metacognitive beliefs. Results are discussed with reference to cognitive behavioral models of social phobia. It is tentatively concluded that while supplementing CBGT with ATT does not improve outcomes, increasing attentional control during CBGT is associated with symptom relief.

A pilot study of clonazepam versus psychodynamic group therapy plus clonazepam in the treatment of generalized social anxiety disorder

BACKGROUND

Both psychodynamic group therapy (PGT) and clonazepam are used as treatment strategies in reducing symptoms of generalized social anxiety disorder (GSAD). However, many individuals remain symptomatic after treatment with PGT or clonazepam.

METHOD

Fifty-eight adult outpatients with a diagnosis of GSAD according to DSM-IV were randomized to 12 weeks PGT plus clonazepam or clonazepam. The Clinical Global Impression-Improvement (CGI-I) Scale was the primary efficacy measure. Secondary efficacy measures included the Liebowitz Social Anxiety Scale (LSAS) total score, the World Health Organization Instrument to Assess Quality of Life-Brief (WHOQOL-Bref) Scale and the Beck Depression Inventory (BDI).

RESULTS

CGI-I data from 57 patients (intent-to-treat population) showed that patients who received PGT plus clonazepam presented significantly greater improvement than those who received clonazepam (P=0.033). There were no significant differences between the two groups in the secondary efficacy measures.

CONCLUSIONS

Our study suggests that the combination of PGT with clonazepam may be a promising strategy for the treatment of GSAD, regarding gains in the global functioning. However the present study failed to detect more specific changes in social anxiety symptomatology between the two groups.

Relaxation training for anxiety: a ten-years systematic review with meta-analysis

BACKGROUND

Relaxation training is a common treatment for anxiety problems. Lacking is a recent quantitative meta-analysis that enhances understanding of the variability and clinical significance of anxiety reduction outcomes after relaxation treatment.

METHODS

All studies (1997-2007), both RCT, observational and without control group, evaluating the efficacy of relaxation training (Jacobson's progressive relaxation, autogenic training, applied relaxation and meditation) for anxiety problems and disorders were identified by comprehensive electronic searches with Pubmed, Psychinfo and Cochrane Registers, by checking references of relevant studies and of other reviews. Our primary outcome was anxiety measured with psychometric questionnaires. Meta-analysis was undertaken synthesizing the data from all trials, distinguishing within and between effect sizes.

RESULTS

27 studies qualified for the inclusion in the meta-analysis. As hypothesized, relaxation training showed a medium-large effect size in the treatment of anxiety. Cohen's d was .57 (95% CI: .52 to .68) in the within analysis and .51 (95% CI: .46 to .634) in the between group analysis. Efficacy was higher for meditation, among volunteers and for longer treatments. Implications and limitations are discussed.

CONCLUSION

The results show consistent and significant efficacy of relaxation training in reducing anxiety. This meta-analysis extends the existing literature through facilitation of a better understanding of the variability and clinical significance of anxiety improvement subsequent to relaxation training.

Buddhist psychology, psychotherapy and the brain: a critical introduction

Buddhist psychology is increasingly informing psychotherapeutic practice in the western world. This article: (a) provides a general background to Buddhist tradition; (b) outlines the central tenets of Buddhist psychology, with particular emphasis on the practice of meditation; (c) provides an overview of research into the effects of Buddhist practice on the brain; (d) outlines the relationships between Buddhist psychology and existing forms of psychotherapy; (e) provides an overview of Buddhist approaches to specific psychiatric disorders and the psychological aspects of physical disorders; and (f) discusses the emergence of Buddhist psychotherapy in western societies and explores likely future developments. There is a need for further research into the neuroscientific correlates of Buddhist concepts of mind and the evidence-base for the use of specific techniques (e.g., meditation) in psychotherapeutic practice.