Impact of Social Developmental Experiences on Cognitive-Behavioral Therapy for Generalized Social Phobia

Trauma history and course of therapy in a naturalistic cognitive behavior therapy outpatient sample: An archive data study

OBJECTIVE

Cognitive Behavior Therapy (CBT) is an effective treatment for anxiety and depression disorders. Nonetheless, nearly 50% of all patients do not respond. Besides other factors, nonresponse may be linked to traumatic life events. This study aims to assess the relationship between trauma history, applied therapy interventions, and therapy outcomes.

METHODS

We analyzed data from 340 CBT outpatients diagnosed with a depression or anxiety disorder and possibly a trauma history treated under naturalistic conditions. Based on their therapy files, we collected information on trauma history, diagnoses, applied interventions, and severity of depression and anxiety symptoms at the start and end of therapy. The relationship between trauma, diagnoses, and intervention use and the development of depression and anxiety symptoms was analyzed using Linear Mixed Models.

RESULTS

Patients with a trauma history reported higher pre- and posttreatment symptom severity than those without trauma. No differences in applied interventions or decrease in symptom severity were found between patients with and without a trauma history. Specialized interventions were seldom applied.

CONCLUSION

Although no differences between patients with and without a trauma history were found in therapy response, patients with a trauma history maintained higher levels of symptom severity. These results indicate a need for more personalized interventions and evidence-based guidelines to personalize CBT for patients with a trauma history and high symptom severity.

Child maltreatment, peer victimization, and social anxiety in adulthood: a cross-sectional study in a treatment-seeking sample

BACKGROUND

Childhood adversities, especially emotional abuse, emotional neglect, and peer victimization are considered to be crucial risk factors for social anxiety disorder (SAD). We investigated whether particular forms of retrospectively recalled childhood adversities are specifically associated with SAD in adulthood or whether we find similar links in other anxiety or depressive disorders.

METHODS

Prevalences of adversities assessed with the Childhood Trauma Questionnaire (CTQ) and a questionnaire of stressful social experiences (FBS) were determined in N = 1091 outpatients. Adversity severities among patients with SAD only (n = 25), specific phobia only (n = 18), and generalized anxiety disorder only (n = 19) were compared. Differences between patients with anxiety disorders only (n = 62) and depressive disorders only (n = 239) as well as between SAD with comorbid depressive disorders (n = 143) and SAD only were tested.

RESULTS

None of the adversity types were found to be specifically associated with SAD and severities did not differ among anxiety disorders but patients with depressive disorders reported more severe emotional abuse, physical abuse, and sexual abuse than patients with anxiety disorders. SAD patients with a comorbid depressive disorder also reported more severe adversities across all types compared to SAD only.

CONCLUSION

Findings indicate that particular forms of recalled childhood adversities are not specifically associated with SAD in adulthood. Previously established links with SAD may be better explained by comorbid depressive symptoms.

Does prior traumatization affect the treatment outcome of CBT for panic disorder? The potential role of the MAOA gene and depression symptoms

Although cognitive behavioral therapy (CBT) is highly effective in the treatment of anxiety disorders, many patients still do not benefit. This study investigates whether a history of traumatic event experience is negatively associated with outcomes of CBT for panic disorder. The moderating role of the monoamine oxidase A (MAOA) gene and depression symptoms as well as the association between trauma history and fear reactivity as a potential mechanism are further analyzed. We conducted a post-hoc analysis of 172 male and 60 female patients with panic disorder treated with CBT in a multi-center study. Treatment outcome was assessed at post-treatment using self-report and clinician rating scales. Fear reactivity before treatment was assessed via heart rate and self-reported anxiety during a behavioral avoidance test. Among females, we did not find any differences in treatment response between traumatized and non-traumatized individuals or any two-way interaction trauma history × MAOA genotype. There was a significant three-way interaction trauma history × MAOA genotype × depression symptoms on all treatment outcomes indicating that in traumatized female patients carrying the low-activity allele, treatment effect sizes decreased with increasing depression symptoms at baseline. No such effects were observed for males. In conclusion, we found no evidence for a differential treatment response in traumatized and non-traumatized individuals. There is preliminary evidence for poorer treatment outcomes in a subgroup of female traumatized individuals carrying the low-active variant of the MAOA gene. These patients also report more symptoms of depression symptomatology and exhibit a dampened fear response before treatment which warrants further investigation.

Parental style and Cloninger's model in psychosis

Parental style and Cloninger's dimensions are associated with psychosis, but it is still unclear whether temperament, character and parenting variables are linked to specific psychotic symptoms. This study extends previous research exploring these issues. 78 patients with psychosis and 156 control subjects were recruited. Parental style was evaluated using the Measure of Parental Style. Temperament and character were evaluated using the Temperament and Character Inventory-Revised. Psychotic symptoms were assessed using the Positive and Negative Syndrome Scale. T-tests, correlations and moderation and mediation analyses were performed. Patients reported dysfunctional parenting and had higher scores for harm avoidance (HA) and self transcendence (ST), and lower scores for self directedness (SD) and cooperativeness (CO) than controls. Maternal indifference, abuse and overcontrol were correlated with positive symptoms (PS). Novelty seeking (NS), reward dependence, SD, CO were correlated with PS; HA and ST were correlated with negative symptoms. After adjusting for age, gender and family history of psychopathology lower CO partially mediated the relationship between maternal abuse and PS; the positive NS-maternal abuse interaction was associated with PS. Different parenting and personality variables may be associated with different psychotic symptoms. NS and CO may be part of a pathway between maternal abuse and PS.

Childhood adversities, bonding, and personality in social anxiety disorder with alcohol use disorder

Social anxiety disorder (SAD) is frequently associated with alcohol use disorders (abuse/dependence). However, there has been little research on the characteristics of this subgroup so far. In the current study we investigated individuals with SAD and comorbid alcohol use disorder (AUD) with regard to socialization experiences and personality. The sample comprised 410 individuals diagnosed with SAD by the Structured Clinical Interview of DSM-IV. 108 participants with comorbid AUD were compared to 302 participants without comorbid AUD concerning traumatic experiences during childhood and adolescence (Adverse Childhood Experiences Questionnaire; ACE), parental bonding (Parental Bonding Instrument; PBI), and personality (Temperament and Character Inventory; TCI). MANCOVA with covariates sex and depression displayed that individuals with SAD plus AUD reported significantly more traumatic events during childhood and adolescence, lower levels of maternal care, as well as lower cooperativeness. Our results highlight that adverse childhood experiences and unfavourable maternal bonding characterize individuals suffering from SAD plus AUD. These experiences might be reflected in a personality-based tendency to distance themselves from others, which corresponds to low scores on the character dimension cooperativeness. A deeper understanding of personality and specific socialization experiences is necessary to develop new treatment options in this clinically challenging subgroup.

Pharmacotherapy for social anxiety disorder: Interpersonal predictors of outcome and the mediating role of the working alliance

Social anxiety disorder (SAD) is highly prevalent and associated with high levels of impairment and distress. Therapies for SAD leave many patients symptomatic at the end of treatment, and little is known about predictors or mechanisms of treatment outcome. Given the interpersonal dysfunction fundamental to SAD, this study investigated whether prominent interpersonal features of SAD (submissive behavior, childhood maltreatment, suppression of anger, and depression) predicted attrition and response to pharmacotherapy and whether the working alliance mediated these relationships. This is the first study to examine the role of the working alliance in pharmacotherapy for SAD. One hundred thirty-eight treatment-seeking individuals with a primary diagnosis of SAD received 12 weeks of open treatment with paroxetine. Higher levels of depression predicted greater severity of SAD at the end of treatment, and higher levels of submissive behavior and childhood emotional maltreatment predicted a greater probability of attrition from treatment. The psychiatrist-assessed working alliance mediated response to pharmacotherapy for individuals who reported a history of emotional maltreatment. These results identify variables that predict pharmacotherapy outcome and emphasize the importance of the working alliance as a mechanism of treatment response for those with a history of emotional maltreatment. Implications for person-specific treatment selection are discussed.

Predicting Response Trajectories during Cognitive-Behavioural Therapy for Panic Disorder: No Association with the BDNF Gene or Childhood Maltreatment

BACKGROUND

Anxiety disorders are highly prevalent and result in low quality of life and a high social and economic cost. The efficacy of cognitive-behavioural therapy (CBT) for anxiety disorders is well established, but a substantial proportion of patients do not respond to this treatment. Understanding which genetic and environmental factors are responsible for this differential response to treatment is a key step towards "personalized medicine". Based on previous research, our objective was to test whether the BDNF Val66Met polymorphism and/or childhood maltreatment are associated with response trajectories during exposure-based CBT for panic disorder (PD).

METHOD

We used Growth Mixture Modeling to identify latent classes of change (response trajectories) in patients with PD (N = 97) who underwent group manualized exposure-based CBT. We conducted logistic regression to investigate the effect on these trajectories of the BDNF Val66Met polymorphism and two different types of childhood maltreatment, abuse and neglect.

RESULTS

We identified two response trajectories ("high response" and "low response"), and found that they were not significantly associated with either the genetic (BDNF Val66Met polymorphism) or childhood trauma-related variables of interest, nor with an interaction between these variables.

CONCLUSIONS

We found no evidence to support an effect of the BDNF gene or childhood trauma-related variables on CBT outcome in PD. Future studies in this field may benefit from looking at other genotypes or using different (e.g. whole-genome) approaches.

Childhood maltreatment and response to cognitive behavioral therapy among individuals with social anxiety disorder

BACKGROUND

The association between childhood maltreatment-particularly emotional maltreatment-and social anxiety disorder (SAD) has been established by research. Only recently have researchers begun to look at the impact of childhood maltreatment on treatment outcomes, and findings have been mixed. Because prior studies have focused on pharmacotherapy outcomes, or used global measures of childhood adversity or abuse, it is not clear how specific types of maltreatment impact outcomes in cognitive-behavioral therapy (CBT) for SAD. The current study reports on how specific types of childhood maltreatment such as physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect impact response to CBT in adults with SAD.

METHODS

Sixty-eight individuals with a primary diagnosis of SAD completed the childhood trauma questionnaire, along with measures of social anxiety, disability, and life satisfaction.

RESULTS

Childhood maltreatment did not affect the rate of response to CBT, but there is evidence for its negative impact. Patients with histories of emotional abuse and emotional neglect reported greater social anxiety, less satisfaction, and greater disability over the course of treatment. Sexual abuse also predicted greater social anxiety.

CONCLUSIONS

Childhood abuse and/or neglect did not result in differential rates of improvement during CBT; however, those reporting histories of emotional and sexual forms of maltreatment evidenced greater symptoms and/or impairment at pre- and posttreatment. Additional attention to the role of traumatic experiences within CBT for SAD may be warranted.

Childhood maltreatment and social anxiety disorder: implications for symptom severity and response to pharmacotherapy

BACKGROUND

Childhood maltreatment has been associated with symptom severity, reduced quality of life, and impaired functioning in adults with social anxiety disorder (SAD). No study has investigated how childhood maltreatment impacts pharmacotherapy outcomes in this population, despite evidence for such a link in depression. The current study replicates previous work on childhood maltreatment within SAD and examines its impact on response to pharmacotherapy.

METHODS

One hundred and fifty six individuals seeking treatment for SAD completed the Childhood Trauma Questionnaire, which measures various types of abuse and neglect, along with the measures of symptom severity, quality of life, and disability. Data from a subset of patients enrolled in a paroxetine trial (N = 127) were analyzed to gauge the impact of childhood maltreatment on attrition and treatment response.

RESULTS

All types of maltreatment except for sexual abuse and physical abuse were related to greater symptom severity. Emotional abuse and neglect were related to greater disability, and emotional abuse, emotional neglect, and physical abuse were related to decreased quality of life. Emotional abuse significantly predicted attrition. A time by emotional abuse interaction suggests that for those who stayed the course, the impact of emotional abuse on severity of social anxiety weakened significantly over time.

CONCLUSIONS

Emotional maltreatment was most strongly linked to dysfunction in SAD, despite a tendency in the anxiety literature to focus on the effects of sexual and physical abuse. Additionally, individuals reporting emotional abuse were more likely to dropout from pharmacotherapy, but those who stayed the course displayed similar outcomes to those without such a history.

Childhood trauma and current psychological functioning in adults with social anxiety disorder

Etiological models of social anxiety disorder (SAD) suggest that early childhood trauma contributes to the development of this disorder. However, surprisingly little is known about the link between different forms of childhood trauma and adult clinical symptoms in SAD. This study (1) compared levels of childhood trauma in adults with generalized SAD versus healthy controls (HCs), and (2) examined the relationship between specific types of childhood trauma and adult clinical symptoms in SAD. Participants were 102 individuals with generalized SAD and 30 HCs who completed measures of childhood trauma, social anxiety, trait anxiety, depression, and self-esteem. Compared to HCs, individuals with SAD reported greater childhood emotional abuse and emotional neglect. Within the SAD group, childhood emotional abuse and neglect, but not sexual abuse, physical abuse, or physical neglect, were associated with the severity of social anxiety, trait anxiety, depression, and self-esteem.

From general day hospital treatment to specialized treatment programmes

Approximately one third of day hospitals in Europe can be designated as predominantly psychotherapeutic. They address mainly patients with personality disorders (PD), but also eating disorders and chronic mood and anxiety disorders without PD. As day treatment programmes tend to become associated with mental health centers, their treatment intensity also tends to become reduced. Available data suggest that approximately 10 hours of treatment a week is sufficient. Is such treatment more effective than specialized outpatient treatment? This research question will probably set the agenda in the years to come. In response to this challenge, day treatment should become more specialized. Data from the Norwegian Network of Psychotherapeutic Day Hospitals (n = 2.205) demonstrate that the majority of day treatment patients suffer from borderline and avoidant PD. Programmes for patients with borderline PD are well developed. The authors call for programme development for patients with avoidant PD.

Interpersonal processes in social phobia

Social phobia is a condition in which anxiety impairs the person's ability to relate to others. Here, we draw on concepts from interpersonal theory to examine the literature on the role of interpersonal processes in creating and maintaining this disorder. Studies that examine interpersonal interactions with significant others and strangers are reviewed. We next consider topics of particular relevance to relationship impairment, such as the effect of anxiety on cognitive processing of social information, and the social developmental pathways to social phobia. The impact of interpersonal factors on the process and outcome of cognitive-behavioral treatment is also discussed. Finally, we identify emerging themes in the research literature and consider directions for future work. Throughout the paper we highlight topics central to the interpersonal perspective, such as the self-perpetuating interpersonal cycle, interpersonal variability in social phobia, and the relational nature of self-related information.