Attention bias modification augments cognitive-behavioral group therapy for social anxiety disorder: a randomized controlled trial.

BACKGROUND: Cognitive-behavioral group therapy (CBGT) is a first-line treatment for social anxiety disorder (SAD). However, since many patients remain symptomatic post-treatment, there is a need for augmenting procedures. This randomized controlled trial (RCT) examined the potential augmentation effect of attention bias modification (ABM) for CBGT. METHODS: Fifty patients with SAD from three therapy groups were randomized to receive an 18-week standard CBGT with either ABM designed to shift attention away from threat (CBGT + ABM), or a placebo protocol not designed to modify threat-related attention (CBGT + placebo). Therapy groups took place in a large mental health center. Clinician and self-report measures of social anxiety and depression were acquired pre-treatment, post-treatment, and at 3-month follow-up. Attention bias was assessed at pre- and post-treatment. RESULTS: Patients randomized to the CBGT + ABM group, relative to those randomized to the CBGT + placebo group, showed greater reductions in clinician-rated SAD symptoms post-treatment, with effects maintained at 3-month follow-up. Group differences were not evident for self-report or attention-bias measures, with similar reductions in both groups. Finally, reduction in attention bias did not mediate the association between group and reduction in Liebowitz Social Anxiety Scale Structured Interview (LSAS) scores. CONCLUSIONS: This is the first RCT to examine the possible augmenting effect of ABM added to group-based cognitive-behavioral therapy for adult SAD. Training patients' attention away from threat might augment the treatment response to standard CBGT in SAD, a possibility that could be further evaluated in large-scale RCTs.

Comorbid major depressive disorder in cognitive-behavior group treatment for social anxiety disorder: An examination of processes of symptom change.

Individuals with social anxiety disorder (SAD) typically have elevated depressive symptoms and approximately 50% also meet criteria for major depressive disorder (MDD; Beesdo et al., 2007). In the present study, we examined the relationship between social anxiety and depressive symptoms during cognitive-behavior group treatment (CBGT) for SAD. Specifically, we compared individuals with SAD and comorbid MDD and individuals with SAD without MDD to examine the role of MDD as a moderator of social anxiety-depression relationship. Participants were 90 individuals seeking treatment for SAD (36% were diagnosed with MDD), who completed self-report measures of social anxiety and depression every 2 weeks during CBGT. Lower level mediational modeling indicated that for individuals without MDD, a reciprocal relationship was observed in which changes in both social anxiety and depressive symptoms mediated changes in each other. However, changes in social anxiety explained all subsequent changes in depression, whereas changes in depression explained 11.26% of subsequent changes in social anxiety. For individuals with both SAD and MDD, neither social anxiety nor depression significantly mediated changes in each other. Our findings suggest that different processes of change occur for individuals with and without MDD and clinical implications of these findings are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of depression on treatment effectiveness and gains maintenance in social phobia: a naturalistic study of cognitive behavior group therapy.

BACKGROUND: The impact of depression on cognitive behavioral group therapy (CBGT) for social phobia (SP) in a naturalistic outpatient setting was examined after treatment termination and at 1-year follow-up. METHODS: Consecutive SP outpatients (N=219) were diagnosed using a structured interview. CBGT was provided in 18 1.5-hr weekly sessions. At pretreatment and posttreatment questionnaires and clinician ratings were administered. Self-report measures were obtained at 1-year follow-up. The main outcome measure was the Liebowitz Social Anxiety Scale. RESULTS: CBGT was found to be effective in reducing both social anxiety (effect size=1.23) as well as depression (effect size=0.94). Individuals with generalized social phobia (GSP) and individuals with specific social phobia (SSP) differed in their presenting psychopathology and in their response to CBGT. Among treatment completers, 44% GSPs and 37% SSPs achieved at least 50% improvement, and 44% GSPs and 87% SSPs reported distress and functioning within the normal range at the end of treatment. Among SPs diagnosed with major depressive disorder (MDD) at the onset of treatment, SP symptoms aggravated during the follow-up period, whereas SPs not diagnosed with MDD experienced a further alleviation of SP symptoms during follow-up. CBGT provided in a public clinic to non-selected, mostly unmedicated and comorbid patients, is an effective treatment for the majority of SP sufferers. CONCLUSIONS: MDD at the onset of CBGT was not associated with poorer treatment response, but predicted exacerbation of SP symptoms following treatment termination. Depressed SPs may need additional intervention to maintain CBGT gains. SSPs may benefit from less intensive CBGT than GSPs.

Social phobia: maintenance models and main components of CBT.

Social phobia (SP, or social anxiety disorder, SAD) is among the most common of all psychiatric disorders. SP typically begins early in life and provokes a great deal of impairment and reduction in quality of life. Despite its high prevalence and associated impact, SP has only recently become the focus of clinical research. We review the current CBT literature on SP, focusing on its main components, such as exposure, safety behaviors, cognitive restructuring, post-event processing, attentional retraining and social skills training. We suggest that although CBT for SP is effective, with effect sizes ranging from .6 to 2.6, much room for improvement remains. We conclude by reviewing some new and promising directions in the development of CBT for SP.

Explicit and implicit self-evaluations in social anxiety disorder.

Cognitive models of social anxiety disorder (SAD) emphasize the role of explicit and implicit self-evaluations (SEs) in the etiology and maintenance of this condition. Whereas individuals with SAD consistently report lower explicit SEs as compared with nonanxious individuals, findings concerning implicit SEs are mixed. To gain a more nuanced understanding of the nature of SEs in SAD, we examined explicit and implicit SEs in two significant interpersonal domains: social rank and affiliation. Consistent with cognitive theorizing, we predicted that, compared to nonclinical controls (NCCs), individuals with SAD would exhibit lower explicit and implicit SEs in both domains. Guided by evolutionary theories we also predicted that the differences in SEs between the groups would be greater in the social rank, as compared to the affiliation, domain. Individuals diagnosed with SAD (n = 38) and NCCs) n = 40) performed two variants of the Self Implicit Association Test: one concerning social rank, and the other concerning affiliation. They also rated themselves on social-rank and affiliation traits. We found that, as compared to NCCs, individuals with SAD exhibited lower social-rank and affiliation SEs. Moreover, differences between the groups in social-rank SEs were greater than in affiliation SEs. Importantly, this pattern was evident in implicit SEs, as much as in explicit SEs. Our findings dovetail with evolutionary accounts highlighting the centrality of the social-rank system in SAD, and refine central tenets of cognitive theories of SAD. A multidomain, multimethod approach to the understanding of the self may broaden our conceptualization of SAD and related disorders. (PsycINFO Database Record

Red cell membrane omega-3 fatty acids are decreased in nondepressed patients with social anxiety disorder.

The "phospholipid hypothesis" attributes a pathophysiologic role to the polyunsaturated fatty acid (PUFA) composition of phospholipids in depression. The aim of the present study was to determine whether the hypothesis is relevant to social anxiety disorder (SAD). The study sample consisted of 27 untreated, nondepressed patients with SAD (DSM-IV) and 22 controls. Severity of SAD was assessed with the Liebowitz Social Anxiety Scale (LSAS). Erythrocyte PUFA concentrations were measured by gas-liquid chromatography. Concentrations of most n-3 PUFAs were lower in the patients: 18:3n-3 by 32% (p < 0.002), 20:3n-3 by 34%, 20:5n-3 by 36% (all p < 0.001) and 22:6n-3 by 18% (p = 0.002). No significant differences were observed in other fatty acids. Significant inverse correlations were obtained between levels of n-3 PUFAs and LSAS scores. In conclusion, the phospholipid hypothesis may apply to SAD, thereby opening new therapeutic options. The robust relationship between low erythrocyte n-3 PUFA concentrations and SAD justifies exploration of relevant neuropathophysiological mechanisms.

Serotonin uptake to lymphocytes of patients with social phobia compared to normal individuals.

Several trials have indicated that selective serotonin reuptake inhibitors (SSRIs) are most efficient in the treatment of social phobia (SP). The activity of the serotonin transporter (5-HTT), as determined by [3H]5-HT uptake to blood lymphocytes, was measured in 15 drug-free patients with generalized SP (7M/8F, aged 21-37 years) and compared to 18 healthy control subjects (10M/8F, aged 21-32 years). The maximum uptake velocity (Vmax) of [3H]5-HT to fresh lymphocytes and the affinity (Km) of the 5-HTT were similar in the two groups (295+/-155 versus 227+/-117 pmol/min/mg protein and 767+/-425 versus 709+/-408 nM, respectively). This study suggests that the functioning of lymphocyte 5-HTT is unaltered in SP.

Cultural Impact on SAD: Social Anxiety Disorder among Ethiopian and Former Soviet Union Immigrants to Israel, in Comparison to Native-born Israelis.

BACKGROUND: Social Anxiety Disorder (SAD) is linked to social norms and role expectations which are culture dependent, such as the construal of one's self as independent or interdependent in relation to others. The current study is the first to examine SAD symptoms among Ethiopian and former Soviet Union immigrants to Israel compared to a sample of native Israelis. We investigated the relationship between SAD, ethnicity and independent/ interdependent self-construals. METHODS: A total of 261 students (151 native-born Israelis, 60 Ethiopian immigrants and 50 students from the former USSR) were administrated the Liebowitz Scale (LSAS), the Self-construal Scale (SCS), Beck Depression Inventory (BDI) and a socio-demographic questionnaire. RESULTS: Ethiopians exhibited highest SAD scores while no differences were found between the FSU immigrants and native-born Israelis. Additionally, Ethiopians and native-born Israeli students exhibited similar high interdependence scores. Finally, SAD scores were predicted by gender, origin, independent and interdependent self-construals. CONCLUSION: Immigration per se is not a universal risk factor of SAD and ethnological-cultural factors do contribute specifically to SAD. A possible psychological mediator between culture and the susceptibility to SAD are the interdependence and independent self-construals. When treating immigrants, clinicians and health care providers are advised to consider the effect of cultural influence on the mental well-being and integration process of immigrants in to their host country.

Expressed emotion: relevance to rehospitalization in schizophrenia over 7 years.

Expressed emotion (EE) is an established factor in short-term relapse in schizophrenia. However, data on its long-term predictive ability are scarce. We extended our short-term investigation over 7 years' followup. The study population consisted of 108 patients, 93 with schizophrenia and 15 with schizoaffective disorder. EE of the key relatives was rated with the Five Minute Speech Sample (FMSS). Patient households were categorized by EE and its two components: criticism (CR) and emotional overinvolvement (EOI). High CR was associated with earlier first and second readmissions (Breslow p = 0.002 and 0.04, respectively). High CR was associated with a higher rate of readmissions (p = 0.01) and a longer hospital stay (p = 0.02) compared with low CR. Both compliance with pharmacotherapy and the interaction of high-CR x poor compliance were additional contributors to time to first readmission. This study is the first to demonstrate the prolonged predictive validity of EE. Our results support the value of CR as a prognostic indicator of the course of schizophrenia. The FMSS appears to have predictive power in respect to psychiatric hospitalization. Therapies aimed at lowering high EE seem warranted as a long-term preventive approach.

Involvement of GABAA receptor modulating neuroactive steroids in patients with social phobia.

Dehydroepiandrosterone (DHEA) and its sulfate ester (DHEA-S), neurosteroids synthesized in the brain, are weak gamma-aminobutyric acid (GABA) A receptor allosteric antagonists that may be involved in anxiety disorders. In the present study we measured the circulatory [corrected] levels of DHEA, DHEA-S, pregnenolone and cortisol in [corrected] untreated patients (n=26) diagnosed with social phobia (SP) compared with sex- and age-matched healthy controls (n=21). No significant differences in neurosteroids were observed in [corrected] untreated SP patients and [corrected] compared with healthy controls. The findings may reflect an absence of involvement of the GABA(A) modulators DHEA, DHEA-S and pregnenolone in SP.

Platelet vesicular monoamine transporter density in untreated patients diagnosed with social phobia.

The vesicular monoamine transporter (VMAT2) is important in the storage and release of monoamines. Platelet VMAT2 was characterized using high-affinity [(3)H]dihydrotetrabenazine ([(3)H]TBZOH) binding in untreated social phobia (SP) patients (n=20) compared with sex- and age-matched healthy controls (n=15). No significant differences in VMAT2 density (B(max)) and affinity constants (K(d)) were observed.

The effects of social anxiety and depression on the evaluation of facial crowds.

Facial crowds of emotion connoting approval or criticism are linked to the fears of socially anxious individuals. We examined evaluation ratings and decision latencies of mixed facial displays by individuals with generalized social phobia (GSPs, n = 18), individuals with comorbid depression and GSP (COMs, n = 18), and normal controls (CONs, n = 18). First, we postulated that GSPs will assign more negative ratings to predominantly disapproving audiences as compared to CONs, and that GSPs will be faster in their evaluation of these audiences (negative bias hypothesis). Second, we expected depression, but not social anxiety, to be associated with diminished positive evaluation of audiences containing predominantly happy expressions and with a slower processing of such positive cues (the impaired positivity hypothesis). Results supported the negative bias hypothesis, and provided partial support for the impaired positivity hypothesis. The importance of examining the processing of complex non-verbal cues in social anxiety and in depression is discussed.

Musical hallucinations: prevalence in psychotic and nonpsychotic outpatients.

BACKGROUND: Musical hallucinations have been considered a rare manifestation of psychotic states or brain and hearing abnormalities. However, an obsessive-compulsive disorder (OCD) assessment tool refers to musical hallucinations and our preliminary study showed that about one third of OCD patients experienced musical hallucinations. AIMS: To elucidate the lifetime prevalence of musical hallucinations among psychotic and nonpsychotic psychiatric outpatients. METHODS: Lifetime experience of musical hallucinations was examined with a specially designed structured interview in 190 consecutive outpatients with diagnoses of anxiety, affective, and schizophrenia disorders. RESULTS: Musical hallucinations occurred in more than one fifth of all diagnoses. The prevalence of musical hallucinations was highest in OCD patients (41%). Musical hallucinations were significantly more frequent with more comorbid disorders, and logistic regression revealed that this finding was mainly due to OCD combined with either social phobia or schizophrenia. CONCLUSION: Musical hallucinations are more common among psychiatric patients than previously reported and are more suggestive of OCD than of other mental disorders.

Sexual function and behavior in social phobia.

BACKGROUND: Social phobia is a type of performance and interpersonal anxiety disorder and as such may be associated with sexual dysfunction and avoidance. The aim of the present study was to evaluate sexual function and behavior in patients with social phobia compared with mentally healthy subjects. METHOD: Eighty subjects participated in the study: 40 consecutive, drug-free outpatients with social phobia (DSM-IV) attending an anxiety disorders clinic between November 1997 and April 1999 and 40 mentally normal controls. The Structured Clinical Interview for DSM-IV Axis I Disorders and the Liebowitz Social Anxiety Scale were used to quantitatively and qualitatively assess sexual function and behavior. RESULTS: Men with social phobia reported mainly moderate impairment in arousal, orgasm, sexual enjoyment, and subjective satisfaction domains. Women with social phobia reported severe impairment in desire, arousal, sexual activity, and subjective satisfaction. In addition, compared with controls, men with social phobia reported significantly more frequent paid sex (p < .05), and women with social phobia reported a significant paucity of sexual partners (p < .05). CONCLUSION: Patients with social phobia exhibit a wide range of sexual dysfunctions. Men have mainly performance problems, and women have a more pervasive disorder. Patients of both genders show difficulties in sexual interaction. It is important that clinicians be aware of this aspect of social phobia and initiate open discussions of sexual problems with patients.

Familial expressed emotion: outcome and course of Israeli patients with schizophrenia.

We investigated the validity of expressed emotion (EE) in Israel. The study sample consisted of 108 patients with schizophrenia and 15 with schizoaffective disorder, and their key relatives. EE was rated with the Five Minute Speech Sample (FMSS). Patient households were categorized by EE and its two components: criticism and emotional overinvolvement. Patients were rated with the Brief Psychiatric Rating Scale (BPRS) at admission, at discharge, and 6 months after discharge. Readmissions were determined over a 9-month period. High EE and particularly high criticism were significantly associated with poorer outcome (higher rate of and earlier readmissions, and higher BPRS score at followup) and worse illness course (higher annual number of prior psychiatric hospital admissions). Odds ratios between high EE and high criticism and readmission were 2.6 and 3.5, respectively. The strongest predictor of earlier readmission was the interaction of high criticism x poor compliance with medication. The results converge to further confirm the notion that familial EE is a valid crosscultural predictor of the clinical course of schizophrenia. Moreover, EE has predictive power in very chronic samples. Criticism appears to be the crucial EE component linked with short-term outcome. Treatment aimed at reducing high criticism is warranted. The FMSS appears to have predictive validity.

QT dispersion in patients with social phobia.

BACKGROUND: QT dispersion (QTd) is the maximal interlead difference in QT interval on the surface 12-lead electrocardiogram (ECG). An increase in QTd is found in various cardiac diseases and reflects cardiac autonomic imbalance. It has recently been associated with increased anxiety levels, thereby predisposing affected individuals to fatal heart disease. This is the first study to assess QTd in social phobia, as a marker of anxiety-induced cardiac dysregulation. METHODS: QTd and rate-corrected QTd were measured in 16 physically healthy and non-depressed outpatients with long-term (mean 28+/-12.2 years; age 37.9+/-9.6 years) social phobia (SP) and in 15 physically and mentally healthy age- and gender-matched controls. The Liebowitz Social Anxiety Scale (LSAS) was scored concomitantly. The intra- and inter-observer reproducibilities of QTd were highly correlated (r=0.96, P<0.001; r=0.74, P=0.002, respectively). RESULTS: QTd and rate-corrected QTd were significantly higher in the patients with SP compared to the controls (70+/-21 versus 43+/-10 ms, P<0.001 and 75+/-23 versus 46+/-10 ms, P<0.001, respectively), and highly correlated with the two LSAS subscores. CONCLUSIONS: Prolonged SP is associated with an increase in QTd. This association may result from prolonged anxiety and, in turn, a decrease in vagal modulation and/or increase in sympathetic modulation. Further large-scale epidemiological studies are needed to determine if increased QTd can serve as a trait/state marker, and if it is a risk factor for sudden cardiac death in patients with SP.

Depression impairs the ability to ignore the emotional aspects of facial expressions: Evidence from the Garner task.

We assessed dysphoric and clinically distressed individuals' ability to ignore the emotional aspects of facial expressions using the Garner speeded-classification task. Garner's paradigm tests the ability to selectively focus on a single relevant dimension while ignoring variations on other, irrelevant, ones. In the present task, the stimuli were faces of men and women expressing happy, angry, and neutral emotions. In Experiments 1 and 2, dysphoric and nondysphoric participants performed the Garner task, focusing on gender and ignoring emotion (Experiment 1) and focusing on emotion and ignoring gender (Experiment 2). Results suggest that dysphoric individuals exhibited more difficulty ignoring the emotional dimension of social stimuli even under specific instructions to do so than nondysphoric individuals. In Experiments 3 and 4, we replicated these results in clinically distressed and nondistressed individuals. The results of Experiment 3 further suggested that depression was more closely associated with the inability to selectively ignore emotion than was social anxiety. Experiment 4 confirmed that this failure of selective attention was specific to processing emotional, and not gender features. The implications of these findings for cognitive and interpersonal theories of depression are discussed.

Cognitive behavior therapy (CBT) in anxiety disorders.

This review examines CBT as a leading evidence-based psychotherapy. It describes briefly the major components of CBT: exposure, reduction of safety behaviors, attention focus modification and cognitive restructuring. Specific CBT strategies suited for the main anxiety disorders are reported (specific phobias, panic disorder and agoraphobia, social phobia, generalized anxiety disorder, obsessive compulsive disorder and post-traumatic stress disorder). The review emphasizes the efficiency of the use of CBT as a psychotherapeutic method in anxiety disorders. Finally, it points to the lack of the use of CBT in Israel and recommends its wide use in the mental health service here.

The link between social anxiety disorder, treatment outcome, and sleep difficulties among patients receiving cognitive behavioral group therapy.

OBJECTIVE: The aim of our study was to examine the association between sleep disturbances and social anxiety disorder (SAD). Another aim was to explore the impact of cognitive behavioral group therapy (CBGT) for SAD on co-occurring sleep difficulties. METHODS: Data were obtained retrospectively from patient files receiving CBGT for SAD. The sample included 63 patients with SAD (mean age, 30.42 years [standard deviation, 6.92 years]). There were 41 men and 22 women, of whom 41 participants completed the treatment protocol. Before treatment onset participants completed the Liebowitz Social Anxiety Scale (LSAS), the Beck Depression Inventory (BDI), the Pittsburgh Sleep Quality Index, and several sociodemographic questions. On completion of the treatment protocol, the same measures were completed, with the addition of the Sheehan Disabilities Scale (SDS). RESULTS: The results of our study suggest that: (1) subjective insomnia is associated with SAD severity even after controlling for depression severity and additional variables; (2) participants with SAD with co-occurring clinical levels of subjective insomnia present a more severe clinical picture both at treatment onset and termination; and (3) although CBGT lead to reduction in SAD and depression symptoms severity, it had no significant impact on co-occurring sleep difficulties. CONCLUSIONS: Sleep difficulties predict SAD severity regardless of depressive symptoms and may be linked to a more severe clinical picture. Clinicians should be aware of these sleep difficulties co-occurring with SAD and consider implementing specific sleep interventions. Future studies should incorporate larger samples sizes from clinical populations outside of Israel.