A comprehensive group-based cognitive behavioural treatment for blood-injection-injury phobia.

OBJECTIVES: A key feature of blood-injection-injury (BII) phobia is activation of disgust responses, in addition to fear. Yet, standard treatments have largely neglected addressing disgust responses. The disorder is further complicated by fainting in 75% of sufferers. Moreover, treatments have been traditionally delivered in an individual format, which may not be as efficient as group treatment. The aim of this study was to develop a group-based programme for BII phobia, with components targeting fear, disgust, and fainting, to determine feasibility and effectiveness of such an intervention. METHODS: Participants took part in an 8-session, group-based Cognitive Behavioural Therapy (CBT) programme for BII phobia (N = 40). The key outcome measure was the Multidimensional Blood/Injury Phobia Inventory, which assesses a range of phobic stimuli and responses (including fear, disgust, and fainting). RESULTS: There were significant improvements, with large effect sizes, across symptoms over the course of treatment. Participants with higher disgust sensitivity reported higher pre-treatment symptom severity and greater life interference than those with lower disgust scores. Despite this, neither pre-treatment disgust sensitivity nor fainting history impacted on treatment response. For the first time, however, we showed that greater reductions in disgust to BII stimuli were associated with greater overall symptom reductions, highlighting the importance of disgust in the treatment of this disorder, and potentially others. CONCLUSION: Despite the heterogeneous nature of BII phobia, this group-based, modified CBT intervention was effective in reducing a variety of phobic responses, including fear, disgust, and fainting. PRACTITIONER POINTS: Disgust is a key maintaining factor in blood-injection-injury phobia, which clinicians should consider in their assessment and treatment of this disorder. There is little in the existing literature to guide clinicians in this regard. This study examined a novel group treatment for blood-injection-injury phobia which included strategies to target disgust, in addition to traditional CBT strategies to address fear and fainting. The treatment was feasible and acceptable. Symptoms of fear, disgust, and fainting reduced significantly over treatment. Changes in disgust symptoms were associated with overall symptom changes, however a control group is needed to determine the effects of individual treatment components and to make more robust conclusions about the benefits of this enhanced approach.

The impact of alcohol use disorders and alcohol consumption on treatment-seeking individuals with social anxiety disorder.

Comorbid social anxiety and alcohol use disorders (SAD-AUD) in the community and the complex interactions that occur between these disorders have emerged as a significant clinical, public health, and research issue. The authors examined (a) the rates of comorbid SAD-AUD, (b) the impact of comorbid SAD-AUD on outcomes targeting social anxiety disorder, and (c) the effect of pretreatment alcohol consumption and alcohol use before, during, and after social situations on a composite measure of social anxiety in 172 adults presenting with social anxiety disorder. There was low incidence of AUD in this sample of individuals with SAD. Results indicated that alcohol consumption did not lead to worse social anxiety symptoms; however, alcohol use before and during social situations was associated with more severe social anxiety symptoms. These findings suggest that the function of alcohol use may be more important than the overall level of alcohol use and has implications for treatment.

Symptoms of offensive type Taijin-Kyofusho among Australian social phobics.

This study investigated the culture specificity of Taijin-Kyofusho (TK) offensive type by examining whether symptoms of the disorder covary with social phobia and determining the proportion of those who meet criteria for a diagnosis of TK offensive type among Australian socially phobic individuals. The study included a total of 94 participants who met the DSM-IV criteria for social phobia and 39 normal controls who did not meet criteria for any mental disorder. All participants were born in Western countries and resided in Australia. Results showed that levels of offensive worry were significantly elevated in socially phobic individuals and decreased after treatment of their social phobia, pointing to a close relationship between symptoms of TK offensive type and social anxiety. Correlational analysis indicated that TK offensive type and social phobia appear to represent distinct constructs, although the two constructs were clearly strongly related. However, diagnostic examination revealed that the prevalence of reported offensive symptoms (eight out of 94; 8.5%) was extremely low among participants with social phobia in Australia and none of them met the full criteria for TK offensive type. The mixed findings relevant to the existence of TK offensive type among an Australian sample with social phobia are discussed in relation to cultural influences on life interference, referral behaviors, and diagnostic customs.

Development and validation of the Core Beliefs Questionnaire in a sample of individuals with social anxiety disorder.

BACKGROUND: Prominent cognitive models of social anxiety have consistently emphasised the importance of beliefs about the self in the aetiology and maintenance of social anxiety. The present study sought to develop and validate a new measure of core beliefs about the self for SAD, the Core Beliefs Questionnaire (CBQ). METHODS: Three versions of the CBQ were developed: a Trait version (fundamental absolute statements about the self), a Contingent version (statements about the self related to a specific social-evaluative situation), and an Other version (statements about how others view the self in social-evaluative situations generally). The psychometric features of the scales were examined in clinical (n=269) and non-clinical (n=67) samples. RESULTS: Exploratory factor analysis yielded a one factor model for all three versions of the questionnaire. Total scores differentiated individuals with SAD from individuals without a psychiatric condition, and demonstrated excellent internal consistency. The three CBQ versions had positive associations with social anxiety while controlling for depression, although zero-order correlations indicated the Trait version was more strongly related to depression than social anxiety, the Contingent version was similarly related to depression and social anxiety, and the Other version was more strongly related to social anxiety than depression. Scores on all three versions of the CBQ reduced from pre- to post-treatment and this change predicted treatment outcome. LIMITATIONS: This is the first validation study of the CBQ. CONCLUSIONS: This study provides initial support for the reliability and validity of the CBQ.

Do empirically supported treatments generalize to private practice? A benchmark study of a cognitive-behavioural group treatment programme for social phobia.

OBJECTIVES: There is much debate as to whether the treatment effects achieved in well-controlled studies such as randomized controlled trials (RCTs) are generalizable to more "naturalistic" clinical populations, such as that seen in private practice. The current study sought to examine this issue in relation to social phobia. DESIGN: A benchmarking strategy was used to compare the effectiveness of a cognitive-behaviour therapy group programme for social phobia that was developed and evaluated in a research unit, to that of a private practice population. METHODS: Fifty-eight participants from a university research unit and 54 participants from an independent private practice who met the principal diagnostic criteria for social phobia completed the 10-session group programme. Symptom severity was measured at pre-treatment, post-treatment, and 3 months after treatment. RESULTS: No significant treatment differences were found between the research unit and private practice groups. Both groups showed significant treatment effects that were maintained at 3-month follow-up. CONCLUSION: These findings suggest that treatments developed for RCTs are potentially transportable to private practice settings.

The Yin and Yang of support from significant others: Influence of general social support and partner support of avoidance in the context of treatment for social anxiety disorder.

Support from social networks is generally considered to protect against mental disorder but in some circumstances support for negative behaviours (such as avoidance) may be counterproductive. Given the critical interplay between social anxiety disorder and social interactions, it is surprising that the relationship of support from significant others to this disorder has received so little attention. The current study evaluated the reciprocal relationships between perceived social support and perceived partner support for avoidance behaviours (avoidance support) among a sample of 131 participants with social anxiety disorder who were assessed three times within the context of a treatment outcome study. A new measure of partner support for avoidance behaviours was developed, called the Avoidance Support Measure, and showed adequate internal consistency and construct validity. Correlations at baseline showed significant negative relationships between perceived social support and social anxiety and significant positive relationships between avoidance support and social anxiety. Path analysis showed that perceived social support at Times 1 and 2 negatively predicted future social anxiety at Times 2 and 3. On the other hand, only a single predictive relationship involving avoidance support was significant and showed that social anxiety at Time 1 positively predicted avoidance support at Time 2. These early results point to the different ways that support from significant others might relate to social anxiety and suggest that further work in this area may be fruitful.

Integrating cognitive bias modification into a standard cognitive behavioural treatment package for social phobia: a randomized controlled trial.

OBJECTIVE: The aim of the current study was to integrate recent developments in the retraining of attentional biases towards threat into a standard cognitive behavioural treatment package for social phobia. METHOD: 134 participants (M age-32.4: 53% female) meeting DSM-IV criteria for social phobia received a 12-week cognitive behavioural treatment program. They were randomly allocated to receive on a daily basis using home practice, either an additional computerised probe procedure designed to train attentional resource allocation away from threat, or a placebo variant of this procedure. Measures included diagnostic severity, social anxiety symptoms, life interference, and depression as well as state anxiety in response to a laboratory social threat. RESULTS: At the end of treatment there were no significant differences between groups in attentional bias towards threat or in treatment response (all p's>0.05). Both groups showed similar and highly significant reductions in diagnostic severity, social anxiety symptoms, depression symptoms, and life interference at post-treatment that was maintained and in most cases increased at 6 month follow-up (uncontrolled effect sizes ranged from d=0.34 to d=1.90). CONCLUSIONS: The current results do not indicate that integration of information processing-derived attentional bias modification procedures into standard treatment packages as conducted in this study augments attentional change or enhances treatment efficacy. Further refinement of bias modification techniques, and better methods of integrating them with conventional approaches, may be needed to produce better effects.

Testing the efficacy of theoretically derived improvements in the treatment of social phobia.

Recent theoretical models of social phobia suggest that targeting several specific cognitive factors in treatment should enhance treatment efficacy over that of more traditional skills-based treatment programs. In the current study, 195 people with social phobia were randomly allocated to 1 of 3 treatments: standard cognitive restructuring plus in vivo exposure, an "enhanced" treatment that augmented the standard program with several additional treatment techniques (e.g., performance feedback, attention retraining), and a nonspecific (stress management) treatment. The enhanced treatment demonstrated significantly greater effects on diagnoses, diagnostic severity, and anxiety during a speech. The specific treatments failed to differ significantly on self-report measures of social anxiety symptoms and life interference, although they were both significantly better than the nonspecific treatment. The enhanced treatment also showed significantly greater effects than standard treatment on 2 putative process measures: cost of negative evaluation and negative views of one's skills and appearance. Changes on these process variables mediated differences between the treatments on changes in diagnostic severity.

A self-report measure of subtle avoidance and safety behaviors relevant to social anxiety: development and psychometric properties.

According to cognitive theories, safety-seeking behaviors are crucial in both the maintenance and management of social anxiety. In order to facilitate assessment of these behaviors the Subtle Avoidance Frequency Examination (SAFE) was developed. Three factors emerged from the SAFE, which appeared to reflect active "safety" behaviors, subtle restriction of behavior, and behaviors aimed at avoiding or concealing physical symptoms. The SAFE demonstrated strong internal consistency, good construct validity and the ability to discriminate between clinical and non-clinical participants. In addition, the SAFE was responsive to the effects of treatment. Given its excellent psychometric properties, the SAFE may be useful to further investigate the role of safety strategies in social anxiety and to assess treatment outcomes.

A randomized controlled trial of D-cycloserine enhancement of exposure therapy for social anxiety disorder.

BACKGROUND: Pilot research has suggested that D-cycloserine (DCS) enhances treatment outcomes for anxiety disorders when employed as an adjunct to exposure therapy (ET). The aim of this study was to determine whether 50 mg of DCS enhances ET for social anxiety disorder (SAD) according to a comprehensive set of symptom and life impairment measures. METHODS: In a randomized double-blind placebo-controlled trial, we administered 50 mg of DCS or placebo in combination with ET to 56 participants who met primary diagnosis for SAD. RESULTS: Participants administered DCS reported greater improvement on measures of symptom severity, dysfunctional cognitions, and life-impairment from SAD in comparison with placebo-treated participants. Effect sizes were mostly in the medium range. Results also indicated that the amount of adaptive learning about one's ability to give speeches in front of an audience interacted with DCS to enhance treatment outcome. CONCLUSIONS: This study shows that the administration of DCS before ET enhances treatment outcomes for SAD. Results also provide the first preliminary evidence to suggest that DCS moderates the relationship between a reduction in negative appraisals about one's speech performance and improvement in overall SAD symptoms.

Treatment of social phobia through pure self-help and therapist-augmented self-help.

BACKGROUND: Self-help for social phobia has not received controlled empirical evaluation. AIMS: To evaluate the efficacy of pure self-help through written materials for severe social phobia and self-help augmented by five group sessions with a therapist. These conditions were compared with a waiting-list control and standard, therapist-led group therapy. METHOD: Participants with severe generalised social phobia (n=224) were randomised to one of four conditions. Assessment included diagnoses, symptoms and life interference at pretreatment, 12 weeks and at 24 weeks. RESULTS: A larger percentage of patients no longer had a diagnosis of social phobia at post-intervention in the pure self-help group than in the waiting-list group, although this percentage decreased slightly over the next 3 months. Symptoms of social anxiety and life interference did not differ significantly between these groups. Augmented self-help was better than waiting list on all measures and did not differ significantly from group treatment. CONCLUSIONS: Self-help augmented by therapist assistance shows promise as a less resource-intensive method for the management of social phobia. Pure self-help shows limited efficacy for this disorder.

Psychometric properties of the general well-being index.

There is a growing interest in the measurement of quality of life as an important marker of health outcomes. The General Well-Being Index (GWBI) is a quality of life measure that has been specifically designed to assess psychological distress rather than physical incapacitation. Previous studies using the GWBI have mainly focussed on clinical samples (e.g., depressed patients). The aim of the current study was to examine the psychometric properties of the GWBI in a non-clinical population. Using data gathered from 447 first year University students, the GWBI was found to have excellent psychometric properties. Both internal consistency and test-retest reliability were high, and the concurrent and construct validity of the measure were sound. Factor analysis revealed three significant factors, which were labelled 'general mood/affect', 'life satisfaction/vitality', and 'poor physical health/somatic complaints'. Limitations to the present study are further discussed.