Positive emotional reactivity to pleasant social and nonsocial stimuli in social anxiety disorder.

Prior research has shown that Social Anxiety Disorder (SAD) is associated with significantly diminished positive affect (PA). Few studies have examined PA reactivity to pleasant experimental stimuli in individuals with SAD and whether emotional responses might be moderated by social context. Here, we investigated repeated measures of PA reactivity among individuals with SAD (n = 46) and healthy controls (HC; n = 39) in response to standardized neutral images, pleasant music, and social versus nonsocial guided imagery. Primary analyses revealed that SAD and HC participants did not differ in their PA reactivity when PA was conceptualized as a unitary construct. Exploratory analyses examining discrete subfacets of PA revealed potential deficits for SAD participants in relaxed and content PA, but not activated PA. Although participants with SAD reported relatively lower levels of relaxed and content PA overall compared with controls, they exhibited normal increases in all PA subfacets in response to pleasant music as well as pleasant social and nonsocial stimuli. These findings support a more nuanced conclusion about PA deficits in SAD than is described in the extant literature, suggesting that detecting PA deficits in SAD may depend upon how PA is conceptualized, evoked, and measured. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Impacts of imagery-enhanced versus verbally-based cognitive behavioral group therapy on psychophysiological parameters in social anxiety disorder: Results from a randomized-controlled trial.

Social anxiety disorder (SAD) is associated with marked physiological reactivity in social-evaluative situations. However, objective measurement of biomarkers is rarely evaluated in treatment trials, despite potential utility in clarifying disorder-specific physiological correlates. This randomized controlled trial sought to examine the differential impact of imagery-enhanced vs. verbal-based cognitive behavioral group therapy (IE-CBGT, n = 53; VB-CBGT, n = 54) on biomarkers of emotion regulation and arousal during social stress in people with SAD (pre- and post-treatment differences in heart rate variability (HRV) and skin conductance). We acquired psychophysiological data from randomized participants across four social stress test phases (baseline, speech preparation, speech, interaction) at pre-treatment, and 1- and 6-months post-treatment. Analyses revealed that IE-CBGT selectively attenuated heart rate as indexed by increases in median heart rate interval (median-RR) compared to VB-CBGT at post-treatment, whereas one HRV index showed a larger increase in the VB-CBGT condition before but not after controlling for median-RR. Other psychophysiological indices did not differ between conditions. Lower sympathetic arousal in the IE-CBGT condition may have obviated the need for parasympathetic downregulation, whereas the opposite was true for VB-CBGT. These findings provide preliminary insights into the impact of imagery-enhanced and verbally-based psychotherapy for SAD on emotion regulation biomarkers.

Imagery-enhanced v. verbally-based group cognitive behavior therapy for social anxiety disorder: a randomized clinical trial.

BACKGROUND: Cognitive behavior therapy (CBT) is effective for most patients with a social anxiety disorder (SAD) but a substantial proportion fails to remit. Experimental and clinical research suggests that enhancing CBT using imagery-based techniques could improve outcomes. It was hypothesized that imagery-enhanced CBT (IE-CBT) would be superior to verbally-based CBT (VB-CBT) on pre-registered outcomes. METHODS: A randomized controlled trial of IE-CBT v. VB-CBT for social anxiety was completed in a community mental health clinic setting. Participants were randomized to IE (n = 53) or VB (n = 54) CBT, with 1-month (primary end point) and 6-month follow-up assessments. Participants completed 12, 2-hour, weekly sessions of IE-CBT or VB-CBT plus 1-month follow-up. RESULTS: Intention to treat analyses showed very large within-treatment effect sizes on the social interaction anxiety at all time points (ds = 2.09-2.62), with no between-treatment differences on this outcome or clinician-rated severity [1-month OR = 1.45 (0.45, 4.62), p = 0.53; 6-month OR = 1.31 (0.42, 4.08), p = 0.65], SAD remission (1-month: IE = 61.04%, VB = 55.09%, p = 0.59); 6-month: IE = 58.73%, VB = 61.89%, p = 0.77), or secondary outcomes. Three adverse events were noted (substance abuse, n = 1 in IE-CBT; temporary increase in suicide risk, n = 1 in each condition, with one being withdrawn at 1-month follow-up). CONCLUSIONS: Group IE-CBT and VB-CBT were safe and there were no significant differences in outcomes. Both treatments were associated with very large within-group effect sizes and the majority of patients remitted following treatment.

The effects of imagery rescripting on memory outcomes in social anxiety disorder.

Imagery rescripting (IR) is an effective intervention for social anxiety disorder (SAD) that targets negative autobiographical memories. IR has been theorized to work through various memory mechanisms, including modifying the content of negative memory representations, changing memory appraisals, and improving negative schema or core beliefs about self and others. However, no prior studies have investigated the unique effects of rescripting itself relative to other IR intervention components on these proposed mechanisms. In this preliminary study, 33 individuals with SAD were randomized to receive a single session of IR, imaginal exposure (IE), or supportive counselling (SC). Memory outcomes were assessed at 1- and 2-weeks post-intervention and at 3-months follow-up. Results demonstrated that the content of participants' autobiographical memory representations changed in distinct ways across the three conditions. Whereas IR facilitated increases only in positive/neutral memory details, IE facilitated increases in both positive/neutral and negative memory details and SC facilitated no changes in memory details. Although memory appraisals did not differ across conditions, participants who received IR were more likely to update their negative memory-derived core beliefs. These unique effects of rescripting on memory representations and core beliefs enhance our understanding of the memory-based mechanisms of IR within the context of exposure-based learning for people with SAD.

Autobiographical memory retrieval and appraisal in social anxiety disorder.

Individuals with social anxiety disorder (SADs; n = 41) and healthy controls (HCs; n = 40) were administered the Waterloo Images and Memories Interview, in which they described mental images that they tend to experience in both anxiety-provoking and non-anxiety-provoking social situations. Participants then recalled, in as much detail as possible, specific autobiographical memories of salient aversive and non-aversive social experiences that they believed led to the formation of these images. Audio-recorded memory narratives were transcribed and coded based on the procedure of the Autobiographical Interview, which provides a precise measure of the degree of episodic detail contained within each memory. Participants also rated the subjective properties of their recalled memories. Results revealed that participants across the two groups retrieved equivalent rates of both aversive and non-aversive social memories. However, SAD participants' memories of aversive events contained significantly more episodic detail than those of HCs, suggesting that they may be more highly accessible. Moreover, participants with SAD appraised their memories of aversive experiences as more distressing and intrusive than HCs, and perceived them as having a significantly greater influence on their self-perception. In contrast, no group differences were observed for memories of non-aversive events. Findings have the potential to shed new light on autobiographical memory in SAD, with implications for psychotherapeutic intervention.

Transportability of imagery-enhanced CBT for social anxiety disorder.

Pilot and open trials suggest that imagery-enhanced group cognitive behaviour therapy (CBT) is highly effective for social anxiety disorder (SAD). However, before being considered reliable and generalisable, the effects of the intervention need to be replicated by clinicians in a setting that is independent of the protocol developers. The current study compared outcomes from clients with a principal diagnosis of SAD at the Australian clinic where the protocol was developed (n = 123) to those from an independent Canadian clinic (n = 46) to investigate whether the large effects would generalise. Trainee clinicians from the independent clinic ran the groups using the treatment protocol without any input from its developers. The treatment involved 12 2-h group sessions plus a one-month follow-up. Treatment retention was comparable across both clinics (74% vs. 78%, ≥9/12 sessions) and the between-site effect size was very small and non-significant on the primary outcome (social interaction anxiety, d = 0.09, p = .752). Within-group effect sizes were very large in both settings (ds = 2.05 vs. 2.19), and a substantial minority (41%-44%) achieved clinically significant improvement at follow-up. Replication of treatment effects within an independent clinic and with trainee clinicians increases confidence that outcomes are generalisable.

Assessing the efficacy of imagery-enhanced cognitive behavioral group therapy for social anxiety disorder: Study protocol for a randomized controlled trial.

Cognitive behavior group therapy (CBGT) is effective for social anxiety disorder (SAD), but a substantial proportion of patients do not typically achieve normative functioning. Cognitive behavioral models of SAD emphasize negative self-imagery as an important maintaining factor, and evidence suggests that imagery is a powerful cognitive mode for facilitating affective change. This study will compare two group CBGT interventions, one that predominantly uses verbally-based strategies (VB-CBGT) and another that predominantly uses imagery-enhanced strategies (IE-CBGT), in terms of (a) efficacy, (b) mechanisms of change, and (c) cost-effectiveness. This study is a parallel groups (two-arm) single-blind randomized controlled trial. A minimum of 96 patients with SAD will be recruited within a public outpatient community mental health clinic in Perth, Australia. The primary outcomes will be self-reported symptom severity, caseness (SAD present: yes/no) based on a structured diagnostic interview, and clinician-rated severity and life impact. Secondary outcomes and mechanism measures include blind observer-rated use of safety behaviors, physiological activity (heart rate variability and skin conductance level) during a standardized speech task, negative self-beliefs, imagery suppression, fear of negative and positive evaluation, repetitive negative thinking, anxiety, depression, self-consciousness, use of safety behaviors, and the EQ-5D-5L and TiC-P for the health economic analysis. Homework completion, group cohesion, and working alliance will also be monitored. The outcomes of this trial will inform clinicians as to whether integrating imagery-based strategies in cognitive behavior therapy for SAD is likely to improve outcomes. Common and distinct mechanisms of change might be identified, along with relative cost-effectiveness of each intervention.

Imagery-Based Interventions for Music Performance Anxiety: An Integrative Review.

Many musicians experience debilitating music performance anxiety (MPA). Outside music performance, imagery-based interventions have been incorporated into treatment protocols to help individuals, including athletes and those with social anxiety, manage heightened levels of anxiety in order to excel in performance-based domains. Despite the frequent use of mental imagery in MPA interventions and its importance as a mental rehearsal technique for musicians, no existing reviews have examined the literature on imagery-based interventions for MPA. The primary aim of this review was to analyze the existing MPA literature in order to summarize what is known about the efficacy and mechanisms of pre-performance mental imagery exercises. A literature search yielded eight studies that used imagery-based interventions for MPA, in both student and professional musicians, which included three dissertations and five peer-reviewed journal articles. In extant MPA treatment research, pre-performance imagery is often used in conjunction with other techniques in order to alleviate anxiety. Arousal imagery refers to imagining one's state of arousal during performance and has been incorporated into MPA interventions in various ways that guide musicians to anticipate the heightened arousal that accompanies performance, predominantly through imagery-based relaxation techniques. However, methodological limitations make it impossible to determine whether imagery is itself an active ingredient of treatment that underlies symptom changes, or whether relaxation imagery is the most effective use of pre-performance imagery for all musicians. There is much need for future well-controlled studies to examine whether and how imagery affects MPA independent of the other therapy components and techniques with which it is commonly combined.

The impact of imagery rescripting on memory appraisals and core beliefs in social anxiety disorder.

Negative mental images in social anxiety disorder (SAD) are often rooted in autobiographical memories of formative, distressing life events. In the present study, 25 participants with SAD retrieved an idiosyncratic negative mental image and associated autobiographical memory. Participants were then randomly assigned either to a single-session of imagery rescripting (IR) targeting the retrieved autobiographical memory or to a non-intervention control condition (no-IR). Outcomes were assessed one week later. Compared to control participants, those who received IR experienced substantial reduction in SAD symptoms accompanied by more positive and less negative appraisals of their autobiographical memories. Moreover, IR relative to no-IR participants reported marked shifts in the content, validity, and accuracy of their memory-derived negative core beliefs about self and others, but not about the world. Results support the promise of IR as a stand-alone intervention for SAD and suggest important directions for future research to enhance our understanding of the cognitive mechanisms that underlie its effects.

Within the mind's eye: Negative mental imagery activates different emotion regulation strategies in high versus low socially anxious individuals.

BACKGROUND AND OBJECTIVES: The link between social anxiety (SA) and maladaptive emotion regulation has been clearly established, but little is known about the spontaneous regulation strategies that may be activated during social stress by negative involuntary mental images and whether the nature of such strategies might distinguish individuals with high vs. low trait SA. METHODS: Participants with high (n = 33) or low (n = 33) trait SA performed an evaluative speech and reported whether they experienced an involuntary negative mental image during the task. They also rated their negative affect (NA) and positive affect (PA) and the extent to which they viewed their image as being controllable and malleable. Finally, they described the types of strategies they spontaneously used to try to control or change their image intrusions. Reported strategies were then subjected to a content analysis and categorized by blinded coders. RESULTS: Among high SA participants, image controllability was both diminished overall and positively correlated with PA. Whereas 90% of low SA individuals reported that they spontaneously self-regulated by altering the content or perceptual features of their images, only about half of the high SA participants used this strategy, with the other 50% reporting that they either suppressed their images or succumbed passively to them in whatever form they took. LIMITATIONS AND CONCLUSIONS: Although these initial findings require replication in future experimental studies on clinical samples, they also help to enrich our understanding of the strategies that are commonly used by high and low SA individuals to manage their image intrusions during in-vivo stress and suggest potential avenues for future research on the role of imagery in adaptive and maladaptive emotion regulation.

The psychophysiology of social anxiety: emotional modulation of the startle reflex during socially-relevant and -irrelevant pictures.

The present study examined affective processes of social anxiety (SA) through emotional modulation of the startle reflex. Eighty-four high and low trait socially anxious undergraduates viewed socially-relevant and socially-irrelevant pleasant, neutral, and unpleasant pictures, and acoustic startle probes were presented during pictures and the inter-trial interval. Startle was potentiated during unpleasant compared to pleasant stimuli, but this valence modulation did not reliably vary between groups or socially-relevant and -irrelevant stimuli. However, when participants were categorized based on public-speaking fears rather than general SA symptoms, the high fear group demonstrated reliable valence modulation, whereas the low fear group did not. These findings are interpreted within the context of the broader literature suggesting that the specificity of fear in SA may influence psychophysiological reactivity.