Pathological network changes in patients with social anxiety disorder before and after an Internet-based CBT.

A network perspective may shed light on the understanding of Internet-based CBT efficacy for social anxiety disorder. Previous cross-sectional evidence revealed a densely interconnected network for individuals with social anxiety. Yet, longitudinal network changes before and after ICBT are lacking. This study aimed to investigate pathological network changes with Graphical Gaussian Model among patients with social anxiety disorder (n = 249). Social phobia scale (SPS) and Social interaction anxiety scale (SIAS) were measured before and after 8 weeks Internet-based CBT. Results revealed the connection between symptom tension when speaking and symptom awkward when being watched was the most robust edges during ICBT interventions. The pathological network benefited from ICBT and exhibited modification in several prominent interconnections. The overall network connectivity continues to exhibit comparable strength after ICBT. This study represents the first examination of social anxiety network changes after patients with SAD completed a systematic ICBT. Changes in critical edges and nodes provide valuable insights for the design and efficacy assessment of ICBT interventions.

Social anxiety does not impair attention inhibition: An emotion anti-saccade task.

BACKGROUND AND OBJECTIVES: Attention avoidance and attention vigilance are two typical attentional biases in individuals with social anxiety disorder (SAD). Attention inhibition is a type of attention control, which may be the key factor affecting attention vigilance and attention avoidance. However, previous studies have not examined the difference between the attention inhibition in individuals with SAD and healthy controls. METHODS: To further explore this question, the current study used the single anti-saccade task with emotional facial stimuli to assess attention inhibition in 27 individuals with SAD and 22 healthy controls. RESULTS: Regardless of the emotional valence of the facial stimuli, error rates in the social anxiety group were lower than that of the healthy control group, but there was no significant group difference in the saccade latency. LIMITATIONS: This research only examined the attentional inhibition process highly related to attention avoidance and attention vigilance. Future research may benefit from adopting different research paradigms for more robust and generalizable conclusions. CONCLUSIONS: Results suggest that individuals with SAD have better attention inhibition abilities than healthy control. Such enhanced attention inhibition may underlie their avoidance of threatening social cues.

Vigilance-Avoidance Toward Negative Faces in Social Anxiety With and Without Comorbid Depression.

Despite the growing evidence for the attentional bias toward emotional related stimuli in patients with social anxiety disorder (SAD), it remains unclear how the attentional bias manifests in normal individuals with SAD and/or depressive traits. To address this question, we recruited three groups of normal participants with different psychiatric traits-individuals with comorbid SAD and depression (SADd, N = 19), individuals with only SAD (SAD, N = 15), and healthy control individuals (HC, N = 19). In a dot-probe paradigm, participants view angry, disgusted, and sad face stimuli with durations ranging from very brief (i.e., 14ms) that renders stimuli completely intangible, to relatively long (i.e., 2000ms) that guarantees image visibility. We find significant early vigilance (i.e., on brief stimuli) and later avoidance (i.e., on long stimuli) toward angry faces in the SADd group. We also find vigilance toward angry and disgusted faces in the SAD group. To our best knowledge, this is the first study to unify both vigilance and avoidance within the same experimental paradigm, providing direct evidence for the "vigilance-avoidance" theory of comorbid SAD and depression. In sum, these results provide evidence for the potential behavioral differences induced by anxiety-depression comorbidity and a single trait in non-clinical populations, but the lack of a depression-only group cannot reveal the effects of high levels of depression on the results. The limitations are discussed.

The Influence of Intolerance of Uncertainty on Anxiety and Depression Symptoms in Chinese-speaking Samples: Structure and Validity of The Chinese Translation of The Intolerance of Uncertainty Scale.

Few studies evaluated the structure of the short versions of the Chinese translation of the Intolerance of Uncertainty Scale (IUS) among Chinese-speaking individuals. Meanwhile, contemporary theory of IU has emphasized the role of IU as the basic transdiagnostic mechanism underlying emotional disorders, and further empirical support is awaited. Thus, the current research aimed to examine the structure of the IUS (Chinese translation) and the hierarchical model of IU. Confirmatory factor analysis was used to compare fit of the two-factor and bifactor models of the original and short versions (IUS-18 and IUS-12) of the IUS (Chinese translation) among Chinese-speaking samples of adults. The direct effects of IU and indirect effects of IU via neuroticism on anxiety and depression symptoms were examined using structural equation modeling. All IUS models demonstrated acceptable fit. Using the bifactor model of the IUS-12 (Chinese translation), the hierarchical model of IU affecting anxiety and depression via neuroticism was supported. The prospective and inhibitory IU factors performed differently in relating to emotional vulnerabilities and symptoms. We provide suggestions for measuring and modeling IU, and the role of IU as the basic transdiagnostic vulnerability was suggested in Chinese-speaking samples.

Self-focused attention vs. negative attentional bias during public speech task in socially anxious individuals.

Enhanced self-focused attention (SFA) and negative attentional bias (NAB) towards social cues are characteristic hallmarks of social anxiety. It is essential to investigate these two attentional phenomena under socially relevant situations using comparable stimuli. In the present study, individuals with high social anxiety (HSA, n = 32) and low social anxiety (LSA, n = 29) were compared according to their attention toward self-related stimuli and toward positive, neutral, and negative feedback related stimuli. Video stimuli of moving indicators of self-anxiety-status and positive, neutral, and negative feedback from an audience were presented during an impromptu speech task (high anxiety condition) and a re-watching phase (low anxiety condition). Eye movements in response to the different stimuli served as readouts for attentional preference. An interaction effect suggested that the HSA group directed more attention to self-related stimuli relative to other stimuli and the LSA group only during the high anxiety condition. The LSA group exhibited a general attentional preference toward positive feedback, especially during the low anxiety condition. Meanwhile, only the total duration of fixation on positive feedback negatively correlated with subjective anxiety rating. Our results point to increased SFA rather than NAB in HSA individuals under social threats.

The Effect of Shame on Patients With Social Anxiety Disorder in Internet-Based Cognitive Behavioral Therapy: Randomized Controlled Trial.

BACKGROUND: Prior research has demonstrated the efficacy of internet-based cognitive behavioral therapy (ICBT) for social anxiety disorder (SAD). However, it is unclear how shame influences the efficacy of this treatment. OBJECTIVE: This study aimed to investigate the role shame played in the ICBT treatment process for participants with SAD. METHODS: A total of 104 Chinese participants (73 females; age: mean 24.92, SD 4.59 years) were randomly assigned to self-help ICBT, guided ICBT, or wait list control groups. For the guided ICBT group, half of the participants were assigned to the group at a time due to resource constraints. This led to a time difference among the three groups. Participants were assessed before and immediately after the intervention using the Social Interaction Anxiety Scale (SIAS), Social Phobia Scale (SPS), and Experience of Shame Scale (ESS). RESULTS: Participants' social anxiety symptoms (self-help: differences between pre- and posttreatment SIAS=-12.71; Cohen d=1.01; 95% CI 9.08 to 16.32; P<.001 and differences between pre- and posttreatment SPS=11.13; Cohen d=0.89; 95% CI 6.98 to 15.28; P<.001; guided: SIAS=19.45; Cohen d=1.20; 95% CI 14.67 to 24.24; P<.001 and SPS=13.45; Cohen d=0.96; 95% CI 8.26 to 18.64; P<.001) and shame proneness (self-help: differences between pre- and posttreatment ESS=7.34; Cohen d=0.75; 95% CI 3.99 to 10.69; P<.001 and guided: differences between pre- and posttreatment ESS=9.97; Cohen d=0.88; 95% CI 5.36 to 14.57; P<.001) in both the self-help and guided ICBT groups reduced significantly after treatment, with no significant differences between the two intervention groups. Across all the ICBT sessions, the only significant predictors of reductions in shame proneness were the average number of words participants wrote in the exposure module (ß=.222; SE 0.175; t96=2.317; P=.02) and gender (ß=-.33; SE 0.002; t77=-3.13; P=.002). We also found a mediation effect, wherein reductions in shame fully mediated the relationship between the average number of words participants wrote in the exposure module and reductions in social anxiety symptoms (SIAS: ß=-.0049; SE 0.0016; 95% CI -0.0085 to -0.0019 and SPS: ß=-.0039; SE 0.0015; 95% CI -0.0075 to -0.0012). CONCLUSIONS: The findings of this study suggest that participants' engagement in the exposure module in ICBT alleviates social anxiety symptoms by reducing the levels of shame proneness. Our study provides a new perspective for understanding the role of shame in the treatment of social anxiety. The possible mechanisms of the mediation effect and clinical implications are discussed. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1900021952; http://www.chictr.org.cn/showproj.aspx?proj=36977.

Predictors of treatment outcomes and adherence in internet-based cognitive behavioral therapy for social anxiety in China.

BACKGROUND: Although internet-based cognitive behaviour therapy (ICBT) is an effective treatment for social anxiety disorder (SAD), a substantial proportion of patients do not achieve clinically significant improvement. More research is needed to identify which factors predict treatment adherence and outcomes. AIMS: The aims of this study were to (1) identify demographic and clinical factors associated with treatment adherence and outcomes in ICBT for social anxiety in China, and (2) explore whether low-intensity therapist support results in improved treatment adherence or outcomes. METHOD: Participants were assigned to either therapist-guided (N = 183) or self-guided ICBT (N = 72). Level of social anxiety was measured at both pre- and post-treatment. Treatment adherence and outcomes were analysed using a two-step linear and logistic regression approach. Clinical and demographic characteristics were examined. RESULTS: No significant group differences were found for treatment adherence or outcomes between the therapist-guided and self-guided conditions. Participants diagnosed with SAD were significantly less likely to drop out (OR 0.531, p = .03) compared with subclinical participants with social anxiety symptoms. Older participants (B = 0.17, SE = 0.04, p = .008) and participants with a diagnosis of SAD (B = 0.16, SE = 0.44, p = .01) tended to complete more modules. Participants who completed more modules (B = 0.24, SE = 0.03, p = .01) and participants who identified as female (B = -0.20, SE = 0.18, p = .04) reported greater reductions in SAD symptoms. CONCLUSIONS: Understanding of factors related to adherence and outcome is necessary to prevent drop-out and optimize outcome.

Avoidance of all feedback? Attention allocation during and after public speech in social anxiety.

BACKGROUND AND OBJECTIVES: Attention avoidance of feedback-related stimuli is proposed to be associated with and maintain social anxiety. However, previous research has mainly focused on comparing the attention bias between two types of stimuli, while little is known about attention distribution patterns among positive, neutral, and negative feedback and non-feedback stimuli in individuals with high trait social anxiety (HSA) or low trait social anxiety (LSA). METHODS: The current study assessed eye movement pattern of participants with HSA or LSA during a speech task (high anxiety condition) or while solely watching audience feedback of the speech (low anxiety condition). A pre-recorded audience who displayed approving, neutral, or disapproving gestures was presented as feedback stimuli, while neutral facial photos were used as non-feedback stimuli. RESULTS: Only in the high anxiety condition, participants with HSA exhibited longer total fixation on non-feedback stimuli compared to those with LSA; whereas in the low anxiety condition, both groups paid more attention to emotional feedback stimuli. LIMITATIONS: The final sample size was modest due to a high suspicion rate of the reality of the audience. CONCLUSIONS: These findings suggest that only in highly anxious social situations, socially anxious individuals lack the attentional preference toward positive feedback that individuals with low anxious have.

Telesupervision-of-supervision across national boundaries: United States and China.

This article describes technology-assisted telesupervision-of-supervision, which is a component of a 2-year U.S.-China collaborative program designed to systematically train clinical supervisors in China. Using Zoom conferencing platform, several U.S.-based supervisors facilitated telesupervision-of-supervision groups, with six to ten participants in each group, from different geographic locations in China. This article employs the perspectives of both U.S.-based supervisors and group participants who are themselves supervision scholars in China, describing their experiences and insights about the rewards and challenges of this telesupervision-of-supervision project.

Trait anxiety is associated with a decreased visual working memory capacity for faces.

Recent work has suggested that anxiety restricts working memory capacity, which may underlie a wide range of cognitive symptoms in anxiety. However, previous literature on the anxiety-visual working memory association yielded mixed results, with some studies demonstrating an anxiety-related increase in visual working memory capacity. In an attempt to gain a more thorough understanding of the relationship between anxiety and visual working memory maintenance function, the current study examined the influence of trait anxiety on visual working memory capacity and resolution for negative, positive, and neutral faces in a large unselected sample, by conducting two different experiments. Experiment 1 used a change-detection task to estimate visual working memory capacity, while Experiment 2 used a modified time-delay estimation task to measure memory precision. Hierarchical linear modeling was used to analyze the relationship between trait anxiety, emotional valence, and visual working memory. Results showed that trait anxiety was associated with decreased visual working memory capacity for faces in a valence-independent manner, whereas anxiety-related change in visual working memory resolution was not significant. This pattern of results was discussed in light of the theories of anxiety and visual working memory.

The influence of uncertainty and intolerance of uncertainty on anxiety.

BACKGROUND AND OBJECTIVES: Although the influence of uncertainty and intolerance of uncertainty (IU) on anxiety pathologies has been well-established, only a few studies examined the interaction between uncertainty and IU in producing anxiety. Meanwhile, there is a lack of research utilizing experimental methods to manipulate the situational uncertainty. Therefore, the current study aimed to more systematically investigate whether and how trait IU interacted with uncertainty in the production of anxiety. METHODS: the current study examined the influence of threat-related uncertainty and IU on anxiety in a lab setting. A variant of the threat-of-shock paradigm was employed to manipulate the uncertainty level. State anxiety and worry were measured immediately before and after this manipulation. Hierarchical linear modeling was used for data analysis. RESULTS: Results showed that trait IU contributed to elevated state anxiety and worry. Meanwhile, when under imminent threat, uncertainty provoked increased worry but exerted limited influence on state anxiety. The interaction effect of uncertainty and IU on anxiety was not evident in this study. LIMITATIONS: Results were based on a non-clinical sample rather than individuals with clinical diagnoses. CONCLUSIONS: Uncertainty could be regarded as a trigger of worrying thoughts, while IU is an important cognitive vulnerability factor of anxiety and related symptoms. The possible reasons for these findings and their implications were discussed in light of theoretical models of anxiety, worry, and IU.

Understanding the Impact of Natural Disasters on Psychological Outcomes in Youth from Mainland China: a Meta-Analysis of Risk and Protective Factors for Post-Traumatic Stress Disorder Symptoms.

Post-traumatic Stress Disorder (PTSD) is a mental illness that causes significant distress and impairment. Studies generally indicate lower rates of PTSD post-disaster in Chinese child populations. Irrespective of population examined, findings suggest that trauma alone cannot account for the development of PTSD (Ma et al. 2011). It is important to understand what other variables may contribute to the onset of PTSD. This was the first meta-analysis conducted to investigate risk and protective factors for PTSD (as well as mediating/moderating variables) in children directly impacted by natural disasters in China. Understanding these factors can help guide disaster readiness efforts, as well as post-disaster interventions (Yule et al. 2000). Also, this study is extremely relevant given recent earthquakes in China that have devastated many.

The role of shame in emotional eating.

Two studies were conducted to examine the role of shame in emotional eating. In the first study, 250 women (mean age: 29.95±8.78years; body mass index: 22.46±5.76) reported their experiences of one negative self-conscious emotion (shame), two negative non-self-conscious emotions (anxiety, depression), and emotional eating. With anxiety and depression controlled for, shame predicted depressive, anxious, angry, and positive emotional eating. In the second study, negative non-self-conscious (anxiety) and self-conscious emotions (shame) were induced in participants. Five types of snack were used in the study. Emotional eating was measured by determining participants' binge impulse, actual food intake, and pleasure in eating the five types of snack. Ninety-one female participants were randomly assigned to either an anxiety-with-shame (n=45; mean age: 22.46±3.22years; body mass index: 20.57±5.42) or anxiety group (mean age: 21.89±2.97years; body mass index: 21.21±5.58). Participants in the anxiety-with-shame group reported a greater binge impulse relative to those in the anxiety group. Actual food intake and pleasure in eating the five snacks did not differ significantly between the two groups. Implications of these findings were discussed.

Social Anxiety and Interpretation Bias: Effect of Positive Priming.

This study examined how positive-scale assessment of ambiguous social stimuli affects interpretation bias in social anxiety. Participants with high and low social anxiety (N = 60) performed a facial expression discrimination task to assess interpretation bias. Participants were then randomly assigned to assess the emotion of briefly presented faces either on a negative or on a positive scale. They subsequently repeated the facial expression discrimination task. Participants with high versus low social anxiety made more negative interpretations of ambiguous facial expressions. However, those in the positive-scale assessment condition subsequently showed reduced negative interpretations of ambiguous facial expressions. These results suggest that interpretation bias in social anxiety could be mediated by positive priming rather than an outright negative bias.

Attention allocation in social anxiety during a speech.

Cognitive models assume that social anxiety is associated with and maintained by biased information processing, leading to change in attention allocation, which can be measured by examining eye movement. However, little is known about the distribution of attention among positive, neutral and negative stimuli during a social task and the relative importance of positive versus negative biases in social anxiety. In this study, eye movement, subjective state anxiety and psychophysiology of individuals with high trait social anxiety (HSA) and low trait social anxiety (LSA) were measured during a speech task with a pre-recorded audience. The HSA group showed longer total fixation on negative stimuli and shorter total fixation on positive stimuli compared to the LSA group. We observed that the LSA group shifted attention away from negative stimuli, whereas the HSA group showed no differential attention allocation. The total duration of fixation on negative stimuli predicted subjective anxiety ratings. These results point to a negative bias as well as a lack of a positive bias in HSA individuals during social threat.

Attentional biases in high social anxiety using a flanker task.

BACKGROUND AND OBJECTIVES: The existence of threat-related attentional bias has been well supported in social anxiety research. However, most previous studies investigated separately attentional bias toward targets or distractors. This study examined the selective attention of socially anxious individuals in the presence of both emotional targets and distractors. METHODS: Participants with high vs. low social anxiety (HSA vs. LSA) took part in a modified flanker task. Participants initially focused on the center of the screen, and then were required to identify the emotion of the central face (target) regardless of the flanking faces (distractors). RESULTS: The response times (RTs) of the HSA and LSA groups did not differ significantly when responding to different central faces (targets), but the HSA group responded more slowly to central faces when the flankers (distractors) were negative faces as opposed to positive or neutral. LIMITATIONS: The depression levels of participants in this non-clinical sample were not controlled. CONCLUSION: The results support attention control theory and suggest impaired inhibition control in HSA..

SPECIFIC EFFECTS OF ANGER RUMINATION ON PARTICULAR EXECUTIVE FUNCTIONS (.).

The effects of two types of rumination on different kinds of executive functions were investigated. Fifty-nine participants (M age = 22.8 yr., SD = 2.5) were assigned to one of three conditions and instructed either to: (1) ruminate in a self-distanced way, (2) ruminate in a self-immersed way, or (3) think about the layout of their campus following anger induction. Afterward, the participants were directed to finish tasks designed to assess three kinds of executive functions: shifting, inhibition, and updating. Results showed that self-immersed rumination impaired shifting ability the most, while participants engaged in self-distanced rumination showed the worst performance on the inhibition task. No significant difference was found in the updating task. These results suggest that rumination influenced particular executive functions in different ways.

Does attention redirection contribute to the effectiveness of attention bias modification on social anxiety?

Attention bias modification (ABM) is designed to modify threat-related attention bias and thus alleviate anxiety. The current research examined whether consistently directing attention towards targeted goals per se contributes to ABM efficacy. We randomly assigned 68 non-clinical college students with elevated social anxiety to non-valence-specific attend-to-geometrics (AGC), attention modification (AMC), or attention control (ACC) conditions. We assessed subjective, behavioral, and physiological reactivity to a speech task and self-reported social anxiety symptoms. After training, participants in the AMC exhibited an attention avoidance from threat, and those in the AGC responded more rapidly toward targeted geometrics. There was a significant pre- to post-reduction in subjective speech distress across groups, but behavioral and physiological reactivity to speech, as well as self-report social anxiety symptoms, remained unchanged. These results lead to questions concerning effectiveness of ABM training for reducing social anxiety. Further examination of the current ABM protocol is required.

Enhanced association between perceptual stimuli and trauma-related information in individuals with posttraumatic stress disorder symptoms.

BACKGROUND AND OBJECTIVES: Intrusive memories in traumatized individuals are often triggered by stimuli that are perceptually (rather than conceptually) similar to those present just before or during the trauma. The present study examined whether those individuals with high levels of Posttraumatic Stress Disorder (PTSD) symptoms show a memory bias recall to perceptual cues and trauma target words compared to those with low levels of PTSD. METHODS: The sample consisted of 30 adult participants who were involved in motor-vehicle or work-related accidents; 15 of the participants endorsed clinically elevated symptoms of PTSD, while a comparison group of 15 participants reported low levels of symptoms. Participants performed an associative recognition task with conceptual or perceptual cue words and trauma-related or neutral target words. Participants were tested for their recognition accuracy by reporting the corresponding target when a cue was given. RESULTS: Both groups performed better for the perceptual word pairs than for the conceptual word pairs, irrespective of the target word type. However, only the high PTSD symptoms group exhibited an additional enhancement in performance for the perceptual word pairs with trauma-related target words. LIMITATIONS: A nonclinical sample was utilized for this study; although PTSD was assessed, diagnoses were not confirmed. In addition, there was lack of a healthy non-traumatized control group. CONCLUSIONS: These results provide partial support for the cognitive model and the notion that intrusive memories are specific to the trauma-related event rather than to a general associative learning bias.