Mediation of social anxiety and depression during internet-delivered treatment for social anxiety disorder.

Many individuals with social anxiety disorder (SAD) have depressive symptoms that meet criteria for major depressive disorder (MDD). In our study, we examined the temporal relationship between symptoms of social anxiety and symptoms of depression during the course of an 11-week internet-delivered cognitive behavioral treatment (ICBT) for SAD (n = 170). Specifically, we investigated whether weekly changes in social anxiety mediated changes in depression, changes in depression mediated changes in anxiety, both or neither. In addition, we compared individuals with SAD and MDD (n = 50) and individuals with SAD and no MDD (n = 120) to examine the role of MDD as a moderator of the social anxiety-depression relationship. Lower-level mediational modeling revealed that changes in social anxiety symptoms mediated changes in depression symptoms to a greater extent than vice versa. In addition, mediation among individuals with SAD and MDD was significantly greater compared to individuals with SAD and no MDD. Our findings suggest that ICBT is effective in treating individuals with SAD regardless of comorbid depression, and that focusing ICBT interventions on social anxiety can lead to significant reductions in depression among individuals with SAD.

Interpersonal factors in internet-based cognitive behavioral therapy for depression: Attachment style and alliance with the program and with the therapist.

Objective This open-trial study examined effects of a culturally-adapted Hebrew version of guided internet-based cognitive behavioural therapy (ICBT) for depression. We examined therapeutic alliance with the therapist and with the programme (content) as potential predictors of outcomes. Furthermore, we examined whether anxious and avoidant attachment styles improved, although relationships were not the focus of treatment. Method: We examined alliance with therapist and alliance with programme and their time-lagged (1 week), longitudinal relationship with depression outcomes, and change in anxious and avoidant attachment during treatment. Results: Depression and insomnia improved significantly (Cohen's d: depression = 1.34, insomnia = 0.86), though dropout was relatively high (49%). Alliance with programme and with the therapist predicted adherence and dropout, whereas only alliance with therapist predicted symptom improvement. Avoidant attachment decreased over treatment whereas anxious attachment did not. Conclusion: A culturally-adapted version of ICBT for depression showed that alliance with therapist and alliance with programme both can play an important role in its effectiveness: alliance with programme and the therapist drive adherence and dropout and alliance with therapist is related to symptom improvement. Although the focus of treatment is not interpersonal, avoidant attachment style can improve following ICBT.

Mechanisms underlying interoceptive exposure: belief disconfirmation or extinction? A preliminary study.

Interoceptive exposure, or exposure to one's feared physical sensations, has been shown to be an important technique in cognitive behavioral therapies for anxiety disorders and related constructs, such as anxiety sensitivity (AS). The current study sought to further clarify the underlying cognitive-behavioral mechanisms of interoceptive exposure in a lab-based, analog study with individuals high in AS. Participants (n = 59) were randomized into three groups: a cognitive-behavioral intervention emphasizing belief disconfirmation (CbI), a behavioral intervention emphasizing exposure (BI), and a control condition. Self-report measures assessing AS, catastrophizing of bodily sensations, and subjective units of distress (SUDS) were collected before, during and after the intervention. Participants also completed online questionnaires at a one-month follow-up. Following the CbI but not BI, a decrease was observed in both AS and catastrophizing interpretations. Furthermore, only the CbI group exhibited a decrease in SUDS ratings, whereas the BI group exhibited a significant increase. Notably, these effects were not maintained at a one-month follow-up. Findings suggest that cognitive interventions without repeated behavioral exposure may be sufficient in reducing self-reported anxiety-related symptoms and catastrophic misinterpretations, though not at maintaining them. This raises questions regarding the role of pure behavioral mechanisms in exposure.

Examining the relationship between cognitive factors and insight in panic disorder before and during treatment.

Individuals with Panic Disorder (PD) often have impaired insight, which can impede their willingness to seek treatment. Cognitive processes, including metacognitive beliefs, cognitive flexibility, and jumping to conclusions (JTC) may influence the degree of insight. By understanding the relationship between insight and these cognitive factors in PD, we can better identify individuals with such vulnerabilities to improve their insight. The aim of this study is to examine the relationships between metacognition, cognitive flexibility, and JTC with clinical and cognitive insight at pretreatment. We investigate the association among those factors' changes and changes in insight over treatment. Eighty-three patients diagnosed with PD received internet-based cognitive behavior therapy. Analyses revealed that metacognition was related to both clinical and cognitive insight, and cognitive flexibility was related to clinical insight at pre-treatment. Greater changes in metacognition were correlated with greater changes in clinical insight. Also, greater changes in cognitive flexibility were related to greater changes in cognitive insight. The current study extends previous studies suggesting potential relationships among insight, metacognition, and cognitive flexibility in PD. Determining the role of cognitive concepts in relation to insight may lead to new avenues for improving insight and can have implications for engagement and treatment-seeking behaviors.

Insight in nonpsychotic disorders: A new model of insight and a systematic review of measures.

OBJECTIVE: There is substantial research examining insight in psychotic disorders and in some nonpsychotic disorders. However, there has been little attention given to many nonpsychotic disorders. Research on insight in psychosis distinguishes between cognitive and clinical insight. In most studies examining insight in nonpsychotic disorders, definitions and assessments of insight vary significantly. The purpose of this review is to suggest a definition of insight in nonpsychotic disorders such that it can be used across different disorders. METHOD: We systematically review the extant literature of insight in nonpsychotic disorders and analyze the assessments used in order to determine how well they capture these two types of insight. Then, we discuss how these two constructs can provide better understanding of the phenomenology of insight in nonpsychotic disorders. RESULTS: The systematic search resulted in 99 articles. These articles used 17 different methods of measuring insight, containing 127 questions. Results of the content analysis of items suggested that measures of insight used in nonpsychotic disorders do not distinguish between cognitive and clinical insight, but that most questions (90%) can indeed be reliably differentiated. CONCLUSION: We provide a multidimensional model of cognitive and clinical insight in nonpsychotic disorders, emphasizing the complexity of assessment and the importance of accurately defining insight. Such definitions have important theoretical and clinical implications, offering a better understanding of the concept of insight in nonpsychotic disorders.

Anxious attachment improves and is predicted by anxiety sensitivity in internet-based, guided self-help cognitive behavioral treatment for panic disorder.

The purpose of this study was to examine whether anxious and avoidant attachment styles improve during guided internet-based cognitive behavioral treatment (ICBT) for panic disorder, and if so, to identify potential theoretically driven mechanisms related to the change. We examined changes in anxious and avoidant attachment and their time-lagged (1 week), longitudinal relationship with panic-related constructs in patients participating in ICBT (n = 79) in an open trial. Anxious attachment scores improved significantly with a medium effect during ICBT, d = 0.76 [0.45, 1.08]. According to benchmark analyses, changes were similar to the magnitude of change in face-to-face CBT and final scores to values of a nonclinical sample. Additionally, similar to findings in face-to-face CBT for panic disorder, longitudinal time analyses revealed that anxiety sensitivity scores predicted later improvement in anxious attachment scores, but not vice versa. Counter to our hypothesis, avoidant attachment did not significantly change during treatment, d = 0.15 [0.02, 0.46]; however, pretreatment level of avoidant attachment in ICBT was similar to the nonclinical sample. Also counter to our hypotheses, agoraphobic avoidant behaviors when alone did not predict changes in anxious attachment. These results suggest that anxious attachment can improve in ICBT for panic disorder even though the focus of the treatment is not on interpersonal relationships. These changes appear to follow changes in anxiety sensitivity. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Patterns of alliance development in cognitive behavioral therapy versus attention bias modification for social anxiety disorder: Sawtooth patterns and sudden gains.

OBJECTIVES: We examined patterns in alliance development in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). We focused on the occurrence of sawtooth patterns (increases within- and decreases between-sessions) and sudden gains and their association with outcome. METHODS: Clients received CBT (n = 33) or ABM (n = 17). Client-rated alliance was measured before and after each session. Self-reported and clinician-rated anxiety were measured weekly and monthly, respectively. RESULTS: The alliance increased in CBT in a sawtooth pattern and did not change in ABM. When examining individual clients, sawtooths were more common in CBT (61% clients) than in ABM (6%) and predicted worse outcome in CBT. Sudden gains were equally frequent (CBT, 18%; ABM, 18%) and did not predict outcome. CONCLUSION: The alliance in CBT is dynamic and important for outcome. Sawtooths are common in CBT and may mark worse outcome.

Agreement in patient-therapist alliance ratings and its relation to dropout and outcome in a large sample of cognitive behavioral therapy for panic disorder.

Objective The therapeutic alliance is related to treatment outcome but less is known about the agreement on alliance between patients and therapists and its relationship to outcomes. We examined the association of patient-therapist congruence of alliance perceptions, early and late in cognitive behavioral therapy for panic disorder in relation to symptom reduction and dropout. Method: Patients (n = 181) and their therapists provided alliance ratings early and late during 11-session treatment. Independent evaluators rated patients' symptomatic levels post-treatment. Polynomial regression and response surface analysis were used to examine congruence as a predictor of outcome. Results: Early in therapy, stronger combined patient-therapist alliances, regardless of agreement, predicted lower symptom severity at the end of therapy and a lower likelihood of dropout. Late in treatment, the outcome was worse when therapist ratings of the alliance were higher than those of the patient. Conclusions: Therapist-patient agreement on the strength of the alliance is important for symptom improvement and dropout. The study highlights the importance of understanding the dyadic nature of the alliance and its impact on therapeutic change.

Doubting what you already know: Uncertainty regarding state transitions is associated with obsessive compulsive symptoms.

Obsessive compulsive (OC) symptoms involve excessive information gathering (e.g., checking, reassurance-seeking), and uncertainty about possible, often catastrophic, future events. Here we propose that these phenomena are the result of excessive uncertainty regarding state transitions (transition uncertainty): a computational impairment in Bayesian inference leading to a reduced ability to use the past to predict the present and future, and to oversensitivity to feedback (i.e. prediction errors). Using a computational model of Bayesian learning under uncertainty in a reversal learning task, we investigate the relationship between OC symptoms and transition uncertainty. Individuals high and low in OC symptoms performed a task in which they had to detect shifts (i.e. transitions) in cue-outcome contingencies. Modeling subjects' choices was used to estimate each individual participant's transition uncertainty and associated responses to feedback. We examined both an optimal observer model and an approximate Bayesian model in which participants were assumed to attend (and learn about) only one of several cues on each trial. Results suggested the participants were more likely to distribute attention across cues, in accordance with the optimal observer model. As hypothesized, participants with higher OC symptoms exhibited increased transition uncertainty, as well as a pattern of behavior potentially indicative of a difficulty in relying on learned contingencies, with no evidence for perseverative behavior. Increased transition uncertainty compromised these individuals' ability to predict ensuing feedback, rendering them more surprised by expected outcomes. However, no evidence for excessive belief updating was found. These results highlight a potential computational basis for OC symptoms and obsessive compulsive disorder (OCD). The fact the OC symptoms predicted a decreased reliance on the past rather than perseveration challenges preconceptions of OCD as a disorder of inflexibility. Our results have implications for the understanding of the neurocognitive processes leading to excessive uncertainty and distrust of past experiences in OCD.

The alliance mediates outcome in cognitive-behavioral therapy for social anxiety disorder, but not in attention bias modification.

Objective: The aim of the current study was to examine changes in the therapeutic alliance and its role as a mediator of treatment outcome in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). Method: Patients were randomized to 16-20 sessions of CBT (n = 33) or 8 sessions of ABM (n = 17). Patient-rated alliance and self-reported social anxiety were measured weekly and evaluator-rated social anxiety was measured monthly. Results: Early alliance predicted greater subsequent anxiety reduction in CBT but not in ABM. The alliance increased and weekly improvements in alliance predicted weekly contemporaneous and subsequent decreases in anxiety only in CBT. Decreases in anxiety did not predict subsequent improvements in alliance. Both treatments were effective in reducing anxiety, but treatment effects were mediated by stronger early alliance and stronger cross-lagged effects of alliance on outcome in CBT compared to ABM. Conclusions: The results highlight the importance of the alliance in CBT for SAD. Further studies should examine the role of alliance alongside additional mediators to better understand differential mechanisms in CBT and ABM.

Patient alliance with the program predicts treatment outcomes whereas alliance with the therapist predicts adherence in internet-based therapy for panic disorder.

This study examines relationships among different aspects of therapeutic alliance with treatment outcome, adherence and attrition in internet delivered cognitive behavioral therapy (ICBT) for panic disorder.We examined alliance-outcome relationships in ICBT (N = 74) using a newly developed self-report alliance measure that disentangles alliance with program content (Internet Patient's Experience of Attunement and Responsiveness with the program; I-PEARp) and with the therapist (I-PEARt). We compared ICBT outcomes of patient rated and therapist-rated alliance with conventional alliance scales (WAI-6 and WAI-T).Consistent with our hypothesis, I-PEARp and I-PEARt distinguished between different aspects of the alliance and predicted outcomes better than standard alliance scales. Furthermore, higher ratings of I-PEARp were associated with subsequent lower symptoms and lower symptoms were associated with higher subsequent alliance. In contrast, I-PEARt predicted adherence, but not symptoms. Although therapists' ratings of alliance (thI-PEAR) improved significantly during treatment, they did not predict subsequent symptoms, adherence, or dropout.Results indicate that the patient experience of the alliance in ICBT includes two aspects, each of which uniquely contributes to outcomes; patient connection to the program is related to symptom outcomes whereas the dyadic relationship with the therapist serves as the glue to allow the treatment to hold.

Emotion regulation in social anxiety: a systematic investigation and meta-analysis using self-report, subjective, and event-related potentials measures.

Recent models of social anxiety disorder emphasise the role of emotion dysregulation; however, the nature of the proposed impairment needs clarification. In a replication and extension framework, four studies (N = 193) examined whether individuals with social anxiety (HSAs) are impaired in using cognitive reappraisal and expressive suppression. Self-reports and lab-based tasks of suppression and reappraisal were utilised among individuals with high and low levels of social anxiety. A meta-analysis of these studies indicated that, compared to controls, HSAs reported less frequent and effective use of reappraisal and more frequent and effective use of suppression. Counter to most models and our hypotheses, HSAs were more successful than controls in lab-based reappraisal of shame-arousing pictures as measured by subjective ratings, but not by event-related potentials. HSAs were less successful than controls in lab-based suppression of shame-arousing pictures as measured by subjective ratings, but not by event-related potentials. The results held even when participants were under social stress (impromptu speech anticipation). Overall, subjective reports of HSAs reveal strong deficits in emotion regulation whereas lab-based measures provided less conclusive evidence of such deficits. These results suggest that individuals with social anxiety experience difficulties implementing their reappraisal abilities in daily life.

Utilization of learned skills in cognitive behavioural therapy for panic disorder.

BACKGROUND: Research has long investigated the cognitive processes in the treatment of depression, and more recently in panic disorder (PD). Meanwhile, other studies have examined patients' cognitive therapy skills in depression to gain insight into the link between acquiring such skills and treatment outcome. AIMS: Given that no scale exists to examine in-session patient use of panic-related cognitive behavioural therapy (CBT) skills, the aim of this study was to develop a new measure for assessing patients' cognitive and behavioural skills in CBT for PD. METHOD: This study included 20 PD patients who received 12 weekly individual therapy sessions. The Cognitive Behavioral Therapy Panic Skills (CBTPS) rating system was developed. Three independent raters coded tapes of therapy sessions at the beginning and end of treatment. RESULTS: The coefficient alphas and inter-rater reliability were high for the cognitive and behavioural subscales. Improvement in the patients' CBTPS scores on both subscales indicated overall symptom improvement, above improvement in anxiety sensitivity. CONCLUSION: To our knowledge, this is the first study examining the impact of patient acquisition of CBT PD skills on treatment outcome. A new measure was developed based on the observations and was deemed reliable and valid. The measure facilitates the examination of the mechanisms of change in treatment for PD. An in-depth examination of the CBTPS may refine our understanding of the impact of each skill on PD treatment outcome. Further research relating to acquiring CBT skills could shed light on the mechanisms of change in treatment.

Improvement in adult anxious and avoidant attachment during cognitive behavioral therapy for panic disorder.

OBJECTIVE: This study examined attachment within the framework of cognitive behavioral therapy (CBT) for panic disorder with agoraphobia (PDA) by measuring the changes in avoidant and anxious attachment in a session-by-session analysis. METHOD: Thirty-one patients with PDA were treated using CBT. Pre-session data on attachment style (ECR), avoidance behaviors (MI-alone: MI-al; MI-accompanied: MI-ac), anxiety sensitivity (ASI), emotion regulation (ERQ), and working alliance (WAI) were collected. Mixed model analyses were conducted to estimate relationship between changes in attachment, PDA symptoms, and related measures. RESULTS: Variables improved during therapy. Changes in ASI were positively related to changes in avoidant and anxious attachment. Changes in MI-al, but not MI-ac, were related to changes in ECR. Changes in ASI and MI-al predicted changes in ECR-anxiety in the following session, but not vice versa. Similarly, changes in avoidance behaviors and ERQ-suppression, preceded changes in ECR-avoidance unidirectionally. Whereas WAI significantly improved, its variability was related only to simultaneous changes in ECR-anxiety. CONCLUSIONS: Overall, avoidant and anxious attachment improved during CBT for PDA. This change was related to and preceded by improved anxiety sensitivity, avoidance behaviors, and emotion regulation. These findings suggest that CBT for panic probably has downstream effects on attachment representations. Clinical or methodological significance of this article: This is the first report of changes in attachment via cognitive behavioral therapy for panic disorder. Data were examined using repeated measures session by session, allowing for examination of temporal precedence of changes. Results revealed that anxiety sensitivity, avoidance, and suppression preceded changes in attachment. Results are discussed in the framework of modern attachment theory models.

Sad as a Matter of Choice? Emotion-Regulation Goals in Depression.

Research on deficits in emotion regulation has devoted considerable attention to emotion-regulation strategies. We propose that deficits in emotion regulation may also be related to emotion-regulation goals. We tested this possibility by assessing the direction in which depressed people chose to regulate their emotions (i.e., toward happiness, toward sadness). In three studies, clinically depressed participants were more likely than nondepressed participants to use emotion-regulation strategies in a direction that was likely to maintain or increase their level of sadness. This pattern was found when using the regulation strategies of situation selection (Studies 1 and 2) and cognitive reappraisal (Study 3). The findings demonstrate that maladaptive emotion regulation may be linked not only to the means people use to regulate their emotions, but also to the ends toward which those means are directed.

How does the therapeutic alliance develop throughout cognitive behavioral therapy for panic disorder? Sawtooth patterns, sudden gains, and stabilization.

OBJECTIVE: There has been little research on the development of the therapeutic alliance in cognitive behavioral therapy (CBT). This study aims to examine the development of therapeutic alliance in CBT for panic disorder. METHOD: Nineteen patients were treated with CBT for panic disorder. Pre- and post-session data of the therapeutic alliance and panic symptoms and cognitions were collected. RESULTS: Several patterns were observed, including a sawtooth pattern (within-session improvements followed by decline between sessions; 63% of the patients), sudden gains in the alliance (58%), and late stabilization (89%). The sawtooth pattern was related to less symptom reduction between sessions (explained variance = 20-48%). Though not statistically significant, there were moderate effect sizes for the relationships between outcomes and early alliance and sudden gains (explained variance = 13-17%). CONCLUSIONS: Overall, results suggest that intensive data collection is likely to yield understanding of the relationship between therapy processes and outcomes.

Considering the Role of Human Empathy in AI-Driven Therapy.

Recent breakthroughs in artificial intelligence (AI) language models have elevated the vision of using conversational AI support for mental health, with a growing body of literature indicating varying degrees of efficacy. In this paper, we ask when, in therapy, it will be easier to replace humans and, conversely, in what instances, human connection will still be more valued. We suggest that empathy lies at the heart of the answer to this question. First, we define different aspects of empathy and outline the potential empathic capabilities of humans versus AI. Next, we consider what determines when these aspects are needed most in therapy, both from the perspective of therapeutic methodology and from the perspective of patient objectives. Ultimately, our goal is to prompt further investigation and dialogue, urging both practitioners and scholars engaged in AI-mediated therapy to keep these questions and considerations in mind when investigating AI implementation in mental health.

Clinical and cognitive insight in panic disorder: phenomenology and treatment effects in internet cognitive behavior therapy.

Clinical observations suggest that individuals with panic disorder (PD) vary in their beliefs about the causes of their panic attacks. Some attribute these attacks to psychological factors, while others to physiological or medical factors. These beliefs also extend to whether individuals perceive panic attacks as dangerous. In other areas of psychiatric nosology, these phenomena are commonly called clinical insight (recognition of disorder and the need for treatment) and cognitive insight (the ability to reflect on one's beliefs). Despite its importance, limited research exists on insight in PD and its relation to symptoms and treatment outcomes. This study examines clinical and cognitive insight in 83 patients with PD who received internet-based cognitive behavioral therapy, investigating their relationship with symptoms, treatment outcomes, and changes in insight. We assessed patients using interview and self-report measures of insight and symptoms. Clinical and cognitive insight were correlated and both constructs improved significantly during treatment. Good clinical insight pretreatment was positively correlated with more severe pretreatment symptoms. Pretreatment clinical and cognitive insight were not correlated with symptom change or attrition. Greater change in clinical and cognitive insight was related to greater change in symptoms. The findings highlight the significance of clinical and cognitive insight in PD, and the importance of distinguishing between them. This suggests the need to develop interventions according to patients' level of insight, particularly focusing on those lacking insight. Further research is essential to advance our understanding of the relationship between insight and the phenomenology and treatment of PD.

Improving Exposure Therapy: Rationale and Design of an International Consortium.

The Exposure Therapy Consortium (ETC) was established to advance the science and practice of exposure therapy. To encourage participation from researchers and clinicians, this article describes the organizational structure and activities of the ETC. Initial research working group experiences and a proof-of-principle study underscore the potential of team science and larger-scale collaborative research in this area. Clinical working groups have begun to identify opportunities to enhance access to helpful resources for implementing exposure therapy effectively. This article discusses directions for expanding the consortium's activities and its impact on a global scale.