Cognitive predictors of treatment outcome for exposure therapy: do changes in self-efficacy, self-focused attention, and estimated social costs predict symptom improvement in social anxiety disorder?

BACKGROUND: Cognitions play an important role in the development and maintenance of social anxiety disorder (SAD). METHODS: To investigate whether changes in cognitions during the first six sessions of exposure therapy are associated with treatment outcome, we assessed reported self-focused attention, self-efficacy in social situations, and estimated social costs in 60 participants (Mage = 36.9 years) diagnosed with SAD who received in vivo or virtual reality exposure therapy. RESULTS: Patients demonstrating a greater decrease in estimated social costs during treatment reported greater improvement of their social anxiety symptoms following both forms of exposure therapy. While changes in self-focused attention and social self-efficacy during treatment were significantly associated with treatment outcome when examined individually, these changes did not significantly predict symptom improvement beyond social costs. CONCLUSIONS: Changes in estimated social costs during treatment are associated with improvement of social anxiety symptoms after exposure therapy. Future research needs to further investigate estimated social costs as a predictor in relation to other cognitive variables. TRIAL REGISTRATION: NCT01746667 ; www.clinicaltrials.gov, November 2012, retrospectively registered.

Baseline Severity as a Moderator of the Waiting List-Controlled Association of Cognitive Behavioral Therapy With Symptom Change in Social Anxiety Disorder: A Systematic Review and Individual Patient Data Meta-analysis.

Importance: Social anxiety disorder (SAD) can be adequately treated with cognitive behavioral therapy (CBT). However, there is a large gap in knowledge on factors associated with prognosis, and it is unclear whether symptom severity predicts response to CBT for SAD. Objective: To examine baseline SAD symptom severity as a moderator of the association between CBT and symptom change in patients with SAD. Data Sources: For this systematic review and individual patient data meta-analysis (IPDMA), PubMed, PsycInfo, Embase, and the Cochrane Library were searched from January 1, 1990, to January 13, 2023. Primary search topics were social anxiety disorder, cognitive behavior therapy, and randomized controlled trial. Study Selection: Inclusion criteria were randomized clinical trials comparing CBT with being on a waiting list and using the Liebowitz Social Anxiety Scale (LSAS) in adults with a primary clinical diagnosis of SAD. Data Extraction and Synthesis: Authors of included studies were approached to provide individual-level data. Data were extracted by pairs of authors following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline, and risk of bias was assessed using the Cochrane tool. An IPDMA was conducted using a 2-stage approach for the association of CBT with change in LSAS scores from baseline to posttreatment and for the interaction effect of baseline LSAS score by condition using random-effects models. Main Outcomes and Measures: The main outcome was the baseline to posttreatment change in symptom severity measured by the LSAS. Results: A total of 12 studies including 1246 patients with SAD (mean [SD] age, 35.3 [10.9] years; 738 [59.2%] female) were included in the meta-analysis. A waiting list-controlled association between CBT and pretreatment to posttreatment LSAS change was found (b = -20.3; 95% CI, -24.9 to -15.6; P < .001; Cohen d = -0.95; 95% CI, -1.16 to -0.73). Baseline LSAS scores moderated the differences between CBT and waiting list with respect to pretreatment to posttreatment symptom reductions (b = -0.22; 95% CI, -0.39 to -0.06; P = .009), indicating that individuals with severe symptoms had larger waiting list-controlled symptom reductions after CBT (Cohen d = -1.13 [95% CI, -1.39 to -0.88] for patients with very severe SAD; Cohen d = -0.54 [95% CI, -0.80 to -0.29] for patients with mild SAD). Conclusions and Relevance: In this systematic review and IPDMA, higher baseline SAD symptom severity was associated with greater (absolute but not relative) symptom reductions after CBT in patients with SAD. The findings contribute to personalized care by suggesting that clinicians can confidently offer CBT to individuals with severe SAD symptoms.

Automatic mechanisms for measuring subjective unit of discomfort.

Current practice in Virtual Reality Exposure Therapy (VRET) is that therapists ask patients about their anxiety level by means of the Subjective Unit of Discomfort (SUD) scale. With an aim of developing a home-based VRET system, this measurement ideally should be done using speech technology. In a VRET system for social phobia with scripted avatar-patient dialogues, the timing of asking patients to give their SUD score becomes relevant. This study examined three timing mechanisms: (1) dialogue dependent (i.e. naturally in the flow of the dialogue); (2) speech dependent (i.e. when both patient and avatar are silent); and (3) context independent (i.e. randomly). Results of an experiment with non-patients (n = 24) showed a significant effect for the timing mechanisms on the perceived dialogue flow, user preference, reported presence and user dialog replies. Overall, dialogue dependent timing mechanism seems superior followed by the speech dependent and context independent timing mechanism.

Social comparison modulates coping with fear in virtual environments.

Social comparison can guide adaptive behavior in fear-related situations. The aim of this study was to investigate the effects of social comparison standards on acute anxiety levels and phobic symptoms. The sample comprised 159 individuals (Mage = 23.4) with self-reported fear of flying (22.6 %) or fear of heights (77.4 %) who were randomly assigned to an upward assimilation (UA) manipulation, a downward assimilation (DA) manipulation, or a control condition (no manipulation of social comparison) and entered a fear-related scenario in virtual reality (i.e., flying in an airplane or walking in a tall building, respectively). Results revealed that individuals in the UA condition reported significantly attenuated increases in anxiety levels from pre-exposure to both during- and post-exposure relative to the control condition. The DA condition did not significantly differ from either condition regarding increases in acute anxiety levels from pre-exposure to either during or post-exposure. At post-assessment, participants in the UA condition also reported fewer phobic symptoms compared to both the DA and the control condition. Our results suggest that social comparison can indeed modulate coping with fearful situations. Future research needs to investigate the underlying processes of social comparison and the extent to which social comparison can facilitate treatment of anxiety disorders.

Correction: Controlling Social Stress in Virtual Reality Environments.

[This corrects the article DOI: 10.1371/journal.pone.0092804.].

Self-report questionnaires, behavioral assessment tasks, and an implicit behavior measure: do they predict social anxiety in everyday life?

Social anxiety is commonly assessed with self-report measures. This study aimed to investigate whether maximum anxiety levels during in vivo and virtual reality behavioral assessment tasks (BATs), and implicit approach-avoidance tendencies during the approach-avoidance task (AAT) explain more variation as predictors of daily social anxiety than self-report measures. A total of 62 university students (Mage = 20.79; SD = 4.91) with high levels of social anxiety completed self-report measures on fear of negative evaluation (FNE-B) as well as fear and avoidance in social situations (Liebowitz social anxiety scale-self report), in vivo and virtual reality BATs, and the AAT (independent variables) in the laboratory. On seven consecutive days, social anxiety, experiential avoidance, and negative social events (dependent variables) were assessed. The results revealed that fear of negative evaluation predicted everyday social anxiety and experiential avoidance. Fear and avoidance in social situations only predicted experiential avoidance. Neither implicit approach-avoidance tendencies during the AAT nor maximum anxiety levels during the in vivo and virtual reality BATs predicted any outcome variable. Our results support the use of self-report questionnaires in the assessment of social anxiety.

Meta-analysis of technology-assisted interventions for social anxiety disorder.

This meta-analysis investigated the efficacy of technology-assisted interventions for individuals with social anxiety disorder (SAD). A systematic literature search in the databases Medline, PsychInfo, and Web of Science revealed 37 randomized controlled trials (2991 participants) that were grouped into internet delivered cognitive behavior therapy (ICBT; 21 trials), virtual reality exposure therapy (VRET; 3 trials), and cognitive bias modification (CBM; 13 trials). Patients undergoing ICBT and VRET showed significantly less SAD symptoms at postassessment than passive control conditions (g=0.84 and 0.82, respectively). Compared to active control conditions, ICBT had a small advantage (g=0.38) and VRET showed comparable effects (p>0.05). CBM was not more effective than passive control conditions, except when delivered in the laboratory (g=0.35). While the efficacy of CBM was limited, substantial evidence for ICBT and preliminary evidence for VRET suggests that both can effectively reduce SAD symptoms indicating the potential of technology-assisted interventions for SAD.

Exposure to virtual social interactions in the treatment of social anxiety disorder: A randomized controlled trial.

This randomized controlled trial investigated the efficacy of a stand-alone virtual reality exposure intervention comprising verbal interaction with virtual humans to target heterogeneous social fears in participants with social anxiety disorder. Sixty participants (Mage = 36.9 years; 63.3% women) diagnosed with social anxiety disorder were randomly assigned to individual virtual reality exposure therapy (VRET), individual in vivo exposure therapy (iVET), or waiting-list. Multilevel regression analyses revealed that both treatment groups improved from pre-to postassessment on social anxiety symptoms, speech duration, perceived stress, and avoidant personality disorder related beliefs when compared to the waiting-list. Participants receiving iVET, but not VRET, improved on fear of negative evaluation, speech performance, general anxiety, depression, and quality of life relative to those on waiting-list. The iVET condition was further superior to the VRET condition regarding decreases in social anxiety symptoms at post- and follow-up assessments, and avoidant personality disorder related beliefs at follow-up. At follow-up, all improvements were significant for iVET. For VRET, only the effect for perceived stress was significant. VRET containing extensive verbal interaction without any cognitive components can effectively reduce complaints of generalized social anxiety disorder. Future technological and psychological improvements of virtual social interactions might further enhance the efficacy of VRET for social anxiety disorder.

Social interactions in virtual reality exposure therapy: A proof-of-concept pilot study.

BACKGROUND AND OBJECTIVES: Research on virtual reality exposure therapy (VRET) has demonstrated good treatment efficacy with regards to several anxiety disorders. Yet, there is lack of knowledge about the value of integrating interaction between clients and virtual humans in VRET. Such interaction might prove effective in treating psychological complaints that involve social interactions, such as social anxiety. METHODS: A VRET system specifically designed to expose clients with social anxiety disorder to anxiety provoking social situations was applied to 16 and 18 individuals with high and low levels of social anxiety, respectively. Participants engaged in two exposure sessions in several free speech dialogues with virtual humans while being monitored by a therapist. RESULTS: Participants with high levels of social anxiety reported significantly lower levels of social anxiety three months after exposure to two virtual reality interaction sessions than before treatment (p < 0.01). In the group with low levels of social anxiety, no significant change of social anxiety was reported between pre-treatment and follow-up. Additionally, participants in both groups reported higher self-efficacy three months after treatment than before treatment (ps ≤ 0.001). CONCLUSION: These findings indicate that virtual reality technology that incorporates social interactions may be successfully applied for therapeutic purposes.

Controlling social stress in virtual reality environments.

Virtual reality exposure therapy has been proposed as a viable alternative in the treatment of anxiety disorders, including social anxiety disorder. Therapists could benefit from extensive control of anxiety eliciting stimuli during virtual exposure. Two stimuli controls are studied in this study: the social dialogue situation, and the dialogue feedback responses (negative or positive) between a human and a virtual character. In the first study, 16 participants were exposed in three virtual reality scenarios: a neutral virtual world, blind date scenario, and job interview scenario. Results showed a significant difference between the three virtual scenarios in the level of self-reported anxiety and heart rate. In the second study, 24 participants were exposed to a job interview scenario in a virtual environment where the ratio between negative and positive dialogue feedback responses of a virtual character was systematically varied on-the-fly. Results yielded that within a dialogue the more positive dialogue feedback resulted in less self-reported anxiety, lower heart rate, and longer answers, while more negative dialogue feedback of the virtual character resulted in the opposite. The correlations between on the one hand the dialogue stressor ratio and on the other hand the means of SUD score, heart rate and audio length in the eight dialogue conditions showed a strong relationship: r(6) = 0.91, p = 0.002; r(6) = 0.76, p = 0.028 and r(6) = -0.94, p = 0.001 respectively. Furthermore, more anticipatory anxiety reported before exposure was found to coincide with more self-reported anxiety, and shorter answers during the virtual exposure. These results demonstrate that social dialogues in a virtual environment can be effectively manipulated for therapeutic purposes.

Training approach-avoidance of smiling faces affects emotional vulnerability in socially anxious individuals.

PREVIOUS RESEARCH REVEALED AN AUTOMATIC BEHAVIORAL BIAS IN HIGH SOCIALLY ANXIOUS INDIVIDUALS (HSAS): although their explicit evaluations of smiling faces are positive, they show automatic avoidance of these faces. This is reflected by faster pushing than pulling of smiling faces in an Approach-Avoidance Task (AAT; Heuer et al., 2007). The current study addressed the causal role of this avoidance bias for social anxiety. To this end, we used the AAT to train HSAs, either to approach smiling faces or to avoid them. We examined whether such an AAT training could change HSAs' automatic avoidance tendencies, and if yes, whether AAT effects would generalize to a new approach task with new facial stimuli, and to mood and anxiety in a social threat situation (a video-recorded self-presentation). We found that HSAs trained to approach smiling faces did indeed approach female faces faster after the training than HSAs trained to avoid smiling faces. Moreover, approach-faces training reduced emotional vulnerability: it led to more positive mood and lower anxiety after the self-presentation than avoid-faces training. These results suggest that automatic approach-avoidance tendencies have a causal role in social anxiety, and that they can be modified by a simple computerized training. This may open new avenues in the therapy of social phobia.