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noted (substance abuse, n = 1 in IE-CBT; temporary increase in suicide risk, n = 1 in each condition, with one being withdrawn at 1-month follow-up).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.

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.

Depression, anxiety, and the MCMI-III: construct validity and diagnostic efficiency.

This study aimed to enhance knowledge of the construct validity and diagnostic efficiency of the depression- and anxiety-related scales of the MCMI-III (Millon, 1994). The MCMI-III, various concurrent depression and anxiety measures, and an Axis I structured diagnostic interview were administered in a total sample of 696 outpatients with depressive disorders, anxiety disorders, or both. Sound construct validity was found for the Dysthymia and Major Depression clinical syndrome scales and the Avoidant and Depressive personality disorder scales. The validity of the Anxiety scale was poor, showing moderate convergence with panic and worry-related anxiety measures, but problems discriminating from depression. Operating characteristics for discriminating depressed patients from anxious patients were fair for the Major Depression scale, but poor for the Anxiety and Dysthymia scales.

Mental imagery-based episodic simulation amplifies motivation and behavioural engagement in planned reward activities.

Preliminary evidence suggests mental imagery-based episodic simulation of planned reward activities may amplify motivation and promote greater behavioural engagement, particularly for activities with high motivational barriers (Renner, Murphy, Ji, Manly, & Holmes, 2019). This study conducted a conceptual replication and extension of Renner et al. (2019). N = 81 first-year university students self-selected and scheduled two reward activities (one hedonic, one mastery) for the following week before being randomly allocated to either an Imagery-Experiential elaboration condition (n = 27), a Verbal-Reasoning elaboration condition (n = 28), or a Scheduling-only Control condition (n = 26). Following the lab session, all participants received standardized daily prompts to complete daily activity diaries online for seven days. The Imagery-Experiential condition reported greater increases in anticipatory pleasure (state mood), anticipated pleasure, and self-reported motivation compared to the Scheduling-only Control condition, and greater increases in anticipatory pleasure (state mood), but not anticipated pleasure or motivation, relative to the Verbal-Reasoning condition. Consistent with Renner et al. (2019), the Imagery-Experiential condition, but not the Verbal-Reasoning condition, reported more frequent engagement in high motivational barrier activities than the Scheduling-only Control condition. Exploratory mediational analyses suggested that mental imagery may exert unique motivational impacts via its impact on anticipatory pleasure (state mood), although indirect effects were only observed for self-reported motivation change in the lab, with real world behavioural effects falling short of statistical significance.

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 enhancements increase the effectiveness of cognitive behavioural group therapy for social anxiety disorder: a benchmarking study.

Emerging evidence suggests that imagery-based techniques may enhance the effectiveness of traditional verbal-linguistic cognitive interventions for emotional disorders. This study extends an earlier pilot study by reporting outcomes from a naturalistic trial of an imagery-enhanced cognitive behavioural group therapy (IE-CBGT, n = 53) protocol for social anxiety disorder (SAD), and comparing outcomes to historical controls who completed a predominantly verbally-based group protocol (n = 129). Patients were consecutive referrals from health professionals to a community clinic specialising in anxiety and mood disorders. Both treatments involved 12, two-hour group sessions plus a one-month follow-up. Analyses evaluated treatment adherence, predictors of dropout, treatment effect sizes, reliable and clinically significant change, and whether self-reported tendencies to use imagery in everyday life and imagery ability predicted symptom change. IE-CBGT patients were substantially more likely to complete treatment than controls (91% vs. 65%). Effect sizes were very large for both treatments, but were significantly larger for IE-CBGT. A higher proportion of the IE-CBGT patients achieved reliable change, and better imagery ability was associated with larger symptom change. Outcomes compared very favourably to published group and individual treatments for SAD, suggesting that IE-CBGT may be a particularly effective and efficient mode of treatment delivery.

Group metacognitive therapy for repetitive negative thinking in primary and non-primary generalized anxiety disorder: an effectiveness trial.

BACKGROUND: Generalized anxiety disorder (GAD) is a common and highly comorbid anxiety disorder characterized by repetitive negative thinking (RNT). Treatment trials tend to exclude individuals with non-primary GAD, despite this being a common presentation in real world clinics. RNT is also associated with multiple emotional disorders, suggesting that it should be targeted regardless of the primary disorder. This study evaluated the acceptability and effectiveness of brief group metacognitive therapy (MCT) for primary or non-primary GAD within a community clinic. METHODS: Patients referred to a specialist community clinic attended six, two-hour weekly sessions plus a one-month follow-up (N=52). Measures of metacognitive beliefs, RNT, symptoms, positive and negative affect, and quality of life were completed at the first, last, and follow-up sessions. RESULTS: Attrition was low and large intent-to-treat effects were observed on most outcomes, particularly for negative metacognitive beliefs and RNT. Treatment gains increased further to follow-up. Benchmarking comparisons demonstrated that outcomes compared favorably to longer disorder-specific protocols for primary GAD. LIMITATIONS: No control group or independent assessment of protocol adherence. CONCLUSIONS: Brief metacognitive therapy is an acceptable and powerful treatment for patients with primary or non-primary GAD.

The five-factor model and personality disorder empirical literature: A meta-analytic review.

The current meta-analysis reviews research examining the relationships between each of the five-factor model personality dimensions and each of the 10 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) personality disorder diagnostic categories. Effect sizes representing the relationships between these two constructs were compiled from 15 independent samples. Results were analyzed both within each individual personality disorder category and across personality disorders, indicating how personality disorders are different and similar, respectively, with regard to underlying personality traits. In terms of how personality disorders differ, the results showed that each disorder displays a five-factor model profile that is meaningful and predictable given its unique diagnostic criteria. With regard to their similarities, the findings revealed that the most prominent and consistent personality dimensions underlying a large number of the personality disorders are positive associations with Neuroticism and negative associations with Agreeableness. Extraversion appears to be a more discriminating dimension, as indicated by prominent but directionally variable associations with the personality disorders. The implications of these meta-analytic findings for clinical application and the advancement of future research are discussed.

Imagery-enhanced cognitive behavioural group therapy for social anxiety disorder: a pilot study.

Cognitive behavioural group therapy (CBGT) for social anxiety disorder (SAD) is efficacious and effective, however a substantial proportion of patients remain in the clinical range so treatment innovations are required. Research suggests that working within the imagery mode may be more emotionally potent than traditional verbal-linguistic strategies. This study piloted an imagery-enhanced CBGT (IE-CBGT) protocol for SAD. It was hypothesised that IE-CBGT would be acceptable to patients, demonstrate large effect sizes, and compare favourably to historical controls who completed CBGT without the imagery-enhancements. Patients (N=19) were consecutive referrals to a community clinic specialising in anxiety and mood disorders. Primary outcomes were self-reported performance and social interaction anxiety. IE-CBGT was highly acceptable to patients with high attendance and completion rates. Effect sizes were large by mid-treatment and very large at post-treatment and follow-up. A high proportion of patients achieved reliable change. Outcomes compared favourably to published group and individual treatments for SAD but larger randomised controlled trials are now required.

MCMI-III personality complexity and depression treatment outcome following group-based cognitive-behavioral therapy.

This study investigated the association of personality disorder complexity to treatment outcome for depression following time-limited group-based cognitive-behavioral therapy. One hundred fifteen outpatients with a primary diagnosis of depression participated in the study. In this study, personality disorder complexity was determined by the degree of personality disorder comorbidity identified by the Millon Clinical Multiaxial Inventory-III (T. Millon, 1994). As predicted, analyses revealed that increasing personality disorder complexity was related to increasing baseline symptom severity and slightly poorer end-state functioning at posttreatment. However, results regarding clinically significant improvement and mean improvement in depression symptoms were less supportive of an association between personality disorder complexity and poorer treatment outcome. The implications of these findings for treatment planning are discussed.

The association between depressive personality and treatment outcome for depression following a group cognitive-behavioral intervention.

The present study investigated the association of depressive personality traits to treatment outcome for depression. One hundred and nineteen patients with a primary diagnosis of major depression were divided into high- and low-depressive personality groups, and depression symptomatology was assessed pre- and postparticipation in a standardized group cognitive-behavioral intervention. Analyses revealed poorer pre-state and end-state functioning for the high-depressive personality group. However, rate of improvement pre- to posttreatment was comparable between the two groups. Subsequent multiple regression analyses revealed that when controlling for pretreatment depression severity, depressive personality was not a predictor of depression treatment outcome. Within the methodological parameters of the current study, depressive personality traits were not associated with a poorer response to cognitive-behavioral treatment for depression.