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noted (substance abuse, n = 1 in IE-CBT; temporary increase in suicide risk, n = 1 in each condition, with one being withdrawn at 1-month follow-up).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

Background: The Bivalent Fear of Evaluation Model proposes that the fears of positive and negative evaluation each uniquely contribute to social anxiety severity. However, the debate continues as to whether these are distinct constructs, and, if so, the degree of influence each has on social anxiety severity. This study used a longitudinal evaluation of these relationships in a clinical sample to identify whether the two fears differentially change over time and differentially relate to social anxiety severity.Methods: Individuals with a social anxiety disorder (N = 105) completed measures of fears of negative and positive evaluation weekly, and social interaction anxiety monthly, for 12 weeks. Temporal relationships were assessed using residual dynamic structural equation modeling.Results: Fears of positive and negative evaluation both predicted the future status of the other (ϕ = 0.18, 95% credibility interval [0.10-0.28] and ϕ = 0.22 [0.12-0.35], respectively). Fear of negative evaluation (ϕ = 0.16 [0.05-0.28]) but not positive evaluation (ϕ < 0.01 [-0.09 to 0.10]) directly predicted future social anxiety severity. Fear of positive evaluation only indirectly predicted anxiety severity via fear of negative evaluation.Conclusions: Previous fears of negative evaluation could not fully explain future fears of positive evaluation (or vice-versa), which is consistent with the two constructs being likely distinct in social anxiety disorder. Given its more direct relationship with social anxiety severity, fear of negative evaluation should be targeted in treatment, as this could both directly reduce social anxiety severity and minimize the indirect impact of fear of positive evaluation. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of psychotherapies for social anxiety disorder (SAD) is typically evaluated using self- and clinician-reported symptom change, while biomarkers of treatment response are rarely measured. The current study aimed to compare biomarkers of response following two brief group interventions for SAD.Methods: This randomized controlled trial evaluated the effectiveness of single-session group interventions for SAD (n = 58) - imagery rescripting (IR) and verbal restructuring (VR) versus waitlist control (WC). The IR intervention guided participants to rescript autobiographical memories through visualization whilst the VR intervention focused on thought challenging. Trial outcomes included change in psychophysiological reactivity (heart rate variability (HRV) and electrodermal responding) to social stress, and symptom-based measures (social interaction anxiety, negative self-portrayal, cognitive avoidance, repetitive negative thinking, memory modification, anxious behaviors).Results: Psychophysiological reactivity was selectively attenuated following IR treatment, compared to VR and WC groups. The specific influence of the imagery-based intervention in modulating autonomic reactivity was evident across HRV parameters, including the standard deviation of intervals between heartbeats (IR vs. WC, d = 0.67, p = 0.021; IR vs. VR, d = 0.58, p = 0.041), and high frequency power - an indicator of parasympathetically mediated emotion regulation (IR vs. WC, d = 0.75, p = 0.034; IR vs. VR, d = 0.95, p = 0.006). Few group differences were observed across self-report measures.Conclusion: The current study highlights the specificity of brief imagery-based interventions in influencing psychophysiological reactivity in SAD and establishes the sensitivity of objective markers of treatment response in quantifying change over symptom-based measurements. [ABSTRACT FROM AUTHOR]

The Social Interaction Anxiety Scale (SIAS) and Social Phobia Scale (SPS) are 20-item companion measures of social anxiety symptoms frequently used to evaluate outcome in treatment trials. The SIAS-6, SPS-6, and Social Interaction Phobia Scale (SIPS) are promising short forms of the SIAS and SPS. The current study evaluated whether it is sound to use these short scales instead of the full-length instruments to measure outcome in social anxiety disorder (SAD) treatment studies, using data from a trial in which 255 adults with SAD were treated with traditional or imagery-enhanced group cognitive-behavioral therapy. Several deficiencies with the short forms were identified including ceiling effects, inflated variances, imprecise effect size estimates, and a loss of statistical power when testing for between-treatment differences. Using the short forms can alter the substantive findings of a treatment trial, as genuine differences in efficacy between treatments can be missed. We recommend treatment outcome be measured using the full SIAS and SPS rather than the SIPS, SIAS-6, and SPS-6. The full-length instruments provide precise estimates of treatment effects and maximize the chance of detecting between-treatment differences when they exist. (PsycINFO Database Record (c) 2018 APA, all rights reserved). [ABSTRACT FROM AUTHOR]

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 ( d s = 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. [ABSTRACT FROM AUTHOR]

Trials of cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) have struggled to identify replicable moderators of treatment outcome. This could be due to a genuine lack of effects, or a spurious finding caused by methodological factors such as inadequate testing of theory-driven moderators, use of small homogenous samples, failure to model non-linear relationships, and over-reliance on significance testing. We probed explanations for the field's failure to detect moderators by testing whether 15 theory-driven and atheoretical variables moderated treatment outcome in a large heterogeneous sample treated with group CBT for SAD. Moderation was not assessed by only using p -values for linear models, but also by considering effect sizes, plots, and non-linear relationships. Despite using a comprehensive approach to assess moderation, only two variables – the baseline severity of SAD symptoms and fear of negative evaluation (FNE) – were found to moderate social anxiety symptom trajectories. FNE had a non-linear relationship with symptom change that would have been missed using common research methods. Our findings suggest both a genuine lack of effects and limitations of research methods have contributed to the field's inability to identify moderators. We provide suggestions that may increase the likelihood of future researchers detecting genuine effects. • Replicable moderators of change in social anxiety treatment have been hard to find. • Explanations include methodological limitations or a genuine lack of effects. • We evaluated 15 potential moderators of change in group CBT for social anxiety. • We addressed numerous methodological limitations of prior studies. • Both weak effects and poor methods may have hampered efforts to detect moderators. [ABSTRACT FROM AUTHOR]

The search for universal processes associated with symptom change across emotional disorders and different forms of psychotherapy offers hope of increased theoretical parsimony and treatment efficiencies. This study investigated whether intolerance of uncertainty (IU) is a universal process by examining whether changes in IU were associated with changes in symptoms across three different cognitive behavior therapy protocols for depression (n = 106), social anxiety disorder (n = 88), or generalized anxiety disorder (n = 62) in a community mental health clinic. IU was associated with reductions in repetitive negative thinking in all treatments, which is consistent with IU being a transdiagnostic and 'trans-therapy' process of change. Changes in IU were also associated with symptom relief in the social anxiety disorder and generalized anxiety disorder groups, but not in the depression group. Implications of these findings are discussed within the broader literature of transdiagnostic approaches to emotional disorders. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]