Visual scanpaths predict treatment response in children and adolescents with social anxiety disorder.

Eye movements predict treatment response in children and adolescents with social anxiety disorder

Social anxiety disorder (SAD) is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large. Cognitive behavioral therapy (CBT) is an established evidence-based treatment for SAD, but its availability is limited. To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for SAD in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT). This single-masked, superiority randomized clinical trial enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, from September 1, 2017, to October 31, 2018. The final participant reached the 3-month follow-up (primary end point) in May 2019. Children and adolescents 10 to 17 years of age with a principal diagnosis of SAD and their parents were included in the study. ICBT and ISUPPORT, both including 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist. The Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors 3 months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating caseness. Secondary outcomes included masked assessor-rated diagnostic status of SAD and global functioning, child- and parent-reported social anxiety and depressive symptoms, and health-related costs. Of the 307 youths assessed for eligibility, 103 were randomized to 10 weeks of therapist-guided ICBT (n = 51) or therapist-guided ISUPPORT (n = 52) for SAD. The sample consisted of 103 youths (mean [SD] age, 14.1 [2.1] years; 79 [77%] female). Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms. Mean (SD) CSR scores for ICBT at baseline and at the 3-month follow-up were 5.06 (0.95) and 3.96 (1.46), respectively, compared with 4.94 (0.94) and 4.48 (1.30) for ISUPPORT. There was a significant between-group effect size of d = 0.67 (95% CI, 0.21-1.12) at the 3-month follow-up. Similarly, all of the secondary outcome measures demonstrated significant differences with small to large effect sizes, except for child-rated quality of life (nonsignificant). The cost-effectiveness analyses indicated cost savings associated with ICBT compared with ISUPPORT, with the main drivers of the savings being lower medication costs (z = 2.38, P = .02) and increased school productivity (z = 1.99, P = .047) in the ICBT group. There was 1 suicide attempt in the ISUPPORT group; no other serious adverse events occurred in either group. In this randomized clinical trial, internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD. ClinicalTrials.gov Identifier: NCT03247075.

Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders: a single-centre, single-blind, randomised controlled trial

Background: Social anxiety disorder (SAD) has its typical onset in childhood and adolescence. Maladaptive processing of social information may contribute to the etiology and maintenance of SAD. During face perception, individuals execute a succession of visual fixations known as a scanpath which facilitates information processing. Atypically long scanpaths have been reported in adults with SAD, but no data exists from pediatric samples. SAD has also been linked to atypical arousal during face perception. Both metrics were examined in one of the largest eye-tracking studies of pediatric SAD to date.Methods: Participants were children and adolescents with SAD (n = 61) and healthy controls (n = 39) with a mean age of 14 years (range 10–17) who completed an emotion recognition task. The visual scanpath and pupil dilation (an indirect index of arousal) were examined using eye tracking.Results: Scanpaths of youth with SAD were shorter, less distributed, and consisted of a smaller number of fixations than those of healthy controls. These findings were supported by both frequentist and Bayesian statistics. Higher pupil dilation was also observed in the SAD group, but despite a statistically significant group difference, this result was not supported by the Bayesian analysis.Conclusions: The results were contrary to findings from adult studies, but similar to what has been reported in neurodevelopmental conditions associated with social interaction impairments. Restricted scanpaths may disrupt holistic representation of faces known to favor adaptive social understanding.

Background: This single-masked randomised controlled superiority trial evaluated the efficacy and cost-effectiveness of therapist guided internet-delivered cognitive behavioural therapy (ICBT) for social anxiety disorder (SAD) in youth compared with an active comparator, internet-delivered supportive therapy (ISUPPORT). Methods: Participants were 103 children and adolescents aged 10-17 years with a principal diagnosis of SAD, and their parents. Participants were randomly allocated to 10 weeks of ICBT (n=51) or ISUPPORT (n=52). Both interventions included three video call sessions with a therapist. The primary outcome measure was the Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule (ADIS-C), rated by masked clinicians post treatment and three months after the end of treatment (primary endpoint). Secondary outcomes included clinician-rated diagnostic status of SAD and global functioning, as well as child- and parent-reported social anxiety and comorbid depression. Findings: ICBT was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms with a significant between-group effect size of d=0·66 (95% CI [0·27, 1·11]) at the 3-month follow-up. Similarly, most of the secondary outcome measures demonstrated moderate effect sizes favouring ICBT. The cost-effectiveness analyses indicated cost savings associated with ICBT compared to ISUPPORT. One suicide attempt was reported and managed in the ISUPPORT condition. No other serious adverse events were reported in either condition. Interpretation: ICBT is an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD. Trial Registration: The trial was registered at ClinicalTrials.gov with id NCT03247075 Funding: This work was funded by the Swedish Research Council for Health, Working Life and Welfare (Forte 2014-4052) and Region Stockholm (HNSV 14099). JH was supported by Region Stockholm (Dnr: K0173-2016; clinical postdoctoral appointment: 2017-2020). ES was supported by Region Stockholm (clinical research appointment; 2017-0605). Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf. Dr. Mataix-Cols reports personal fees from Elsevier, personal fees from UpToDate, Inc., outside the submitted work. None of the other authors declare any conflict of interests. Ethics Approval Statement: The trial was approved by the Stockholm regional ethical review board (2017/1027-31/2).

BackgroundGuided internet-delivered cognitive behavior therapy (ICBT) has been tested in several trials on social anxiety disorder (SAD) with moderate to large effects. The aims of this study were threefold. First, to compare the effects of ICBT including online discussion forum with a moderated online discussion forum only. Second, to investigate if knowledge about SAD increased following treatment and third to compare the effects of inexperienced versus experienced therapists on patient outcomes.MethodsA total of 204 participants with a primary diagnosis of SAD were included and randomized to either guided ICBT or the control condition. ICBT consisted of a 9-week treatment program which was guided by either psychology students at MSc level (n = 6) or by licensed psychologists with previous experience of ICBT (n = 7). A knowledge test dealing with social anxiety was administered before and after treatment. Measures of social anxiety and secondary outcomes dealing with general anxiety, depression, and quality of life were administered before and after treatment. In addition, a 1-year follow-up was conducted on the treated individuals.ResultsImmediately following treatment, the ICBT group showed superior outcome on the Liebowitz Social Anxiety Scale self-report version with a between group posttreatment Hedges g effect size of g = 0.75. In addition, significant differences on all the secondary outcomes were observed. Gains were well maintained one year later. Knowledge, as assessed by the knowledge test, increased following treatment with little gain in the control group. Therapist experience did not result in different outcomes, but experienced therapists logged in less frequently compared to the inexperienced therapists, suggesting that they needed less time to support patients.DiscussionWe conclude that guided ICBT reduce symptoms of SAD, increase knowledge about SAD and that therapist experience does not make a difference apart from the finding that experienced therapist may require less time to guide patients.Trial RegistrationUMIN.ac.jp UMIN000001383

Alcohol use disorder and social anxiety disorder are interconnected disorders that commonly co-occur. We report the first trial to assess whether integrated treatment for social anxiety and alcohol use disorder comorbidity improves outcomes relative to standard alcohol-focussed treatment. Participants were recruited to a randomised controlled trial, and randomly allocated to one of two treatments, Integrated (n = 61) or Control (alcohol-focussed; n = 56). Assessment and treatment session were conducted at two sites in Sydney, Australia. Inclusion criteria were as follows: (1) clinical diagnosis of social anxiety disorder and (2) Diagnosis or sub-clinical symptoms of alcohol use disorder. Diagnoses were determined according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.). All participants (n = 117) received 10 sessions of cognitive behavioural treatment and motivational enhancement. The Integrated treatment simultaneously targeted social anxiety disorder, alcohol use disorder and the connections between these disorders. The Control treatment focussed on alcohol use disorder only. Outcomes were assessed at 6-month follow-up, with interim assessments at post-treatment and 3 months. Primary outcomes were social anxiety disorder severity (composite Social Phobia Scale and Social Interaction Anxiety Scale), alcohol use disorder severity (standard drinks per day and Severity of Alcohol Dependence Questionnaire) and quality of life (Short-Form Health survey) was assessed to capture the combined impairment of social anxiety and alcohol use disorder comorbidity. At 6-month follow-up, both conditions showed significant reductions in social anxiety and alcohol use disorder symptoms, and improved quality of life. There was no evidence of between-condition differences for alcohol outcomes, with mean consumption reduced by 5.0 (0.8) and 5.8 (1.0) drinks per day following Alcohol and Integrated treatments, respectively. Integrated treatment achieved greater improvements in social anxiety symptoms (mean difference = -14.9, 95% confidence interval = [-28.1, -1.6], d = 0.60) and quality of life (mean difference = 7.6, 95% confidence interval = [1.2, 14.0], d = 0.80) relative to alcohol-focused treatment. These results suggest that integrated social anxiety and alcohol use disorder treatment enhances quality of life and social anxiety disorder symptom improvement, but not alcohol outcomes, compared to treatment focussed on alcohol use disorder alone.

Therapist guided Internet-Delivered Cognitive Behavior Therapy (ICBT) is effective, but as in traditional CBT, not all patients improve, and clinicians generally fail to identify them early enough. We predict treatment failure in 12-week regular care ICBT for Depression, Panic disorder and Social anxiety disorder, using only patients' weekly symptom ratings to identify when the accuracy of predictions exceed 2 benchmarks: (a) chance, and (b) empirically derived clinician preferences for actionable predictions. Screening, pretreatment and weekly symptom ratings from 4310 regular care ICBT-patients from the Internet Psychiatry Clinic in Stockholm, Sweden was analyzed in a series of regression models each adding 1 more week of data. Final score was predicted in a holdout test sample, which was then categorized into Success or Failure (failure defined as the absence of both remitter and responder status). Classification analyses with Balanced Accuracy and 95% Confidence intervals was then compared to predefined benchmarks. Benchmark 1 (better than chance) was reached 1 week into all treatments. Social anxiety disorder reached Benchmark 2 (> 65%) at week 5, whereas Depression and Panic Disorder reached it at week 6. For depression, social anxiety and panic disorder, prediction with only patient-rated symptom scores can detect treatment failure 6 weeks into ICBT, with enough accuracy for a clinician to take action. Early identification of failing treatment attempts may be a viable way to increase the overall success rate of existing psychological treatments by providing extra clinical resources to at-risk patients, within a so-called Adaptive Treatment Strategy. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Internet-based psychodynamic therapy vs cognitive behavioural therapy for social anxiety disorder: A preference study

Social Anxiety Disorder (SAD) is characterised by fear or anxiety around potential judgement, scrutiny and negative evaluation by others in social situations. For those with the disorder, social engagement can lead to considerable distress and functional impairment in daily life. Therefore, how individuals with SAD respond to stress, specifically social stress, is of particular importance to the understanding and treatment of the disorder. Much of the existing SAD research has been conducted in the laboratory setting, which provides optimal experimental control but offers little insight into how the disorder plays out in daily life. The symptoms of SAD are context-dependent and fluctuate over time, making them difficult to assess realistically in the laboratory or using retrospective reporting. Ambulatory assessment could deepen our understanding of the symptoms and experiences of those with SAD through frequent assessments in their naturally occurring environment. However, it is difficult to capture how individuals with SAD respond to social stressors using a traditional ambulatory assessment design, as SAD is associated with avoidance of such situations in daily life. This thesis examined the acute social stress response of those with SAD in daily life. A standardised lab-induced social stressor was embedded within an ambulatory assessment design to study the effect of acute social stress on naturalistic subjective and physiological stress responding among individuals with SAD (n = 40) and healthy controls (n = 41). After completing two days of baseline daily life assessment, participants were informed that they would complete a social stress task (the Trier Social Stress Test; TSST) in two days’ time. Following the TSST, participants continued with daily life assessment for an additional two days. This distinguished the anticipatory (days prior to TSST), acute (during the TSST protocol) and recovery (days after TSST) phases of stress responding. Subjective responses were assessed using a smartphone app called SEMA and physiological responses were collected on three days (once during each phase) through ambulatory saliva sampling. The first empirical study of this thesis (Study 1, Chapter 6) reports on the acute social stress response to the TSST assessed in the lab, compared between individuals with SAD versus healthy controls. The second large scale empirical study (Study 2, Chapter 7) reports the results of naturalistic responding to the TSST in daily life, captured using ambulatory assessment, in the same participants. Results from the two empirical studies demonstrated that overall individuals with SAD reported a significantly worse experience across all measures of affect, self-esteem and threatawareness when compared to healthy controls. Between group comparison during the anticipation of social stress in daily life found those with SAD responded with increased anxiety, reduced happiness and less appearance satisfaction, when compared to healthy controls and baseline. In response to social stress, SAD individuals responded with increased stress sensitivity in their subjective experience in the lab and outside of the lab in daily life, seen in the increased anxiety and anger, reduced happiness and less appearance satisfaction reported during the recovery from a social stressor, compared to healthy controls. However, between group comparison revealed no physiological (salivary cortisol) differences were observed between SAD and healthy controls in either the lab or daily life settings. Overall, this thesis adds novel information to the understanding of SAD, especially to the subjective and physiological experience of SAD in daily life in response to social stress. This thesis supports models of SAD that highlight cognitive, psychological and behavioural factors in the aetiology and maintenance of the disorder. Lastly, this thesis provides a valuable source in the form of a laboratory manual (see Chapter 5) to ease the application of implementing the TSST by other researchers.

Neuroimaging, genetic, clinical, and demographic predictors of treatment response in patients with social anxiety disorder

Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10–17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials.

Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder

Internet-delivered cognitive behavioural therapy with and without an initial face-to-face psychoeducation session for social anxiety disorder: A pilot randomized controlled trial

Depressive and anxiety disorders are among the leading causes of disability worldwide. Therapist-guided, Internet-delivered cognitive behaviour therapy (ICBT) is an established treatment for depression and anxiety, but a considerable proportion of treated patients do not achieve sufficient improvement. Predicting symptom change from clinical variables alone is challenging. Genetic data could potentially add predictive power and help us understand who will benefit most from ICBT. We conducted a study including 2668 adults (62% women, mean age 35.6 years) from the Swedish MULTI-PSYCH cohort to investigate the association between polygenic risk scores (PRS) from eight psychiatric and cognitive phenotypes and symptom change after ICBT. All participants had been diagnosed with depression, panic disorder or social anxiety disorder and treated with ICBT. The primary clinical outcome was a harmonised score across three different diagnosis-specific symptom rating instruments and measured weekly throughout ICBT. PRS were computed for attention-deficit/hyperactivity disorder, autism spectrum disorder, bipolar disorder, major depressive disorder and schizophrenia, cross-disorder psychopathology, educational attainment, and intelligence, using large discovery data sets. Linear mixed-effects models identified a significant association between the PRS for educational attainment (PRS-EDU) and symptom change (B = -0.73, p = .03), suggesting that a higher PRS-EDU was associated with lower symptom severity. This remained significant after additional covariate adjustment. No other PRS were significant. In the adjusted model, there was a significant PRS-EDU*time interaction, indicating that PRS-EDU also influenced the symptom change rate during treatment. When excluding outliers, the interaction effect was significant in both the crude and adjusted model. While these results await replication, they could have important implications for how the ICBT could be adapted to suit a wider portion of the population.