Social Anxiety Symptom Severity Research Articles

Digital Biomarkers of Social Anxiety Severity: Digital Phenotyping Using Passive Smartphone Sensors

BackgroundSocial anxiety disorder is a highly prevalent and burdensome condition. Persons with social anxiety frequently avoid seeking physician support and rarely receive treatment. Social anxiety symptoms are frequently underreported and underrecognized, creating a barrier to the accurate assessment of these symptoms. Consequently, more research is needed to identify passive biomarkers of social anxiety symptom severity. Digital phenotyping, the use of passive sensor data to inform health care decisions, offers a possible method of addressing this assessment barrier.ObjectiveThis study aims to determine whether passive sensor data acquired from smartphone data can accurately predict social anxiety symptom severity using a publicly available dataset.MethodsIn this study, participants (n=59) completed self-report assessments of their social anxiety symptom severity, depressive symptom severity, positive affect, and negative affect. Next, participants installed an app, which passively collected data about their movement (accelerometers) and social contact (incoming and outgoing calls and texts) over 2 weeks. Afterward, these passive sensor data were used to form digital biomarkers, which were paired with machine learning models to predict participants’ social anxiety symptom severity.ResultsThe results suggested that these passive sensor data could be utilized to accurately predict participants’ social anxiety symptom severity (r=0.702 between predicted and observed symptom severity) and demonstrated discriminant validity between depression, negative affect, and positive affect.ConclusionsThese results suggest that smartphone sensor data may be utilized to accurately detect social anxiety symptom severity and discriminate social anxiety symptom severity from depressive symptoms, negative affect, and positive affect.

Endogenous testosterone levels are predictive of symptom reduction with exposure therapy in social anxiety disorder

The Hypothalamus-Pituitary-Gonadal (HPG)-axis, and testosterone in particular, play an important role in social motivational behavior. Socially avoidant behavior, characteristic of social anxiety disorder (SAD), has been linked to low endogenous testosterone levels, and can be alleviated by testosterone administration in SAD. Although these beneficial effects of testosterone may translate to exposure therapy, it remains unknown whether testosterone increases prior to exposure improve therapy outcomes. In this proof-of-principle study, we tested whether pre-exposure (reactive and baseline) endogenous testosterone levels were predictive of exposure outcome in SAD. Seventy-three participants (52 females) with a principal SAD diagnosis performed four speech exposures: three during one standardized exposure therapy session and one at post-assessment one week later. Subjective fear levels were assessed before and after each speech exposure and social anxiety symptoms were assessed at pre- and post-treatment. Pre-treatment testosterone levels were assessed before (baseline) and in response to a pre-exposure instruction session (reactive). Pre-treatment testosterone levels were not related to fear levels during exposure therapy, but predicted pre- to post-treatment reductions in social anxiety symptom severity. Specifically, low baseline and high reactive pre-treatment testosterone levels were associated with larger reductions in social anxiety symptom severity. These findings support the role of HPG-axis in social fear reduction. Specifically, our finding that high reactive testosterone as well as low baseline testosterone predicted exposure outcome in SAD, suggests that good reactivity of the HPG-axis is a promising marker for the symptom-reducing effects of exposure therapy.

Effectiveness of an Integrative Body-Mind-Spirit group intervention in improving the skin symptoms and psychosocial well-being in children living with atopic dermatitis: A randomized-waitlisted controlled trial

ObjectiveThe symptomatology of atopic dermatitis (AD) imposes heavy physical, psychological, and social burdens on children, yet their psychosocial needs have been commonly ignored in AD management. Evidence of the psychosocial effects of psychosocial interventions on childhood AD is thin. The present study aimed to examine the effects of a customized Integrative Body-Mind-Spirit (IBMS) group intervention on physical, psychological, and social outcomes for children with AD. MethodsA randomized-waitlisted controlled trial was conducted. Children of primary-school age who had been diagnosed with AD and their parents were recruited. Parent-child dyads were randomized to either the IBMS group or waitlisted controlled (WLC) group. Children and their parents attended six three-hour sessions incorporating treatment components based on the IBMS intervention model. The group intervention was conducted in parallel format that the children and parents attended independently of each other. Outcome measures included the severity of AD, generalized and social anxiety symptoms, emotion regulation, self-esteem, quality of relationships with parents, and dermatology-specific quality of life (QoL) at pre-intervention (T0), post-intervention (T1) and 5-weeks post-intervention (T2). ResultsData from 58 children in the IBMS group and 55 children in the WLC group were analyzed. There were no differences in baseline measures. Children in the IBMS group displayed significant decrease in severity of AD, generalized anxiety and social phobia, and improvement in emotion regulation as compared with the WLC group. No significant difference in self-esteem, quality of relationships with parents, or dermatology-specific QoL between the two groups was found. ConclusionWith a rigorously designed evaluation, the study found that the IBMS parallel-group intervention based on a holistic perspective and Eastern philosophies on health and well-being was effective in improving skin symptoms and psychosocial well-being among 6–12-year old children living with AD. Future research needs to customize this IBMS intervention to other developmental stages of children with AD in other geographical contexts so as to benefit wider populations.

Problematic Smartphone Use, Social Anxiety Symptom Severity, and Technology-related Behaviors and Attitudes

Problematic Smartphone Use, Social Anxiety Symptom Severity, and Technology-related Behaviors and Attitudes

Improvement in indices of cellular protection after psychological treatment for social anxiety disorder

Telomere attrition is a hallmark of cellular aging and shorter telomeres have been reported in mood and anxiety disorders. Telomere shortening is counteracted by the enzyme telomerase and cellular protection is also provided by the antioxidant enzyme glutathione peroxidase (GPx). Here, telomerase, GPx, and telomeres were investigated in 46 social anxiety disorder (SAD) patients in a within-subject design with repeated measures before and after cognitive behavioral therapy. Treatment outcome was assessed by the Liebowitz Social Anxiety Scale (self-report), administered three times before treatment to control for time and regression artifacts, and posttreatment. Venipunctures were performed twice before treatment, separated by 9 weeks, and once posttreatment. Telomerase activity and telomere length were measured in peripheral blood mononuclear cells and GPx activity in plasma. All patients contributed with complete data. Results showed that social anxiety symptom severity was significantly reduced from pretreatment to posttreatment (Cohen’s d = 1.46). There were no significant alterations in telomeres or cellular protection markers before treatment onset. Telomere length and telomerase activity did not change significantly after treatment, but an increase in telomerase over treatment was associated with reduced social anxiety. Also, lower pretreatment telomerase activity predicted subsequent symptom improvement. GPx activity increased significantly during treatment, and increases were significantly associated with symptom improvement. The relationships between symptom improvement and putative protective enzymes remained significant also after controlling for body mass index, sex, duration of SAD, smoking, concurrent psychotropic medication, and the proportion of lymphocytes to monocytes. Thus, indices of cellular protection may be involved in the therapeutic mechanisms of psychological treatment for anxiety.

Amygdala volume and social anxiety symptom severity: Does segmentation technique matter?

The amygdala factors prominently in neurobiological models of social anxiety (SA), yet amygdala volume findings regarding SA have been inconsistent and largely focused on case-control characterization. One source of discrepant findings could be variability in volumetric techniques. Therefore, we compared amygdala volumes derived via an automated technique (Freesurfer) against a manually corrected approach, also involving Freesurfer. Additionally, we tested whether the relationship between volume and SA symptom severity would differ across volumetric techniques. We pooled participants (n = 76) from archival studies. SA severity was assessed with the Liebowitz Social Anxiety Scale; scores ranged from non-clinical to clinical levels. Freesurfer produced significantly larger amygdalar volumes for participants with poor image quality. Even after excluding such participants, paired sample t-tests showed Freesurfer's boundaries produced significantly larger amygdalar volumes than manually corrected ones, bilaterally. Yet, intra-class correlation coefficients between the two methods were high, which suggests that Freesurfer's over-estimation of amygdala volume was systemic. Regardless of segmentation technique, volumes were not associated with SA symptom severity. Potentially, amygdala sub-regions may yield clearer patterns regarding SA symptoms. Further, our study underscores the importance of image quality for segmentation of the amygdala, and image quality may be particularly valuable when examining anatomical data for subtle inter-individual differences.

A Study of the State of Interpersonal Rejection Sensitivity by the Severity of Depression Symptoms and Social Anxiety Symptoms Based on ACT.

A Study of the State of Interpersonal Rejection Sensitivity by the Severity of Depression Symptoms and Social Anxiety Symptoms Based on ACT.

Changes in post-event processing during cognitive behavioural therapy for social anxiety disorder: A longitudinal analysis using post-session measurement and experience sampling methodology

PurposePost-event processing (PEP) is posited to be an important factor in the maintenance of social anxiety symptoms. Previous research has demonstrated that general PEP tendencies are sensitive to treatment. However, it remains unclear how momentary PEP following social interactions changes over the course of treatment for social anxiety disorder. The purpose of the present study was to examine how both momentary and general PEP change over the course of treatment, and how such changes predict treatment outcome. MethodParticipants (N = 60) with social anxiety disorder were enrolled in group cognitive behavioural therapy. All participants completed measures of PEP and social anxiety symptom severity at five time points over treatment. A subset (N = 33) also completed repeated experience sampling measurements of PEP following social interactions across the course of treatment. ResultsBoth general and momentary PEP decreased over the course of treatment. Decreases in both types of PEP predicted lower social anxiety symptom severity following treatment. ConclusionThe results of the study demonstrate that momentary experiences of PEP can be influenced by treatment, and can in turn impact treatment outcome. The findings have significant clinical and theoretical implications.

Increased psychiatric symptoms in university students with autism spectrum disorder are associated with reduced adaptive behavior

High variability in adaptive behavior in cognitively-able adults with autism spectrum disorder has been previously reported, and may be caused by the high prevalence of psychiatric comorbidity in this population. This study's goals were to examine self-reported psychiatric symptoms in students with ASD, and to identify their relative contribution to the variance in adaptive behaviors. The study population included 95 students: 55 diagnosed with ASD (4 females; age range 18–34) who participated in a university integration program (ASD group), and 40 regularly matriculated students (non-ASD group, 7 females; age range 20–36). The ASD group showed a lower adaptive skill level than the non-ASD group as measured by the Adaptive Behavior Assessment System (GAC-ABAS). Significantly higher scores for the ASD group were found for social anxiety, trait anxiety, obsessive-compulsive symptoms, and depression symptoms. The level of adaptive skills correlated negatively and significantly with the severity of social anxiety symptoms in both groups and with severity of obsessive-compulsive symptoms only in the ASD group. Additionally, in a regression model, significant contributions of having an ASD diagnosis and severity of social anxiety explained 41.7% of the variance in adaptive skills. Adequate evaluation and treatment, if needed, are recommended in this population.

Evaluating a Web-Based Social Anxiety Intervention Among Community Users: Analysis of Real-World Data.

BackgroundSocial anxiety is both harmful and prevalent. It also currently remains among the most undertreated major mental disorders, due, in part, to socially anxious individuals’ concerns about the stigma and expense of seeking help. The privacy and affordability of computer-aided psychotherapy interventions may render them particularly helpful in addressing these concerns, and they are also highly scalable, but most tend to be only somewhat effective without therapist support. However, a recent evaluation of a new self-guided, 7-module internet-delivered cognitive behavioral therapy intervention called Overcome Social Anxiety found that it was highly effective.ObjectiveThe initial evaluation of Overcome Social Anxiety revealed that it led to significant reductions in symptom severity among university undergraduates. The aim of this study was to extend the results of the initial study and investigate their generalizability by directly evaluating the intervention’s effectiveness among a general community sample.MethodsWhile signing up for Overcome Social Anxiety, users consented to the usage of their anonymized outcome data for research purposes. Before and after completing the intervention, users completed the Fear of Negative Evaluation Scale (FNE), which we employed as the primary outcome measure. Secondary outcome measures included the Depression Anxiety Stress Scales (DASS) and 2 bespoke questionnaires measuring socially anxious thoughts (Thoughts Questionnaire) and avoidance behaviors (Avoidance Questionnaire).ResultsParticipants who completed the intervention (102/369, 27.7%) experienced significant reductions in the severity of their symptoms on all measures employed, including FNE (P<.001; Cohen d=1.76), the depression subscale of DASS (P<.001; Cohen d=0.70), the anxiety subscale of DASS (P<.001; Cohen d=0.74), the stress subscale of DASS (P<.001; Cohen d=0.80), the Thoughts Questionnaire (P<.001; Cohen d=1.46), and the Avoidance Questionnaire (P<.001; Cohen d=1.42).ConclusionsOur results provide further evidence that Overcome Social Anxiety reduces the severity of social anxiety symptoms among those who complete it and suggest that its effectiveness extends to the general community. The completion rate is the highest documented for a fully automated intervention for anxiety, depression, or low mood in a real community sample. In addition, our results indicate that Overcome Social Anxiety reduces the severity of symptoms of depression, physiological symptoms of anxiety, and stress in addition to symptoms of social anxiety.

A Randomized Controlled Trial of Compassion Focused Therapy for Social Anxiety Disorder

Background: One of the most common anxiety disorders is the social anxiety disorder (SAD), which is characterized by intolerable anxiety and self-consciousness in daily social situations. A large body of study is conducted on the treatment of this disorder, though further studies are required on new psychological therapies. Objectives: The present study aims to evaluate the effectiveness of compassion focused therapy (CFT) on patients with SAD. Methods: The present randomized controlled trial study, which is along with pre-test, post-test, and follow-up with control group, 34 subjects who based on the structured clinical interview for DSM (SCID) had the criteria for social anxiety disorder on the basis of DSM-IV-TR, and had no other severe psychiatric disorders, were assigned completely randomly and equally into experimental and control groups. The experimental group was treated with 12 one-weekly CFT sessions, whereas the control group did not receive any treatment. At the beginning of the research, after 12 weeks and after a follow-up period of 8 weeks, all subjects were evaluated with acceptance and action questionnaire (AAQ-II), mindful attention awareness scale (MAAS), levels of self-criticism scale (LOSC), self-compassion scale (SCS), World Health Organization quality of life-BREF (WHOQOL-BREF), and Liebowitz social anxiety scale (LSAS) instruments. In addition to descriptive statistics, repeated measure analysis of variance (RM-ANOVA) was used in order to analyze the findings and using SPSS-21 software all analyzes were conducted. Results: Based on the RM-ANOVA, CFT was significantly more effective than non-treatment in reducing psychological inflexibility, self-criticism, and severity of social anxiety symptoms (P < 0.001) in both post-test and two months’ follow-up. Moreover, CFT was able to significantly increase the mindfulness levels, self-compassion, and quality of life in patients with social anxiety (P < 0.01). Conclusions: Compassion-focused interventions apparently play a quite effective role in reducing symptoms and increasing the quality of life of patients with social anxiety disorder.

Altered Amygdala Resting-State Functional Connectivity and Hemispheric Asymmetry in Patients With Social Anxiety Disorder.

Background: The amygdala plays a key role in emotional hyperreactivity in response to social threat in patients with social anxiety disorder (SAD). We investigated resting-state functional connectivity (rs-FCN) of the left and right amygdala with various brain regions and functional lateralization in patients with SAD.Methods: A total of 36 patients with SAD and 42 matched healthy controls underwent functional magnetic resonance imaging (fMRI) at rest. Using the left and right amygdala as seed regions, we compared the strength of the rs-FCN in the patient and control groups. Furthermore, we investigated group differences in the hemispheric asymmetry of the functional connectivity maps of the left and right amygdala.Results: Compared with healthy controls, the rs-FCN between the left amygdala and the dorsolateral prefrontal cortex was reduced in patients with SAD, whereas left amygdala connectivity with the fusiform gyrus, anterior insula, supramarginal gyrus, and precuneus was increased or positively deflected in the patient group. Additionally, the strength rs-FCN between the left amygdala and anterior insula was positively associated with the severity of the fear of negative evaluation in patients with SAD (r = 0.338, p = 0.044). The rs-FCN between the right amygdala and medial frontal gyrus was decreased in patients with SAD compared with healthy controls, whereas connectivity with the parahippocampal gyrus was greater in the patient group than in the control group. The hemispheric asymmetry patterns in the anterior insula, intraparietal sulcus (IPS), and inferior frontal gyrus of the patient group were opposite those of the control group, and functional lateralization of the connectivity between the amygdala and the IPS was associated with the severity of social anxiety symptoms (r = 0.365, p = 0.037).Conclusion: Our findings suggest that in addition to impaired fronto-amygdala communication, the functional lateralization of amygdala function plays a central role in the pathophysiology of SAD.

Attention Bias Modification Treatment for Adolescents With Social Anxiety Disorder

Social anxiety disorder (SAD) tends to emerge during the early teenage years and is particularly refractory to change even when standard evidence-based CBT treatments are delivered. Efforts have been made to develop novel, mechanistic-driven interventions for this disorder. In the present study, we examined Attention Bias Modification Treatment (ABMT) for youth with SAD. Participants were 58 adolescents (mean age = 14.29 years) who met diagnostic criteria for SAD and who were randomized to ABMT or a placebo control condition, Attention Control Training (ACT). We predicted that ABMT would result in greater changes in both threat biases and social anxiety symptoms. We also explored potential moderators of change including the severity of social anxiety symptoms, the level of threat bias at pretreatment, and the degree of temperament-defined attention control. Contrary to our hypotheses, changes in attention bias were not observed in either condition, changes in social anxiety symptoms and diagnosis were small, and significant differences were not observed between the ABMT and ACT conditions. Little support for the proposed moderators was obtained. Reasons for our failure to find support for ABMT and its potential moderators are explored and recommendations for changes in the ABMT paradigm are suggested.

Characterising the relationship between theory of mind and anxiety in children with Autism Spectrum Disorder and typically developing children

Background: Social communication impairments associated with Autism Spectrum Disorder (ASD) is a multi-faceted phenomenon that encapsulates a broad range of skills with Theory of Mind (ToM) as a key component. Early Theory of Mind (ToM) skills, such as joint attention, typically develop during infancy and provide a foundation for the co-emergence of affect regulation via social referencing. Children with Autism Spectrum Disorder (ASD) demonstrate delays and impairments in the development of ToM, and up to 40% of children with ASD also experience co-occurring symptoms of anxiety and poor affect regulation. Method: Using parent report, this cross-sectional study aimed to characterise the relationship between ToM competency and anxiety, and explore how specific ToM deficits may confer vulnerability to anxiety in children (4–8 years old) with ASD. Results: Early ToM skills, such as joint attention and social referencing, mediated the relationship between broader social communication impairments and anxiety symptom severity in children with ASD. Conclusions: Increasing competency of early ToM skills might provide additional therapeutic benefits for clinical interventions targeting anxiety in children with ASD.

Maladaptive Self-Beliefs During Cognitive Behavioural Therapy for Social Anxiety Disorder: A Test of Temporal Precedence

Given the putative importance of maladaptive self-beliefs in cognitive models of social anxiety, there is growing interest in the construct’s influence on social anxiety reduction in treatment. The present study sought to examine whether maladaptive self-beliefs reduce over a 12-week course of cognitive behavioural therapy (CBT) for social anxiety disorder (SAD), and whether change in self-beliefs is an indicator of later change in social anxiety symptom severity within treatment. Participants were 77 individuals with SAD who completed measures of maladaptive self-beliefs every 2 weeks of the treatment protocol and measures of social anxiety each week. Using a dynamic bivariate latent difference score framework, results indicated that maladaptive self-beliefs reduced during CBT for SAD, and that change in maladaptive self-beliefs was a significant predictor of later change in social anxiety symptom severity. Reductions in social anxiety was not a significant predictor of later change in self-beliefs. Findings underscore the importance of maladaptive self-beliefs in the maintenance of social anxiety and in treatment for SAD. Moreover, they permit inferences about the temporal sequence of change processes in therapy and are consistent with CBT therapeutic models suggesting that cognitive change precedes symptom change.

Facial and prosodic emotion recognition in social anxiety disorder

ABSTRACTIntroduction: Patients with social anxiety disorder (SAD) have a cognitive preference to negatively evaluate emotional information. In particular, the preferential biases in prosodic emotion recognition in SAD have been much less explored. The present study aims to investigate whether SAD patients retain negative evaluation biases across visual and auditory modalities when given sufficient response time to recognise emotions.Methods: Thirty-one SAD patients and 31 age- and gender-matched healthy participants completed a culturally suitable non-verbal emotion recognition task and received clinical assessments for social anxiety and depressive symptoms. A repeated measures analysis of variance was conducted to examine group differences in emotion recognition.Results: Compared to healthy participants, SAD patients were significantly less accurate at recognising facial and prosodic emotions, and spent more time on emotion recognition. The differences were mainly driven by the lower accuracy and longer reaction times for recognising fearful emotions in SAD patients. Within the SAD patients, lower accuracy of sad face recognition was associated with higher severity of depressive and social anxiety symptoms, particularly with avoidance symptoms.Conclusion: These findings may represent a cross-modality pattern of avoidance in the later stage of identifying negative emotions in SAD. This pattern may be linked to clinical symptom severity.

Psychiatric associations of adult-onset focal dystonia phenotypes

BackgroundDepression and anxiety frequently accompany the motor manifestations of isolated adult-onset focal dystonias. Whether the body region affected when this type of dystonia first presents is associated with the severity...

Voxel-based morphometry multi-center mega-analysis of brain structure in social anxiety disorder.

Social anxiety disorder (SAD) is a prevalent and disabling mental disorder, associated with significant psychiatric co-morbidity. Previous research on structural brain alterations associated with SAD has yielded inconsistent results concerning the direction of the changes in gray matter (GM) in various brain regions, as well as on the relationship between brain structure and SAD-symptomatology. These heterogeneous findings are possibly due to limited sample sizes. Multi-site imaging offers new opportunities to investigate SAD-related alterations in brain structure in larger samples.An international multi-center mega-analysis on the largest database of SAD structural T1-weighted 3T MRI scans to date was performed to compare GM volume of SAD-patients (n = 174) and healthy control (HC)-participants (n = 213) using voxel-based morphometry. A hypothesis-driven region of interest (ROI) approach was used, focusing on the basal ganglia, the amygdala-hippocampal complex, the prefrontal cortex, and the parietal cortex. SAD-patients had larger GM volume in the dorsal striatum when compared to HC-participants. This increase correlated positively with the severity of self-reported social anxiety symptoms. No SAD-related differences in GM volume were present in the other ROIs. Thereby, the results of this mega-analysis suggest a role for the dorsal striatum in SAD, but previously reported SAD-related changes in GM in the amygdala, hippocampus, precuneus, prefrontal cortex and parietal regions were not replicated. Our findings emphasize the importance of large sample imaging studies and the need for meta-analyses like those performed by the Enhancing NeuroImaging Genetics through Meta-Analysis (ENIGMA) Consortium.

Attention bias dynamics and symptom severity during and following CBT for social anxiety disorder.

Threat-related attention bias figures prominently in contemporary accounts of the maintenance of anxiety disorders, yet longitudinal intervention research relating attention bias to anxiety symptom severity is limited. Capitalizing on recent advances in the conceptualization and measurement of attention bias, we aimed to examine the relation between attention bias, indexed using trial-level bias scores (TLBSs) to quantify temporal dynamics reflecting dysregulation of attentional processing of threat (as opposed to aggregated mean bias scores) and social anxiety symptom severity over the course of cognitive-behavioral therapy (CBT) and 1-month follow-up. Adults with social anxiety disorder (N = 39) assigned to either yohimbine- or placebo-augmented CBT completed measures of attention bias and social anxiety symptom severity weekly throughout CBT (5 sessions) and at 1-week and 1-month posttreatment. TLBSs of attention bias temporal dynamics showed stronger psychometric properties than mean aggregated scores and were highly interrelated, in line with within-subject temporal variability fluctuating in time between attentional overengagement and strategic avoidance from threat. Attention bias toward threat and temporal variability in attention bias (i.e., attentional dysregulation), but not attention bias away from threat, significantly reduced over the course of CBT. Cross-lag analyses revealed no evidence of a causal relation between reductions in attentional dysregulation leading to symptom severity reduction, or vice versa. Observed relations did not vary as a function of time. We found no evidence for attentional dysregulation as a causal mechanism for symptom reduction in CBT for social anxiety disorders. Implications for future research are discussed. (PsycINFO Database Record

Combining escitalopram and cognitive–behavioural therapy for social anxiety disorder: Randomised controlled fMRI trial

Selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioural therapy (CBT) are often used concomitantly to treat social anxiety disorder (SAD), but few studies have examined the effect of this combination. To evaluate whether adding escitalopram to internet-delivered CBT (ICBT) improves clinical outcome and alters brain reactivity and connectivity in SAD. Double-blind, randomised, placebo-controlled neuroimaging trial of ICBT combined either with escitalopram (n = 24) or placebo (n = 24), including a 15-month clinical follow-up (trial registration: ISRCTN24929928). Escitalopram+ICBT, relative to placebo+ICBT, resulted in significantly more clinical responders, larger reductions in anticipatory speech state anxiety at post-treatment and larger reductions in social anxiety symptom severity at 15-month follow-up and at a trend-level (P = 0.09) at post-treatment. Right amygdala reactivity to emotional faces also decreased more in the escitalopram+ICBT combination relative to placebo+ICBT, and in treatment responders relative to non-responders. Adding escitalopram improves the outcome of ICBT for SAD and decreased amygdala reactivity is important for anxiolytic treatment response.