Therapy For Social Anxiety Disorder Research Articles

Pilot randomized trial of self-guided virtual reality exposure therapy for social anxiety disorder

BackgroundVirtual reality exposure therapy (VRE) has shown promising efficacy for the treatment of social anxiety disorder (SAD) and related comorbidities. However, most trials conducted to date were therapist-led, and little is known about the efficacy of self-guided VRE. Therefore, this randomized controlled trial (RCT) aimed to determine the efficacy of a self-directed VRE for SAD. MethodForty-four community-dwelling or undergraduate adults diagnosed with SAD based on the Mini International Neuropsychiatric Interview were randomly assigned to VRE designed to last four sessions or more (n = 26) or waitlist (WL; n = 18). Self-reported SAD severity (Social Phobia Diagnostic Questionnaire and Social Interaction Anxiety Scale), job interview anxiety (Measure of Anxiety in Selection Interviews), trait worry (Penn State Worry Questionnaire), and depression symptoms (Patient Health Questionnaire-9) were administered at baseline, post-treatment, 3-month-follow-up (3MFU), and 6-month-follow-up (6MFU). Piecewise multilevel modeling analyses were conducted to manage clustering in the data. ResultsVRE vs. WL resulted in greater reductions in SAD symptom severity, job interview fear, and trait worry, with moderate-to-large effect sizes (Hedge's g = −0.54 to −1.11) from pre-to-post treatment. Although significant between-group differences did not emerge for change in depression, VRE led to change in depression, whereas waitlist did not. These gains were also maintained at 3MFU and 6MFU. Further, facets of presence increased during the course of VRE (g = 0.36–0.45), whereas cybersickness decreased (g = −0.43). DiscussionBrief, self-guided VRE might ameliorate SAD and comorbid worry, for young-to-middle-aged adults with SAD. Other theoretical and practical implications were also discussed.

A pilot study of intensive 7-day internet-based cognitive behavioral therapy for social anxiety disorder

Accessible, affordable cognitive behavioral therapy (CBT) options for Social Anxiety Disorder (SAD) that allow for rapid symptom improvement are needed. The present study investigated the first intensive, 7-day internet-based CBT for SAD. An open pilot trial was conducted to test the acceptability, feasibility and preliminary outcomes of the program in a sample of 16 participants (9 females, M age = 40.34, SD = 10.55) with a DSM-5 diagnosis of SAD. Participants were enrolled into the 6-lesson online program, and completed the Social Phobia Scale [SPS], Social Interaction Anxiety Scale [SIAS], Patient Health Questionnaire-9 (PHQ-9), and Work and Social Adjustment Scale (WSAS) at baseline, post and one month follow-up. We found support for the feasibility and acceptability of the program; 15 participants (93.8%) completed the program, and all participants reported the program was satisfactory. Large, significant reductions in social anxiety severity on both the SPS and SIAS (Hedges’ gs = 1.26–1.9) and functional impairment (WSAS; gs = 0.88–0.98) were found at post-treatment and follow-up. Medium, significant reductions in depressive symptom severity were also found (gs = 0.88–0.98 at post and follow-up, respectively). A third of participants scored below the clinical cut-off on both the SPS and SIAS at post-treatment and follow-up. A randomized controlled trial with longer follow-up is needed to evaluate the efficacy of this intensive internet-based treatment for SAD. Implications and future research directions are discussed.

Virtual reality exposure in cognitive behavioral group therapy for social anxiety disorder: A qualitative evaluation based on patients’ and therapists’ experiences.

Virtual reality exposure in cognitive behavioral group therapy for social anxiety disorder: A qualitative evaluation based on patients’ and therapists’ experiences.

Does treatment preference affect outcome in a randomized trial of a mindfulness intervention versus cognitive behaviour therapy for social anxiety disorder?

Research suggests that treatment preference may affect outcome of randomized clinical trials, but few studies have assessed treatment preference in trials comparing different types of psychosocial interventions. This study used secondary data analysis to evaluate the impact of treatment preference in a randomized trial of a mindfulness-based intervention adapted for social anxiety disorder (MBI-SAD) versus cognitive behaviour group therapy (CBGT). Ninety-seven participants who met DSM-5 criteria for SAD were randomized. Prior to randomization, twice as many participants expressed a preference for the MBI-SAD over CBGT. However, being allocated or not to one's preferred treatment had no impact on treatment response. Additionally, with the exception of perception of treatment credibility, treatment matching had no impact on treatment-related variables, including treatment initiation, session attendance, homework compliance, satisfaction with treatment and perception that treatment met expectations. In sum, despite the greater preference for the mindfulness intervention in this sample of participants with SAD, we found little evidence of preference effects on our study outcomes. Findings should be viewed as preliminary and require replication.

Brief Cognitive Behavioral Group Therapy and Verbal-Exposure-Augmented Cognitive Behavioral Therapy for Social Anxiety Disorder in University Students: A Randomized Controlled Feasibility Trial.

Considering the need for developing and examining evidenced-based programs using a brief group format for management of social anxiety disorder (SAD) at the community level, we studied the efficacy of two brief versions of cognitive-behavioral therapy (CBT) programs, brief cognitive-behavioral group therapy (bCBGT), and verbal exposure augmented cognitive behavioral therapy (VE-CBT), on social anxiety among university students. A single-center, randomized, parallel-group design was adopted. We delivered six weekly two-hour group sessions, bCBGT and VE-CBT, to 41 university students diagnosed with SAD. An independent rater assessed participants using the Liebowitz Social Anxiety Scale (LSAS) and Clinical Global Impression scale-Severity (CGI-S) at baseline, postintervention, and two-month follow-up. A patient-rated measure, Social Phobia Inventory (SPIN), was assessed at the same time-points. There was a significant improvement in severity of social anxiety from baseline to posttreatment and baseline to two-month follow-up in both groups. However, the treatment effects in bCBGT were statistically superior to VE-CBT at postintervention (SPIN, P = 0.038; LSAS, P = 0.028; CGI-S, P = 0.036) and follow-up (SPIN, P = 0.006; LSAS, P = 0.01; CGI-S, P = 0.04). Brief CBT treatments, both bCBGT and VE-CBT, are efficacious for SAD among university students. They have the potential to address barriers associated with SAD management. However, we recommend a longer follow-up and replications in diverse settings.Clinical trial registration number: CTRI/2019/11/021954.

False Safety Behavior Elimination Therapy for Social Anxiety Disorder in Japanese: A Pilot, Single‐Arm Uncontrolled Study1

AbstractSocial anxiety disorder (SAD) is characterized by an excessive fear of social situations that can lead to serious functional impairment; it negatively affects a person’s self‐esteem and social interactions. Its prevalence has increased over the past four decades, and SAD is one of the most prevalent psychiatric disorders in Japan. Therefore, more precise interventions are needed. This study administered false safety behavior elimination therapy (F‐SET), which eliminates safety behavior (i.e., strategies that reduce anxiety), to six Japanese patients with SAD. This is the first adaptation of F‐SET into Japanese. Seven patients were screened and six (Mage = 27.83 years, only males) were eligible for the study criteria. Each patient received five weekly 60‐min F‐SET sessions. At post‐F‐SET, the mean reduction in Liebowitz Social Anxiety Scale score from baseline was −20.50 (95% confidence interval: −30.65, −10.35; p = .003). After completing the treatment, all participants showed substantially decreased SAD symptoms, which indicates preliminary support for the adapted treatment’s efficacy.

Meta-analysis of virtual reality exposure therapy for social anxiety disorder.

Meta-analysis of virtual reality exposure therapy for social anxiety disorder.

Recognizing oneself in the encounter with others: Meaningful moments in systemic therapy for social anxiety disorder in the eyes of patients and their therapists after the end of therapy.

There is evidence that systemic therapy is effective, but there is little evidence about meaningful moments in systemic therapy in general, and none at all in systemic therapy for social anxiety disorders. Meaningful moments are one of the relevant research objects in change process research, as they contribute to a better understanding of therapeutic change.ObjectiveThe objective of this study is to characterize and describe meaningful moments in the context of systemic psychotherapy, from the point of view of patients and their therapists, after the end of therapy. The therapy studied is a manualized, monitored systemic therapy for social anxiety disorder.MethodSemi-structured follow-up interviews were conducted separately with five patients and their therapists (N = 10). Methodological triangulation was used: Grounded theory was used to code the transcripts as described by Charmaz. Then the passages of the selected code “meaningful moment” were evaluated using thematic comparison, in line with Meuser & Nagel.FindingsThree categories involving meaningful moments were identified: (1) meeting other patients in group therapy session, (2) therapeutic resource orientation and (3) recognizing oneself in a diagnosis or pattern of behaviour. These categories emerged as contexts related to the occurrence of meaningful moments from a subjective perspective.DiscussionMeaningful moments seem to be consistently related to the therapist input and to specific interventions or settings, both from the perspective of the patients and the therapists. Two tandems each described a coincident moment. One central aspect of all 14 moments is that the patients and therapists described patients being able to acquire another outlook on themselves.

Emotion regulation therapy for social anxiety disorder: a single case series study.

Despite the vast majority of evidence indicating the efficacy of traditional and recent cognitive behaviour therapy (CBT) therapies in treating social anxiety disorder (SAD), some individuals with SAD do not improve by these interventions, particularly when co-morbidity is present. It is not clear how emotion regulation therapy (ERT) can improve SAD co-morbid with symptoms of generalized anxiety disorder (GAD) and depression. This study investigated this gap. Treatment efficacy was assessed using a single case series methodology. Four clients with SAD co-occurring with GAD and depression symptoms received a 16-session version of ERT in weekly individual sessions. During the treatment, self-report measures and clinician ratings were used to assess the symptom intensity, model-related variables, and quality of life, work and social adjustment of participants every other week throughout the treatment. Follow-up was also conducted at 1, 2 and 3 months after treatment. Data were analysed using visual analysis, effect size (Cohen's d) and percentage of improvement. SAD clients with depression and GAD symptoms demonstrated statistically and clinically significant improvements in symptom severity, quality of life, work, social adjustment and model-related measures (i.e. negative emotionality/safety motivation, emotion regulation strategies). The improvements were largely maintained during the follow-up period and increased for some variables. These findings showed preliminary evidence for the role of emotion dysregulation and motivational factors in the aetiology and maintenance of SAD and the efficacy of ERT in the treatment of co-morbid SAD.

Brain markers predicting response to cognitive\u2010behavioral therapy for social anxiety disorder: an independent replication of Whitfield-Gabrieli et al. 2015

Predictive brain markers promise a number of important scientific, clinical, and societal applications. Over 600 predictive brain markers have been described in published reports, but very few have been tested in independent replication attempts. Here, we conducted an independent replication of a previously published marker predicting treatment response to cognitive-behavioral therapy for social anxiety disorder from patterns of resting-state fMRI amygdala connectivity1. The replication attempt was conducted in an existing dataset similar to the dataset used in the original report, by a team of independent investigators in consultation with the original authors. The precise model described in the original report positively predicted treatment outcomes in the replication dataset, but with marginal statistical significance, permutation test p = 0.1. The effect size was substantially smaller in the replication dataset, with the model explaining 2% of the variance in treatment outcomes, as compared to 21% in the original report. Several lines of evidence, including the current replication attempt, suggest that features of amygdala function or structure may be able to predict treatment response in anxiety disorders. However, predictive models that explain a substantial amount of variance in independent datasets will be needed for scientific and clinical applications.

Rescripting Social Trauma: A Pilot Study Investigating Imagery Rescripting as an Adjunct to Cognitive Behaviour Therapy for Social Anxiety Disorder

The current pilot study aimed to investigate the benefit of imagery rescripting (IR) as an adjunct to Group Cognitive Behavioural Therapy (GCBT) for SAD, given recent research suggesting that IR is beneficial in the treatment of social anxiety disorder (SAD). Fifteen participants with SAD completed eight sessions of GCBT and two additional individual sessions of IR to address negative meanings embedded in memories of traumatic social experiences. As expected, participants reported significant reductions in fear of negative evaluation and identification of negative core beliefs as valid/accurate over the course of the two session IR intervention. Moreover, IR yielded significant improvements in negative affect and maladaptive appraisals associated with self-imagery and aversive memories, as well as depressive symptoms. However, unexpectedly, IR did not yield significant additive reductions in social anxiety symptoms over and above GCBT. Results indicate that IR appears to be a beneficial adjunct to GCBT, and lack of improvement in social anxiety symptoms across IR sessions may be due to methodological limitations. Outcomes suggest that IR may also benefit patients with comorbid depression, given high rates of comorbid unipolar depression for people with SAD, presenting an exciting area for further investigation. Taken together, findings suggest that IR may be a valuable adjunct to GCBT for SAD, especially among patients with comorbid unipolar depression. However, further research including a follow up period is indicated.

Virtual Reality-Based Psychotherapy in Social Anxiety Disorder: fMRI Study Using a Self-Referential Task.

BackgroundAlthough it has been well demonstrated that the efficacy of virtual reality therapy for social anxiety disorder is comparable to that of traditional cognitive behavioral therapy, little is known about the effect of virtual reality on pathological self-referential processes in individuals with social anxiety disorder.ObjectiveWe aimed to determine changes in self-referential processing and their neural mechanisms following virtual reality treatment.MethodsWe recruited participants with and without a primary diagnosis of social anxiety disorder to undergo clinical assessments (Social Phobia Scale and Post-Event Rumination Scale) and functional magnetic resonance imaging (fMRI) scans. Participants with social anxiety disorder received virtual reality–based exposure treatment for 6 sessions starting immediately after baseline testing. After the sixth session, participants with social anxiety disorder completed follow-up scans during which they were asked to judge whether a series of words (positive, negative, neutral) was relevant to them.ResultsOf 25 individuals with social anxiety disorder who participated in the study, 21 completed the sessions and follow-up; 22 control individuals also participated. There were no significant differences in age (P=.36), sex (P=.71), or handedness (P=.51) between the groups. Whole-brain analysis revealed that participants in the social anxiety disorder group had increased neural responses during positive self-referential processing in the medial temporal and frontal cortexes compared with those in the control group. Participants in the social anxiety disorder group also showed increased left insular activation and decreased right middle frontal gyrus activation during negative self-referential processing. After undergoing virtual reality–based therapy, overall symptoms of the participants with social anxiety disorder were reduced, and these participants exhibited greater activity in a brain regions responsible for self-referential and autobiographical memory processes while viewing positive words during postintervention fMRI scans. Interestingly, the greater the blood oxygen level dependent changes related to positive self-referential processing, the lower the tendency to ruminate on the negative events and the lower the social anxiety following the virtual reality session. Compared with that at baseline, higher activation was also found within broad somatosensory areas in individuals with social anxiety disorder during negative self-referential processing following virtual reality therapy.ConclusionsThese fMRI findings might reflect the enhanced physiological and cognitive processing in individuals with social anxiety disorder in response to self-referential information. They also provide neural evidence of the effect of virtual reality exposure therapy on social anxiety and self-derogation.

The renewal effect in fear conditioning with aversive facial expression and negative sentences as unconditioned stimuli

It has been suggested that relapse after exposure therapy for social anxiety disorder is related to the renewal effect. This study aimed to investigate whether the renewal effect occurs in fear conditioning utilizing social stimuli and the quantitative predictions obtained by the Rescorla-Wagner and Bouton’s model using Bayesian modeling fit their data. A total of 63 students participated in this study and received differential fear conditioning, extinction, and testing. For participants in Group AAA, a single context (context A) was used during all the phases. For those in Group ABA, the acquisition and test phases were conducted in the same context (context A), whereas the extinction phase was completed differently (context B). This experiment revealed that the renewal effect was observed in the expectancy rating, but not the valence rating. Bayesian modeling demonstrated that both predictions were generally consistent with the data. These results suggest that relapse of social anxiety is related with the renewal effect in Pavlovian fear conditioning. These findings might provide some implications for the improvement of exposure therapy.

Delivering cognitive therapy for adolescent social anxiety disorder in NHS CAMHS: a clinical and cost analysis.

Cognitive therapy, based on the Clark and Wells (1995) model, is a first-line treatment for adults with social anxiety disorder (SAD), and findings from research settings suggest it has promise for use with adolescents (Cognitive Therapy for Social Anxiety Disorder in Adolescents; CT-SAD-A). However, for the treatment to be suitable for delivery in routine clinical care, two questions need to be addressed. Can therapists be trained to achieve good outcomes in routine Child and Adolescent Mental Health Services (CAMHS), and what are the costs associated with training and treatment? CAMHS therapists working in two NHS trusts received training in CT-SAD-A. They delivered the treatment to adolescents with SAD during a period of supervised practice. We examined the clinical outcomes for the 12 patients treated during this period, and estimated costs associated with treatment and training. Treatment produced significant improvements in social anxiety symptoms, general anxiety and depression symptoms, and reductions in putative process measures. Seventy-five per cent (9 out of 12) patients showed a reliable and clinically significant improvement in social anxiety symptoms, and 64% (7/11) lost their primary diagnosis of SAD. The total cost to the NHS of the CT-SAD-A treatment was £4047 (SD = £1003) per adolescent treated, of which £1861 (SD = £358) referred to the specific estimated cost of face-to-face delivery; the remaining cost was for training and supervising therapists who were not previously familiar with the treatment. This study provides preliminary evidence that clinicians can deliver good patient outcomes for adolescents with SAD in routine CAMHS during a period of supervised practice after receiving a 2-day training workshop. Furthermore, the cost of delivering CT-SAD-A with adolescents appeared to be no more than the cost of delivering CT-SAD with adults.

Cognitive therapy compared with CBT for social anxiety disorder in adolescents: a feasibility study.

Social anxiety disorder (SAD) is common, typically starts in adolescence and has a low natural recovery rate. Existing psychological treatments for adolescent SAD are only moderately effective. It is possible that recovery rates for adolescents could be substantially improved by adapting a psychological therapy that is highly effective among adults with SAD. To train child and adolescent mental health services (CAMHS) therapists to deliver cognitive therapy for SAD in adolescents (CT-SAD-A) and assess therapist competence. To estimate the costs to the NHS of training therapists to deliver CT-SAD-A and the mean cost per adolescent treated. To examine the feasibility of a randomised controlled trial (RCT) to compare CT-SAD-A with the general form of cognitive-behavioural therapy that is more commonly used. During the training phase of the study, it became clear that the RCT would not be feasible because of high staff turnover and unfilled posts within CAMHS and changes in the nature of referrals, which meant that few young people with primary SAD were accessing some of the participating services. The study design was altered to comprise the following: a training case series of CT-SAD-A delivered in routine CAMHS, an estimate of the cost to the NHS of training therapists to deliver CT-SAD-A and of the mean cost per adolescent treated, and qualitative interviews with participating young people, parents, therapists and service managers/leads. Five CAMHS teams within Berkshire Healthcare and Oxford Health NHS Foundation Trusts. Eight therapists received training in CT-SAD-A. Twelve young people received CT-SAD-A, delivered by six therapists. Six young people, six parents, seven therapists and three managers participated in qualitative interviews. Cognitive therapy for social anxiety disorder in adolescents (CT-SAD-A). Measured outcomes included social anxiety symptoms and diagnostic status, comorbid symptoms of anxiety and depression, social and general functioning, concentration in class and treatment acceptability. Patient level utilisation of the intervention was collected using clinicians' logs. Nine out of 12 participants achieved good outcomes across measures (r ≥ 0.60 across social anxiety measures). The estimated cost of delivering CT-SAD-A was £1861 (standard deviation £358) per person. Qualitative interviews indicated that the treatment was acceptable to young people, parents and therapists, but therapists and managers experienced challenges when implementing the training and treatment within the current CAMHS context. Findings were based on a small, homogeneous sample and there was no comparison arm. CT-SAD-A is a promising treatment for young people with SAD, but the current CAMHS context presents challenges for its implementation. Further work is needed to ensure that CAMHS can incorporate and test CT-SAD-A. Alternatively, CT-SAD-A should be delivered and tested in other settings that are better configured to treat young people whose lives are held back by SAD. The new schools Mental Health Support Teams envisaged in the 2017 Children's Mental Health Green Paper may provide such an opportunity. The National Institute for Health Research (NIHR) Health Technology Assessment programme. Individual funding was also provided for Cathy Creswell, David M Clark and Eleanor Leigh as follows: NIHR Research Professorship (Cathy Creswell); Wellcome Senior Investigator Award (Anke Ehlers and David M Clark); and the Wellcome Clinical Research Training Fellowship (Eleanor Leigh).

Appropriate Number of Treatment Sessions in Virtual Reality-Based Individual Cognitive Behavioral Therapy for Social Anxiety Disorder.

Virtual reality (VR) was introduced to maximize the effect of cognitive behavioral therapy (CBT) by efficiently performing exposure therapy. The purpose of this study was to find out whether VR-based individual CBT with relatively few treatment sessions is effective in improving social anxiety disorder (SAD). This therapy was applied to 115 patients with SAD who were retrospectively classified into 43 patients who completed the nine or 10 sessions normally (normal termination group), 52 patients who finished the sessions early (early termination group), and 20 patients who had extended the sessions (session extension group). The Brief Fear of Negative Evaluation Scale (BFNE) scores tended to decrease in all groups as the session progressed, and the slope of decrease was the steepest in the early termination group and the least steep in the session extension group. Severity of social anxiety in the last session and symptom reduction rate showed no significant group difference. Our findings suggest that short-term VR-based individual CBT of nine to 10 sessions may be effective. When the therapeutic effect is insufficient during this period, the additional benefit may be minimal if the session is simply extended. The improvement in the early termination group suggests that even shorter sessions of five or six can also be effective.

Personal value, self-efficacy, and social acceptability of a social behavior as correlates of behavioral action in social anxiety.

Introduction Current therapies for social anxiety disorder emphasize taking behavioral action; active engagement of a behavior despite any present fear or anxiety that is associated with the behavior, through use of exposures. However, less is known about the mechanisms of behavioral action. The present study aimed to examine personal value, self-efficacy, and the perceived social acceptability of a social behavior as correlates of behavioral action in a high social anxiety sample.Method The present study utilized vignettes and self-report measures to examine self-efficacy, personal value, and the social acceptability of a social behavior as correlates of behavioral action in a high social anxiety sample (N = 92).Results The findings indicated that self-efficacy, but not personal value or social acceptability, was significantly associated with social anxiety. Additionally, with all variables included in the multiple regression model, social anxiety was significantly associated with behavioral action, while personal value and self-efficacy were associated with behavioral action over and above social anxiety.Discussion The results highlight the potential for self-efficacy and personal value as target mechanisms for increasing engagement with exposures and behavioral experiments in treatments for social anxiety.

Effectiveness of Group Cognitive Therapy for Social Anxiety Disorder in Routine Care

AbstractSocial anxiety disorder (SAD) is a prevalent chronic condition with a large demand for treatment. This community outpatient study examined the effectiveness of a group intervention version of the established one-to-one cognitive therapy derived from the Clark and Wells model for SAD. Questionnaires were completed pre-treatment and post-treatment for SAD symptoms (Social Phobia Scale, Social Interaction Anxiety Scale), depressive symptoms (BDI-II), self-focused attention, safety behaviours (Social Phobia Weekly Summary Scale and Subtle Avoidance Frequency Examination), and impaired functioning (Work and Social Adjustment Scale). From an initial sample of 159 participants, 101 completed at least seven of the nine weekly group sessions (Mage = 34.1 years, SDage = 10.8 years, 53% female). Significant improvements were demonstrated on all measures. Large effect sizes were found for social anxiety symptoms and safety behaviour use. Self-focused attention, depressive symptoms, and impaired functioning had moderate effect sizes. Effect sizes for anxiety (d = 1.00 and 1.32) and mood measures (d = 0.71) were as high, or in some cases, higher than previous group treatment studies. Results suggest group cognitive therapy for SAD based on the Clark and Wells model is effective in a clinical setting for individuals with moderate/severe and treatment-resistant social anxiety.

The efficacy of internet-based cognitive behavioural therapy for social anxiety disorder: A systematic review and meta-analysis.

Social anxiety disorder (SAD) is one of the most common lifelong anxiety disorders. Although cognitive behavioural therapy (CBT) has proven to be effective in treating people with SAD, it may not be available for a considerable proportion of patients. Internet-based CBT (ICBT) is more accessible than face-to-face treatment. This meta-analysis evaluated the efficacy of ICBT in patients with SAD. We searched five databases, PubMed, Cochrane Central Register of Controlled Trials, Health Management Information Consortium, Ovid MEDLINE and EMBASE, and identified 20 eligible randomized controlled trials published from inception to 25 July 2020, with the outcome data from 1,743 participants. The results indicated that ICBT had a significant positive effect on patients with SAD compared with the control groups (g=-0.55). A subgroup analysis revealed that ICBT and CBT had an equal effect on treating patients with SAD (g=-0.18). There was also no difference between ICBT and ICBT plus other therapies in the treatment of patients with SAD (g=-0.07). The effect size of ICBT on patients with SAD was maintained at the 6-month follow-up (g=-0.08) and at the 12-month follow-up (g=-0.17). The findings of this review demonstrated that ICBT can significantly reduce SAD symptoms and that ICBT and face-to-face CBT produce equivalent effects. The results of this meta-analysis contributed to the literature on ICBT for the treatment of patients with SAD, although numerous aspects of ICBT were identified for future investigations.

The alliance mediates outcome in cognitive–behavioral therapy for social anxiety disorder, but not in attention bias modification

Objective: The aim of the current study was to examine changes in the therapeutic alliance and its role as a mediator of treatment outcome in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). Method: Patients were randomized to 16–20 sessions of CBT (n = 33) or 8 sessions of ABM (n = 17). Patient-rated alliance and self-reported social anxiety were measured weekly and evaluator-rated social anxiety was measured monthly. Results: Early alliance predicted greater subsequent anxiety reduction in CBT but not in ABM. The alliance increased and weekly improvements in alliance predicted weekly contemporaneous and subsequent decreases in anxiety only in CBT. Decreases in anxiety did not predict subsequent improvements in alliance. Both treatments were effective in reducing anxiety, but treatment effects were mediated by stronger early alliance and stronger cross-lagged effects of alliance on outcome in CBT compared to ABM. Conclusions: The results highlight the importance of the alliance in CBT for SAD. Further studies should examine the role of alliance alongside additional mediators to better understand differential mechanisms in CBT and ABM.