Comorbid major depressive disorder in cognitive-behavior group treatment for social anxiety disorder: An examination of processes of symptom change.

Individuals with social anxiety disorder (SAD) typically have elevated depressive symptoms and approximately 50% also meet criteria for major depressive disorder (MDD; Beesdo et al., 2007). In the present study, we examined the relationship between social anxiety and depressive symptoms during cognitive-behavior group treatment (CBGT) for SAD. Specifically, we compared individuals with SAD and comorbid MDD and individuals with SAD without MDD to examine the role of MDD as a moderator of social anxiety-depression relationship. Participants were 90 individuals seeking treatment for SAD (36% were diagnosed with MDD), who completed self-report measures of social anxiety and depression every 2 weeks during CBGT. Lower level mediational modeling indicated that for individuals without MDD, a reciprocal relationship was observed in which changes in both social anxiety and depressive symptoms mediated changes in each other. However, changes in social anxiety explained all subsequent changes in depression, whereas changes in depression explained 11.26% of subsequent changes in social anxiety. For individuals with both SAD and MDD, neither social anxiety nor depression significantly mediated changes in each other. Our findings suggest that different processes of change occur for individuals with and without MDD and clinical implications of these findings are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Attention bias modification augments cognitive-behavioral group therapy for social anxiety disorder: a randomized controlled trial.

BACKGROUND: Cognitive-behavioral group therapy (CBGT) is a first-line treatment for social anxiety disorder (SAD). However, since many patients remain symptomatic post-treatment, there is a need for augmenting procedures. This randomized controlled trial (RCT) examined the potential augmentation effect of attention bias modification (ABM) for CBGT. METHODS: Fifty patients with SAD from three therapy groups were randomized to receive an 18-week standard CBGT with either ABM designed to shift attention away from threat (CBGT + ABM), or a placebo protocol not designed to modify threat-related attention (CBGT + placebo). Therapy groups took place in a large mental health center. Clinician and self-report measures of social anxiety and depression were acquired pre-treatment, post-treatment, and at 3-month follow-up. Attention bias was assessed at pre- and post-treatment. RESULTS: Patients randomized to the CBGT + ABM group, relative to those randomized to the CBGT + placebo group, showed greater reductions in clinician-rated SAD symptoms post-treatment, with effects maintained at 3-month follow-up. Group differences were not evident for self-report or attention-bias measures, with similar reductions in both groups. Finally, reduction in attention bias did not mediate the association between group and reduction in Liebowitz Social Anxiety Scale Structured Interview (LSAS) scores. CONCLUSIONS: This is the first RCT to examine the possible augmenting effect of ABM added to group-based cognitive-behavioral therapy for adult SAD. Training patients' attention away from threat might augment the treatment response to standard CBGT in SAD, a possibility that could be further evaluated in large-scale RCTs.

Explicit and implicit self-evaluations in social anxiety disorder.

Cognitive models of social anxiety disorder (SAD) emphasize the role of explicit and implicit self-evaluations (SEs) in the etiology and maintenance of this condition. Whereas individuals with SAD consistently report lower explicit SEs as compared with nonanxious individuals, findings concerning implicit SEs are mixed. To gain a more nuanced understanding of the nature of SEs in SAD, we examined explicit and implicit SEs in two significant interpersonal domains: social rank and affiliation. Consistent with cognitive theorizing, we predicted that, compared to nonclinical controls (NCCs), individuals with SAD would exhibit lower explicit and implicit SEs in both domains. Guided by evolutionary theories we also predicted that the differences in SEs between the groups would be greater in the social rank, as compared to the affiliation, domain. Individuals diagnosed with SAD (n = 38) and NCCs) n = 40) performed two variants of the Self Implicit Association Test: one concerning social rank, and the other concerning affiliation. They also rated themselves on social-rank and affiliation traits. We found that, as compared to NCCs, individuals with SAD exhibited lower social-rank and affiliation SEs. Moreover, differences between the groups in social-rank SEs were greater than in affiliation SEs. Importantly, this pattern was evident in implicit SEs, as much as in explicit SEs. Our findings dovetail with evolutionary accounts highlighting the centrality of the social-rank system in SAD, and refine central tenets of cognitive theories of SAD. A multidomain, multimethod approach to the understanding of the self may broaden our conceptualization of SAD and related disorders. (PsycINFO Database Record

Cultural Impact on SAD: Social Anxiety Disorder among Ethiopian and Former Soviet Union Immigrants to Israel, in Comparison to Native-born Israelis.

BACKGROUND: Social Anxiety Disorder (SAD) is linked to social norms and role expectations which are culture dependent, such as the construal of one's self as independent or interdependent in relation to others. The current study is the first to examine SAD symptoms among Ethiopian and former Soviet Union immigrants to Israel compared to a sample of native Israelis. We investigated the relationship between SAD, ethnicity and independent/ interdependent self-construals. METHODS: A total of 261 students (151 native-born Israelis, 60 Ethiopian immigrants and 50 students from the former USSR) were administrated the Liebowitz Scale (LSAS), the Self-construal Scale (SCS), Beck Depression Inventory (BDI) and a socio-demographic questionnaire. RESULTS: Ethiopians exhibited highest SAD scores while no differences were found between the FSU immigrants and native-born Israelis. Additionally, Ethiopians and native-born Israeli students exhibited similar high interdependence scores. Finally, SAD scores were predicted by gender, origin, independent and interdependent self-construals. CONCLUSION: Immigration per se is not a universal risk factor of SAD and ethnological-cultural factors do contribute specifically to SAD. A possible psychological mediator between culture and the susceptibility to SAD are the interdependence and independent self-construals. When treating immigrants, clinicians and health care providers are advised to consider the effect of cultural influence on the mental well-being and integration process of immigrants in to their host country.

The link between social anxiety disorder, treatment outcome, and sleep difficulties among patients receiving cognitive behavioral group therapy.

OBJECTIVE: The aim of our study was to examine the association between sleep disturbances and social anxiety disorder (SAD). Another aim was to explore the impact of cognitive behavioral group therapy (CBGT) for SAD on co-occurring sleep difficulties. METHODS: Data were obtained retrospectively from patient files receiving CBGT for SAD. The sample included 63 patients with SAD (mean age, 30.42 years [standard deviation, 6.92 years]). There were 41 men and 22 women, of whom 41 participants completed the treatment protocol. Before treatment onset participants completed the Liebowitz Social Anxiety Scale (LSAS), the Beck Depression Inventory (BDI), the Pittsburgh Sleep Quality Index, and several sociodemographic questions. On completion of the treatment protocol, the same measures were completed, with the addition of the Sheehan Disabilities Scale (SDS). RESULTS: The results of our study suggest that: (1) subjective insomnia is associated with SAD severity even after controlling for depression severity and additional variables; (2) participants with SAD with co-occurring clinical levels of subjective insomnia present a more severe clinical picture both at treatment onset and termination; and (3) although CBGT lead to reduction in SAD and depression symptoms severity, it had no significant impact on co-occurring sleep difficulties. CONCLUSIONS: Sleep difficulties predict SAD severity regardless of depressive symptoms and may be linked to a more severe clinical picture. Clinicians should be aware of these sleep difficulties co-occurring with SAD and consider implementing specific sleep interventions. Future studies should incorporate larger samples sizes from clinical populations outside of Israel.

Body image in social anxiety disorder, obsessive-compulsive disorder, and panic disorder.

Body dysmorphic disorder falls under the category of obsessive-compulsive and related disorders, yet research has suggested it may also be highly associated with social anxiety disorder. The current study examined body image variables among 68 outpatients with primary obsessive-compulsive disorder (OCD; n=22), social anxiety disorder (SAD; n=25), and panic disorder (PD; n=21). Participants filled out self-report measures of body image disturbance, attitudes toward one's appearance, and anxiety. Body image disturbance and attitudes toward appearance did not significantly differ between the groups. However, SAD symptoms predicted body image disturbance, Appearance Evaluation and Body Areas Satisfaction, and OCD symptoms predicted Appearance Orientation. These findings suggest that SAD and OCD may be associated with different facets of body image. Implications for the treatment of anxiety disorders and for future research are discussed.

Impression formation and revision in social anxiety disorder.

Interpersonal relations are markedly impaired in social anxiety. Yet, little is known about the ways social anxiety affects social cognition. We examined impression formation and impression revision among individuals with social anxiety disorder (SAD, n = 26) and non-anxious individuals (n = 29). Participants read initial descriptions of protagonists depicted as dominant, neutral or submissive and rated them on social rank and affiliation dimensions. Next, participants were presented with behavioral acts that were either congruent, incongruent or irrelevant to the initial descriptions, and re-rated the protagonists. Individuals with SAD (a) rated others as more extreme on social rank dimension, (b) rated others as lower on the affiliation dimension, and (c) revised their impressions of others to a greater extent than did the non-anxious individuals. Understanding the ways social anxiety affects the formation and revision of perceptions of others can improve our understanding of maintaining processes in SAD.

Information-seeking bias in social anxiety disorder.

In the present study, we sought to examine information seeking among individuals with social anxiety disorder (SAD, n = 31) and nonanxious controls (n = 32) during an impression-formation task. Participants were given an initial description of a protagonist that included polarized information on the social rank dimension (i.e., dominant or submissive) or on the affiliation dimension (i.e., friendly or unfriendly). Participants were told that their task was to rate the protagonist on social rank and affiliation traits and were given the opportunity to obtain additional information in order to make their decisions. Results indicated that compared to controls, individuals with SAD sought less information before making social rank ratings. In addition, individuals with SAD rated dominant protagonists as higher in social rank than did controls. These findings suggest that even in nonevaluative conditions, individuals with SAD may have an information-seeking bias. In addition, individuals with SAD may have a bias in forming impressions of dominant others. Implications for cognitive and interpersonal models of SAD are discussed.

Functional impairment in social anxiety disorder.

The present study examined functional impairment among treatment seekers with social anxiety disorder (SAD). We investigated the effects of diagnostic subtypes of SAD and comorbidity with mood and anxiety disorders on impairment. In addition, we used cluster analysis procedures to empirically identify subgroups of individuals with distinct patterns of impairment. Participants were 216 treatment-seeking individuals with SAD. Clinical interviews were undertaken to determine diagnoses of anxiety disorders and major depressive disorder, and a battery of self-report measures was administered to index symptoms of social anxiety, depression and extent of impairment. Results indicated that individuals with the generalized subtype of SAD had greater impairment in all three life domains compared to individuals with the nongeneralized subtype. Comorbidity with mood disorders was associated with greater impairment than SAD alone, but comorbidity with anxiety disorders was not. Four distinct impairment profiles emerged from the cluster analysis: primary work/studies impairment, primary social life impairment, both work/studies and social impairment, and impairment in all domains. Findings from this study suggest that SAD is associated with substantial impairment across multiple domains, and that individuals with SAD present diverse impairment profiles. These profiles may inform subtyping of the disorder as well as therapeutic interventions.

Social rank and affiliation in social anxiety disorder.

The present study examined the interpersonal lives of individuals with social anxiety disorder (SAD). According to evolutionary and interpersonal theories, we construed the interpersonal world using the social rank and the affiliation psychological systems. Two studies assessed measures of social rank, affiliation, social anxiety and depression among a population of treatment-seeking individuals with SAD. In study 1, individuals with SAD without major depressive disorder (MDD; n=42) were compared to healthy controls (n=47). In study 2, individuals with SAD and MDD (n=45) were compared to individuals with other anxiety disorders and MDD (n=31). Results indicated that SAD was related to perceiving oneself as having low social rank, being inferior, and behaving submissively, as well as to low perceived intimacy and closeness among peer relations, friendships and romantic relations. SAD was distinctly associated with these perceptions above and beyond the symptomatic (study 1) and the syndrome-level (study 2) effects of depression. These findings were further supported by a path analysis of the SAD participants from both studies. Our findings highlight the need to address both social rank and affiliation issues in the assessment and treatment of SAD.

Alteration learning in social anxiety disorder: an fMRI study.

The present study attempts to challenge the orbitofrontal cortex by using a learning paradigm which is specifically subserved by this cortical region. We implemented a version of alternation learning specifically designed for fMRI and assessed the cognitive performance and fMRI response in wide range of social anxiety disorder (SAD) severity (n=15). The main regions that were activated by the alternation learning task included portions of frontal and orbitofrontal cortex as well as the calcarine fissure. Correlations between brain activation and performance of the alternation learning task were found, among other regions, in the left and right orbitofrontal cortex. Highest correlations between degree of activation and the anxiety scores as assessed by the Leibovitch Social Anxiety Scale (LSAS) were obtained in the left temporal region as well as orbitofrontal cortex. This study supports the involvement of the orbitofrontal cortex in emotion and cognitive regulation in SAD.

Impact of depression on treatment effectiveness and gains maintenance in social phobia: a naturalistic study of cognitive behavior group therapy.

BACKGROUND: The impact of depression on cognitive behavioral group therapy (CBGT) for social phobia (SP) in a naturalistic outpatient setting was examined after treatment termination and at 1-year follow-up. METHODS: Consecutive SP outpatients (N=219) were diagnosed using a structured interview. CBGT was provided in 18 1.5-hr weekly sessions. At pretreatment and posttreatment questionnaires and clinician ratings were administered. Self-report measures were obtained at 1-year follow-up. The main outcome measure was the Liebowitz Social Anxiety Scale. RESULTS: CBGT was found to be effective in reducing both social anxiety (effect size=1.23) as well as depression (effect size=0.94). Individuals with generalized social phobia (GSP) and individuals with specific social phobia (SSP) differed in their presenting psychopathology and in their response to CBGT. Among treatment completers, 44% GSPs and 37% SSPs achieved at least 50% improvement, and 44% GSPs and 87% SSPs reported distress and functioning within the normal range at the end of treatment. Among SPs diagnosed with major depressive disorder (MDD) at the onset of treatment, SP symptoms aggravated during the follow-up period, whereas SPs not diagnosed with MDD experienced a further alleviation of SP symptoms during follow-up. CBGT provided in a public clinic to non-selected, mostly unmedicated and comorbid patients, is an effective treatment for the majority of SP sufferers. CONCLUSIONS: MDD at the onset of CBGT was not associated with poorer treatment response, but predicted exacerbation of SP symptoms following treatment termination. Depressed SPs may need additional intervention to maintain CBGT gains. SSPs may benefit from less intensive CBGT than GSPs.

Social phobia: maintenance models and main components of CBT.

Social phobia (SP, or social anxiety disorder, SAD) is among the most common of all psychiatric disorders. SP typically begins early in life and provokes a great deal of impairment and reduction in quality of life. Despite its high prevalence and associated impact, SP has only recently become the focus of clinical research. We review the current CBT literature on SP, focusing on its main components, such as exposure, safety behaviors, cognitive restructuring, post-event processing, attentional retraining and social skills training. We suggest that although CBT for SP is effective, with effect sizes ranging from .6 to 2.6, much room for improvement remains. We conclude by reviewing some new and promising directions in the development of CBT for SP.

Social phobia symptoms: prevalence, sociodemographic correlates, and overlap with specific phobia symptoms.

BACKGROUND: Social phobia (SP) is a highly prevalent disorder in Western countries, but is rather rare in Eastern societies. Prevalence rates range from 0.5% in Eastern samples up to 16% in Western studies. Its prevalence in Israel, an Asian state characterized by Western culture, has not yet been studied. The present study aimed to assess the prevalence of SP symptoms in a nonclinical sample of Israeli adolescents, to characterize sociodemographic correlates of SP symptoms and to evaluate comorbidity with specific phobia symptoms. METHODS: Participants included 850 young soldiers from the Israel Defense Forces. Measures included the Liebowitz Social Anxiety Scale (LSAS; self-report version), a questionnaire on specific fears and phobias, and a sociodemographic questionnaire. Clinical and demographic correlates of SP were also examined. RESULTS: Probable SP (LSAS >or=80) was present in 4.5% of the sample. Overall, SP symptoms were reported by a great percentage of the subjects, as displayed by the rather high mean LSAS scores (29; SD = 23.79) in this nonclinical sample. The following variables were accompanied by higher LSAS scores according to our regression model: inability to perform command activities, receiving psychotropic medication before army service, having less than two friends, shy family members, and treatment during military service. Subjects with probable SP had a rate of comorbidity with specific phobia symptoms of 44%. CONCLUSIONS: Our findings corroborate those from other studies in Western countries, both regarding the high prevalence of SP symptoms and its demographic and clinical correlates, as well as regarding the high overlap rate with specific phobia symptoms.

Serotonin uptake to lymphocytes of patients with social phobia compared to normal individuals.

Several trials have indicated that selective serotonin reuptake inhibitors (SSRIs) are most efficient in the treatment of social phobia (SP). The activity of the serotonin transporter (5-HTT), as determined by [3H]5-HT uptake to blood lymphocytes, was measured in 15 drug-free patients with generalized SP (7M/8F, aged 21-37 years) and compared to 18 healthy control subjects (10M/8F, aged 21-32 years). The maximum uptake velocity (Vmax) of [3H]5-HT to fresh lymphocytes and the affinity (Km) of the 5-HTT were similar in the two groups (295+/-155 versus 227+/-117 pmol/min/mg protein and 767+/-425 versus 709+/-408 nM, respectively). This study suggests that the functioning of lymphocyte 5-HTT is unaltered in SP.

Red cell membrane omega-3 fatty acids are decreased in nondepressed patients with social anxiety disorder.

The "phospholipid hypothesis" attributes a pathophysiologic role to the polyunsaturated fatty acid (PUFA) composition of phospholipids in depression. The aim of the present study was to determine whether the hypothesis is relevant to social anxiety disorder (SAD). The study sample consisted of 27 untreated, nondepressed patients with SAD (DSM-IV) and 22 controls. Severity of SAD was assessed with the Liebowitz Social Anxiety Scale (LSAS). Erythrocyte PUFA concentrations were measured by gas-liquid chromatography. Concentrations of most n-3 PUFAs were lower in the patients: 18:3n-3 by 32% (p < 0.002), 20:3n-3 by 34%, 20:5n-3 by 36% (all p < 0.001) and 22:6n-3 by 18% (p = 0.002). No significant differences were observed in other fatty acids. Significant inverse correlations were obtained between levels of n-3 PUFAs and LSAS scores. In conclusion, the phospholipid hypothesis may apply to SAD, thereby opening new therapeutic options. The robust relationship between low erythrocyte n-3 PUFA concentrations and SAD justifies exploration of relevant neuropathophysiological mechanisms.

Involvement of GABAA receptor modulating neuroactive steroids in patients with social phobia.

Dehydroepiandrosterone (DHEA) and its sulfate ester (DHEA-S), neurosteroids synthesized in the brain, are weak gamma-aminobutyric acid (GABA) A receptor allosteric antagonists that may be involved in anxiety disorders. In the present study we measured the circulatory [corrected] levels of DHEA, DHEA-S, pregnenolone and cortisol in [corrected] untreated patients (n=26) diagnosed with social phobia (SP) compared with sex- and age-matched healthy controls (n=21). No significant differences in neurosteroids were observed in [corrected] untreated SP patients and [corrected] compared with healthy controls. The findings may reflect an absence of involvement of the GABA(A) modulators DHEA, DHEA-S and pregnenolone in SP.