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Comorbid social anxiety disorder in clients with depressive disorders: Predicting changes in depressive symptoms, therapeutic relationships, and focus of attention in group treatment
Abstract
The current study examined whether depressed outpatients with comorbid SAD respond differently to a cognitive-behavioral group intervention and if so, how and why. Using growth curve modeling, we found evidence that depressed clients with comorbid SAD had rapid improvement in depressive symptoms over the course of treatment and generally did not differ from those without comorbidity in developing close therapeutic relationships and modifying the direction of attentional focus away from the self. Non-linear effects demonstrated that rates of change in depressive symptoms, relationship variables, and focus of attention, were most rapid early in treatment. In contrast to hypotheses, trajectories of change in therapeutic relationships and attentional focus did not mediate the effect of SAD on treatment improvement in depressive symptoms. These findings suggest that comorbid SAD does not have a detrimental effect on the course of depression treatment and group-based treatments can be as beneficial for depressed individuals with comorbid SAD. It may be that group-based treatments for depression provide explicit opportunity for emotional processing in social situations (i.e., exposure) and hence mimic efficacious therapies for SAD.
... Several studies showed similar treatment outcomes for individuals with and without anxiety disorders or with and without anxiety symptoms (Brent et al., 1998;Forand and Derubeis, 2013;Fournier et al., 2009;McEvoy and Nathan, 2007;Persons et al., 2006;Smits et al., 2009). Surprisingly, other CT studies reported a more accelerated depressive symptom improvement when comorbid anxiety disorders or symptoms were present (de Azevedo Cardoso et al., 2014;Forand et al., 2011;Kashdan and Roberts, 2011;Rohde et al., 2001;Smits et al., 2012). With regard to treatment continuation, in the majority of CT studies, anxiety disorders (Forand et al., 2011;Kashdan and Roberts, 2011;Rohde et al., 2001;Schindler et al., 2013;Smits et al., 2009) and anxiety symptoms (Forand et al., 2011;Fournier et al., 2009;McEvoy and Nathan, 2007;Smits et al., 2012) did not affect treatment dropout, although one study reported higher dropout rates for individuals with a comorbid anxiety disorder (Arnow et al., 2007). ...
... Surprisingly, other CT studies reported a more accelerated depressive symptom improvement when comorbid anxiety disorders or symptoms were present (de Azevedo Cardoso et al., 2014;Forand et al., 2011;Kashdan and Roberts, 2011;Rohde et al., 2001;Smits et al., 2012). With regard to treatment continuation, in the majority of CT studies, anxiety disorders (Forand et al., 2011;Kashdan and Roberts, 2011;Rohde et al., 2001;Schindler et al., 2013;Smits et al., 2009) and anxiety symptoms (Forand et al., 2011;Fournier et al., 2009;McEvoy and Nathan, 2007;Smits et al., 2012) did not affect treatment dropout, although one study reported higher dropout rates for individuals with a comorbid anxiety disorder (Arnow et al., 2007). For IPT, fewer findings on the impact of comorbid anxiety on MDD treatment outcome and completion are available. ...
... Trial follow-up phase 8,9,10,11 of adverse effects of anxiety for CT (Brent et al., 1998;de Azevedo Cardoso et al., 2014;Forand and Derubeis, 2013;Forand et al., 2011;Fournier et al., 2009;Kashdan and Roberts, 2011;McEvoy and Nathan, 2007;Persons et al., 2006;Rohde et al., 2001;Smits et al., 2009). In addition, there is evidence that CT outperformed IPT in the treatment of panic disorder (Vos et al., 2012) and social anxiety disorder (Stangier et al., 2011). ...
... The predictive relationship between pretreatment anxiety and the course of symptom change in depression treatment has received increasing attention (Forand, Gunthert, Cohen, Butler, & Beck, 2011;Kashdan & Roberts, 2011;Smits, Minhajuddin, & Jarrett, 2009;Smits, Minhajuddin, Thase, & Jarrett, 2012). Anxiety commonly co-occurs with depression and is associated with greater symptom severity, impairment, and dysfunction (Brown, Schulberg, Madonia, Shear, & Houck, 1996;Fava et al., 2004). ...
... Because the pathology of depression with concurrent anxiety is believed to be more complex, some authors have suggested it requires specialized interventions (e.g., Kush, 2004;Papakostas et al., 2010). However, although many studies report negative or equivocal effects of anxiety on change in medication or psychotherapy (Fava et al., 2004;Gibbons & DeRubeis, 2008;Howland et al., 2009;Smits et al., 2009), a few studies of cognitive behavioral therapy (CBT) for depression revealed, surprisingly, that anxiety predicts increased rapidity of early change as well as greater overall change (Forand et al., 2011;Kashdan & Roberts, 2011;Rohde, Clarke, Lewinsohn, Seeley, & Kaufman, 2001;Smits et al., 2012). In the current study, we investigate further the association between anxiety and change in depression in a sample of outpatients who were given CBT for depression, and we extend this investigation to a sample of patients who were given antidepressant medications (ADMs). ...
... Three other studies assessed the relationship between anxiety and depression change over time using hierarchical linear models. In a study of group CBT for depression, comorbid social anxiety disorder predicted greater change in depressive symptoms over the course of treatment (Kashdan & Roberts, 2011). In particular, the authors noted that the social anxiety group experienced more rapid gains in early treatment sessions. ...
Objective:
Some studies report that initial anxiety is associated with equivocal or negative effects in depression treatment. In contrast, at least 4 studies of cognitive behavioral therapy (CBT) report that anxiety predicts greater or more rapid change in depression. Further exploration is needed to clarify the relationship between initial anxiety and depression change. Questions include the relationship between anxiety and patterns of change and time to relapse, as well as the specificity effects to CBT.
Method:
The study assessed the relation of Beck Anxiety Inventory anxiety scores to early rapid change and overall change in Beck Depression Inventory-II depression scores during acute depression treatment. Participants were 178 individuals enrolled in a randomized controlled trial of CBT versus antidepressant medications (ADMs) for moderate to severe depression. They were 58% female and 83% Caucasian, with an average age of 40 (SD = 11.5). Thirty-four percent (34%) were married or cohabitating. Hierarchical linear models, including quadratic growth parameters, were used to model change. The relation of anxiety to the probability of posttreatment relapse was also examined.
Results:
Findings indicate that higher levels of anxiety predict early rapid change, but not overall change, in both CBT and ADM. However, patients with higher levels of intake anxiety evidenced increased risk for relapse after CBT.
Conclusions:
Early rapid change predicted by anxiety occurs across different treatment conditions, but this early rapid response is not indicative of positive overall outcome in all cases. These findings might indicate that anxiety predicts a response to nonspecific "common factors" of treatment.
... There are, however, studies that have examined trajectories of depressive symptoms across treatment. Gunthert,Cohen (18) and Kashdan and Roberts (19) found that symptom relief throughout the course of cognitive therapy and group CBTwas best described as curvilinear, with an initial drop before levelling off. Furthermore, we are not familiar with any studies that have explored cross-lagged relations between insomnia and anxiety/depression from session to session during treatment (whether insomnia at one session predict anxiety/depression at the subsequent session and vice versa). ...
... Our main findings from the latent growth curve models were, as expected, a decrease in insomnia (linear) and MAD (cubic) over the course of treatment. The latter is in line with studies that have reported a curvilinear trend for depressive symptoms over the course of treatment (18,19). insomnia and mental distress (5)(6)(7)(9)(10)(11). ...
Objective: Previous studies have suggested that there is a reciprocal relationship betweenanxiety/depression and insomnia. However, little is known about the prospective relationships between these constructs across the course of cognitive behavioural therapy (CBT). The present study examined these relationships in clients who received short-term cognitive behavioral therapy in a primary care setting.
Methods: 653 clients (mean age = 37.8 [12.9], 26.4% men)with mild to moderate levels of anxiety and depression and a treatment duration of at least 7 weeks were included for analyses. The clients completed questionnaires measuring mixed anxiety-depression (MAD - Patient Health Questionnaire Anxiety and Depression Scale) and insomnia (3 items derived from the Karolinska Sleep Questionnaire representing core DSM-V criteria) on a session-to-session basis. The data were analysed using latent growth curve models and random intercept cross-lagged panel models.
Results: The results of the latent growth curve models showed that there was a significant decrease in both mixed anxiety-depression (cubic slope; B=.002, p<.001, quadratic slope; B=.036, p<.001, linear slope; B= -.205, p<.001) and insomnia (linear slope; B= -.080, p<.001) across treatment. A strong correlation (r=.838, p<.001) between the linear slopes indicated co-occurring change processes. The cross-lagged panel model showed that insomnia significantly predicted mixed anxiety-depression at the subsequent measurements (B=.190; p<.001), but not vice versa (B=.252; p=.343).
Conclusions: Changes in mixed anxiety-depression and insomnia are co-occurring processes during the course of CBT. Changes in insomnia predicted prospectively changes in mixed anxiety-depression, but not vice versa. Targeting insomniain the context of brief CBT in clients with mild to moderate anxiety and depression may thereforenot only further reduce symptoms of insomnia, but also symptoms of anxiety and depression.
... High levels of perceived stress in social interactions and their subsequent avoidance have a severe impact on the individual's well-being, affecting the normal functioning in everyday life across multiple domains (Aderka et al., 2012). Furthermore, SAD is commonly associated with high self-criticism (Cox et al., 2004), other anxiety disorders (Coelho et al., 2007), obsessive−compulsive disorder (Assunção et al., 2012), depression (Kashdan & Roberts, 2011), eating disorders (Levinson & Rodebaugh, 2012), and alcohol-related disorders (Schneier et al., 2010). Regarding the prevalence of SAD, a cross-national epidemiology survey has shown that in high-income countries (such as the United States, Germany, or Italy), the estimated prevalence of SAD was 5.5% for lifetime, 3.1% for 12 months, and 1.7% for 30 days (Stein et al., 2017), and it has been reported that 12.1% of US adults experience SAD at some time in their lives (Harvard Medical School, 2007). ...
Objective:
The Liebowitz Social Anxiety Scale-Self Report (LSAS-SR) is a self-report measure of social anxiety (SA), which has shown adequate psychometric properties across cultures. However, no study has systematically evaluated its measurement invariance (MI) between (a) individuals with and without a diagnosis of social anxiety disorder (SAD) and (b) males and females. The current study addresses this issue.
Methods:
We collected data on 257 (158 females) Italian individuals diagnosed with SAD and 356 (232 females) community-dwelling adults.
Results:
We initially found support for the unidimensionality of the Italian LSAS-SR measurement model in all samples. Using the Graded Response Model, we obtained evidence of partial MI and differential item functioning between community-dwelling and SAD-diagnosed individuals and evidence of strong MI between male and female participants.
Conclusions:
The results of this study suggest that the Italian LSAS-SR measures the same trait in the same way across the symptom continuum and sexes, making it a psychometrically sound tool for assessment, screening, and research purposes.
... In studies focused on diagnostic comorbidity within depression, some reported that comorbid anxiety disorders predicted greater attrition (van Bronswijk et al., 2018) and less favorable symptom trajectories and response (Brent et al., 1998;Vittengl et al., 2019), whereas other studies have evidenced minimal impact of comorbid anxiety diagnoses on depressive symptoms post-treatment (e.g., Smits et al., 2009). Notably, favorable changes in depressive symptoms over the course of group (Kashdan and Roberts, 2011;Rohde et al., 2001) and individual cognitive-behavioral therapy (CBT; Vittengl et al., 2019) have also been reported for those with comorbid social anxiety disorder, although the latter study reported greater residual social avoidance post-treatment (Vittengl et al., 2019). Similarly, using dimensional measures of anxiety, results remain mixed regarding the impact of anxiety symptom severity on depression treatment trajectory and outcome. ...
We examined how anxiety sensitivity - the fear of symptoms of anxiety due to their perceived harmful effects - and gender are associated with treatment trajectory and outcomes in a large outpatient sample (N = 278) who received 14-weeks of cognitive-behavioral group therapy (CBGT) for depression. Three dimensions of anxiety sensitivity (cognitive, physical, and social concerns) and depression were assessed at pre-treatment, and the latter was assessed weekly during treatment. Latent growth curve models supported a link between cognitive concerns (fears of losing control over thoughts) and greater improvement in depression near the end of treatment (i.e., weeks 10-14); gender did not moderate trajectory. Gender (i.e., identifying as a woman) and greater physical concerns (fears of physical consequences of arousal symptoms) were associated with completion of < 8 sessions. Results suggest that those with more cognitive concerns might require greater time in treatment and/or benefit most from the focus on maladaptive assumptions and core beliefs in later CBGT sessions. Future research, including investigation of intervening variables, may elucidate the mechanisms through which greater physical concerns and gender are associated with treatment non-completion. Results supported differential associations of anxiety sensitivity dimensions with depression treatment outcomes, though further research attention is needed.
... One study demonstrated that a high anxiety level increased the risk of relapse after CBT for depression (Forand and Derubeis, 2013) and that focusing on anxiety during sessions reduced the effect on depressive symptoms (Gibbons and DeRubeis, 2008). However, there are also studies indicating that a comorbid anxiety disorder does not affect the outcome of CBT for depression (Smits et al., 2009), and in a study by Kashdan and Roberts (2011), comorbid social anxiety actually increased the effect of CBT for depression. ...
Internet-based cognitive behavior therapy (ICBT) has proved effective in reducing mild to moderate depressive symptoms. However, only a few studies have been conducted in a regular healthcare setting which limits the generalizability of the results. The influence of psychiatric comorbidity on outcome is not well understood. In the current study, patients with mild to moderate depressive symptoms in primary and psychiatric care were interviewed using the SCID-I and SCID-II to assess psychiatric diagnoses. Those included were randomly allocated to ICBT (n = 48) or to an active control condition (n = 47). Both groups received therapist support. At post-treatment, ICBT had reduced depressive symptoms on the BDI-II more than the active control intervention (p = .021). However, the difference between groups was no longer significant at the 6-, 12- or 24-month follow-ups. The within-group effect size after ICBT (BDI-II) was large (d = 1.4). A comorbid anxiety disorder didn't moderate the outcome, while the presence of a personality disorder predicted significantly less improvement in depressive symptoms. ICBT had a large effect on depressive symptoms in a sample from regular healthcare. It is possible to obtain a large effect from ICBT despite comorbid anxiety, however, including patients with a comorbid personality disorder in the current form of ICBT seems questionable.
... Recent work, has supported this hypothesis, given that depressed individuals who completed Interpersonal Therapy reported greater attachment security following completion of treatment (Ravitz et al., 2008). Similarly, individuals with MDD and SAD who completed Cognitive Behavioural Group Therapy for depression also had a reduction in attachment insecurity at the end of treatment (Kashdan and Roberts, 2011). Still, a clear understanding of the mechanism relating attachment to MDD and SAD and their amenability to treatment by either reducing attachment insecurity with the help of treatments for depression or vice versa, has yet to be determined through future longitudinal work. ...
Major depressive disorder (MDD) frequently co-occurs with social anxiety disorder (SAD), and their comorbidity (MDDSAD) increases clinical severity and functional impairment. Still, the specific psychological vulnerabilities of individuals with MDD-SAD are poorly understood. Individual attachment characteristics develop early in life through interactions with primary caregivers, and tend to persist throughout life. Early trauma can worsen attachment insecurity, increasing the risk for future anxiety and depression. The purpose of this study is to examine differences in individual attachment and history of trauma in depressed individuals with or without comorbid SAD and controls. One hundred sixty-two participants were categorized into three groups based on SCID-I interview: healthy controls (HC), individuals with current MDD without SAD (MDD), and individuals with current MDD comorbid with SAD (MDD-SAD). MDD-SAD group had significantly greater attachment anxiety and attachment avoidance compared to the MDD and HC groups. MDDSAD group had greater clinician-rated depression severity and dysfunction compared to MDD group. In summary, the study further supports the clinical risks associated with MDD-SAD and suggests that insecure attachment might represent an associated vulnerability and a possible pathway which warrants further research and clinical attention.
... Emerging evidence has shown that attachment insecurity is amenable to a variety of focused therapies such as Interpersonal Psychotherapy (Ravitz, Maunder, & McBride, 2008), Cognitive Behavioural Therapy (Kashdan & Roberts, 2011), and Transference-Focused Therapy (Levy et al., 2006), to name a few. Further interventional studies can explore how this amelioration in attachment dimensions due to treatment can impact the future risk for SIB. ...
Background: Self-injurious behaviours (SIB) continue to afflict a significant segment of the clinical and general population, sometimes with fatal consequences. The development of SIB seems to share developmental pathways and mechanisms similar to attachment insecurity. To date, no reviews have explored their relationship.
Methods: A search of publication databases PubMed and PsychInfo from 1969 through April 2018 was conducted. 17 papers met inclusion criteria.
Results: Of the 17 articles identified, 13 reported a positive relationship and 1 reported a negative relationship between attachment insecurity and SIB.
Conclusion: Both attachment anxiety and avoidance seem to play a role in the risk for SIB, possibly through different mechanisms and likely with different impacts on the choice for either self-harm or suicide attempts.
... ﺳﺎزه از دﯾﮕﺮ ﯾﮑﯽ ذﻫﻨﯽ ﻧﺸﺨﻮار اﺧﺘﻼل ﻣﯿﺎن ﻣﺸﺘﺮک ﻫﺎی ﻫﺎی اﺳﺖ اﻓﺴﺮدﮔﯽ و اﺟﺘﻤﺎﻋﯽ اﺿﻄﺮاب [16] . [14] و ﻣﺸﮑﻼت ، ﭘﺮﯾﺸﺎﻧﯽ اﺟﺘﻤﺎﻋﯽ و ﺷﻐﻠﯽ ﺗﺤﺼﯿﻠﯽ، ﻋﻤﻠﮑﺮد در اﺧﺘﻼل و ﺑﯿﺸﺘﺮ دارﻧﺪ ﺑﯿﺸﺘﺮی [32] . [42] . ...
... Torna-se relevante identifi car a presença de sintomas comórbidos, visto que a presença de dois ou mais transtornos psiquiátricos é mais comum do que apenas um transtorno, associados a um maior prejuízo na qualidade de vida do sujeito (Lacerda, Quarantini, Miranda-Scippa & Del Porto, 2009). A comorbidade entre depressão e a presença de sintomas de ansiedade vai de 33% a 51% em jovens adultos (Quevedo & Silva, 2013) e não raramente, indivíduos que preenchem critérios diagnósticos apenas para depressão, apresentam sintomas de ansiedade (Roberts & Kadashan, 2011). ...
Symptoms of mental disorders bring numerous prejudice to individuals. Among these disturbances, Depression Disorder and Social Phobia (FS) are highlighted. Both directly affect the social life of human beings and, considering the constant need to interact with others, it becomes important to investigate the symptomatology of comorbid disorders. The present study is configured as quantitative, observational. The sample consisted of 40 subjects, undergraduate students of an institution of higher education in the Rio Grande do Sul. The instruments used were Social Anxiety Questionnaire for Adults (SAQ-30) and Beck Depression Inventory (BDI). Of the total sample, 67.5% (n = 27) were female and 32.5% (n = 13) male, with a mean age of 25.9 years (SD = 9,34). The results indicated that 62% (n=25) showed Social Phobia symptoms. From this amount 28% (n=7) had mild depression symptoms and 20% (n=5) showed moderate intensity depression symptoms scores. The data suggest that individuals with symptoms of Social Phobia have comorbid depressive symptoms.
... Eng et al., 2001; Lionberg, 2003; Weisman et al., 2011; Michail and Birchwood, 2014). However, Kashdan and Roberts (2011) observed no difference in attachment to therapeutic group and therapist between depressed service-users with or without social anxiety. This difference may be due to the specific focus on attachment to therapeutic group, as opposed to romantic partners or parents, as in other studies. ...
Background:
Attachment has been implicated in the development of social anxiety. Our aim was to synthesise the extant literature exploring the role of adult attachment in these disorders.
Method:
Search terms relating to social anxiety and attachment were entered into MEDLINE, PsycINFO and Web of Science. Risk of bias of included studies was assessed using and adapted version of the Agency for Healthcare Research and Quality assessment tool. Eligible studies employed validated social anxiety and attachment assessments in adult clinical and analogue samples. The review included cross sectional, interventional and longitudinal research.
Results:
Of the 30 identified studies, 28 showed a positive association between attachment insecurity and social anxiety. This association was particularly strong when considering attachment anxiety. Cognitive variables and evolutionary behaviours were identified as potential mediators, concordant with psychological theory.
Limitations:
Due to a lack of longitudinal research, the direction of effect between attachment and social anxiety variables could not be inferred. There was substantial heterogeneity in the way that attachment was conceptualised and assessed across studies.
Conclusions:
The literature indicates that attachment style is associated with social anxiety. Clinicians may wish to consider attachment theory when working clinically with this population. In the future, it may be useful to target the processes that mediate the relationship between attachment and social anxiety.
... More recent evidence suggests that interpersonal anxiety could lead to fewer sexual partners, less frequent sexual encounters, and by extension less frequent CRAI or CIAI Ramrakha et al., 2013). Also, anxiety is commonly comorbid with depression, which is associated with decreased sexual behavior (Kashdan & Roberts, 2011;Laurent & Simons, 2009). Given that the items selected to measure the latent factor "interpersonal anxiety" were drawn from the CES-D, it may be more sensitive to depression-related anxiety. ...
Exposure to childhood religious affiliations where the majority of members discourage homosexuality may have negative psychological impacts for Black men who have sex with men. This study tested the hypothesis that exposures to these environments during childhood were associated with adulthood human immunodeficiency virus (HIV)/sexually transmitted infection (STI) behavioral risk and HIV infection, because these exposures influenced HIV/STI risk by undermining race/sexual identity congruence and increasing internalized homophobia and interpersonal anxiety. Structural equation modeling as well as logistic and Poisson regressions were performed using baseline data from HIV Prevention Trials Network 061 (N = 1,553). Childhood religion affiliations that were more discouraging of homosexuality were associated with increased likelihood of HIV infection; however, the association was no longer significant after adjusting for age, income, and education. Having a childhood religion affiliation with high prevalence of beliefs discouraging homosexuality was associated with increased numbers of sexual partners (adjusted odds ratio = 4.31; 95% confidence interval [3.76, 4.94], p < .01). The hypothesized path model was largely supported and accounted for 37% of the variance in HIV infection; however, interpersonal anxiety was not associated with HIV/STI risk behaviors. Structural interventions are needed that focus on developing affirming theologies in religious institutions with Black men who have sex with men congregants.
... Depression is a highly prevalent mental disorder that is characterized by low mood, anhedonia and decreased activity. Furthermore, depression is associated with abnormally increased, self-defeating thoughts and self-referential concerns, which are known to contribute to dysfunctional interpersonal expectations and thereby make successful participation in social interaction difficult [67]. In particular, individuals with depression lose the sense of having an impact on other people, while, in fact, they do. ...
Psychiatric disorders can affect our ability to successfully and enjoyably
interact with others. Conversely, having difficulties in social relations is
known to increase the risk of developing a psychiatric disorder. In this article,
the assumption that psychiatric disorders can be construed as disorders of
social interaction is reviewed from a clinical point of view. Furthermore,
it is argued that a psychiatrically motivated focus on the dynamics of social
interaction may help to provide new perspectives for the field of social neuroscience.
Such progress may be crucial to realize social neuroscience’s
translational potential and to advance the transdiagnostic investigation of
the neurobiology of psychiatric disorders.
... Torna-se relevante identifi car a presença de sintomas comórbidos, visto que a presença de dois ou mais transtornos psiquiátricos é mais comum do que apenas um transtorno, associados a um maior prejuízo na qualidade de vida do sujeito (Lacerda, Quarantini, Miranda-Scippa & Del Porto, 2009). A comorbidade entre depressão e a presença de sintomas de ansiedade vai de 33% a 51% em jovens adultos (Quevedo & Silva, 2013) e não raramente, indivíduos que preenchem critérios diagnósticos apenas para depressão, apresentam sintomas de ansiedade (Roberts & Kadashan, 2011). A depressão tem como um de seus sintomas o isolamento social (Buarque, Santos & Silva, 2012) e as habilidades sociais necessárias para um relacionamento social satisfatório são desenvolvidas de acordo com nossas interações sociais (Pajares & Olaz, 2008; Olaz, 2009). ...
Symptoms of mental disorders bring numerous prejudice to individuals. Among these disturbances, Depression Disorder and Social Phobia (FS) are highlighted. Both directly affect the social life of human beings and, considering the constant need to interact with others, it becomes important to investigate the symptomatology of comorbid disorders. The present study is configured as quantitative, observational. The sample consisted of 40 subjects, undergraduate students of an institution of higher education in the Rio Grande do Sul. The instruments used were Social Anxiety Questionnaire for Adults (SAQ-30) and Beck Depression Inventory (BDI). Of the total sample, 67.5% (n = 27) were female and 32.5% (n = 13) male, with a mean age of 25.9 years (SD = 9,34). The results indicated that 62% (n=25) showed Social Phobia symptoms. From this amount 28% (n=7) had mild depression symptoms and 20% (n=5) showed moderate intensity depression symptoms scores. The data suggest that individuals with symptoms of Social Phobia have comorbid depressive symptoms.
... As elaborated below, those high in trait social interaction anxiety reported particularly high anxiety at times of greater evaluative threat, and more shame and anxiety in the hour following SSET. Consistent with laboratory research (Shimizu et al., 2011), these results suggest that socially anxious individuals show particularly pronounced negative emotions in response to perceived social evaluation (Kashdan & Roberts, 2006). Research suggests that individuals with social anxiety tend to ruminate more frequently (Mellings & Alden, 2000; Rachman, Grṻter-Andrew, & Shafran, 2000), potentially perpetuating social anxiety and promoting feelings of shame. ...
Background and objectives:
This study examined concurrent and delayed emotional and cardiovascular correlates of naturally occurring experiences with subjective social evaluative threat (SSET) and tested whether individual differences in social interaction anxiety moderated those associations.
Methods:
Sixty-eight participants wore ambulatory blood pressure monitors for three days. Following each blood pressure reading, participants reported on SSET and negative emotions, yielding 1770 momentary measures.
Results:
Multilevel modeling suggested that reports of greater SSET uniquely predicted elevations in anxiety and embarrassment, with elevations in anxiety, embarrassment, and shame extending to the hour following SSET. Reports of concurrent and previous-hour SSET also predicted cardiovascular elevations. Linkages between SSET and anxiety and shame, but not cardiovascular measures, were moderated by social interaction anxiety. Those higher in social interaction anxiety showed especially strong associations between SSET and both concurrent and delayed anxiety and greater delayed shame.
Conclusions:
This research suggests an important role for anxiety, embarrassment, and shame as emotional consequences of naturally occurring evaluative threat, especially for those who are more socially anxious. Further, this work replicates other naturalistic studies that have documented increased blood pressure at times of SSET and extends that work by documenting cardiovascular responses into the following hour.
... The disorder is characterized by an intense fear of social situations or situations where a performance is required. It is commonly associated with other anxiety disorders, low social-efficacy (Essau et al. 1999), depressive disorders (Kashdan and Roberts 2011), and substance abuse (Merikangas and Angst 1995), including Alcohol Use Disorder (AUD) (Kushner et al. 2000; Van Ameringen et al. 1991). In recent years interest in Social Phobia has grown, and many interviews and questionnaires suitable for self-administration have been developed in order to assess the symptoms and severity of social anxiety. ...
Objective: Social Phobia, one of the most common psychological disorders, can cause serious discomfort and impairment in a person's life. The importance of assessing the specific features of this disorder is well-known. This paper assesses the psychometric properties of the Italian version of the Social Phobia Inventory (I-SPIN). Method: Data from 410 subjects were analyzed in order to assess the factor structure and the discriminant validity of the I-SPIN. The sample was sub-divided into two groups: 1) a group of normal population; 2) a clinical group. Results: Results of Exploratory and Confirmatory Factor Analysis showed a three-factor structure of the I-SPIN. The discriminating ability of the I-SPIN was good. Conclusions: The Italian version of the I-SPIN emerges as a useful instrument for research and clinical practice.
Background:
Menopause syndrome generally includes psychological problems. Group treatment delivered via the Internet and mobile phone (imGT) may improve women's physiological and psychological conditions.
Objective:
To investigate the efficacy of group cognitive behavioural therapy of menopause-related mood swings and quality of life, delivered face to face or via the Internet and mobile phone.
Methods:
This protocol is for a randomized controlled clinical trial with a sample of 140 menopausal women divided into 2 groups: imGT and face-to-face group treatment (ffGT). The primary outcome will be the improvement in the menopausal symptoms of the two groups, as assessed by the Greene Climacteric Scale. The secondary outcomes will be: quality of life, assessed by the Short Form 36 Health Survey Questionnaire; insomnia, assessed by the Pittsburgh Sleep Quality Inventory; anxiety, assessed by the Hamilton Anxiety Rating Scale; and therapeutic alliance, assessed by the Working Alliance Inventory-Short Revised and Client Sat-is-fac-tion Qes-tion-naire-8. imGT will be performed once a week for 1.5 h for 10 weeks with a daily 'Punched-in' on the WeChat app; ffGT will be performed once a week for 1.5 h for 10 weeks. All outcomes will be assessed at baseline, at a post-intervention evaluation (week 10), and at a follow-up evaluation (week 22).
Discussion:
This study will be the first clinical trial to examine the effects of imGT on menopausal women in China. If imGT is found to be non-inferior to ffGT, it will facilitate access to menopausal health services.
The aim of this article was to investigate how anxiety and depression impact upon each other over the course of a counselling intervention. A single-group repeated measures quasi-experimental design was employed. Data were collected at four time points: at pre-therapy assessment and at first, third, and last sessions. The sample consisted of 562 predominantly white British clients receiving Integrative Counselling at North Kent Mind, UK. Two measures were used: the Generalised Anxiety Disorder (GAD) Scale to measure anxiety and the Patient Health Questionnaire (PHQ) to measure depression. Clients improved in both dimensions at every measurement point. Path analysis suggested that anxiety and depression remained interlinked throughout treatment but they presented different effect profiles. They both appeared to have a premature effect on the other, but they did so in different ways. The therapeutic relationship may be a crucial factor in understanding the premature effect observed and future research should utilise direct measures of the relationship.
Full text:
https://www.tandfonline.com/eprint/6MUWY6CU8A9864XENDBF/full?target=10.1111/cp.12113
Background and objectives:
This study examined the extent to which social anxiety treatment studies report the demographic characteristics of their participants. One hundred and fifty six treatment studies published in English between 2001-2012 articles were collected.
Methods:
Each study was evaluated on whether or not it reported information on gender, age, race, relationship status, education, socioeconomic status, sexual orientation, and disability and also the extent to which the racial composition of the sample was described.
Results:
The majority of studies reported information on age (96.2%) and gender (94.2%), but the percentage of studies that reported anything else is much lower: race (50.0%), education (42.3%), relationship status (37.8%), socioeconomic status (5.1%), disability (2.6%), and sexual orientation (1.3%). One third (34.0%) of studies reported the race of all participants in their samples, while the remaining reported no information or information for only a subset of participants (e.g., "mostly white").
Conclusions:
Participants of social anxiety disorder treatment studies generally are not described beyond their age and gender. Standards for reporting participant characteristics of treatment studies (similar to standards for reporting the methodology of treatment studies) could improve clinical researchers' and clinicians' ability to evaluate the external validity of this body of work.
The most commonly used method to test an indirect effect is to divide the estimate of the indirect effect by its standard error and compare the resulting z statistic with a critical value from the standard normal distribution. Confidence limits for the indirect effect are also typically based on critical values from the standard normal distribution. This article uses a simulation study to demonstrate that confidence limits are imbalanced because the distribution of the indirect effect is normal only in special cases. Two alternatives for improving the performance of confidence limits for the indirect effect are evaluated: (a) a method based on the distribution of the product of two normal random variables, and (b) resampling methods. In Study 1, confidence limits based on the distribution of the product are more accurate than methods based on an assumed normal distribution but confidence limits are still imbalanced. Study 2 demonstrates that more accurate confidence limits are obtained using resampling methods, with the bias-corrected bootstrap the best method overall.
Alexithymia involves problems differentiating affective states such as fear, sadness, or anger; difficulty expressing feelings; and a tendency to rely on external cues rather than internal experience for making decisions. This study examined alexithymia as a possible mediator by which dysfunctional family environment in childhood affects adult clients' attachment relationship to their therapist. Clients (
N = 61) completed measures of dysfunctional family structure (Family Structure Survey), alexithymia (Toronto Alexithymia Scale), and their counseling relationship (Client Attachment to Therapist Scale). Findings suggest that fear of separation was associated with both alexithymia and poor client attachment to therapist. Parent–child role reversal was associated with problems in identifying feelings. Role reversal and marital conflict were both associated with problems in client attachment to therapist. Results suggest that alexithymia may be a significant mediator of the relationship between family dysfunction and client attachment to therapist. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The psychometric adequacy of the Social Interaction Anxiety Scale (SIAS; R. P. Mattick & J. C. Clark, 1989), a measure of social interaction anxiety, and the Social Phobia Scale (SPS; R. P. Mattick & J. C. Clark, 1989), a measure of anxiety while being observed by others, was evaluated in anxious patients and normal controls. Social phobia patients scored higher on both scales and were more likely to be identified as having social phobia than other anxious patients (except for agoraphobic patients on the SPS) or controls. Clinician-rated severity of social phobia was moderately related to SIAS and SPS scores. Additional diagnoses of mood or panic disorder did not affect SIAS or SPS scores among social phobia patients, but an additional diagnosis of generalized anxiety disorder was associated with SIAS scores. Number of reported feared social interaction situations was more highly correlated with scores on the SIAS, whereas number of reported feared performance situations was more highly correlated with scores on the SPS. These scales appear to be useful in screening, designing individualized treatments, and evaluating the outcomes of treatments for social phobia. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Current social competencies and memories of attachment bonds with each parent were examined as they related to influences on formation of the working alliance. Female clients (
N = 76) at 4 university and community agencies completed surveys containing the Parental Bonding Instrument, the Self-Efficacy Scale, the Adult Attachment Scale, and the Working Alliance Inventory. Results indicated that parental bonds, especially with fathers, were significantly associated with social competencies. Multiple regression analyses indicated that social competencies (self-efficacy and adult attachment) accounted for 14% of the variance in client working alliance ratings, whereas recalled parental bonds accounted for 23% of the variance. Working alliance was negatively associated with father bonds, positively associated with mother bonds, and (among social competencies) significantly associated with capacity for adult attachment. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We conducted two studies that assessed the role of initial anxiety in rate of change (depression reduction) in cognitive therapy
for major depression. In both studies, depression and anxiety were assessed at intake, and depression was assessed at every
treatment session. Longitudinal growth modeling was used to predict rate of change in treatment from sessions 1–12 controlling
for intake depression, with intake anxiety as a moderator of change. In Study 1, high initial anxiety was associated with
a faster rate of depression reduction across the course of cognitive therapy, whereas in Study 2, high initial anxiety was
associated with a faster rate of depression reduction in the early sessions of treatment. The influence of intake depression
on rate of change was controlled, and therefore the results are likely not due to greater symptom severity or distress among
those high in anxiety. BAI subscale analyses suggest that the results are likely due to the physiological arousal characteristic
of anxiety. These results suggest a potentially beneficial role for initial anxiety in cognitive therapy for depression.
KeywordsCognitive therapy–Depression–Anxiety–Comorbidity–Rate of change
The dosage model provides a normative estimate of the overall pattern of patient improvement in psychotherapy. The phase model further specifies patterns of change in the domains of subjective well-being, symptom remediation, and functioning. The expected treatment response (ETR) approach uses patient characteristics to predict an expected path of progress for each patient. With repeated measures of mental health status, the treatment progress of an individual patient can be assessed against the patients ETR to support decisions that would enhance the quality of a clinical service while it is being delivered.
A recent randomized controlled trial found nearly equivalent response rates for antidepressant medications and cognitive therapy in a sample of moderate to severely depressed outpatients. In this article, the authors seek to identify the variables that were associated with response across both treatments as well as variables that predicted superior response in one treatment over the other. The sample consisted of 180 depressed outpatients: 60 of whom were randomly assigned to cognitive therapy; 120 were assigned to antidepressant medications. Treatment was provided for 16 weeks. Chronic depression, older age, and lower intelligence each predicted relatively poor response across both treatments. Three prescriptive variables-marriage, unemployment, and having experienced a greater number of recent life events-were identified, and each predicted superior response to cognitive therapy relative to antidepressant medications. Thus, 6 markers of treatment outcome were identified, each of which might be expected to carry considerable clinical utility. The 3 prognostic variables identify subgroups that might benefit from alternative treatment strategies; the 3 prescriptive variables identify groups who appear to respond particularly well to cognitive therapy.
The authors investigated patient characteristics predictive of treatment response in the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program.
Two hundred thirty-nine outpatients with major depressive disorder according to the Research Diagnostic Criteria entered a 16-week multicenter clinical trial and were randomly assigned to interpersonal psychotherapy, cognitive-behavior therapy, imipramine with clinical management, or placebo with clinical management. Pretreatment sociodemographic features, diagnosis, course of illness, function, personality, and symptoms were studied to identify patient predictors of depression severity (measured with the Hamilton Rating Scale for Depression) and complete response (measured with the Hamilton scale and the Beck Depression Inventory).
One hundred sixty-two patients completed the entire 16-week trial. Six patient characteristics, in addition to depression severity previously reported, predicted outcome across all treatments: social dysfunction, cognitive dysfunction, expectation of improvement, endogenous depression, double depression, and duration of current episode. Significant patient predictors of differential treatment outcome were identified. 1) Low social dysfunction predicted superior response to interpersonal psychotherapy. 2) Low cognitive dysfunction predicted superior response to cognitive-behavior therapy and to imipramine. 3) High work dysfunction predicted superior response to imipramine. 4) High depression severity and impairment of function predicted superior response to imipramine and to interpersonal psychotherapy.
The results demonstrate the relevance of patient characteristics, including social, cognitive, and work function, for prediction of the outcome of major depressive disorder. They provide indirect evidence of treatment specificity by identifying characteristics responsive to different modalities, which may be of value in the selection of patients for alternative treatments.
Working largely independently, numerous investigators have explored the role of self-focused attention in various clinical disorders. This article reviews research examining increased self-focused attention in these disorders. Results indicate that regardless of the particular disorder under investigation, a heightened degree of self-focused attention is found. Hence, as ordinarily conceptualized, self-focused attention has little discriminatory power among different psychological disorders. Using information processing constructs, a somewhat different model of self-focused attention is proposed, and it is suggested that certain deviations in this process constitute a psychopathological kind of attention. A meta-construct model of descriptive psychopathology is then outlined to examine how certain aspects of attention can be considered specific to certain disorders and others common to different disorders.
Ilardi and Craighead (1994) observed that 60-70% of symptom improvement in cognitive behavioral therapy (CBT) occurs in the first 4 weeks, and they assumed that cognitive modification techniques are not extensively applied in these weeks. They thus concluded that Beck's cognitive hypothesis of CBT cannot explain this early improvement. However, studies have shown that cognitive modification techniques are applied extensively in early sessions. Also, in most CBT studies there have been two sessions per week for the first: 4 weeks and 1 session per week thereafter Thus, 40-60% of CBT sessions in studies occur in the first 4 weeks, which arguably is enough therapeutic time for cognitive techniques to have a substantial effect on symptoms. Finally, Ilardi and Craighead's method assumes homogeneity among the patients' time courses, which is inconsistent with empirical data. We conclude that symptom change time course data do not contradict Beck's cognitive hypothesis.
In this study of cognitive-behavioral therapy for depression, many patients experienced large symptom improvements in a single between sessions. These sudden gains' average magnitude was 11 Beck Depression Inventory points, accounting for 50% of these patients' total improvement. Patients who experienced sudden gains were: less depressed than the other patients at posttreatment, and they remained so IB months later. Substantial cognitive changes were observed in the therapy sessions preceding sudden gains, but few cognitive! changes were observed in control sessions, suggesting that cognitive change in the pregain sessions triggered the sudden gains, improved therapeutic alliances were also observed in the therapy sessions immediately after the sudden gains, as were additional cognitive changes, suggesting a three-stage model for these patients' recovery: preparation --> critical session/sudden gain --> upward spiral.
The relationship between four dimensions of client attachment (secure, preoccupied, fearful, and dismissing) and client ratings of four dimensions of the working alliance (goals, tasks, bonds, and global) was examined in a sample of first-time clients (n = 63) seeking services through a university-based counselling clinic. Significant relationships were found between secure and fearful attachment and the bond component of the Working Alliance Inventory (WAI). Secure attachment was also significantly associated with the WAI goals subscale as well as global WAI ratings. Implications of these findings for counselling practice and future research are discussed.
This study investigated 3 broad classes of individual-differences variables (job-search motives, competencies, and constraints) as predictors of job-search intensity among 292 unemployed job seekers. Also assessed was the relationship between job-search intensity and reemployment success in a longitudinal context. Results show significant relationships between the predictors employment commitment, financial hardship, job-search self-efficacy, and motivation control and the outcome job-search intensity. Support was not found for a relationship between perceived job-search constraints and job-search intensity. Motivation control was highlighted as the only lagged predictor of job-search intensity over time for those who were continuously unemployed. Job-search intensity predicted Time 2 reemployment status for the sample as a whole, but not reemployment quality for those who found jobs over the study's duration. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Contemporary attachment theory is inspiring a burgeoning literature on adult attachment. This literature offers counseling psychology a compelling framework for understanding the healthy and effective self. In this article, the authors review studies probing the cognitive processes, affect self-regulatory dynamics, and relationship behaviors associated with secure (primary) and insecure (secondary) adult attachment strategies. They then offer a portrait of the healthy, effective personality that is consistent with theory and research on adult attachment. Finally, in an effort to understand key characteristics of successful movement toward the healthy and effective self, the authors review empirical extensions of attachment theory to the therapeutic context. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Describes the development of the Relationship Closeness Inventory (RCI), which draws on the conceptualization of closeness as high interdependence between two people's activities proposed by Kelley et al. (1983). The current "closest" relationship of individuals (
N = 241) drawn from the college student population served as the basis for RCI development, with the closest relationship found to encompass several relationship types, including romantic, friend, and family relationships. The development and psychometric properties of the three RCI subscales (Frequency, Diversity, Strength), their scoring, and their combination to form an overall index of closeness are described. The RCI's test–retest reliability is reported and the association between RCI score and the longevity of the relationship is discussed. RCI scores for individuals' closest relationships are contrasted to those of not-close relationships, to a subjective closeness index, and to several measures of relationship affect, including Rubin's (1973) Liking and Loving scales. Finally, the ability of the RCI to predict relationship break up is contrasted to that of the Subjective Closeness Index, an index of the emotional tone of the relationship, and to relationship longevity. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Describes a multimodal, psychoeducational group treatment course for unipolar depression offered at the University of Oregon Depression Research Unit. The course teaches people techniques and strategies for coping with the problems that are assumed to be related to their depression, focusing on target behaviors such as social skills, thinking, pleasant activities, and relaxation, and on cognitive-behavioral therapy for depression. The rationale and theoretical framework of the course are reviewed, and a course overview is presented. The course consists of 12 2-hr sessions conducted over 8 wks, and participants are selected from respondents to newspaper, TV, and radio advertisements. Efficacy of the course was evaluated by comparing Ss who received immediate treatment with Ss who were on a waiting list for 8 wks before starting treatment. Findings reveal more clinical improvement for all of the active conditions compared with the delayed treatment condition, and improvement continued to be substantial at 1- and 6-mo follow-up. A syllabus of the course is presented, emphasizing the goals, assignments, and thoughts to consider for each session. (23 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
In 2 studies, the Inclusion of Other in the Self (IOS) Scale, a single-item, pictorial measure of closeness, demonstrated alternate-form and test–retest reliability; convergent validity with the Relationship Closeness Inventory (E. Berscheid et al, 1989), the R. J. Sternberg (1988) Intimacy Scale, and other measures; discriminant validity; minimal social desirability correlations; and predictive validity for whether romantic relationships were intact 3 mo later. Also identified and cross-validated were (1) a 2-factor closeness model (Feeling Close and Behaving Close) and (2) longevity–closeness correlations that were small for women vs moderately positive for men. Five supplementary studies showed convergent and construct validity with marital satisfaction and commitment and with a reaction-time (RT)-based cognitive measure of closeness in married couples; and with intimacy and attraction measures in stranger dyads following laboratory closeness-generating tasks. In 3 final studies most Ss interpreted IOS Scale diagrams as depicting interconnectedness. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Results of 24 studies (based on 20 distinct data sets) relating the quality of the working alliance (WA) to therapy outcome were synthesized using meta-analytic procedures. A moderate but reliable association between good WA and positive therapy outcome was found. Overall, the quality of the WA was most predictive of treatment outcomes based on clients' assessments, less so of therapists' assessments, and least predictive of observers' report. Clients' and observers' rating of the WA appear to be more correlated with all types of outcomes reported than therapists' ratings. The relation of WA and outcome does not appear to be a function of the type of therapy practiced, the length of treatment, whether the research is published, or the number of participants in the study. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This article reviews the role of nonspecific treatment factors in cognitive-behavior therapy (CBT) for depression. An analysis of relevant studies reveals that the majority of symptomatic improvement in CBT occurs prior to the formal introduction of cognitive restructuring techniques. This suggests that other, likely nonspecific, treatment factors play a large role in mediating clinical improvement. Nonspecific factors are hypothesized to ameliorate patients’ feelings of hopelessness at the beginning of treatment, a process that catalyzes improvement across other depressive symptoms. Reviewed evidence supports a mediation role for the hopelessness construct in CBT. Two nonspecific factors, the treatment rationale and the assignment of homework, appear integral to early symptomatic improvement. The role of cognitive techniques is discussed in light of these findings.
Increasing attention is being given to the elucidation of interpersonal processes in depression. The present study was designed to examine the accuracy of depressives' self-perceptions of their social competence. In addition, depressed subjects' perceptions of others with whom they interacted, and these others' perceptions of their depressed partners, were also assessed. Finally, the self-perceptions of nondepressed individuals following interactions with depressed subjects were examined. Depressed and nondepressed subjects were observed and rated in dyadic interactions with other nondepressed subjects, and postinteraction competence ratings of all participants were obtained from the subjects, their partners, and external observers. Analyses indicated that although the depressed subjects rated themselves as less socially competent than did nondepressed subjects, neither the ratings made by the subjects' partners nor those made by the observers discriminated between the depressed and nondepressed subjects. In addition, the depressed subjects rated their partners as lower in social competence than did the nondepressed subjects, and interestingly, the partners of the depressed subjects rated themselves as lower in social skill following the interaction than did the partners of the nondepressed subjects. Finally, the observer ratings of all participants were significantly lower than the participants' ratings of themselves. The results are discussed with respect to previous investigations in this area, and directions for future research are suggested.
The contributions of changes in cognitions (degree of belief in automatic thoughts) and the patient's relationship with his therapist to mood changes occurring during sessions of cognitive therapy were examined in data collected from 17 depressed and anxious patients. Results showed that both changes in automatic thoughts and the patient's relationship with his therapist made independent, additive contributions to mood changes. In addition, two patient characteristics (initial degree of belief in automatic thoughts and diagnosis) made significant unique contributions to mood changes. The stronger the patient's initial belief in his automatic thoughts, the smaller the mood change occurring in the session. Smaller mood changes also occurred in patients with a personality disorder diagnosis. These results suggest that mood changes in cognitive therapy sessions are a function of three types of factors: technical cognitive therapy interventions, the patient's relationship with his/her therapist, and patient characteristics. A multiple regression model with independent variables measuring these factors accounted for 89% of the variance in mood change in the session.
Several controlled treatment-outcome studies have demonstrated the clinical efficacy of group behavioral and cognitive behavioral treatments for depression. However, there is a significant lack of evidence on mental health outcome evaluation studies for depression conducted in nonresearch clinical settings. Subjects in research settings may represent only about 20% of the clinical population because of stringent inclusion criteria, requirements to accept random assignment to conditions, etc. The present study is a clinical replication series of the effectiveness of group cognitive behavior therapy for depression administered in a nonresearch community setting. The subjects included 138 adult patients referred by mental health clinic providers for participation in a six-session (12-hour) depression management group. Outcome measures using the Beck Depression Inventory indicated that the level of depression was decreased for 84% of the participants, the average reduction in depression as measured by the BDI was 38%, and 43% of the patients had a greater than 50% reduction in their BDI score. The results indicated that group cognitive behavior therapy can be effectively applied in a clinical setting with a heterogeneous patient population, although the magnitude of the treatment effect was somewhat less than found in research settings (38% reduction on the BDI as compared to 57%). Group cognitive behavior therapy is a cost-effective treatment approach and the potential for benefits significantly outweighs the cost. In this era of managed care initiatives, group cognitive behavior therapy for depression should be considered as a first-line treatment intervention for many patients with depression as part of a stepped-care treatment approach to provide “the best treatment at the best value.”
We hypothesized that patients' initial ability to cope with daily stress would predict their rates of improvement in cognitive therapy (CT). For 1 week at the beginning of CT, 43 adult outpatients with depression and/or anxiety diagnoses completed daily assessments of stressors and associated appraisals, negative cognitions, coping strategies, and negative mood. Depression was assessed at intake and at every treatment session. Even after the statistical control of intake depression level, treatment length, and concurrent medication status, many of the stress and coping variables were associated with rates of depression-reduction in the expected direction. We discuss the findings' implications for CT theory and practice as well as the heuristic value of a daily process design to evaluate the predictive role of patient factors in psychotherapy outcome.
Objective:
To assess the predictors of treatment outcome across treatments, as well as those associated with differential treatment response.
Method:
One hundred seven adolescent outpatients, aged 13 to 18 years, with DSM-III-R major depression were randomly assigned to one of three manual-based, brief (12 to 16 sessions) psychosocial treatments: cognitive-behavioral therapy (CBT), systemic-behavioral family therapy, or nondirective supportive therapy. Those with good and poor outcomes were compared.
Results:
Continued depression was predicted by clinical referral (versus via advertisement) and was in part mediated by hopelessness. Other predictors of depression were comorbid anxiety disorder and higher levels of cognitive distortion and hopelessness at intake. Achievement of clinical remission was predicted by a higher level of self-reported depression. Poorer functional status was predicted by a higher level of initial interviewer-rated depression. Comorbid anxiety and maternal depressive symptoms predicted differential treatment efficacy. CBT's performance continued to be robust with respect to nondirective supportive therapy, even in the presence of the above-noted adverse predictors.
Conclusion:
Predictors of poor outcome may give clues as to how to boost treatment response. Subjects who come to treatment for clinical trials via advertisement (versus clinical referral) may show more favorable treatment responses. CBT is likely to be a robust intervention even in more complex and difficult-to-treat patients.
Previous research on the role of therapeutic alliance in cognitive behavioral interventions has shown mixed results. Building on the suggestion that the trajectory of the therapeutic relationship may be more predictive of outcome than simple level of alliance, we examined therapeutic alliance, group cohesion, and homework compliance over the course of treatment for 53 socially phobic clients involved in cognitive-behavioral group therapy. Working alliance increased in a linear fashion over the course of treatment, particularly for clients with social fears limited to public speaking. Homework compliance declined linearly, while group cohesion remained static. Curvilinear models did not explain additional variance beyond the linear terms. Notably, treatment outcome was not significantly related to the development of alliance or decline in homework compliance.
The Coping With Depression course is a cognitive behavioral treatment for unipolar depression. The psychoeducational format allows this intervention to be used in several ways, for example, in bibliotherapy, primary prevention, relapse prevention, and treatment of specific populations. Possibly, depressed individuals who otherwise would not seek treatment can be reached with this course because of the nonstigmatizing format and active recruitment. In a literature search, 20 studies on the effects of one of the several forms of the Coping With Depression course were found. An important limitation is that few of the 20 studies made direct comparisons between the effects of the course and those of other psychological and pharmacological interventions. The results of a meta-analysis indicate that this course is an effective therapy for unipolar depression, with effect sizes that are comparable to those of other treatment modalities for depression.
Diminished positive experiences and events might be part of the phenomenology of social anxiety; however, much of this research is cross-sectional by design, limiting our understanding of the everyday lives of socially anxious people. Sexuality is a primary source of positive experiences. We theorized that people with elevated social anxiety would have relatively less satisfying sexual experiences compared to those who were not anxious. For 21 days, 150 college students described their daily sexual episodes. Social anxiety was negatively related to the pleasure and feelings of connectedness experienced when sexually intimate. The relationship between social anxiety and the amount of sexual contact differed between men and women-it was negative for women and negligible for men. Being in a close, intimate relationship enhanced the feelings of connectedness during sexual episodes for only individuals low in social anxiety. Depressive symptoms were negatively related to the amount of sexual contact, and the pleasure and feelings of connectedness experienced when sexually intimate. Controlling for depressive symptoms did not meaningfully change the social anxiety effects on daily sexuality. Our findings suggest that fulfilling sexual activity is often compromised by social anxiety.
Although it is clear that people with social phobia have interpersonal impairment, evidence that social phobia (as opposed to other mental disorders) affects friendship in particular is lacking. Two large epidemiological datasets were used to test whether diagnosis of social phobia is related to perceived friendship quality above and beyond perceived family relationship quality, diagnosis of other mental disorders, and a variety of demographic variables. After Bonferroni correction, social phobia was the only diagnosis related to perceived friendship quality above and beyond other factors, such that people with social phobia reported more impaired friendship quality. Social phobia's effect was similar in magnitude to demographic characteristics in both samples. The current study demonstrates that social phobia is specifically related to perceived friendship quality, suggesting that this aspect of social phobia's effects is worthy of further study.
Outcomes in depression treatment research include both changes in symptom severity and functional impairment. Symptom measures tend to be the standard outcome but we argue that there are benefits to considering functional outcomes. An exhaustive literature review shows that the relationship between symptoms and functioning remains unexpectedly weak and often bidirectional. Changes in functioning often lag symptom changes. As a result, functional outcomes might offer depression researchers more critical feedback and better guidance when studying depression treatment outcomes. The paper presents a case for the necessity of both functional and symptom outcomes in depression treatment research by addressing three aims-1) review the research relating symptoms and functioning, 2) provide a rationale for measuring both outcomes, and 3) discuss potential artifacts in measuring functional outcomes. The three aims are supported by an empirical review of the treatment outcome and epidemiological literatures.
Evidence suggests that comorbid depression influences the outcome of cognitive-behavioral treatment for patients presenting with social phobia. Little is known, however, about the influence of comorbid social phobia on the response to cognitive therapy (CT) for depression among adults presenting with recurrent major depressive disorder (MDD). These analyses seek to clarify this relationship.
Patients (N=156) with recurrent DSM-IV MDD entered CT (20% also met DSM-IV criteria for social phobia). Every week during the course of CT, clinicians assessed depressive symptoms and patients completed self-report instruments measuring severity of depression and anxiety.
At presentation, outpatients with comorbid social phobia reported greater levels of depressive symptoms and clinicians rated their impairment as more severe, compared to their counterparts without social phobia. Patients with or without comorbid social phobia did not differ significantly in (1) attrition rates; (2) response or sustained remission rates; (3) time to response or sustained remission; or (4) rate of improvement in symptoms of depression or anxiety.
The lack of domain-specific measures limits inference with respect to the improvements in social anxiety that occur with CT of depression.
These findings introduce the hypothesis that CT for depression may be flexible enough to treat the depressive symptoms of patients presenting with MDD who also suffer from social phobia.
The present study attempted to identify patient characteristics predictive of individual outcome in a psychoeducational group treatment for unipolar depression. Forty participants meeting Research Diagnostic Criteria for depressive disorders were assessed on demographic and psychological variables at both pre- and posttreatment and on participation variables during treatment. The treatment modality was the Coping With Depression Course. At the end of treatment, 85% of the subjects no longer met diagnostic criteria for depressive disorders. A stepwise multiple regression analysis attained a multiple correlation of .92, accounting for 85% of the variance in posttreatment depression level. Ten variables accounted for significant portions of the outcome variance beyond that explained by pretreatment Beck Depression Inventory scores. The results of previous studies were partially replicated; predictive ability was improved markedly over prior reports. The results suggest that the most robust predictors of outcome are pretreatment levels of depression, social functioning, perceived mastery over events, and early positive perceptions of group cohesiveness. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
63 16-65 yr olds exhibiting unipolar depression were assigned to 1 of 4 conditions (i.e., class, individual tutoring, minimal contact, or delayed treatment control) with regard to a course of treatment for coping with depression to investigate the efficacy of a psychoeducational approach in treating unipolar depression. The course addressed specific target behaviors (i.e., social skills, thinking, pleasant activities, relaxation) and more general components hypothesized to be critical to successful cognitive-behavioral therapy for depression. Ss in the immediate-treatment conditions were assessed pre- and posttreatment and at 1- and 6-mo follow-up sessions; the delayed-treatment group was assessed prior to and following an 8-wk waiting period. Results indicate clinical improvement by all of the active treatment conditions, as compared to the delayed-treatment condition. Differences between active-treatment conditions were small, and some differences between high and low responders to treatment were found. (33 ref) (PsycINFO Database Record (c) 2006 APA, all rights reserved).
This paper reviews evidence from clinical, epidemiologic, and family studies regarding the association between social phobia and other syndromes. Social phobia is strongly associated with other anxiety disorders, substance abuse, and affective disorders in both clinical and community samples. An average of 80% of social phobics identified in community samples meet diagnostic criteria for another lifetime condition. Social phobia is most strongly associated with other subtypes of anxiety disorders, with an average of 50% of social phobics in the community reporting a concomitant anxiety disorder including another phobic disorder, generalized anxiety, or panic disorder. Approximately 20% of subjects in the community meet lifetime criteria for a major depressive disorder. The onset of social phobia generally precedes that of all other disorders, with the exception of simple phobia. Both clinical severity and treated prevalence are consistently greater among social phobics with comorbid disorders. The results of family and twin studies reveal that shared etiologic factors explain a substantial proportion of the comorbidity between social phobia and depression, whereas the association between social phobia and alcoholism derives from a nonfamilial causal relationship between the two conditions. Clinical and phenomenologic implications of these findings are discussed.
This study examined the nature of impairment of functioning in persons with social phobia and assessed the validity of two new rating scales for describing impairment in social phobia.
In 32 patients with social phobia and 14 normal control subjects, impairment was assessed using the Disability Profile and the Liebowitz Self-Rated Disability Scale, new instruments designed to provide clinician- and patient-rated descriptive measures of current and lifetime functional impairment related to emotional problems. Validity of the new scales was assessed by measuring internal consistency, comparing scores for patients and controls, and comparing scores with those on standard measures of disability, social phobia symptoms, and social support.
More than half of all social phobic patients reported at least moderate impairment at some time in their lives, due to social anxiety and avoidance, in areas of education, employment, family relationships, marriage/romantic relationships, friendships/social network, and other interests. Social phobic patients were rated more impaired than normal controls on nearly all items on both measures. Both scales were internally consistent, with Cronbach's alpha coefficients for lifetime and current disability subscales in the range of .87 to .92. Significant positive correlations of scores on the new scales with scores on coadministered standard scales of social phobia symptoms and disability demonstrated concurrent validity. Disability was not significantly correlated with measures of social support.
Social phobia is associated with impairment in most areas of functioning, and the new scales appear useful in assessing functional impairment related to social phobia.
Interest has been renewed in methods for determining individual client change. Currently, there are at least 4 pretreatment-posttreatment (pre-post) difference score methods. A 5th method, based on a random effects model and multiwave data, represents a growth curve approach and was hypothesized to be more sensitive to detecting significant (p < .05) change than the pre-post methods. The change rates produced by the 5 methods were compared in a sample of 73 older outpatients with 3 to 5 assessments per client on a measure of well-being (H. J. Dupuy, 1977). Results indicated that the growth curve approach improvement rate was the highest (68.5%). The growth curve and the Edwards-Nunnally (63.0%) methods produced significantly (p < .05) higher improvement rates than the other 3 methods, with 1 exception.
Data are presented on the general population prevalences, correlates, comorbidities, and impairments associated with DSM-III-R phobias.
Analysis is based on the National Comorbidity Survey. Phobias were assessed with a revised version of the Composite International Diagnostic Interview.
Lifetime (and 30-day) prevalence estimates are 6.7% (and 2.3%) for agoraphobia, 11.3% (and 5.5%) for simple phobia, and 13.3% (and 4.5%) for social phobia. Increasing lifetime prevalences are found in recent cohorts. Earlier median ages at illness onset are found for simple (15 years of age) and social (16 years of age) phobias than for agoraphobia (29 years of age). Phobias are highly comorbid. Most comorbid simple and social phobias are temporally primary, while most comorbid agoraphobia is temporally secondary. Comorbid phobias are generally more severe than pure phobias. Despite evidence of role impairment in phobia, only a minority of individuals with phobia ever seek professional treatment.
Phobias are common, increasingly prevalent, often associated with serious role impairment, and usually go untreated. Focused research is needed to investigate barriers to help seeking.
Self-focused attention has been linked to social anxiety and poor social performance, but the causal direction of this relationship has not been established. For this study, focus of attention was manipulated during a speech task, conducted in pairs for 38 individuals with generalized social phobia. Results indicated that intensifying self-focused attention increased anticipated anxiety and anxious appearance, regardless of whether the individual was giving a speech or passively standing before the audience. The self-focus manipulation also increased self-reported anxiety during the task, but only for individuals assigned to a passive role. Contrary to expectation, self-focused attention did not affect any measure of social performance. These results indicate that self-focused attention may play a causal role in exacerbating social anxiety.
Major depression occurs with generalized anxiety disorder and panic disorder in up to 60% of psychiatric and primary care patients. This comorbidity has been associated with greater severity of depression, poorer psychosocial functioning, and poorer treatment outcomes in psychiatric samples. This study examined the clinical outcomes for depressed primary care patients with and without a lifetime anxiety disorder.
A total of 157 primary care patients who met criteria for major depression were randomly assigned to standardized interpersonal psychotherapy or pharmacotherapy with nortriptyline and were assessed at baseline and at 4 and 8 months on severity of depression, psychosocial functioning, and health-related functioning.
Depressed patients with a comorbid anxiety disorder presented with significantly more psychopathology and tended to prematurely terminate treatment more frequently than patients with major depression alone. Both standardized depression-specific treatments were effective for depressed patients with and without a comorbid generalized anxiety disorder, although time to recovery was longer for the former. Patients with lifetime panic disorder showed poor recovery in response to psychotherapy or pharmacotherapy.
Standardized psychotherapy and pharmacotherapy are effective for patients with major depression with and without a generalized anxiety disorder. However, the longer time to recovery for the former group and lack of response to these treatments by patients with lifetime panic disorder suggest that primary care physicians should carefully assess history of anxiety disorder among depressed patients so as to select a proper intervention.
For those with social phobia self-focused attention has been linked with impairment in social performance increased social anxiety, and a higher frequency of self-critical thoughts during social situations. The purpose of this investigation was to assess correlates of changes in situational self-focus over the course of cognitive-behavioral treatment (CBT). Focus of attention was assessed after in-session role-plays and after in vivo homework assignments during group CBT for social phobia. Analyses revealed a significant decrease in self-focused attention over time; focus on events and stimuli outside of the self remained unchanged. Treatment gains on anxiety during dyadic interactions, on negative self-judgments, and on personalized social fears were related to reduction in self-focused attention. Those with public speaking phobias showed a strong relationship between decreased self-focus and speech anxiety. These findings suggest that changes in self-focused attention during the course of CBT are related to important therapeutic gains Specific interventions aimed at decreasing self-focus may be a useful treatment strategy.
This study examined the extent to which the presence of comorbid anxiety disorder affected the course of depression. 650 depressed outpatients visiting general medical clinicians and mental health specialists were followed for 1 or 2 years. All types of anxiety increased the probability of a new depressive episode among patients with subthreshold depression. Co-occurring panic and phobia decreased the likelihood of remission. The initial number of depressive symptoms was greatest among depressed patients with comorbid anxiety and this relatively higher level persisted over two years. The findings emphasize the poor clinical prognosis associated with comorbid anxiety disorder.
The current paper presents a model of the experience of anxiety in social/evaluative situations in people with social phobia. The model describes the manner in which people with social phobia perceive and process information related to potential evaluation and the way in which these processes differ between people high and low in social anxiety. It is argued that distortions and biases in the processing of social/evaluative information lead to heightened anxiety in social situations and, in turn, help to maintain social phobia. Potential etiological factors as well as treatment implications are also discussed.
The development and validation of the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS) two companion measures for assessing social phobia fears is described. The SPS assesses fear of being scrutinised during routine activities (eating, drinking, writing, etc.), while the SIAS assesses fear of more general social interaction, the scales corresponding to the DSM-III-R descriptions of Social Phobia--Circumscribed and Generalised types, respectively. Both scales were shown to possess high levels of internal consistency and test-retest reliability. They discriminated between social phobia, agoraphobia and simple phobia samples, and between social phobia and normal samples. The scales correlated well with established measures of social anxiety, but were found to have low or non-significant (partial) correlations with established measures of depression, state and trait anxiety, locus of control, and social desirability. The scales were found to change with treatment and to remain stable in the face of no-treatment. It appears that these scales are valid, useful, and easily scored measures for clinical and research applications, and that they represent an improvement over existing measures of social phobia.
We assessed whether a coexisting anxiety disorder predicts risk for persistent depression in primary care patients with major depression at baseline. Patients with major depression were identified in a 12-month prospective cohort study at a University-based family practice clinic. Presence of an anxiety disorder and other potential prognostic factors were measured at baseline. Persistent depressive illness (major depression, minor depression, or dysthymia) was determined at 12 months. Of 85 patients with major depression at baseline, 43 had coexisting anxiety disorder (38 with social phobia). The risk for persistent depression at 12 months was 44% greater [Risk Ratio (RR) = 1.44, 95% confidence interval (CI) 1.02-2.04] in those with coexisting anxiety. This risk persisted in stratified analysis controlling for other prognostic factors. Patients with coexisting anxiety had greater mean depressive severity [repeated measures analysis of variance (ANOVA), p < 0.04] and total disability days (54.9 vs 19.8, p < 0.02) over the 12-month study. Patients with social phobia had similar increased risk for persistent depression (RR = 1.40, 95% CI 0.98-2.00). A coexisting anxiety disorder indicates risk for persistent depression in primary care patients with major depression. Social phobia may be important to recognize in these patients. Identifying anxiety disorders can help primary care clinicians target patients needing more aggressive treatment for depression.
This study attempted to replicate an earlier study (R. J. DeRubeis & M. Feeley, 1990) of the prediction of symptom change from process variables in cognitive therapy for depressed outpatients. Measures of in-session therapist behavior and therapist-patient interactions were correlated with prior and subsequent symptom change. One of the positive findings was confirmed, but the other received only marginal support. A "concrete" subset of theory-specified therapist actions, measured early in treatment, predicted subsequent change in depression. The therapeutic alliance was predicted by prior symptom change in 1 of the 2 later assessments, but only at a trend level. Several negative findings were similar to those obtained in the earlier study. Specifically, the alliance, an "abstract" subset of theory-specified therapist actions, and facilitative conditions did not predict subsequent change. Implications for causal inferences in psychotherapy process research are discussed.
To investigate the combined roles of level and perceived stability of self-esteem in prospectively predicting depression.
Symptoms of depression and anxiety were measured both before and after psychoeducational treatment for depression; level and perceived stability of self-esteem were measured before treatment.
Participants were 26 adults (16 female), age range 21-75 years.
More stable self-esteem was associated with greater depressive symptomatology at treatment completion, particularly among participants who began treatment with the lowest self-esteem. Effects were specific to symptoms of depression in contrast with anxiety.
These results suggest that a stable, well-consolidated negative self-concept is associated with prolonged depression and a poor response to psychosocial interventions.
It has been hypothesized that effective psychological treatment for social phobia changes the person's representation of the self in a more positive direction. In order to test this hypothesis, we analyzed 506 thoughts that were endorsed by 23 social phobic individuals while anticipating socially stressful situations before and after exposure therapy. Treatment efficacy was assessed with the Social Phobia and Anxiety Inventory (SPAI) [Turner, S. M., Beidel, D. C., Dancu, C. V., & Stanley M. A. (1989) An empirically derived inventory to measure social fears and anxiety: the Social Phobia and Anxiety Inventory. Psychological Assessment, 1, 35-40)]. Subjects endorsed significantly fewer negative self-focused thoughts after treatment (on average 8.7% of the thoughts) than before treatment (26.5%, p < 0.005). These changes were highly correlated with pre-post difference scores in the social phobia subscale of the SPAI (r = 0.74, p < 0.0001). Implications of the results for the cognitive model of social phobia will be discussed.