Hostname: page-component-586b7cd67f-vdxz6 Total loading time: 0 Render date: 2024-12-01T00:17:44.744Z Has data issue: false hasContentIssue false
  • English
  • Français

Imagery-enhanced v. verbally-based group cognitive behavior therapy for social anxiety disorder: a randomized clinical trial

Published online by Cambridge University Press:  11 September 2020

Peter M. McEvoy Open the ORCID record for Peter M. McEvoy [Opens in a new window] ,
Matthew P. Hyett ,
Samantha R. Bank ,
David M. Erceg-Hurn ,
Andrew R. Johnson ,
Michael J. Kyron ,
Lisa M. Saulsman ,
Michelle L. Moulds ,
Jessica R. Grisham  and
Emily A. Holmes
...Show all authors
Peter M. McEvoy*
Affiliation:
School of Psychology, Curtin University, Perth, Australia Centre for Clinical Interventions, Perth, Australia
Matthew P. Hyett
Affiliation:
School of Psychology, Curtin University, Perth, Australia
Samantha R. Bank
Affiliation:
School of Psychology, Curtin University, Perth, Australia Centre for Clinical Interventions, Perth, Australia
David M. Erceg-Hurn
Affiliation:
School of Psychology, Curtin University, Perth, Australia Centre for Clinical Interventions, Perth, Australia
Andrew R. Johnson
Affiliation:
School of Psychology, Curtin University, Perth, Australia
Michael J. Kyron
Affiliation:
School of Psychology, Curtin University, Perth, Australia
Lisa M. Saulsman
Affiliation:
School of Psychological Science, University of Western Australia, Perth, Australia
Michelle L. Moulds
Affiliation:
School of Psychology, University of New South Wales, Sydney, Australia
Jessica R. Grisham
Affiliation:
School of Psychology, University of New South Wales, Sydney, Australia
Emily A. Holmes
Affiliation:
Department of Psychology, Uppsala University, Uppsala, Sweden
David A. Moscovitch
Affiliation:
Department of Psychology, Centre for Mental Health Research and Treatment, University of Waterloo, Waterloo, Canada
Ottmar V. Lipp
Affiliation:
School of Psychology, Curtin University, Perth, Australia
Bruce N. C. Campbell
Affiliation:
Centre for Clinical Interventions, Perth, Australia
Ronald M. Rapee
Affiliation:
Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, Australia
*
Author for correspondence: Peter M. McEvoy, E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Cognitive behavior therapy (CBT) is effective for most patients with a social anxiety disorder (SAD) but a substantial proportion fails to remit. Experimental and clinical research suggests that enhancing CBT using imagery-based techniques could improve outcomes. It was hypothesized that imagery-enhanced CBT (IE-CBT) would be superior to verbally-based CBT (VB-CBT) on pre-registered outcomes.

Methods

A randomized controlled trial of IE-CBT v. VB-CBT for social anxiety was completed in a community mental health clinic setting. Participants were randomized to IE (n = 53) or VB (n = 54) CBT, with 1-month (primary end point) and 6-month follow-up assessments. Participants completed 12, 2-hour, weekly sessions of IE-CBT or VB-CBT plus 1-month follow-up.

Results

Intention to treat analyses showed very large within-treatment effect sizes on the social interaction anxiety at all time points (ds = 2.09–2.62), with no between-treatment differences on this outcome or clinician-rated severity [1-month OR = 1.45 (0.45, 4.62), p = 0.53; 6-month OR = 1.31 (0.42, 4.08), p = 0.65], SAD remission (1-month: IE = 61.04%, VB = 55.09%, p = 0.59); 6-month: IE = 58.73%, VB = 61.89%, p = 0.77), or secondary outcomes. Three adverse events were noted (substance abuse, n = 1 in IE-CBT; temporary increase in suicide risk, n = 1 in each condition, with one being withdrawn at 1-month follow-up).

Conclusions

Group IE-CBT and VB-CBT were safe and there were no significant differences in outcomes. Both treatments were associated with very large within-group effect sizes and the majority of patients remitted following treatment.

Keywords

Cognitive behavior therapyfear of negative evaluationgroup therapyimageryrandomized controlled trialsocial anxiety disordersocial interaction anxiety
Type
Original Article
Information
Psychological Medicine , Volume 52 , Issue 7 , May 2022 , pp. 1277 - 1286
Check for updates
Copyright
Copyright © The Author(s), 2020. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Acarturk, C., Cuijpers, P., van Straten, A., & de Graaf, R. (2009). Psychological treatment of social anxiety disorder: A meta-analysis. Psychological Medicine, 39, 241–254. https://doi.org/10.1017/S0033291708003590.CrossRefGoogle ScholarPubMed
Alden, L. E., Buhr, K., Robichaud, M., Trew, J. L., & Plasencia, M. L. (2018). Treatment of social approach processes in adults with social anxiety disorder. Journal of Consulting and Clinical Psychology, 86(6), 505–517. https://doi.org/10.1037/ccp0000306.CrossRefGoogle ScholarPubMed
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Washington, DC: American Psychiatric Association.Google Scholar
Andrews, G., Bell, C., Boyce, P., Gale, C., Lampe, L., Marwat, O., … Wilkins, G. (2018). Royal Australian and New Zealand college of psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Australian & New Zealand Journal of Psychiatry, 52(12), 1109–1172. https://doi.org/10.1177/0004867418799453.CrossRefGoogle Scholar
Barkowski, S., Schwartze, D., Strauss, B., Burlingame, G. M., Barth, J., & Rosendahl, J. (2016). Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized-controlled trials. Journal of Anxiety Disorders, 39, 44–64. https://doi.org/10.1016/j.janxdis.2016.02.005.CrossRefGoogle ScholarPubMed
Blackburn, I.-M., James, I. A., Milne, D. L., Baker, C., Standart, S., Garland, A., & Reichelt, F. K. (2001). The Revised Cognitive Therapy Scale (CTS-R): Psychometric properties. Behavioural and Cognitive Psychotherapy, 29, 431–446. https://doi.org/10.1017/S1352465801004040.CrossRefGoogle Scholar
Carleton, R. N., Thibodeau, M. A., Weeks, J. W., Teale Sapach, M. J., McEvoy, P. M., Horswill, S. C., & Heimberg, R. G. (2014). Comparing short forms of the social interaction anxiety scale and the social phobia scale. Psychological Assessment, 26(4), 1116–1126. https://doi.org/10.1037/a0037063.CrossRefGoogle ScholarPubMed
Clarke, D. M., & Wells, A. (1995). A cognitive model of social phobia. In Heimberg, R. G., Liebowitz, M. R., Hope, D. A. and Schneier, F. R. (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 69–93). New York: Guildford Press.Google Scholar
First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, R. L. (2015). Structured clinical interview for DSM-5 -research version (SCID-5 for DSM-5, research version; SCID-5–RV). Arlington, VA: American Psychiatric Association.Google Scholar
Hackmann, A., Clark, D. M., & McManus, F. (2000). Recurrent images and early memories in social phobia. Behaviour Research and Therapy, 38(6), 601–610. https://doi.org/10.1016/S0005-7967(99)00161-8.CrossRefGoogle ScholarPubMed
Heimberg, R. G., Brozovich, F. A., & Rapee, R. M. (2014). A cognitive-behavioral model of social anxiety disorder: Update and extension. In Hofmann, S. G., & DiBartolo, P. M. (Eds.), Social anxiety: Clinical, developmental and social perspectives (pp. 705–728). New York: Elsevier.10.1016/B978-0-12-394427-6.00024-8CrossRefGoogle Scholar
Hirsch, C. R., Clark, D. M., Mathews, A., & Williams, R. (2003). Self-images play a causal role in social phobia. Behaviour Research and Therapy, 41(8), 909–921. https://doi.org/10.1016/S0005-7967(02)00103-1.CrossRefGoogle ScholarPubMed
Hirsch, C. R., Meynen, T., & Clark, D. M. (2004). Negative self-imagery in social anxiety contaminates social interactions. Memory (Hove, England) 12, 496–506. https://doi.org/10.1080/09658210444000106.CrossRefGoogle ScholarPubMed
Holmes, E. A., Lang, T. J., & Shah, D. M. (2009). Developing interpretation bias modification as a “cognitive vaccine” for depressed mood: Imagining positive events makes you feel better than thinking about them verbally. Journal of Abnormal Psychology, 118(1), 76–88. https://doi.org/10.1037/a0012590.CrossRefGoogle ScholarPubMed
Holmes, E. A., & Mathews, A. (2005). Mental imagery and emotion: A special relationship? Emotion (Washington, D.C.), 5(4), 489–497. https://doi.org/10.1037/1528-3542.5.4.489.CrossRefGoogle ScholarPubMed
Holmes, E. A., & Mathews, A. (2010). Mental imagery in emotion and emotional disorders. Clinical Psychology Review, 30(3), 349–362. https://doi.org/10.1016/j.cpr.2010.01.001.CrossRefGoogle ScholarPubMed
Hyett, M. P., Bank, S. R., Lipp, O. V., Erceg-Hurn, D. M., Alvares, G. A., Maclaine, E., … McEvoy, P. M. (2018). Attenuated psychophysiological reactivity following single-session group imagery rescripting versus verbal restructuring in social anxiety disorder: Results from a randomized controlled trial. Psychotherapy and Psychosomatics, 87(6), 340–349. https://doi.org/10.1159/000493897.CrossRefGoogle ScholarPubMed
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12–19. https://doi.org/10.1037/0022-006X.59.1.12.CrossRefGoogle ScholarPubMed
Kazantzis, N., Deane, F., & Ronan, K. (2005). Using homework assignments in cognitive behavior therapy. In Kazantzis, N., Deane, F. P., Ronan, K. R., & L'Abate, L. (Eds.), Using homework assignments in cognitive behavior therapy (pp. 61–72). New York: Routledge.10.4324/9780203499825CrossRefGoogle Scholar
Makkar, S. R., & Grisham, J. R. (2011). Social anxiety and the effects of negative self-imagery on emotion, cognition, and post-event processing. Behaviour Research and Therapy, 49(10), 654–664. https://doi.org/10.1016/j.brat.2011.07.004.CrossRefGoogle ScholarPubMed
Mallinckrodt, C., & Lipkovich, I. (2017). Analyzing longitudinal clinical trial data: A practical guide. Boca Raton, FL: CRC Press.Google Scholar
Mattick, R. P., & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36(4), 455–470. https://doi.org/10.1016/S0005-7967(97)10031-6.CrossRefGoogle ScholarPubMed
Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: A systematic review and network meta-analysis. The Lancet. Psychiatry, 1(5), 368–376. https://doi.org/10.1016/S2215-0366(14)70329-3.CrossRefGoogle ScholarPubMed
McEvoy, P. M. (2007). Effectiveness of cognitive behavioural group therapy for social phobia in a community clinic: A benchmarking study. Behaviour Research and Therapy, 45(12), 3030–3040. https://doi.org/10.1016/j.brat.2007.08.002.CrossRefGoogle Scholar
McEvoy, P. M., Erceg-Hurn, D. M., Saulsman, L. M., & Thibodeau, M. A. (2015). Imagery enhancements increase the effectiveness of cognitive behavioural group therapy for social anxiety disorder: A benchmarking study. Behaviour Research and Therapy, 65, 42–51. https://doi.org/10.1016/j.brat.2014.12.011.CrossRefGoogle ScholarPubMed
McEvoy, P. M., Moulds, M. L., Grisham, J. R., Holmes, E. A., Moscovitch, D. A., Hendrie, D., … Erceg-Hurn, D. M. (2017). Assessing the efficacy of imagery-enhanced cognitive behavioral group therapy for social anxiety disorder: Study protocol for a randomized controlled trial. Contemporary Clinical Trials, 60, 34–41. https://doi.org/10.1016/j.cct.2017.06.010.CrossRefGoogle ScholarPubMed
McEvoy, P. M., Nathan, P., Rapee, R. M., & Campbell, B. N. (2012). Cognitive behavioural group therapy for social phobia: Evidence of transportability to community clinics. Behaviour Research and Therapy, 50(4), 258–265. https://doi.org/10.1016/j.brat.2012.01.009.CrossRefGoogle ScholarPubMed
McEvoy, P. M., & Saulsman, L. M. (2014). Imagery-enhanced cognitive behavioural group therapy for social anxiety disorder: A pilot study. Behaviour Research and Therapy, 55, 1–6. https://doi.org/10.1016/j.brat.2014.01.006.CrossRefGoogle ScholarPubMed
McEvoy, P. M., Saulsman, L. M., & Rapee, R. M. (2018). Imagery-enhanced CBT for social anxiety disorder. New York: Guildford Press.Google ScholarPubMed
Moscovitch, D. A. (2009). What is the core fear in social phobia? A new model to facilitate individualized case conceptualization and treatment. Cognitive and Behavioral Practice, 16, 123–134. https://doi.org/10.1016/j.cbpra.2008.04.002.CrossRefGoogle Scholar
Moscovitch, D. A., Gavric, D. L., Merrifield, C., Bielak, T., & Moscovitch, M. (2011). Retrieval properties of negative vs. Positive mental images and autobiographical memories in social anxiety: Outcomes with a new measure. Behaviour Research and Therapy, 49(8), 505–517. https://doi.org/10.1016/j.brat.2011.05.009.CrossRefGoogle ScholarPubMed
National Institute for Health and Care Excellence. (2013). Social anxiety disorder: recognition, assessment and treatment. Downloaded from www.nice.org.uk/guidance/cg159 on 1/2/2020.Google Scholar
National Statement on Ethical Conduct in Human Research. (2007, updated 2018). The National Health and Medical Research Council, the Australian Research Council and Universities Australia. Canberra: Commonwealth of Australia.Google Scholar
Norton, A. R., & Abbott, M. J. (2016). The efficacy of imagery rescripting compared to cognitive restructuring for social anxiety disorder. Journal of Anxiety Disorders, 40, 18–28. https://doi.org/10.1016/j.janxdis.2016.03.009.CrossRefGoogle ScholarPubMed
Orr, E. M., & Moscovitch, D. A. (2010). Learning to re-appraise the self during video feedback for social anxiety: Does depth of processing matter? Behaviour Research and Therapy, 48(8), 728–737. https://doi.org/10.1016/j.brat.2010.04.004.CrossRefGoogle ScholarPubMed
Pilkonis, P. A., Choi, S. W., Reise, S. P., Stover, A. M., Riley, W. T., Cella, D., & Group, P. C. (2011). Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS(R)): Depression, anxiety, and anger. Assessment 18, 263–283. https://doi.org/10.1177/1073191111411667.CrossRefGoogle ScholarPubMed
Rapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Testing the efficacy of theoretically derived improvements in the treatment of social phobia. Journal of Consulting and Clinical Psychology, 77(2), 317–327. https://doi.org/10.1037/a0014800.CrossRefGoogle ScholarPubMed
Rapee, R. M., & Hayman, K. (1996). The effects of video feedback on the self-evaluation of performance in socially anxious subjects. Behaviour Research and Therapy, 34(4), 315–322. https://doi.org/10.1016/0005-7967(96)00003-4.CrossRefGoogle ScholarPubMed
Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35(8), 741–756. https://doi.org/10.1016/S0005-7967(97)00022-3.CrossRefGoogle ScholarPubMed
R Development Core Team. (2010). R: A language and environment for statistical computing. R Foundation for Statistical Computing: Vienna.Google Scholar
Reimer, S. G., & Moscovitch, D. A. (2015). The impact of imagery rescripting on memory appraisals and core beliefs in social anxiety disorder. Behaviour Research and Therapy, 75, 48–59. https://doi.org/10.1016/j.brat.2015.10.007.CrossRefGoogle ScholarPubMed
Rodebaugh, T. L., Woods, C. M., Thissen, D. M., Heimberg, R. G., Chambless, D. L., & Rapee, R. M. (2004). More information from fewer questions: The factor structure and item properties of the original and brief fear of negative evaluation scale. Psychological Assessment, 16(2), 169–181. https://doi.org/10.1037/1040-3590.16.2.169.CrossRefGoogle ScholarPubMed
Sherman, R. E., Anderson, S. A., Dal Pan, G. J., Gray, G. W., Gross, T., Hunter, N. L., … Califf, R. M. (2016). Real-world evidence – what is it and what can it tell us? New England Journal of Medicine, 375(23), 2293–2297. https://doi.org/10.1056/NEJMsb1609216.CrossRefGoogle ScholarPubMed
Steinert, C., Stadter, K., Stark, R., & Leichsenring, F. (2017). The effects of waiting for treatment: A meta-analysis of waitlist control groups in randomized controlled trials for social anxiety disorder. Clinical Psychology & Psychotherapy, 24(3), 649–660. https://doi.org/10.1002/cpp.2032.CrossRefGoogle ScholarPubMed
Stokes, J. P. (1983). Toward an understanding of cohesion in personal change groups. International Journal of Group Psychotherapy, 33(4), 449–467. https://doi.org/10.1080/00207284.1983.11491345.CrossRefGoogle ScholarPubMed
Tracey, T. J., & Kokotovic, A. M. (1989). Factor structure of the working alliance inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1, 207–210. https://doi.org/10.1037/1040-3590.1.3.207.CrossRefGoogle Scholar
van Buuren, S., & Groothuis-Oudshoorn, K. (2011). MICE: Multivariate imputation by chained equations in R. Journal of Statistical Software 45, 1–67. https://doi.org/10.18637/jss.v045.i03.Google Scholar
Weeks, J. W., Heimberg, R. G., & Rodebaugh, T. L. (2008). The fear of positive evaluation scale: Assessing a proposed cognitive component of social anxiety. Journal of Anxiety Disorders, 22(1), 44–55. https://doi.org/10.1016/j.janxdis.2007.08.002.CrossRefGoogle ScholarPubMed
Supplementary material: File

McEvoy et al. supplementary material

McEvoy et al. supplementary material

Download McEvoy et al. supplementary material(File)
File 26.5 KB