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Imagery-enhanced cognitive behavioural group therapy for social anxiety disorder: A pilot study

https://doi.org/10.1016/j.brat.2014.01.006Get rights and content

Highlights

  • Evaluated imagery-enhanced cognitive behavioural group therapy (IE-CBGT).

  • Attrition was very low suggesting that IE-CBGT was acceptable to patients.

  • Effect sizes were large by session eight and doubled by the end of treatment.

  • Most patients reliably improved on interaction and performance anxiety.

  • IE-CBGT was superior to historical controls not receiving imagery enhancements.

Abstract

Cognitive behavioural group therapy (CBGT) for social anxiety disorder (SAD) is efficacious and effective, however a substantial proportion of patients remain in the clinical range so treatment innovations are required. Research suggests that working within the imagery mode may be more emotionally potent than traditional verbal-linguistic strategies. This study piloted an imagery-enhanced CBGT (IE-CBGT) protocol for SAD. It was hypothesised that IE-CBGT would be acceptable to patients, demonstrate large effect sizes, and compare favourably to historical controls who completed CBGT without the imagery-enhancements. Patients (N = 19) were consecutive referrals to a community clinic specialising in anxiety and mood disorders. Primary outcomes were self-reported performance and social interaction anxiety. IE-CBGT was highly acceptable to patients with high attendance and completion rates. Effect sizes were large by mid-treatment and very large at post-treatment and follow-up. A high proportion of patients achieved reliable change. Outcomes compared favourably to published group and individual treatments for SAD but larger randomised controlled trials are now required.

Introduction

Social anxiety disorder (SAD) is characterised by significant and persistent fear or anxiety in situations where an individual is exposed to possible scrutiny by others, such as interacting socially, being observed, or performing in front of others (American Psychiatric Association, APA, 2013). SAD is common, chronic, debilitating, and is one of the earliest onset anxiety disorders (Andrews et al., 2001, McEvoy et al., 2011). Cognitive behavioural therapy for SAD has demonstrated efficacy within randomised controlled trials (RCTs, Rapee, Gaston, & Abbott, 2009) and effectiveness within real world community clinics (Lincoln et al., 2003, McEvoy et al., 2012). However, a substantial proportion of patients completing gold-standard treatments remain symptomatic so treatment innovations are required.

Cognitive theories suggest that negative images are important maintaining factors of emotional disorders in general (Holmes & Mathews, 2010) and SAD in particular (Rapee & Heimberg, 1997). According to Clark and Wells' (1995) model of SAD, self-focused attention results in the construction of negative self-images viewed from the perspective of others. Rather than being an accurate impression, these negative images reflect the individual's feared outcome (Hackmann, Clark, & McManus, 2000) and are imbued with a threatening meaning, such as “I look like an idiot and will be rejected” (Chiupka, Moscovitch, & Bielak, 2012). Consistent with these theories, studies of SAD (e.g., Hackmann et al., 2000) and high social anxiety (Chiupka et al., 2012) have demonstrated that between 90% and 100% of individuals report experiencing negative social images. Experimental studies have also found that holding a negative image in mind is associated with greater anxiety, higher self-ratings of anxiety visibility, more negative self-cognitions and performance appraisals, increased safety behaviours, poorer performance ratings by conversational partners, increased self-focus, and more negative post-event processing (e.g., Hirsch, Meynen, & Clark, 2004). Contemporary CBT protocols incorporate video-feedback to correct distorted self-images and associated meanings (e.g., Rapee et al., 2009).

Hackmann et al. (2000) found that recurrent intrusive images in their SAD sample were often associated with early traumatic social experiences occurring around the time of disorder onset. Imagery rescripting (IR) targeting past traumatic events has been incorporated in comprehensive manuals or as a stand-alone treatment for a range of clinical problems, including post-traumatic stress disorder (Grunert, Smucker, Weis, & Rusch, 2003), depression (Brewin et al., 2009), and more recently in SAD (Wild, Hackmann, & Clark, 2008). One CBT trial for SAD found that a protocol including IR was superior to in vivo exposure with applied relaxation (Clark et al., 2006). Subsequent small clinical trials have found that IR in SAD is associated with significant improvements in negative social beliefs, the vividness and distress of negative images and early memories, fear of negative evaluation, and social anxiety symptoms (Frets et al., 2014, Lee and Kwon, 2013, Nilsson et al., 2012, Wild et al., 2007, Wild et al., 2008). These studies provide proof of concept and suggest that IR may be a powerful technique for treating SAD. However, to date IR has only been conducted individually, so it is unknown whether it could potentiate greater improvements within cognitive behavioural group therapy (CBGT).

Imagery is characterised as sensory-perceptual representations that may have visual, somatic, auditory, olfactory, and/or gustatory elements, and which have particularly strong links to both positive and negative emotions (Holmes & Mathews, 2010). For instance, one study found that compared to verbal processing instructions, cognitive bias modification training involving imagery was more powerful at changing emotion and interpretations (Holmes, Lang, & Shah, 2009). Compared to verbal thoughts, images are more potent in triggering emotional responses because they share similar neural mechanisms as the perceptual experiences one obtains from direct sensory experiences (Brewin, Gregory, Lipton, & Burgess, 2010). These findings have been replicated and extended to naturalistic settings (e.g., Holmes, Mathews, Dalgleish, & Mackintosh, 2006). A review by Holmes and Mathews (2010) concluded that “…images appear to act as ‘emotional amplifiers’ for both positive and negative information” (p. 353), and speculated that cognitive restructuring using imagery, rather than verbal representations, would have greater impacts on therapeutic outcomes. It may be that integrating imagery-based techniques into all treatment components (e.g., behavioural experiments, attention retraining) could enhance emotional change, and there is evidence that imagery facilitates access to negative core beliefs (Pratt, Cooper, & Hackmann, 2004).

The main aim of this study was to pilot a new, imagery-enhanced CBGT protocol (IE-CBGT) for SAD. In addition to including video-feedback and IR, the IE-CBGT protocol exploits the strong relationship between imagery and emotion by using imagery-based techniques in all components of the program. The first hypothesis was that IE-CBGT would be acceptable to patients and thus attrition would be low. The second hypothesis was that effect sizes on symptoms of social interaction and performance anxiety would be large. The third hypothesis was that the IE-CBGT would compare favourably to historical controls, who completed a gold standard CBGT protocol, in terms of attrition, effect sizes, and reliable and clinically significant change.

Section snippets

Participants

Participants comprised 19 consecutive referrals by health professionals (General Medical Practitioners, Psychiatrists, Psychologists) with a diagnosis of SAD to a specialist community mental health clinic. Mean age was 29.7 (SD = 11.6), 10 (53%) were women, and most were born in Australia or New Zealand (n = 14), with the remainder from Britain (n = 2), Asia (n = 2), and North America (n = 1). Inclusion criteria were (a) a Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 1994

Attrition

Most (18/19, 95%) IE-CBGT participants completed eight or more sessions, with an average of 10.68 (SD = 2.29). Eight patients (42.1%) attended all 12 sessions, six (31.6%) attended 11 sessions, 3 (15.8%) attended 10 sessions, and 1 (5.3%) attended 9 sessions.

Symptom change

Repeated-measures ANOVAs demonstrated significant main effects of Time for the SIAS, F(5, 85) = 27.39, p < .001, Partial ɳ2 = .62, and SPS, F(5, 85) = 19.94, p < .001, Partial ɳ2 = .54. Paired-samples t-tests were not significant between T0

Discussion

CBGT for SAD is efficacious in research settings and effective within real world clinics, however a substantial proportion of patients remain in the clinical range. The aim of this study was to pilot an imagery-enhanced CBGT protocol. It was hypothesised that IE-CBGT would be acceptable to patients as shown by low attrition, that effect sizes for social interaction and performance anxiety would be large, and that outcomes would compare favourably to historical CBGT controls in terms of

Acknowledgement

The authors are grateful to David Erceg-Hurn for assistance with data imputation.

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