Optimizing Cognitive-behavioral Therapy for Social Anxiety Disorder Using the Factorial Design
- Conditions
- Social Anxiety Disorder (Social Phobia)
- Interventions
- Behavioral: ExposureBehavioral: Attention TrainingBehavioral: Cognitive RestructuringBehavioral: Psychoeducation
- Registration Number
- NCT04879641
- Lead Sponsor
- University of Bern
- Brief Summary
Social Anxiety Disorder (SAD) is characterized by a marked fear of negative evaluation in social situations. It is the third most common psychiatric disorder and highly disabling (American Psychiatric Association, 2000). Although effective treatments such as cognitive-behavioral therapy (CBT) are available, most individuals suffering from SAD do not seek and eventually find help, and even in the best available treatments, remission rates are below 50%. The overall aim of the project is to better understand and improve the efficacy of Internet-based CBT (ICBT) that has shown to be efficacious in many trials and that provide broad and low-threshold access to empirically supported treatments. Specifically the objectives of the study are:
1. to investigate the active ingredients of ICBT for SAD by testing the main effects and interactions for the four main treatment components (i.e., psychoeducation, cognitive restructuring, attention training, and exposure);
2. to investigate the effects of each treatment component on hypothesized change mechanisms, and to explore whether and which change mechanisms mediate the effect of the treatment components on symptom reduction.
3. to investigate whether the specific mechanisms mediate the effect of the treatment components on primary and secondary outcomes.
- Detailed Description
Social Anxiety Disorder (SAD) is characterized by a marked fear of negative evaluation in social situations. It is the third most common psychiatric disorder and highly disabling. Although effective treatments such as cognitive-behavioral therapy (CBT) are available, most individuals suffering from SAD do not seek and eventually find help, and even in the best available treatments, remission rates are below 50%. The overall aim of the project is to improve the efficacy of Internet-based CBT (ICBT) that has shown to be efficacious in many trials and that provide broad and low-threshold access to empirically supported treatments. Specifically, the objectives of the study are:
1. to investigate the active ingredients of ICBT for SAD by testing the main effects and interactions for the four main treatment components (i.e., psychoeducation, cognitive restructuring, attention training, and exposure);
2. to investigate the effects of each treatment component on hypothesized change mechanisms (change of the knowledge of SAD, change on negative social cognitions, changes on self-focused attention, changes on social avoidance and use of safety behaviors), and to explore whether and which change mechanisms mediate the effect of the treatment components on symptom reduction.
3. to investigate whether the specific mechanisms mediate the effect of the treatment components on primary and secondary outcomes.
The study is a single-center, factorial trial with four experimental factors (treatment components, i.e., psychoeducation, cognitive restructuring, attention training, and exposure) each evaluated at two levels (presence vs. absence) resulting in 16 conditions.
Recruitment: Participants will be recruited using reports in newspapers, through internet forums, social media (e.g., Facebook), and via our website (https://www.online-therapy.ch/) in German-speaking countries.
Sampling: After checking the inclusion criteria, participants will be randomized with equal probability to one of the 16 conditions. The random allocation will be unknown to the investigators. In order to keep the sample sizes of the 16 conditions similar, the allocation list will be made using randomly permuted blocks. A total of 464 participants with a Diagnostic and Statistical Manual of Mental Disorders diagnosis of SAD will be included, with 29 patients being assigned to each of the 16 conditions.
Assessment procedures: The primary outcome measure is change in symptoms of SAD at post-treatment, i.e., after 8 weeks. Secondary outcomes include sustaining change at follow up (6 months after baseline), changes in depressive symptoms, changes in general anxiety symptoms, changes in quality of life, adherence to treatment, treatment satisfaction, negative effects and changes of diagnosis of SAD. Furthermore, the hypothesized change mechanisms (change of the knowledge of SAD, change on negative social cognitions, changes in self-focused attention, changes in social avoidance and use of safety behaviors) will be assessed. Self-report measures are taken at pre-treatment (baseline), after 4 weeks (mid-treatment), after 8 weeks (post-treatment), and at 6 months after randomization (follow-up). Besides the self-report measures, a diagnostic interview will be conducted by phone at pre-treatment, eight weeks (posttreatment), and six months (follow-up). The structured M.I.N.I. Interview will be used. The interviews will be administered by advanced Master students in clinical psychology and psychotherapy supervised by the study team. Interrater reliability will be assessed on a subset of the cases.
Treatment: The internet-based self-help program ("Shyne", https://selfhelp1.psy.unibe.ch/shyne/) is based on the well-established cognitive-behavioral treatment of social anxiety by Clark and Wells and has been proven efficacious in previous studies. Shyne is accessed through a secure website, with each participant having a password-protected account. It consists of the following four treatment components: (1) psychoeducation (knowledge about SAD and its treatment); (2) cognitive restructuring (challenging dysfunctional social cognitions); (3) attention training (decrease of self-focused attention); and (4) exposure (decrease of avoidance of feared situations and safety behaviors). These treatment components will be offered in 16 different combinations.
Data analysis: Primary analyses will be conducted on the Intention-To-Treat (ITT) sample (i.e., all randomized participants). The analyses are carried out on the basis of the intention-to-treat (ITT) approach using linear mixed models. In addition, but only secondary, completers analysis will be carried out. In order to test for main and interaction effects of treatment components on outcomes and change mechanisms across the time points of assessment, linear mixed models Analysis of Variance (ANOVA) or latent growth curve modelling will be used. Main effects and interactions will be based on aggregates across experimental conditions. Sensitivity analyses will explore the impact of the imputation of missing values. For binary outcome data (i.e., SAD diagnosis), a logistic regression model will be used. Furthermore, mediation analyses will be used to determine whether the hypothesized change mechanisms mediate the effect of the treatment components on primary and secondary outcomes. The mediation will be tested using an approach that allows multiple mediators in one model. In addition, potential moderation of the treatment components by various measured variables such as comorbid disorder, medication, the severity of SAD, age and sex will be investigated. Reporting will follow CONSORT E-Health standards.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 464
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- read the study information and sign informed consent;
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- are 18 years or older;
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- have access to the Internet, to a smartphone, PC or tablet;
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- have sufficient knowledge of German;
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- exceed predefined cut-off scores on one of the social anxiety measures (22 points on the Social Phobia Scale or 33 points on the Social Interaction Anxiety Scale; SPS & SIAS);
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- fulfil the diagnostic criteria of SAD according to the diagnostic telephone interview (the presence of other disorders does not result in exclusion if SAD is the primary diagnosis)
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- in the case of taking psychiatric medication, the treatment is stabilized (over one month)
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- they score 2 or higher on the suicide item of the PHQ-9 (Spitzer, 1999) or with active suicidal plans in the diagnostic telephone interview.
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- they have other comorbid psychiatric conditions that might be the main focus of clinical attention (e.g., psychotic symptoms, bipolar disorder, or other severe disorder)
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- they undergo another psychological treatment at the beginning of the study.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- FACTORIAL
- Arm && Interventions
Group Intervention Description 4_Exposure + Attention Training Exposure Randomized participants will get Exposure + Attention Training components 2_Exposure only Exposure Randomized participants will only get the Exposure component 4_Exposure + Attention Training Attention Training Randomized participants will get Exposure + Attention Training components 7_Cognitive Restructuring + Attention Training Cognitive Restructuring Randomized participants will get Cognitive Restructuring + Attention Training components 3_Attention Training only Attention Training Randomized participants will only get the Attention Training component 8_Cognitive Restructuring + Attention Training + Exposure Exposure Randomized participants will get Cognitive Restructuring + Attention Training + Exposure components 5_Cognitive Restructuring only Cognitive Restructuring Randomized participants will only get the Cognitive Restructuring component 6_Cognitive Restructuring + Exposure Exposure Randomized participants will get Cognitive Restructuring + Exposure components 6_Cognitive Restructuring + Exposure Cognitive Restructuring Randomized participants will get Cognitive Restructuring + Exposure components 10_Psychoeducation + Exposure Exposure Randomized participants will get the Psychoeducation + Exposure components 10_Psychoeducation + Exposure Psychoeducation Randomized participants will get the Psychoeducation + Exposure components 12_Psychoeducation + Attention Training + Exposure Exposure Randomized participants will get the Psychoeducation + Attention Training + Exposure components 16_full version (Psychoeducation + Cognitive Restructuring + Attention Training + Exposure) Attention Training Randomized participants will get the Psychoeducation + Cognitive Restructuring + Attention Training + Exposure components 16_full version (Psychoeducation + Cognitive Restructuring + Attention Training + Exposure) Psychoeducation Randomized participants will get the Psychoeducation + Cognitive Restructuring + Attention Training + Exposure components 7_Cognitive Restructuring + Attention Training Attention Training Randomized participants will get Cognitive Restructuring + Attention Training components 8_Cognitive Restructuring + Attention Training + Exposure Cognitive Restructuring Randomized participants will get Cognitive Restructuring + Attention Training + Exposure components 9_Psychoeducation only Psychoeducation Randomized participants will only get the Psychoeducation component 11_Psychoeducation + Attention Training Attention Training Randomized participants will get the Psychoeducation + Attention Training components 13_Psychoeducation + Cognitive Restructuring Cognitive Restructuring Randomized participants will get the Psychoeducation + Cognitive Restructuring components 8_Cognitive Restructuring + Attention Training + Exposure Attention Training Randomized participants will get Cognitive Restructuring + Attention Training + Exposure components 11_Psychoeducation + Attention Training Psychoeducation Randomized participants will get the Psychoeducation + Attention Training components 12_Psychoeducation + Attention Training + Exposure Psychoeducation Randomized participants will get the Psychoeducation + Attention Training + Exposure components 14_Psychoeducation + Cognitive Restructuring + Exposure Exposure Randomized participants will get the Psychoeducation + Cognitive Restructuring + Exposure components 14_Psychoeducation + Cognitive Restructuring + Exposure Cognitive Restructuring Randomized participants will get the Psychoeducation + Cognitive Restructuring + Exposure components 12_Psychoeducation + Attention Training + Exposure Attention Training Randomized participants will get the Psychoeducation + Attention Training + Exposure components 16_full version (Psychoeducation + Cognitive Restructuring + Attention Training + Exposure) Exposure Randomized participants will get the Psychoeducation + Cognitive Restructuring + Attention Training + Exposure components 13_Psychoeducation + Cognitive Restructuring Psychoeducation Randomized participants will get the Psychoeducation + Cognitive Restructuring components 15_Psychoeducation + Cognitive Restructuring + Attention Training Psychoeducation Randomized participants will get the Psychoeducation + Cognitive Restructuring + Attention Training components 16_full version (Psychoeducation + Cognitive Restructuring + Attention Training + Exposure) Cognitive Restructuring Randomized participants will get the Psychoeducation + Cognitive Restructuring + Attention Training + Exposure components 14_Psychoeducation + Cognitive Restructuring + Exposure Psychoeducation Randomized participants will get the Psychoeducation + Cognitive Restructuring + Exposure components 15_Psychoeducation + Cognitive Restructuring + Attention Training Attention Training Randomized participants will get the Psychoeducation + Cognitive Restructuring + Attention Training components 15_Psychoeducation + Cognitive Restructuring + Attention Training Cognitive Restructuring Randomized participants will get the Psychoeducation + Cognitive Restructuring + Attention Training components
- Primary Outcome Measures
Name Time Method Change on social anxiety symptoms at post-treatment Baseline, Mid-treatment (4 weeks after baseline), Post-treatment (8 weeks after baseline) Composite endpoint. Social anxiety symptoms are measured as the combined score of the Social Phobia Scale and the Social Interaction Anxiety Scale (SPS \& SIAS; Mattick \& Clarke, 1998). These instruments are complementary and used as one single measurement. They assess the fear of being judged by others during daily activities (SPS) and more general fears in social interaction (SIAS). The combined scale consists of 40 items and scores range from 0 (no social anxiety symptoms) to 160 (severe social anxiety symptoms).
- Secondary Outcome Measures
Name Time Method Change on social anxiety symptoms at follow-up Baseline, Mid-treatment (4 weeks after baseline), Post-treatment (8 weeks after baseline), Follow-up (6 months after baseline) Social anxiety symptoms are measured as the combined score of the Social Phobia Scale and the Social Interaction Anxiety Scale (SPS \& SIAS; Mattick \& Clarke, 1998). These instruments are complementary and used as one measurement. They assess the fear of being judged by others during daily activities (SPS) and more general fears in social interaction (SIAS). The combined scale consists of 40 items and scores range from 0 (no social anxiety symptoms) to 160 (severe social anxiety symptoms).
Change on the severity of depressive symptoms Baseline, Mid-treatment (4 weeks after baseline), Post-treatment (8 weeks after baseline), Follow-up (6 months after baseline) Depressive symptoms will be measured by the Patient Health Questionnaire (PHQ-9; Spitzer et al., 1999). Scores range from 0 (no depressive symptoms) to 27 (severe depressive symptoms).
Change on quality of life Baseline, Mid-treatment (4 weeks after baseline), Post-treatment (8 weeks after baseline), Follow-up (6 months after baseline) Quality of life will be measured by the Short-Form Health Survey-12 (SF-12; Ware et al., 1996). Scores range from 12 (high quality of life) to 53 (poor quality of life).
Level of satisfaction with the treatment Post-treatment (8 weeks after baseline) Treatment satisfaction will be measured by the Client Satisfaction Questionnaire (CSQ-8; Attkisson \& Zwick, 1982), adapted to internet-based interventions. Scores range from 0 (not satisfied at all) to 24 (extremely satisfied).
Change on the diagnosis of social anxiety disorder Baseline, Post-treatment (8 weeks after baseline), Follow-up (6 months after baseline) Diagnosis of social anxiety disorder will be assessed with M.I.N.I International Neuropsychiatric Interview for DSM-IV 6.0.0 (M.I.N.I; Sheehan et al., 1998). Possible diagnoses are absence or presence of SAD, current or past, generalized or specific, primary diagnosis (yes or no)
Change on the severity of general anxiety symptoms Baseline, Mid-treatment (4 weeks after baseline), Post-treatment (8 weeks after baseline), Follow-up (6 months after baseline) Severity of anxiety symptoms will be measured by the Generalized Anxiety Disorder Scale (GAD-7; Spitzer et al., 2006). Scores range from 0 (no general anxiety symptoms) to 21 (severe general anxiety symptoms)
Negative effects of the treatment Mid-treatment (4 weeks after baseline), Post-treatment (8 weeks after baseline), Follow-up (6 months after baseline) Adverse effects on social, intrapersonal or work-related situations and whether they are attributed to the intervention will be measured on the 15 items Negative Effects of the Treatment scale (INEP; Ladwig et al., 2014). The scores range from - 39 (worse) to +18 (best), in which negative values indicate negative effects of the intervention
Trial Locations
- Locations (1)
Clinical Psychology and Psychotherapy Department, University of Bern
🇨🇭Bern, Switzerland