Brian E. Bunnell

A randomized trial of attention training for generalized social phobia: does attention training change social behavior?

The use of attention training protocols for the treatment of generalized social anxiety disorder (SAD) is undergoing increased examination. Initial investigations were positive but more recent investigations have been less supportive of the treatment paradigm. One significant limitation of current investigations is overreliance on self-report. In this investigation, we expanded on initial investigations by using a multimodal assessment of patient functioning (i.e., including behavioral assessment). Patients with a primary diagnosis of SAD (n=31) were randomly assigned to eight sessions of attention training (n=15) or placebo/control (n=16). Participants were assessed at pre- and posttreatment via self- and clinician-report of social anxiety as well as anxious and behavioral response to two in vivo social interactions. Results revealed no differences between groups at posttreatment for all study outcome variables, suggesting a lack of effect for the attention training condition. The results are concordant with recent investigations finding a lack of support for the use of attention training as an efficacious treatment for patients with SAD.

An Examination of Psychopathology and Daily Impairment in Adolescents with Social Anxiety Disorder

Although social anxiety disorder (SAD) is most often diagnosed during adolescence, few investigations have examined the clinical presentation and daily functional impairment of this disorder exclusively in adolescents. Prior studies have demonstrated that some clinical features of SAD in adolescents are unique relative to younger children with the condition. Furthermore, quality of sleep, a robust predictor of anxiety problems and daily stress, has not been examined in socially anxious adolescents. In this investigation, social behavior and sleep were closely examined in adolescents with SAD (n = 16) and normal control adolescents (NC; n = 14). Participants completed a self-report measure and an actigraphy assessment of sleep. Social functioning was assessed via a brief speech and a social interaction task, during which heart rate and skin conductance were measured. Additionally, participants completed a daily social activity journal for 1 week. No differences were observed in objective or subjective quality of sleep. Adolescents with SAD reported greater distress during the analogue social tasks relative to NC adolescents. During the speech task, adolescents with SAD exhibited a trend toward greater speech latency and spoke significantly less than NC adolescents. Additionally, SAD participants manifested greater skin conductance during the speech task. During the social interaction, adolescents with SAD required significantly more confederate prompts to stimulate interaction. Finally, adolescents with SAD reported more frequent anxiety-provoking situations in their daily lives, including answering questions in class, assertive communication, and interacting with a group. The findings suggest that, although adolescents with SAD may not exhibit daily impaired sleep, the group does experience specific behavioral and physiological difficulties in social contexts regularly. Social skills training may be a critical component in therapeutic approaches for this group.

Evaluation of children with selective mutism and social phobia: a comparison of psychological and psychophysiological arousal.

Although children with social phobia (SP) and selective mutism (SM) present similarly in a clinical setting, it remains unclear whether children with SM are unable to speak due to overwhelming anxiety, or whether withholding speech functions as an avoidance mechanism. A total of 35 children (ages 5-12 years) with either SM (n = 10), SP (n = 11), or no diagnosis (n = 14) participated in the current study. Measurements included clinician, child, and parent ratings as well as behavioral observations and psychophysiological measures. Independent evaluators and clinicians rated children with SM as more severely impaired, more anxious, and less socially effective, but the groups did not differ in self- or parent-reported anxiety. Psychophysiological measures indicated that children in the SM group experienced less arousal than other children during social interaction tasks. The authors postulate that lack of speech may serve as an avoidance mechanism and thus account for this lack of arousal.

Measurement Invariance of the Social Phobia and Anxiety Inventory

The Social Phobia and Anxiety Inventory (SPAI) is a commonly used self-report measure of social phobia that has demonstrated adequate reliability, convergent validity, discriminant validity, and criterion-related validity. However, research has yet to address whether this measure functions equivalently in (a) individuals with and without a diagnosis of social phobia and (b) males and females. Evaluating measurement equivalence/invariance is necessary in order to determine that the construct of social anxiety is interpreted similarly across these populations. The results of the current investigation, using a series of nested factorial models proposed by Vandenberg and Lance (2000), provide evidence for strong equivalence across 420 individuals with and without diagnoses of social phobia and across male and female samples. Accordingly, these results provide psychometric justification for comparison of SPAI scores across the symptom continuum and sexes.

The Use of Virtual Reality Technology in the Treatment of Anxiety and Other Psychiatric Disorders

Learning objectives After participating in this activity, learners should be better able to: • Evaluate the literature regarding the effectiveness of incorporating virtual reality (VR) in the treatment of psychiatric disorders • Assess the use of exposure-based intervention for anxiety disorders Abstract Virtual reality (VR) allows users to experience a sense of presence in a computer-generated, three-dimensional environment. Sensory information is delivered through a head-mounted display and specialized interface devices. These devices track head movements so that the movements and images change in a natural way with head motion, allowing for a sense of immersion. VR, which allows for controlled delivery of sensory stimulation via the therapist, is a convenient and cost-effective treatment. This review focuses on the available literature regarding the effectiveness of incorporating VR within the treatment of various psychiatric disorders, with particular attention to exposure-based intervention for anxiety disorders. A systematic literature search was conducted in order to identify studies implementing VR-based treatment for anxiety or other psychiatric disorders. This article reviews the history of the development of VR-based technology and its use within psychiatric treatment, the empirical evidence for VR-based treatment, and the benefits for using VR for psychiatric research and treatment. It also presents recommendations for how to incorporate VR into psychiatric care and discusses future directions for VR-based treatment and clinical research.

The impact of military deployment on children: Placing developmental risk in context

During recent conflicts in the Middle East, U.S. military families have endured multiple separations, relocations, and alterations in family structure/routines, combined with other significant stressors. This review examines what is known about childrens mental health and functioning in relation to parental military deployment during conflicts spanning the last 14years. Findings are organized and considered by age group (i.e., toddlers and preschoolers, school age children, and adolescents) in an effort to highlight unique challenges and strengths present at different stages of development. Across all age groups, numerous studies document an increase in the number of military-connected children receiving mental health services in relation to parental deployment, though specific types of problems and long-term outcomes are not well understood. Evidence for a concerning increase in rates of child maltreatment related to parental deployment has also emerged. However, findings are largely based on aggregate data and the specific perpetrator is often unclear. Overall, we emphasize several critical next steps for research in this area including investigations characterized by greater methodological rigor, consideration of broader parental and contextual influences on child mental health, objective indicators of stress and coping, and longitudinal designs to examine persistence of child emotional/behavioral problems. A focus on adaptive/resilient outcomes is equally essential for understanding long-term outcomes and developing effective intervention programs.

Incorporating Technology Into the Treatment of a 17-Year-Old Female With Selective Mutism:

Selective mutism (SM) is a relatively rare disorder and is most commonly found among young children. Children and adolescents presenting with SM and its associated features (e.g., social anxiety, social skills deficits) are often challenging to treat, and recent data suggest that SM is characterized by heightened levels of autonomic arousal, often coupled with behavioral avoidance. In this report, we present the case of Nina, a 17-year-old Caucasian female diagnosed with comorbid SM and social anxiety disorder. Standard intervention designed to treat social anxiety disorder (i.e., intensive exposure based on an extinction paradigm) met with a minimal response and no changes in speech behavior. Reconceptualization of the treatment approach led to a decision to focus directly on speech using a graduated exposure (desensitization) paradigm. To create an emotional response incompatible with anxiety, initial desensitization sessions used Apple iPad applications that allowed for engagement in amusing tasks and the pairing of vocalization with positive emotions. Traditional social skills training constituted the final treatment component. Advantages and limitations associated with the various treatment modalities used are discussed as well as recommendations for future clinical research.

A Critical Review of Negative Affect and the Application of CBT for PTSD.

Forms of cognitive and behavioral therapies (CBTs), including prolonged exposure and cognitive processing therapy, have been empirically validated as efficacious treatments for posttraumatic stress disorder (PTSD). However, the assumption that PTSD develops from dysregulated fear circuitry possesses limitations that detract from the potential efficacy of CBT approaches. An analysis of these limitations may provide insight into improvements to the CBT approach to PTSD, beginning with an examination of negative affect as an essential component to the conceptualization of PTSD and a barrier to the implementation of CBT for PTSD. As such, the literature regarding the impact of negative affect on aspects of cognition (i.e., attention, processing, memory, and emotion regulation) necessary for the successful application of CBT was systematically reviewed. Several literature databases were explored (e.g., PsychINFO and PubMed), resulting in 25 articles that met criteria for inclusion. Results of the review indicated that high negative affect generally disrupts cognitive processes, resulting in a narrowed focus on stimuli of a negative valence, increased rumination of negative autobiographical memories, inflexible preservation of initial information, difficulty considering counterfactuals, reliance on emotional reasoning, and misinterpretation of neutral or ambiguous events as negative, among others. With the aim to improve treatment efficacy of CBT for PTSD, suggestions to incorporate negative affect into research and clinical contexts are discussed.

Development and Pilot Evaluation of a Tablet-Based Application to Improve Quality of Care in Child Mental Health Treatment

Background Children need access to high quality mental health care. Effective treatments now exist for a wide range of mental health conditions. However, these interventions are delivered with variable effectiveness in traditional mental health service settings. Innovative solutions are needed to improve treatment delivery quality and effectiveness. Objective The aim of this study was to develop a scalable, sustainable technology-based approach to improve the quality of care in child mental health treatment. Methods A tablet-based resource was developed with input from mental health training experts, mental health providers, and patients. A series of qualitative data collection phases (ie, expert interviews, patient and provider focus groups, usability testing) guided the initial concept and design of the resource, and then its refinement. The result was an iPad-based “e-workbook” designed to improve child engagement and provider fidelity in implementation of a best-practice treatment. We are currently conducting a small scale randomized controlled trial to evaluate the feasibility of e-workbook facilitated child mental health treatment with 10 providers and 20 families recruited from 4 local community-based mental health clinics. Results Usability and focus group testing yielded a number of strong, favorable reactions from providers and families. Recommendations for refining the e-workbook also were provided, and these guided several improvements to the resource prior to initiating the feasibility trial, which is currently underway. Conclusions This study aimed to develop and preliminarily evaluate a tablet-based application to improve provider fidelity and child engagement in child mental health treatment. If successful, this approach may serve as a key step toward making best-practice treatment more accessible to children and families. As various technologies continue to increase in popularity worldwide and within the health care field more specifically, it is essential to rigorously test the usability, feasibility, acceptability, and effectiveness of novel health technology solutions. It is also essential to ensure that patients and providers drive decision making that supports the development of these resources to ensure that they can be seamlessly integrated into practice. Trial Registration Clinicaltrials.gov NCT01915160; https://clinicaltrials.gov/ct2/show/NCT01915160 (Archived by WebCite at http://www.webcitation.org/6cPIiQDpu)

The impact of ecological momentary assessment on posttraumatic stress symptom trajectory

Ecological momentary assessment includes continuous, real-time gathering of self-report data in a participants natural environment. The current study evaluated the possible impact of this assessment strategy on severity of posttraumatic stress (PTS) in a sample of participants who reported experiencing a past traumatic event. Participants with clinically elevated PTS symptoms reported symptom severity at three time-points: during an initial screening, following an unmonitored period, and following two weeks of monitoring. During the monitoring period, participants carried an Android device which prompted them to report PTS symptoms and negative emotions six times daily. PTS severity scores were then compared across these three time-points. Results indicated that participating in the ecological momentary assessment protocol was associated with a significant reduction in PTS severity, whereas significant changes were not noted over the unmonitored control condition. The authors conclude that ecological momentary assessment may have therapeutic value even when not combined with formal intervention, and it may be a useful tool for improving the efficiency of a stepped-care approach to treating PTS symptoms.