Viktoria Ritter

Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social Anxiety Disorder: A Multicenter Randomized Controlled Trial

OBJECTIVE Various approaches to cognitive-behavioral therapy (CBT) have been shown to be effective for social anxiety disorder. For psychodynamic therapy, evidence for efficacy in this disorder is scant. The authors tested the efficacy of psychodynamic therapy and CBT in social anxiety disorder in a multicenter randomized controlled trial. METHOD In an outpatient setting, 495 patients with social anxiety disorder were randomly assigned to manual-guided CBT (N=209), manual-guided psychodynamic therapy (N=207), or a waiting list condition (N=79). Assessments were made at baseline and at end of treatment. Primary outcome measures were rates of remission and response, based on the Liebowitz Social Anxiety Scale applied by raters blind to group assignment. Several secondary measures were assessed as well. RESULTS Remission rates in the CBT, psychodynamic therapy, and waiting list groups were 36%, 26%, and 9%, respectively. Response rates were 60%, 52%, and 15%, respectively. CBT and psychodynamic therapy were significantly superior to waiting list for both remission and response. CBT was significantly superior to psychodynamic therapy for remission but not for response. Between-group effect sizes for remission and response were small. Secondary outcome measures showed significant differences in favor of CBT for measures of social phobia and interpersonal problems, but not for depression. CONCLUSIONS CBT and psychodynamic therapy were both efficacious in treating social anxiety disorder, but there were significant differences in favor of CBT. For CBT, the response rate was comparable to rates reported in Swedish and German studies in recent years. For psychodynamic therapy, the response rate was comparable to rates reported for pharmacotherapy and cognitive-behavioral group therapy.

Brain activation during anticipatory anxiety in social anxiety disorder

Exaggerated anticipatory anxiety during expectation of performance-related situations is an important feature of the psychopathology of social anxiety disorder (SAD). The neural basis of anticipatory anxiety in SAD has not been investigated in controlled studies. The current study used functional magnetic resonance imaging (fMRI) to investigate the neural correlates during the anticipation of public and evaluated speaking vs a control condition in 17 SAD patients and 17 healthy control subjects. FMRI results show increased activation of the insula and decreased activation of the ventral striatum in SAD patients, compared to control subjects during anticipation of a speech vs the control condition. In addition, an activation of the amygdala in SAD patients during the first half of the anticipation phase in the speech condition was observed. Finally, the amount of anticipatory anxiety of SAD patients was negatively correlated to the activation of the ventral striatum. This suggests an association between incentive function, motivation and anticipatory anxiety when SAD patients expect a performance situation.

Neural correlates of emotional interference in social anxiety disorder.

Disorder-relevant but task-unrelated stimuli impair cognitive performance in social anxiety disorder (SAD); however, time course and neural correlates of emotional interference are unknown. The present study investigated time course and neural basis of emotional interference in SAD using event-related functional magnetic resonance imaging (fMRI). Patients with SAD and healthy controls performed an emotional stroop task which allowed examining interference effects on the current and the succeeding trial. Reaction time data showed an emotional interference effect in the current trial, but not the succeeding trial, specifically in SAD. FMRI data showed greater activation in the left amygdala, bilateral insula, medial prefrontal cortex (mPFC), dorsal anterior cingulate cortex (ACC), and left opercular part of the inferior frontal gyrus during emotional interference of the current trial in SAD patients. Furthermore, we found a positive correlation between patients’ interference scores and activation in the mPFC, dorsal ACC and left angular/supramarginal gyrus. Taken together, results indicate a network of brain regions comprising amygdala, insula, mPFC, ACC, and areas strongly involved in language processing during the processing of task-unrelated threat in SAD. However, specifically the activation in mPFC, dorsal ACC, and left angular/supramarginal gyrus is associated with the strength of the interference effect, suggesting a cognitive network model of attentional bias in SAD. This probably comprises exceeded allocation of attentional resources to disorder-related information of the presented stimuli and increased self-referential and semantic processing of threat words in SAD.

Changes in implicit and explicit self-esteem following cognitive and psychodynamic therapy in social anxiety disorder

Abstract The present investigation is the first to analyse changes in implicit and explicit self-esteem following cognitive therapy (CT) and psychodynamic therapy (PDT) in social anxiety disorder (SAD). We assessed a sub-sample of patients with SAD (n=27 per treatment group, n=12 waitlist condition) in the course of a randomized controlled trial prior to and following individual treatment or wait assessment with an Implicit Association Test and the Rosenberg Self-Esteem Scale. Both CT and PDT consisted of 25 sessions. Treatments were effective in enhancing implicit and explicit self-esteem. In CT and PDT, changes in explicit self-esteem were associated with SAD symptom change. No such relationships were found in implicit self-esteem. The results seem to indicate that both CT and PDT are effective in establishing a positive implicit and explicit self-esteem in SAD. The differential relationships of changes in implicit and explicit self-esteem to treatment effects on social phobic symptoms are discussed.

Seeing in the Mind's eye: Imagery rescripting for patients with body dysmorphic disorder. A single case series

BACKGROUND Intrusive images of appearance play an important role in the maintenance of body dysmorphic disorder (BDD) and are often linked to negative autobiographical experiences. However, to date there is no study examining the use and efficacy of imagery rescripting in BDD. METHOD This study investigated imagery rescripting in six patients with BDD, using a single case series A-B design. The intervention consisted of two treatment sessions (T1, T2). BDD and depressive symptoms were evaluated prior to (T1), post (T2) and two weeks after intervention (FU), using the Yale -Brown Obsessive Compulsive Scale for BDD (BDD-YBOCS), the Body Dysmorphic Symptoms Inventory, and the Beck Depression Inventory. RESULTS At post-treatment, significant reductions in negative affect, distress, vividness and encapsulated beliefs associated with images and memories as well as an increased control were observed for five of six patients. These were maintained or decreased at two weeks follow-up. Scores on the BDD-YBOCS indicated a significant 26% improvement in BDD severity at follow-up for the whole group. Considering response as a ≥ 30% reduction in BDD-YBOCS score, four of six patients were classified as treatment responders. At follow-up, significant improvements in BDD and depressive symptoms were observed for the whole group. LIMITATIONS The small sample size and the lack of a control group limit the generalizability of our results. CONCLUSIONS The findings indicate the potential efficacy of imagery rescripting, and highlight the need for further controlled trials. Imagery rescripting should be considered as a treatment technique within the cognitive framework of BDD.

Social anxiety as a potential mediator of the association between attachment and depression

OBJECTIVE The study represents a conceptual replication of the study by Eng et al. (2001) in a sample of adult patients diagnosed with social anxiety disorder as primary diagnosis. METHODS Two different attachment questionnaires (Bielefeld Questionnaire of Client Expectations (BQCE) and Experiences in Close Relationships (ECR-RD)) were applied to examine whether the effect of attachment on depression (measured by the BDI) is mediated by social anxiety (measured by the LSAS) in a cross-sectional study. RESULTS The data confirms such a mediation. The effect of attachment measured with the BQCE on depression was completely mediated, whereas the effect of both scales of the ECR-RD (attachment related avoidance and anxiety) on depression was only partially mediated by social anxiety disorder. CONCLUSION The study supports the association of attachment, social anxiety, and depressive symptoms and the need to consider different perspectives on attachment.

Variants of Exposure in Body Dysmorphic Disorder and Hypochondriasis

Currently, hypochondriasis and body dysmorphic disorder (BDD) are classified as somatoform disorders in DSM-IV-TR (APA, 2000). In ICD-10 (WHO, 1993), BDD is subsumed under hypochondrias. Hypochondriasis and BDD have some similarities with respect to symptomatology (fear and avoidance), cognitive and emotional processing (selective attention to abnormalities of the body), and behavioral factors (bodily preoccupation, compulsive checking, reassurance, seeking medical treatment). In turn, due to their similarities within the spectrum of somatoform disorders on the one hand, and their shared features and high comorbidity with anxiety disorders on the other hand, the APA is recommending the removal of at least BDD from the current category of somatoform disorders and placing it in the new category of anxiety and obsessive–compulsive spectrum disorders (Phillips et al., 2010). Although less clear, there is some evidence that a reconceptualization of hypochondriasis as illness anxiety disorder might also be reasonable (see below). Besides these similarities, however, there are also differences with regard to the focus of concern, with hypochondriasis relating to physical health concerns and BDD to concerns about appearance. This chapter describes diagnostic and summarizes empirical evidence for psychological treatment approaches. Finally, an outlook is given on future development of transdiagnostic interventions in the treatment of hypochondriasis and BDD.

Body dysmorphic concerns, social adaptation, and motivation for psychotherapeutic support in dermatological outpatients.

Dermatologists are increasingly confronted with patients affected by body dysmorphic disorder (BDD). BDD is characterized by excessive preoccupation with one or more perceived defect(s) or flaw(s) in physical appearance which are not observable or appear slight to others. So far, there have been only few studies examining the prevalence of BDD in dermatological outpatients. In addition, the need for psychotherapeutic support in dermatological outpatients with body dysmorphic concerns has not yet been systematically examined. The objective of the present study was therefore to investigate the frequency of body dysmorphic concerns as well as social adaptation and the need for psychotherapeutic support in the aforementioned patient group.

Körperdysmorphe Symptome, soziale Anpassung und Motivation zu psychotherapeutischer Beratung bei ambulanten dermatologischen Patienten

Die Dermatologie ist zunehmend mit Patienten konfrontiert, die unter einer körperdysmorphen Störung (KDS) leiden. Die KDS ist gekennzeichnet durch die übermäßige Beschäftigung mit einem oder mehreren wahrgenommenen Defekten oder Makeln in der äußeren Erscheinung, die für andere nicht oder allenfalls minimal erkennbar sind. Bislang gibt es nur wenige Prävalenzstudien bei KDS im ambulanten dermatologischen Setting. Darüber hinaus wurde die Motivation zu psychotherapeutischer Beratung bei ambulanten dermatologischen Patienten mit körperdysmorphen Symptomen noch nicht systematisch erfasst. Ziel der vorliegenden Studie war daher, die Häufigkeit körperdysmorpher Symptome, die soziale Anpassung sowie die Motivation zu psychotherapeutischer Beratung bei ambulanten dermatologischen Patienten zu untersuchen.

Negative Indikatoren im psychotherapeutischen Prozess: Häufigkeit und Zusammenhang mit Bindungsmerkmalen und Therapieerfolg bei Patienten mit sozialer Angststörung

Within the SOPHO-Net-Project, mainly focusing on a randomized-controlled trial comparing short term cognitive and psychodynamic psychotherapy for social anxiety disorder, a subsample consisting of 88 patients from 3 of the 5 study sites was investigated to examine the relationship between outcome, initial attachment characteristics and negative indicators during the process. These negative indicators were assessed with the Vanderbilt Negative Indicators Scale which was applied to an early (3rd), a middle (9th) as well as a late therapy (22nd) session. The study shows that negative indicators as a whole were relatively rare with a higher frequency within the psychodynamic therapies for which a relationship between negative indicators and outcome could be found. Contrary to expectation, initial attachment characteristics were not related to negative indicators.