خط سیر تغییر در تنظیم احساسات و اضطراب اجتماعی در طول درمان شناختی رفتاری برای اختلال اضطراب اجتماعی
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|39248||2014||9 صفحه PDF||سفارش دهید||محاسبه نشده|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Behaviour Research and Therapy, Volume 56, May 2014, Pages 7–15
Abstract Cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD) may decrease social anxiety by training emotion regulation skills. This randomized controlled trial of CBT for SAD examined changes in weekly frequency and success of cognitive reappraisal and expressive suppression, as well as weekly intensity of social anxiety among patients receiving 16 weekly sessions of individual CBT. We expected these variables to (1) differ from pre-to-post-CBT vs. Waitlist, (2) have differential trajectories during CBT, and (3) covary during CBT. We also expected that weekly changes in emotion regulation would predict (4) subsequent weekly changes in social anxiety, and (5) changes in social anxiety both during and post-CBT. Compared to Waitlist, CBT increased cognitive reappraisal frequency and success, decreased social anxiety, but had no impact on expressive suppression. During CBT, weekly cognitive reappraisal frequency and success increased, whereas weekly expressive suppression frequency and social anxiety decreased. Weekly decreases in social anxiety were associated with concurrent increases in reappraisal success and decreases in suppression frequency. Granger causality analysis showed that only reappraisal success increases predicted decreases in subsequent social anxiety during CBT. Reappraisal success increases pre-to-post-CBT predicted reductions in social anxiety symptom severity post-CBT. The trajectory of weekly changes in emotion regulation strategies may help clinicians understand whether CBT is effective and predict decreases in social anxiety. ClinicalTrials.gov identifier NCT00380731; http://www.clinicaltrials.gov/ct2/show/NCT00380731?term=social+anxiety+cognitive+behavioral+therapy+Stanford&rank=1
Introduction Three decades ago, David Barlow and colleagues suggested several compelling reasons to measure change during therapy ( Barlow, Hayes, & Nelson, 1984). One reason is that more refined assessment of change in a patient's psychological functioning during treatment provides the opportunity to modify specific treatment components or to shift the type of treatment being offered. Another reason is that such a focus is needed to advance our understanding of how, why, and for whom these clinical interventions work. A third reason is that more refined measurements of change during therapy may lead to greater accountability in how clinicians deliver and assess treatments they provide and may empirically elucidate for patients, insurance companies, and governmental agencies the efficacy of psychotherapy. Despite this urgent call for research on change processes during therapy, the empirical record of measuring change during therapy is still quite slim. Cognitive-behavioral therapy (CBT) is one of the best validated psychosocial interventions for psychological disorders ( Butler, Chapman, Forman, & Beck, 2006), especially mood and anxiety disorders ( Hofmann & Smits, 2008). Although change in emotion regulation processes has been proposed as one key mechanism of action in CBT for mood and anxiety disorders ( Campbell-Sills and Barlow, 2007 and Hofmann et al., 2012), the session-to-session changes in emotion regulation and their relation to changes in clinical symptoms are still not well understood. One psychological disorder in which emotion regulation processes have been examined is social anxiety disorder (SAD) (Goldin et al., 2009, Goldin et al., 2009 and Werner et al., 2011). SAD is highly prevalent (12%; Kessler et al., 2005), usually begins early in life, well before the onset of other anxiety disorders, substance use, and major depression (Otto et al., 2001), and is associated with significant impairment in social, educational, and occupational functioning (Acarturk et al., 2008 and Stein and Kean, 2000). SAD is characterized by excessive fear of humiliation and embarrassment in social evaluative situations (Stein & Stein, 2008), exaggerated emotional reactivity, and a maladaptive emotion-regulation profile characterized by relatively high levels of generally maladaptive forms of emotion regulation such as expressive suppression, and relatively low levels of generally adaptive forms of emotion regulation such as cognitive reappraisal (Goldin et al., 2009 and Goldin et al., 2009). Thus, SAD can be viewed as involving problematic cognition–emotion interactions that persist unless treated (Bruce et al., 2005). Both group (Heimberg & Becker, 2002) and individual (Clark et al., 2003, Clark et al., 2006, Goldin et al., 2012, Hope et al., 2000 and Ledley et al., 2009) formats of CBT have demonstrated efficacy as psychosocial interventions for SAD with similar levels of clinically significant change in social anxiety symptom severity (Goldin et al., 2012 and Moscovitch et al., 2012). Because not all patients achieve clinically significant reduction of social anxiety symptoms, however, there is clearly a need to better understand what changes are occurring during CBT that relate to treatment outcome. Prior studies have shown changes in several cognitive processes during CBT for SAD, including changes in probability bias for negative social events (Smits, Rosenfield, McDonald, & Telch, 2006), estimated probability and estimated cost of negative social events, safety behaviors (Hoffart, Borge, Sexton, & Clark, 2009), anticipated aversive social outcomes (Hofmann, 2004), positive and negative self-views (Goldin et al., 2013), interpersonal core beliefs (Boden et al., 2012), and cognitive reappraisal self-efficacy (Goldin et al., 2012). What has not been reported to date, however, is how cognitive processes (specifically cognitive reappraisal and expressive suppression) change weekly during treatment, and whether they predict weekly changes in social anxiety and CBT outcome. This is important given the proposed role of emotion regulation in the etiology, maintenance, and treatment of most forms of psychopathology (Campbell-Sills and Barlow, 2007 and Hofmann et al., 2012). To investigate this proposed mechanism of action underlying CBT for SAD, clinical treatment studies have begun to quantify changes in specific emotion regulation processes during treatment in patients with SAD. Using the Emotion Regulation Questionnaire (ERQ; Gross & John, 2003), which measures the frequency of use of cognitive reappraisal and expressive suppression, Moscovitch and colleagues (Moscovitch et al., 2012) found that (a) group CBT led to linear increases in the habitual use of cognitive reappraisal but no changes in the use of expressive suppression, and (b) pre-to-mid-CBT increases in use of cognitive reappraisal were correlated with pre-to-post-CBT decreases in social anxiety symptoms. Using a more recently developed variant of the ERQ designed to assess emotion regulation self-efficacy (Goldin, Manber-Ball, et al., 2009), Goldin et al. (2012) found that the impact of individual CBT for SAD on reduction of social anxiety symptom severity was mediated by increases in cognitive reappraisal self-efficacy. These two studies provide initial empirical support for the role of change in emotion regulation during CBT for SAD. However, notwithstanding the imperative to elucidate the mechanisms of treatments by measuring change during therapy ( Barlow et al., 1984), no studies have measured weekly change trajectories in emotion regulation processes and social anxiety symptoms throughout CBT for SAD. Our goal in the present study was to investigate changes in the frequency and success of use of cognitive reappraisal and expressive suppression, as well as changes in social anxiety, during CBT for SAD. Hypothesis 1: From pre-to-post-treatment, we expected that, compared to a waitlist condition (WL), CBT for SAD would result in greater increases in the frequency and success of cognitive reappraisal, greater decreases in the frequency of expressive suppression, and greater decreases in social anxiety. Hypothesis 2: Across 16 sessions of CBT, we expected a linear trajectory of increases in the weekly frequency and success of cognitive reappraisal, decreases in the frequency of expressive suppression, and decreases in social anxiety. Hypothesis 3: During CBT, we expected that increases in cognitive reappraisal (both the frequency and success) would covary inversely with social anxiety. Hypothesis 4: Using Granger causality analysis, we expected that changes in weekly cognitive reappraisal would predict subsequent weekly social anxiety during CBT. Hypothesis 5: We expected that increases in both the frequency and success of cognitive reappraisal during CBT, as well as greater inverse covariation of social anxiety with both frequency and success in cognitive reappraisal would predict pre-to-post-CBT decreases in social anxiety.
نتیجه گیری انگلیسی
Results Preliminary analyses As reported previously (Goldin et al., 2013 and Goldin et al., 2012), patients in the CBT and WL groups did not differ significantly in gender, age, education, ethnicity, income, marital status, current or past Axis I comorbidity, past non-CBT psychotherapy or pharmacotherapy, age at symptom onset, and years since symptom onset. To investigate test–retest reliability of the weekly single-item measures of frequency and success of reappraisal and expressive suppression, we computed correlation coefficients between adjacent pairs of the 5 measurement time points for the Waitlist group (baseline, 1 month, 2 months, 3 months, post-Waitlist). The mean test–retest correlation coefficients across five time points for reappraisal frequency (.69, range = .49–.81) and success (.57, range = .46–.71), and expressive suppression frequency (.68, range = .47–.87) and success (.62) were adequate. The only non-significant test–retest correlation was for expressive suppression success from baseline to 1 month. Fourteen of 16 correlation coefficients were significant at p < .009 or better. These results suggest overall significant stability across the 5 measurement time points during WL for the 1-item measures of the four emotion regulation processes in an untreated group of patients with generalized SAD. Hypothesis 1 Pre-post CBT change To address Hypothesis 1, we conducted between-group t-tests on pre-to-post-CBT/WL change scores for emotion regulation and social anxiety. For emotion regulation, compared to WL, CBT resulted in greater increases in reappraisal frequency (ΔCBT, Mean ± SD: 22.3 ± 31.0 vs. ΔWL: 4.7 ± 27.2; t73 = 2.60, p = .011, ηp2 = .09) and reappraisal success (ΔCBT: 33.6 ± 30.0 vs. ΔWL: 9.4 ± 29.4; t73 = 3.52, p = .001, ηp2 = .15), but no group differences in suppression frequency (ΔCBT: −11.8 ± 37.5 vs. ΔWL: −2.2 ± 24.3; t73 = 1.30, p = .20, ηp2 = .02) or suppression success (ΔCBT: 0.8 ± 27.9 vs. ΔWL: 5.8 ± 28.5; t73 = 0.78, p = .44, ηp2 = .01). For social anxiety, compared to WL, CBT resulted in greater decreases (ΔCBT: −30.4 ± 26.6 vs. ΔWL: −8.2 ± 12.4; t73 = 4.64, p < .001, ηp2 = .23). Hypothesis 2 Trajectories of change during CBT Multivariate multilevel models were used to address Hypothesis 2. As shown in Figs. 1 and 2, there were increases during 16 sessions of CBT in reappraisal frequency (γ = 1.26, SE = .18, p < .01) and reappraisal success (γ = 1.94, SE = .21, p < .01), decreases in suppression frequency (γ = −1.17, SE = .24, p < .01), but no change in suppression success (γ = .31, SE = .21, p = .14). As shown in Fig. 3, social anxiety decreased throughout CBT (γ = −1.64, SE = .16, p < .01). To characterize the slope that best fit each group mean emotion regulation time series, we conducted a follow-up curve estimation analysis using a Bonferroni corrected p-value of .01. This revealed that a cubic slope fit reappraisal frequency (R2 = .88, F(3,14) = 33.08, p < .001), a quadratic slope fit reappraisal success (R2 = .96, F(2,15) = 165.26, p < .001), a quadratic slope fit suppression frequency (R2 = .84, F(2,15) = 38.24, p < .001), and there was no fit for suppression success (all ps > .05). Hypothesis 3 Response covariation during CBT Trajectories of cognitive reappraisal frequency and success during ... Fig. 1. Trajectories of cognitive reappraisal frequency and success during cognitive-behavioral therapy (CBT) and waitlist (WL) conditions. Figure options Trajectories of expressive suppression frequency and success during ... Fig. 2. Trajectories of expressive suppression frequency and success during cognitive-behavioral therapy (CBT) and waitlist (WL) conditions. Figure options Trajectories of social anxiety during cognitive-behavioral therapy (CBT) and ... Fig. 3. Trajectories of social anxiety during cognitive-behavioral therapy (CBT) and waitlist (WL) conditions. Figure options To address Hypothesis 3, we used multivariate multilevel models to identify patterns of significant covariation in weekly emotion regulation and social anxiety across 16 sessions of CBT. Increases in reappraisal success were related to decreases in social anxiety (r = −.54, p < .05). Decreases in suppression frequency were also related to decreases in social anxiety (r = .52, p < .05). None of the other pairwise associations were significant (all ps > .05). Hypothesis 4 Weekly changes in emotion regulation to predict subsequent social anxiety For Hypothesis 4, a Granger causality analysis indicated that weekly ratings of reappraisal success predicted subsequent weekly ratings of social anxiety (unstandardized beta = −1.02, SE = .36, standardized beta = −.98, t = 2.81, p = .01; F(1,15) = 8.44, p = .01, ΔR2 = .07). There was no evidence that social anxiety predicted subsequent reappraisal success (F(1,15) = .02, p > .05), reappraisal frequency predicted subsequent social anxiety (F(1,15) = 1.85, p > .05), social anxiety predicted subsequent reappraisal frequency (F(1,15) = 1.41, p > .05), or expressive suppression frequency or success predicted subsequent social anxiety (all Fs < 2.33, ps > .05). These results suggest a single specific unidirectional predictive relationship characterized by increases in weekly reappraisal success predicting subsequent decreases in weekly social anxiety across 16 weekly sessions of CBT for SAD. Hypothesis 5 Predicting CBT outcomes To address Hypothesis 5, we implemented a linear regression to predict post-CBT decreases in social anxiety symptom severity (LSAS-SR). After controlling for baseline LSAS-SR, only pre-to-post-CBT increases in reappraisal success, but not in reappraisal frequency (p > .08) or suppression frequency (p > .17), predicted post-CBT LSAS-SR (unique variance explained: ΔR2 = .10, standardized β = −.33, F1,51 = 6.3, p = .02). A follow-up analysis showed that LSAS-SR reduction post-CBT was associated with reappraisal success both during the early phase of CBT (psychoeducation and cognitive restructuring training during sessions 1 to 6; r(32) = .41, p = .02) and during the later phase of CBT (exposure + cognitive restructuring during sessions 7–16; r(32) = .58, p < .001). We also investigated whether covariation of emotion regulation and social anxiety trajectories predicted improvement in LSAS-SR post-CBT. A linear regression showed that, after controlling for baseline social anxiety symptom severity, weekly social anxiety, and weekly reappraisal success, greater inverse covariation of reappraisal success and social anxiety trajectories during CBT significantly predicted reductions in LSAS-SR post-CBT (ΔR2 = .07, standardized β = .32, F(1,15) = 6.74, p = .012). All other covariation relationships were not predictive (all ps > .05).