تاثیر آموزش مهارت های اجتماعی برای اختلال اضطراب اجتماعی: مطالعه کنترل شده تصادفی

Abstract Objective Social anxiety disorder (SAD) impacts social, occupational and academic functioning. Although many interventions report change in social distress, improvement in social behavior remains under-addressed. This investigation examined the additive impact of social skills training (SST) for the treatment of SAD. Method Using a sample of 106 adults who endorsed SAD across numerous social settings, participants were randomized to exposure therapy (imaginal and in vivo) alone, a combination of SST and exposure therapy known as Social Effectiveness Therapy (SET), or a wait list control. The assessment strategy included self-report measures, blinded clinical ratings and blinded assessment of social behavior. Results Both interventions significantly reduced distress in comparison to the wait list control and at post-treatment, 67% of patients treated with SET and 54% of patients treated with exposure therapy alone no longer met diagnostic criteria for SAD, a difference that was not statistically significant. When compared to exposure therapy alone, SET produced superior outcomes (p < .05) on measures of social skill and general clinical status. In addition to statistical significance, participants treated with SET or exposure reported clinically significant decreases on two measures of self-reported social anxiety and several measures of observed social behavior (all ps < .05). Conclusions Both interventions produced efficacious treatment outcome, although SET may provide additional benefit on measures of social distress and social behavior.

Introduction Social anxiety disorder (SAD) is a marked and persistent fear of scrutiny in social or performance situations (American Psychiatric Association [APA], 2013). Individuals who experience social distress across a broad range of social settings1 have severe social and general anxiety, social inhibition, fear of negative evaluation, avoidance, fearfulness, and self-consciousness and may account for up to 70% of patients seeking treatment (e.g., see Beidel & Turner, 2007 for a review). Without treatment, SAD results in long-term functional impairment, but evidence based interventions do exist. Meta-analytic and qualitative reviews (Butler, Chapman, Forman, & Beck, 2006Hofmann, 2010, Jørstad-Stein and Heimberg, 2009 and Ponniah and Hollon, 2008) and recent individual comparative trials (Clark et al., 2006, Mörtberg et al., 2007, Rapee et al., 2009 and Stangier et al., 2011) suggest that cognitive behavioral interventions are efficacious treatments for SAD, based on self-report and clinician ratings of improvement. Despite these positive reports, enthusiasm for current CBT outcomes must be tempered by several important limitations. First, statistically significant symptom improvement does not always meet the threshold for diagnostic remission and second, outcome assessment strategies that fail to objectively assess social behavior change do not allow an assessment of changes in functional impairment. Specifically, extent outcome data are reliant on self-report and clinician ratings, which document that CBT results in perceived decreases in social distress (e.g., Clark et al., 2006, Mörtberg et al., 2007 and Stangier et al., 2011). Few studies have examined actual changes in impaired social functioning/behavior, which is an important element in SAD's clinical presentation (Beidel, Rao, Scharfstein, Wong, & Alfano, 2010). Even among the few investigations that included behavioral tasks in their assessment battery, most used the tasks only to assess social anxiety, not social behavior (Clark et al., 2006, Herbert et al., 2005 and Rapee et al., 2009). Given the plethora of available treatment trials for SAD, why the lack of attention to assessing objective social skill? First, conducting observational assessments is clearly more challenging and time-intensive than completion of subjective measures. Another reason, however, is that some conceptualizations of SAD begin with the premise that people with SAD possess adequate social skills but their ability to focus on social interactions and use the skills appropriately is hindered by anxiety. This suggests that SAD is associated with a performance deficit, not a skill deficit (Hopko, McNeil, Zvolensky, & Eifert, 2001). Theoretically then, eliminating social anxiety should allow for adequate/appropriate social skills to emerge, but few studies have directly addressed this issue. One investigation (Hope, Herbert & White, 1995) reported that group CBT (with no formal social skills training) improved social skills across both DSM-IV generalized and non-generalized subtypes. This would suggest support for the performance deficit model, but the small sample size and the limited assessment of social skill (a one item Likert scale) limits the conclusions of this investigation. A recent review (Poniah & Hollon, 2008) reported that social skills training (SST) alone is not efficacious for improving social skills in adult SAD. This conclusion would be consistent with the accepted practice that exposure therapy is an essential component of treatment for anxiety disorders ( Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). However, extant efficacy data for adding SST to established treatments are contradictory. On one hand, Stravynski et al. (2000) reported that SST did not enhance treatment outcome to an interpersonal approach and the majority of individuals remained symptomatic at outcome. In contrast, Turner, Beidel, Cooley, Woody, and Messer (1994) treated thirteen individuals with SAD with SST (12 sessions) followed by exposure therapy (12 sessions). Patients showed significant improvement on measures of social anxiety/distress as well as improvement in social behavior. Blinded ratings indicated that social effectiveness and social skill improved after SST but before exposure therapy. After additional exposure therapy, gains were maintained, but there was no further improvement in social skill. However, the small number of participants and the lack of randomization prohibit drawing firm conclusions about the additional nature of SST. A more recent randomized controlled trial (Herbert et al., 2005) compared group CBT (CBGT) to SST plus CBGT. In the combined condition, SST included education, modeling, and behavior rehearsal in the context of the simulated exposure exercises, feedback and cognitive restructuring that is characteristic of CBGT. The results indicated that adding SST enhanced outcome over CBGT alone. Blinded observer ratings of social skill revealed statistically significant differences favoring the combined group, and significantly more individuals treated with the CBGT plus SST were judged as treatment responders when compared to CBGT alone (79% vs. 38%, respectively); at 3 month follow-up, the difference remained but was no longer significant (83% vs. 57%). As the authors noted, despite these improvements, post treatment scores on a self-report inventory of social anxiety fell well above the mean for non-clinical samples, suggesting continuing impairment, and the need to continue the search for efficacious treatment strategies. Although the less than optimal outcome might be due to a myriad of factors, one important consideration is that the addition of SST resulted in less time being devoted to other elements of the treatment package. Optimally, a comparative treatment trial should assess all treatment elements at full strength. To summarize, current interventions for SAD have focused primarily on CBT in various iterations but most studies do not directly address how these interventions affect impaired social functioning. This is significant shortcoming in the existing literature because functional impairment is now a critical factor when determining the presence/absence of a psychiatric disorder (American Psychiatric Association [APA], 2013). Additionally, the inability to behave as desired is perhaps the reason why most individuals seek treatment. Furthermore, not all individuals with SAD respond to CBT suggesting that alternative strategies are necessary. Although Herbert et al. (2005) provide evidence that SST may enhance treatment outcome, those findings require replication and the interventions (including exposure therapy) must be provided at optimal strength. In this investigation, we compared exposure therapy (EXP), a well-established treatment for SAD to a multi-faceted intervention (group social skills training plus individual exposure), known as Social Effectiveness Therapy (SET) for people with SAD. In addition to self-report and blinded clinician ratings, we attempted to address several limitations in the extant literature. First, we included direct observation of behavioral skill using several different behavioral tasks. Second, unlike most previous investigations, we assessed clinical significance as well as statistical significance, using a normative comparison group. We hypothesized that (a) both SET and EXP would produce positive treatment outcome when compared to wait list control, (b) SET would produce superior treatment outcome to EXP alone, particularly on measures of observed social behavior, and (c) treatment gains would be maintained at follow-up.

Results 3.1.1. Planned analyses Outcome data were analyzed with a series of χ2 comparisons and Mixed-model ANOVAs to examine change as a function of group (WL, SET, EXP). Follow-up analyses examined maintenance of treatment gains for SET and EXP groups. Multiple imputation methods using SPSS 19 Missing Data Module were used across all study waves to address attrition and missing data ( Rubin, 1987 and Schafer and Graham, 2002). Multiple imputation (MI) uses all available data, including non-completers’ pretreatment data, and all the completers data, to estimate likely values for each outcome for each participant. For these analyses presented, the computer ran the imputation 10 times, creating 10 unique datasets, meaning that each dataset had different values imputed for each missing data point based on the estimation procedures. The data analytic procedures are then run for each dataset, and then combined across the 10 sets of results using Rubin's (1987) rules. Multiple imputation methods lead to less biased/more accurate results relative to single imputation, last observation carried forward, and complete case analysis ( Schafer & Graham, 2002 ; Sterne et al., 2009). For each imputation, participant age, gender, and clinician-rated pre-treatment ADIS symptom severity ratings were used as additional predictors to improve imputation precision ( Sterne et al., 2009). In the final step, results from these 10 analyses were combined using Rubin's rules for combining estimates obtained from multiple imputed datasets ( Rubin, 1987). 3.2. Post-treatment comparison of the WL, SET, and EXP groups 3.2.1. Attrition It is important to note that even when data are missing not at random, MI approaches are valid as long as any systematic differences between completers and noncompleters are included in MI models (e.g., different attrition rates for men and women). For this analysis, all available data (see below) were included in the multiple imputation analysis in order to get the best estimate of how dropouts would have fared in treatment. Based on the number of participants randomized to a treatment condition (N = 106), 71 individuals completed treatment and the post-treatment assessment (67%). Completers did not differ from noncompleters in age, sex (proportion of females), number of children, race/ethnicity, or any of the 10 pre-treatment clinical indicators (all p > .23). In addition, attrition was not significantly related to treatment condition, χ2 [2] = 2.85, p = .24. Collectively, these findings were interpreted as evidence that a missing at random (MAR) assumption was defensible. Nevertheless, it is impossible to know whether non-completers differed from completers during waves at which the former were not assessed. Therefore, all 106 participants who were initially randomized to the three conditions were included in an intent to treat analysis using multiple imputation to handle missing data according to the above methodological rationale. 3.3. Primary outcome variables 3.3.1. Treatment responders (presence/absence of social phobia) There were significant group differences at post-treatment (χ2 [2] = 21.30, p < .001), with significantly higher percentages of the SET (67%; d = 1.26) and EXP (54%; d = .95) groups no longer meeting diagnostic criteria for SAD compared to the WL group (10%; both χ2 [1] ≥ 11.08, p < .001). The percentage of patients without a SAD diagnosis in the SET and EXP groups were not significantly different (χ2 [1] = 3.68, p = .12; d = .42). 3.3.2. Alternative treatment responder criteria (CGI ratings) Based on CGI Improvement ratings, patients treated with SET or EXP were significantly more likely to be considered treatment responders when compared to the WL control group (χ2 [2] = 45.37, p < .0005); 92% of patients treated with SET (d = 2.68) and 75% for EXP (d = 1.61) compared to 6% for WL (6%; both χ2 [1] ≥ 23.55, both p < .001) met treatment responder criteria. There were significantly more treatment responders for SET relative to EXP (χ2 [1] = 4.30, p < 05; d = .46). 3.4. Secondary outcome variables A series of 3 (group: WL, SET, EXP) × 2 (time: Pre, Post) Mixed-Model ANOVAs further examined group differences on secondary outcome variables: (a) self-reported anxiety, (b) BAT objective ratings of anxiety and skill, and (c) clinician rated symptoms. For planned comparisons, pre-treatment scores were not significantly different across groups unless noted. For the few variables in which pre-treatment differences were apparent, pre-treatment score was used as a covariate to examine post-treatment group differences. 3.5. Self-reported anxiety For the SPAI, BSPS, and BAT Self-reported Anxiety Factor, all omnibus between-group and interaction terms were significant (F[1–2, 103] range: 3.68 to 13.34, all p < .05; see Table 2). SET and EXP groups had lower scores than the WL group on all three measures (all p < .0005; SET vs. WL: drange = 1.26 to 1.92; EXP vs. WL: drange = .99 to 1.29). In addition, participants treated with SET had significantly lower scores than the EXP group on the BSPS (p = .01; d = .56) and BAT self-reported anxiety (p = .02; d = .46) but were not significantly different on the SPAI (p = .46; d = .16; see Table 2). As illustrated in Fig. 2, both treatment groups had post treatment scores that fell below the cut-off score for clinical significance. Furthermore, the SET group had scores that fell below the normative sample (at post-treatment and six month follow-up). Table 2. Pre–post data for primary outcomes variables. Outcome Pre-treatment Post-treatment Omnibus testsa WL SET EXP Contrasts (Cohen's d Effect Size) WL SET EXP Contrasts (Cohen's d effect size) Between-group F (1, 103) Within-group F(1, 103) Pre-post interaction F(2, 103) Self-reported BAT self-reported anxiety and .55 (.20) −.18 (.16) −.04 (.16) SET < WL (.72) EXP < WL (.60) SET = EXP (.13) 1.02 (.25) −.50 (.11) .10 (.16) SET < WL (1.79) EXP < WL (1.08) SET < EXP (.46) 19.28*** – 3.68* BSPS 45.26 (2.56) 42.79 (1.53) 43.46 (1.78) WL = SET (.23) WL = EXP (.16) SET = EXP (.06) 37.52 (3.26) 17.07 (1.30) 22.44 (1.61) SET < WL (1.92) EXP < WL (1.29) SET < EXP (.56) 12.74*** 183.51*** 13.34*** SPAI 104.67 (5.82) 107.85 (3.13) 104.46 (4.4) WL = SET (.14) WL = EXP (.01) SET = EXP (.14) 93.65 (5.92) 67.60 (2.68) 70.77 (3.38) SET < WL (1.26) EXP < WL (.99) SET = EXP (.16) 3.19* 91.83*** 7.29*** Clinician-rated CGI avoidance 4.32 (.13) 4.39 (.11) 4.53 (.15) WL = SET (.11) WL = EXP (.25) EXP = SET (.16) 3.84 (.30) 1.01 (.16) 1.78 (.23) SET < WL (2.50) EXP < WL (1.44) SET < EXP (.61) 25.13*** 236.78*** 25.13*** CGI severity 5.21 (.21) 5.14 (.16) 5.15 (.11) WL = SET (.07) WL = EXP (.08) EXP = SET (.01) 4.78 (.29) 2.08 (.15) 2.83 (.21) SET < WL (2.45) EXP < WL (1.49) SET < EXP (.63) 22.34*** 200.84*** 27.34*** HAMA 18.42 (1.26) 15.53 (1.05) 16.27 (1.20) WL = SET (.43) WL = EXP (.30) EXP = SET (.10) 12.92 (1.49) 5.06 (.60) 6.89 (.74) SET < WL (1.62) EXP < WL (1.13) SET < EXP (.42) 8.67*** 121.92*** 3.17* HAMDc 11.16 (1.18) 8.19 (.68) 9.32 (.79) WL < SET (.62) WL = EXP (.36) EXP = SET (.23) 8.98 (1.34) 2.10 (.41) 4.96 (.69) SET < WL (1.77) EXP < WL (.82) SET < EXP (.79) 11.35*** 81.15*** 5.41** Observer-rated BAT anxietyc .22 (.20) −.38 (.14) .31 (.16) SET < WL (.64) WL = EXP (.09) SET < EXP (.69) .07 (.22) −.50 (.16) .54 (.21) SET < WL (.36) WL = EXP (.40) SET < EXP (.74) 15.49*** – 1.60, ns BAT skillc −.48 (.20) .23 (.15) −.06 (.16) WL < SET (.73) WL = EXP (.42) EXP = SET (.29) −.12 (.26) .47 (.15) −.44 (.16) WL < SET (.38) WL = EXP (.47) EXP < SET (.87) 8.65*** – 4.55* BAT total timeb 3.56 (.51) 4.81 (.32) 4.10 (.28) WL < SET (.57) WL = EXP (.26) EXP = SET (.37) 3.45 (.55) 5.89 (.28) 5.33 (.32) WL < SET (1.04) WL < EXP (.87) EXP = SET (.18) 9.83*** 9.42** 2.60, ns Note: Values reflect × (SE). a F values combined across 10 multiple imputation datasets according to Rubin's rules ( Schafer & Graham, 2002). b Significant pre-treatment scores were entered as covariates for post-treatment comparisons. c Values reflect latent factors interpreted as z-scores, and reflect each group's relative standing in relation to the other groups. Significant interaction effects indicate changes in the relative standing of groups across assessments. Within-subjects effects are not interpreted because scores are standardized at each assessment point. * p < .05. ** p < .01. *** p < .001. Table options Self-reported anxiety during behavioral tasks. Fig. 2. Self-reported anxiety during behavioral tasks. Figure options 3.5.1. Objective measures of anxiety and skill For the three objective anxiety and skill measures (BAT Observer Anxiety Factor, BAT Observer Skill Factor, and BAT Total Speaking Time during the IST), all omnibus between-group effects were significant (F[1, 103] range: 8.65 to 15.49, all p ≤ .001). Within-subjects effects were not interpreted because factor scores are standardized at each wave (i.e., mean = 0 and SD = 1 at each wave). The interaction term was significant for BAT Observer Skill (p = .02), reflecting changes in the relative standing of groups across pre- and post-treatment. Planned comparisons were conducted separately for each variable with pre-treatment scores as a covariate due to pre-treatment group differences. At post-treatment, the SET group demonstrated lower anxiety (d = .36), higher skill (d = .38), and longer speech duration (d = 1.04) than the WL group (all p ≤ .005; Fig. 3, Fig. 4 and Fig. 5 present the z scores for each group for each of these variables, allowing illustration of group changes across time). In addition, the SET group demonstrated lower anxiety (d = .74), higher skill (d = .87), and longer speech duration (d = .18) relative to the EXP group (all p ≤ .017). Only patients treated with SET had post-treatment scores that exceeded the clinical significance cut-off scores and attained ratings consistent with a normative sample. In contrast, the EXP group demonstrated higher anxiety (d = .40) and lower skill (d = .47), but longer speech duration (d = .87), relative to the WL group (all p < .049). Blinded observer-report ratings of anxiety by group during behavioral task. Fig. 3. Blinded observer-report ratings of anxiety by group during behavioral task. Figure options Blinded observer ratings of skill by group during behavioral assessment tasks. Fig. 4. Blinded observer ratings of skill by group during behavioral assessment tasks. Figure options Total speech time by group during behavioral assessment tasks. Fig. 5. Total speech time by group during behavioral assessment tasks. Figure options 3.5.2. Clinician-rated symptoms For the Behavioral Avoidance, CGI Severity, HAMA, and HAMD (see Table 2), all omnibus between-group and interaction terms were significant (F[1–2, 103] range: 3.17 to 30.75, all p < .05). Planned comparisons revealed that the SET and EXP groups were rated as less avoidant, less anxious, less depressed, and having less severe symptomatology relative to the WL group (all p < .003; SET vs. WL: drange = 1.62 to 2.50; EXP vs. WL drange = .82 to 1.49). In addition, the SET group was less avoidant (p = .005; d = .61), less symptomatic, (p = .005; d = .63), and less depressed (p ≤ .0005; d = .79) relative to the EXP group. SET-EXP group differences were non-significant for the HAMA (p = .05; d = .42). 3.5.3. Clinical significance A final set of analyses examined the clinical significance of the treatment outcome (Jacobson & Truax, 1991), using a normative sample to calculate a cut-off score beyond which treatment-related change is considered clinically meaningful. Normative data was available for the BAT variables (Beidel et al., 2010) and the SPAI (Turner et al., 1989). At post-treatment, 97% of the SET and 85% of the EXP group reported clinically meaningful decreases in BAT self-reported anxiety, relative to 14% of the WL group (χ2 results: SET = EXP > WL, p < .0005). In addition, 57% of the SET group and 43% of the EXP group demonstrated clinically meaningful improvements in BAT total speech time, relative to 12% of the WL group (SET = EXP > WL, p ≤ .002). BAT observer ratings of anxiety and skill indicate that 67% and 79% of SET participants demonstrated clinically meaningful improvements on these variables, respectively, relative to 27% and 43% of the EXP group, and 35% and 50% of the WL group (SET > EXP = WL, p ≤ .03). Finally, examination of SPAI scores (see Fig. 6) revealed that 50% of SET participants, relative to 26% (EXP) and 11% (WL), demonstrated clinically meaningful improvements (SET > EXP = WL, p ≤ .05). Clinical significance of treatment outcome using normative sample data. Fig. 6. Clinical significance of treatment outcome using normative sample data. Figure options 3.6. Three- and six-month follow-up of SET and EXP groups 3.6.1. Attrition Because the WL group was offered treatment after completion of the wait list, data were not available for follow-up. Of the 59 individuals who completed SET (n = 32) or EXP (n = 27) treatment, 63% provided data at 3-month follow-up, and 50% were available at 6 months. A series of χ2 and t-tests compared completers and noncompleters at each wave on demographic variables, treatment condition, and all outcome variables from preceding waves. Treatment condition (SET, EXP) was not related to attrition at any wave (all p ≥ .32). All other variables were nonsignificant at all waves (p ≥ .11) with the following exceptions. Pre-treatment BAT observer-rated anxiety was significantly related to attrition at the 6-month (p = .03), but not 3-month follow-up (p = .07). Post-treatment BAT observer-rated anxiety was related to attrition at 3-month follow-up (p = .02) but not at 6 months (p = .75). Finally, BAT speech duration at 3 months predicted attrition at 6 months (p = .04). All significant variables were included with the predictors described previously when creating multiple imputation models to correct for missing data at the 3-, and 6-month follow-up periods. 3.7. Primary outcome variables 3.7.1. Presence/absence of social phobia Significant group differences were apparent at 3-month follow-up (χ2 [1] = 7.32, p = .025; d = .61). Seventy-four percent of participants treated with SET no longer meeting diagnostic criteria for SAD compared to 57% for EXP. The groups were not significantly different at the 6-month follow-up (63% vs. 57%; d = .36). 3.8. Secondary outcome variables A series of 2 (group: SET, EXP) × 3 (time: Post-treatment, 3-month, 6-month follow-ups) Mixed-Model ANOVAs examined maintenance of treatment gains for both groups using the same strategy described for the post-treatment analysis (see Table 3). Table 3. Pretreatment, posttreatment and follow-up means and standard errors for self-report and clinician measures. Measure SET EXP p Self-report Brief Social Phobia Scale <.0005 Pretreatment 42.79 (1.53) 43.46 (1.78) Posttreatment 17.07 (1.3) 22.44 (1.61) 3 Month follow-up 16.30 (1.08) 25.22 (1.09) 6 Month follow-up 19.91 (1.33) 22.90 (1.26) Social Phobia and Anxiety Inventory .61 Pretreatment 107.85 (3.13) 104.46 (4.4) Posttreatment 67.59 (2.68) 70.77 (3.38) 3 Month follow-up 67.16 (1.94) 62.66 (2.41) 6 Month follow-up 63.98 (2.31) 60.62 (2.36) Clinician ratings Behavioral avoidance rating <.0005 Pretreatment 4.39 (.11) 4.53 (.15) Posttreatment 1.00 (.15) 1.78 (.23) 3 Month follow-up 1.43 (.17) 1.86 (.19) 6 Month follow-up 1.53 (.31) 1.82 (.3) CGI severity of illness <.0005 Pretreatment 5.14 (.16) 5.15 (.11) Posttreatment 2.08 (.15) 2.83 (.21) 3 Month follow-up 2.4 (.18) 2.39 (.26) 6 Month follow-up 2.47 (.29) 2.64 (.39) Hamilton Anxiety Scale <.0005 Pretreatment 15.53 (1.05) 16.27 (1.2) Posttreatment 5.05 (.6) 6.89 (.74) 3 Month follow-up 6.6 (.68) 7.82 (.6) 6 Month follow-up 6.94 (.8) 7.61 (.61) Hamilton Depression Scale <.0005 Pretreatment 8.19 (.68) 9.32 (.79) Posttreatment 2.1 (.41) 4.96 (.69) 3 Month follow-up 3.57 (.44) 3.42 (.47) 6 Month follow-up 4.18 (.54) 4.72 (.5) Table options 3.8.1. Self-reported anxiety Both treatment groups maintained their treatment gains across the follow-up period for all self-report measures. Furthermore, the SET group continued to report lower anxiety than the EXP group on the BSPS and the BAT self-ratings (all p < .0005; See Fig. 2), whereas there were no group differences on the SPAI (p = .61). Paired sample t-test revealed that the SET group maintained their treatment gains, whereas the EXP group continued to show improvement, with significant lower scores at follow-up compared to post-treatment (ps < .02). 3.8.2. BAT objective measures of anxiety and skill For the BAT Observer Anxiety Factor, BAT Observer Skill Factor and BAT Total Speech Time (see Fig. 3, Fig. 4 and Fig. 5), pre-treatment scores were used as covariates due to significant pre-treatment differences. All omnibus and planned comparison between-group effects were significant (all p < .001), and indicated that the SET group continued to demonstrate less anxiety (d = .64 to 1.26) and more skill (d = .58 to .92) than the EXP group at follow-up. The BAT Total Speech Time interaction effect was significant (p = .036). Planned comparison paired t-tests revealed that the SET group maintained their treatment gains at follow-up (both p ≥ .17). In contrast, speech duration for the EXP group was not significantly different than pre-treatment at 3-month follow-up (p = .13). 3.8.3. Clinician-rated symptoms Across follow-up, the SET group was rated as less avoidant, less anxious, less depressed, and having less severe symptoms relative to the EXP group (all p ≤ .0005). Although some variability in scores was observed across assessment periods, treatment gains were maintained for all measures (see Table 3).