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Social anxiety disorder is the fourth most prevalent mental disorder in the US. Over the past several decades, psychotherapeutic, specifically cognitive behavioral, and pharmacologic approaches have been found efficacious for social anxiety disorder. A number of meta-analyses have been conducted since 1995 examining the efficacy of cognitive behavioral therapy (CBT) and/or pharmacotherapy for social anxiety disorder. Though there have been numerous trials in the past decade, no meta-analysis examining both psychotherapy and pharmacotherapy for social anxiety disorder has been published since 2001. For the present study, a comprehensive literature search produced 93 publications featuring 94 controlled trials (N = 11,503), which were included in the final analyses. We found a moderate to large effect size for all active treatments compared to control conditions. Significant heterogeneity among treatment effects was evident, largely accounted for by true variation between effects, versus standard error. Examination of potential study characteristic moderators indicated that treatment type (CBT, medication, combination), analysis type (intent-to-treat vs. completer), funding source, type of screening interview, type of treatment clinic (academic or private), version of diagnostic criteria, type of social anxiety sample (generalized social anxiety disorder only vs. mixed sample of generalized and specific social anxiety disorder) and type of inclusion/exclusion criteria related to other anxiety disorders were significant moderators. Publication type, inclusion/exclusion criteria related to depression and substance abuse/dependence, and full sample comorbidity with another disorder were not. Treatment type was no longer a significant moderator once control condition was accounted for. In psychotherapy trials, self-exposure (as compared to all other types of CBT) and psychotherapist training were significant moderators, whereas variables corresponding to treatment modality and delivery were not. Medication class and specific drug type were significant moderators for pharmacotherapy studies comparing an active treatment to a control condition. Head-to-head comparisons, which included trials comparing active treatments, indicated no differences between psychotherapy, medication, and the combination of the two. Further, social anxiety treatment had moderate to large effects on depression and quality of life. / Psychology

Social anxiety disorder (SAD) and alcohol use disorders (AUDs; i.e., alcohol dependence, alcohol abuse) are highly prevalent and potentially debilitating. They also commonly co-occur, and when they do, their combined effect may be even more devastating. The onset of SAD most commonly precedes the onset of AUDs, suggesting that SAD may be a marker or risk factor for the onset of these other disorders. Previous research has not sufficiently examined the mechanisms involved in the development of AUDs, and longitudinal research is lacking. The current study examined mechanisms related to the development of AUDs among incoming college freshman students at two large universities in the United States. Incoming freshmen are at higher risk for developing symptoms consistent with SAD, particularly during their first semester, and they may be more likely to cope with their symptoms of anxiety by drinking alcohol. The current study aimed to explicate the relationship between social anxiety and alcohol consumption in college freshmen. Baseline data collection occurred late in the summer after registration for the Fall semester or early in the Fall semester. Follow-up data collection occurred later in the Fall semester. It was expected that social anxiety, the quantity and frequency of drinking alcohol (including frequency of intoxication), and alcohol-related problems would increase among the freshmen over the course of the fall semester. Additionally, several relationships among the variables being examined were hypothesized. Drinking motives, symptoms of depression, and quality of life were expected to mediate the relationship between social anxiety and the drinking outcome variables. In addition, expectancies about alcohol consumption were expected to moderate the mediated relationship. However, there were no increases in social anxiety, alcohol consumption, or alcohol-related problems between baseline and follow-up. There were few hypothesized relationships found, although there was a positive relationship between social anxiety and negative alcohol expectancies and a negative relationship between social anxiety and quality of life. Model testing generated one promising model in which the relationship of positive expectancies regarding alcohol use to alcohol use and problems was mediated by coping with anxiety drinking motives. In particular, the main effect of positive expectancies of alcohol and coping with anxiety drinking motives generated a medium effect whereas the other relationships generated small to medium effects. Clinical implications and limitations of the current study are discussed. / Psychology

本研究的主要目的在於運用自傳式記憶的作業探討高社交焦慮者是否有記憶偏誤的現象。根據Clark和Wells（1995）的模型，高社交焦慮者在社交焦慮情境中容易把大部分的注意力集中在自身相關（self-related）的訊息上，因而造成對自身相關訊息的記憶優於外界環境訊息的現象；然而根據Repee和Heimberg（1997）的模型則假設高社交焦慮者在社交情境中會關注與負向自我評價有關的訊息，而不論該訊息是來自自身或外界環境。本研究企圖同時檢測上述兩個模型。 本研究篩選出六十四名大學生分為高社交焦慮與低社交焦慮兩組，所有受試者皆須分別回憶一件社交焦慮事件及一件中性事件，受試者被要求先在腦海中形成對該事件的影像，然後寫下有關回憶事件的詳細描述並完成記憶清晰度的評估。 研究結果得出高社交焦慮者在進行社交焦慮事件的回憶時，傾向回憶出比低社交焦慮組更多的自身相關訊息；且高社交焦慮組在回憶社交焦慮事件時比低社交焦慮組更傾向評估自身相關訊息的記憶清晰度高於外界環境訊息，研究結果較支持Clark和Well（1995）的說法。 / The purpose of the present study was to utilize the autobiographical memory task to investigate the memory bias in socially anxious individuals. According to Clark and Wells’ (1995) view, socially anxious individuals were hypothesized to preferentially allocate almost attentional resources to self-related information and remember self-related information better than external information on entering an anxiety-provoking social situation. However, according to Repee and Heimberg’ s (1997) model, they supposed that socially anxious individuals tend to focus on negative self-evaluated information regardless of it were self-related or external information. The present study tried to examine the two models simultaneously. Sixty-four undergraduate students were assigned to either high or low social-anxiety group. All subjects were asked to recall one anxiety-provoking social situation about public-speaking and another neutral situation. They were requested to form an image of the event and write a detailed description about it. They then completed rating of memory vividness for each situation. The results revealed that high social anxiety group showed to retrieve more self-related information than low social anxiety group and displayed more preferential to rate the vividness of self-related information higher than external environmental information than low social anxiety group did when recalling anxiety-provoking social situation. The result supported Clark and Wells’ s model.

Social anxiety disorder (SAD) is a common psychiatric disorder associated with considerable suffering. Cognitive behaviour therapy (CBT) has been shown to be effective but a significant proportion does not respond or relapses, stressing the need of augmenting treatment. Using neuroimaging could elucidate the psychological and neurobiological interaction and may help to improve current therapeutics. To address this issue, functional and structural magnetic resonance imaging (MRI) were repeatedly conducted on individuals with SAD randomised to receive CBT or an active control condition. MRI was performed pre-, and post-treatment, as well as at one-year follow-up. Matched healthy controls were also scanned to be able to evaluate disorder-specific neural responsivity and structural morphology. This thesis aimed at answering three major questions. I) Does the brain’s fear circuitry (e.g., the amygdala) change, with regard to neural response and structural morphology, immediately after CBT? II) Are the immediate changes in the brain still present at long-term follow-up? III) Can neural responsivity in the fear circuitry predict long-term treatment outcome at the level of the individual? Thus, different analytic methods were performed. Firstly, multimodal neuroimaging addressed questions on concomitant changes in neural response and grey matter volume. Secondly, two different experimental functional MRI tasks captured both neural response to emotional faces and self-referential criticism. Thirdly, support vector machine learning (SVM) was used to evaluate neural predictors at the level of the individual. Amygdala responsivity to self-referential criticism was found to be elevated in individuals with SAD, as compared to matched healthy controls, and the neural response was attenuated after effective CBT. In individuals with SAD, amygdala grey matter volume was positively correlated with symptoms of anticipatory speech anxiety, and CBT-induced symptom reduction was associated with decreased grey matter volume of the amygdala. Also, CBT-induced reduction of amygdala grey matter volume was evident both at short- and long-term follow-up. In contrast, the amygdala neural response was weakened immediately after treatment, but not at one-year follow-up. In extension to treatment effects on the brain, pre-treatment connectivity between the amygdala and the dorsal anterior cingulate cortex (dACC) was stronger in long-term CBT non-responders, as compared to long-term CBT responders. Importantly, by use of an SVM algorithm, pre-treatment neural response to self-referential criticism in the dACC accurately predicted (&gt;90%) the clinical response to CBT. In conclusion, modifying the amygdala is a likely mechanism of action in CBT, underlying the anxiolytic effects of this treatment, and the brain’s neural activity during self-referential criticism may be an accurate and clinically relevant predictor of the long-term response to CBT. Along these lines, neuroimaging is a vital tool in clinical psychiatry that could potentially improve clinical decision-making based on an individual’s neural characteristics. / Social ångest är en av de vanligaste psykiska sjukdomarna. Mer än en miljon svenskar bedöms lida av detta. Social ångest leder ofta till svåra konsekvenser för den som drabbas, men även ökade kostnader för samhället har noterats, t ex i form av ökad sjukfrånvaro. Även om många som drabbas inte söker hjälp så finns effektiva behandlingar för social ångest, både farmakologiska och psykologiska behandlingar rekommenderas av Socialstyrelsen. Kognitiv beteendeterapi (KBT) är en evidensbaserad och rekommenderad psykologisk behandling för social ångest. Trots att nuvarande interventioner är effektiva så är det fortfarande en andel individer som inte blir förbättrade. Det finns en stor andel studier som visar att individer med social ångest, i jämförelse med friska individer, karakteriseras av överdriven aktivitet i ett nätverk som har till uppgift att tolka och reagera på hotfull information. Denna aktivitet är lokaliserad i rädslonätverket där området amygdala spelar en central roll. Det finns ett behov att utveckla nuvarande behandlingar och denna avhandling syftar till att öka vår förståelse för en neurobiologisk verkningsmekanism bakom KBT för social ångest. I detta forskningsprojekt har magnetresonanstomografi (MRT) använts för att undersöka personer som lider av social ångest. Upprepade mätningar har genomförts, innan, efter, och vid uppföljning ett år efter ångestlindrande behandling. Utöver detta har individer som inte lider av social ångest undersökts för att förstå hur patienter skiljer sig från friska personer, men också för att undersöka om behandlingen normaliserar patientens hjärna. Under tiden som deltagarna undersöktes med MRT genomfördes två experiment för att ta reda på hur hjärnan reagerar på affektiv information. Deltagarna tittade på bilder med ansikten som uttrycker emotioner, t ex arga och rädda ansiktsuttryck, samt information som innehöll kritiska kommentarer riktade till personen själv eller någon annan, t ex ”ingen tycker om dig” eller ”hon är inkompetent”. Strukturella bilder på deltagarnas hjärnor har också samlats in vid varje mättillfälle. Utöver detta fick alla deltagare instruktioner om att de efter MRT skulle hålla en muntlig presentation inför en publik. Denna uppgift är oftast den värsta tänkbara för individer med social ångest, och syftet med uppgiften var att relatera hjärnans struktur och aktivitet till hur mycket ångest som individerna upplevde inför denna situation. I arbetet med denna avhandling har tre frågor ställts. a) Uppstår strukturella och funktionella förändringar i rädslonätverket direkt efter avslutad KBT (Studie I och II)? b) Är de tidiga förändringarna efter behandlingen även kvarstående ett år senare (Studie III)? c) Kan hjärnans reaktioner i rädslonätverket förutspå vilka individer som kommer att bli förbättrade av en ångestlindrande psykologisk behandling på lång sikt? Resultat från studierna i denna avhandling sammanfattas nedan: Reaktioner till självriktad kritik i amygdala är överdrivna hos individer med social ångest, i jämförelse med friska individer Reaktioner i amygdala minskar efter att individerna blivit behandlade med KBT och minskningarna korrelerar till minskade symptom av social ångest Den strukturella volymen av amygdala korrelerar positivt med hur mycket ångest individerna upplever inför en muntlig presentation, och minskningen av dessa symptom korrelerar även med hur mycket volymen av amygdala minskar efter KBT Minskningen av amygdalavolym och den samtidigt minskade reaktiviteten i amygdala till självriktad kritik är korrelerade. Medieringsanalyser antyder att det är den minskade volymen som driver förhållandet mellan minskad reaktivitet och minskad ångest inför att hålla en muntlig presentation Den strukturella minskningen av amygdala ses både direkt efter behandlingens avslut, men även vid uppföljning ett år senare. Hjärnans reaktivitet till självriktad kritik i amygdala minskar direkt efter behandling, men är inte kvarstående vid uppföljning ett år senare Kopplingen mellan hjärnans reaktivitet till självriktad kritik i amygdala och dorsala främre cingulum var starkare hos de som inte blev förbättrade (jämfört med de som blev bättre) av en ångestlindrande behandling på lång sikt Med hjälp av en stödvektormaskin (en. support vector machine learning) och ett mönster av hjärnaktivitet i dorsala främre cingulum innan behandling påbörjades, predicerades (med 92% träffsäkerhet) vilka individer som ett år senare var fortsatt förbättrade av en effektiv psykologisk behandling Utifrån dessa observationer är slutsatserna att strukturell och funktionell påverkan på amygdala är en möjlig neurobiologisk mekanism för minskad social ångest efter KBT, samt att reaktivitet i främre cingulum kan ge kliniskt relevant data om vem som kommer att bli förbättrad av en psykologisk behandling. Denna information kan potentiellt vara viktig i framtidens psykiatri för att utveckla existerande behandlingar, men även för att stödja klinikers beslutsfattande huruvida en viss individ bör erbjudas en specifik behandling eller ej. / <p>Illustration on the cover by Jan Lööf. Cover image printed with permission from Jan Lööf and Bonnier Carlsen Förlag. The cover was art directed by Staffan Lager.</p><p>The thesis is reprinted and the previous ISBN was 9789176856888.</p>

The importance of simultaneous consideration of forms and functions in youth measures of aggressive behavior is well established. Competing models have presented these highly interrelated constructs as either independent (e.g., reactive or overt) or paired factors (e.g., reactive and overt). The current study examines these models in the context of assessing the viability of a new self-report measure, the Peer Conflict Scale – 20 Item Version. Confirmatory factor analyses were conducted on PCS 20 responses from 1,048 school-age youth living in the Gulf Coast region. Both models significantly improved upon one or two-factor alternatives, and demonstrated partial invariance across gender and grade. The models showed comparable levels of fit to the data, though some loadings for the independent factors model were non-significant. Results encourage use of the PCS 20 across research settings and developmental contexts, while also demonstrating the viability of a paired factors model of aggression.

Diferentes ensaios clínicos randomizados demonstram que a Terapia Cognitivo-Comportamental (TCC) é muito efetiva no tratamento do Transtorno de Ansiedade Social (TAS). Entretanto, uma quantidade significativa de pacientes não apresentam melhora após a finalização da intervenção com TCC. Tal dado indica a necessidade de desenvolver novas estratégias de tratamento para o TAS. A Terapia Cognitiva Processual (TCP) é uma nova abordagem dentro do campo da TCC que tem como principal objetivo auxiliar os pacientes a identificar e modificar suas crenças centrais disfuncionais, sendo o Processo uma das principais técnicas utilizadas. Algumas pesquisas têm demonstrado a efetividade do Processo no tratamento do TAS e de outros transtornos psiquiátricos. Entretanto, novas pesquisas são necessárias para avaliação não somente de tal técnica, mas de todo o protocolo de intervenção da TCP. Esta pesquisa objetivou avaliar se participantes que receberam uma intervenção individual em TCP apresentam diferenças em relação a sintomas de ansiedade social, medo da avaliação negativa, esquiva e desconforto social, ansiedade, depressão, sofrimento psíquico, distorções cognitivas e viés atencional. Este é um ensaio clínico randomizado que comparou um grupo que recebeu intervenção em TCP e um grupo lista de espera no tratamento do TAS. O estudo apresenta três grupos de pesquisa: o TCP (n =18), o lista de espera (n =21) e o saudável (n =19). Um pesquisador independente ao estudo realizou a distribuição aleatória dos participantes com TAS entre os grupos TCP e lista de espera. Foram realizadas avaliações no pré e pós-teste através de diferentes escalas de auto-relato e do teste de Stroop emocional. Adicionalmente, o grupo TCP respondeu tais escalas a cada quatro sessões. O tratamento foi realizado em 16 sessões com duração de 1h30min cada utilizando a TCP no formato individual. Houve uma redução significativa nos sintomas de ansiedade social, ansiedade, depressão, esquiva e desconforto social, e sofrimento psíquico no grupo TCP ao longo do tratamento (p < 0,05). Tais reduções foram associadas a tamanhos de efeito grandes. Não foram observadas mudanças em nenhum dos instrumentos utilizados no grupo lista de espera (p > 0,05). Houve ainda uma significativa redução no medo da avaliação negativa após a utilização do Processo no grupo tratado, além de uma redução em distorções cognitivas (p < 0,05). Não foram observadas diferenças no pré e pós-teste em relação ao viés atencional nos três grupos da pesquisa (p > 0,05). Este estudo sugere que a TCP pode ser uma nova abordagem clínica efetiva no tratamento do TAS associado à diferentes comorbidades, haja vista que houve uma redução em sintomas de ansiedade social e sintomas comórbidos / Different randomized clinical trials show that Cognitive Behavioral Therapy (CBT) is highly effective in the treatment of Social Anxiety Disorder (SAD). However, a large number of patients do not show improvement after receiving CBT. This indicates that it is important to develop new treatments for SAD. Trial-Based Cognitive Therapy (TBCT) is a new approach within the field of CBT area. It aims to help patients to identify and to modify their dysfunctional core beliefs. One of the main TBCT techniques proposed by TBCT is the Trial. Some research studies have demonstrated the effectiveness of Trial in the treatment of SAD, and other disorders. However, further investigation is needed to firmly establish the efficacy not just for the Trial technique, but also the TBCT approach as a treatment for SAD and other disorders. This research aims to evaluate wheter SAD participants receiving TBCT individual-sessions differ from a SAD waiting list group condition regarding symptoms of social anxiety, fear of negative evaluation, social avoidance and distress, anxiety, depression, mental suffering, and attentional bias. This is a randomized clinical trial comparing TBCT and a Waitlist control condition for the treatment of SAD. The study has three groups: TBCT (n =18), Wailist (n =21), and healthy group (n =19). An independent researcher to study distributed randomly the participants with SAD between TBCT or Waitlist condition. Assessments were made at pre and post-test using several self-report scales, and the emotional Stroop test in the three groups. Additionaly, the TBCT group answered these scales each four sessions. The treatment was delivered in sixteen 1.5 hour sessions using the individual TBCT format. There were reductions in social anxiety, anxiety, depression, social avoidance and distress, and mental suffering symptoms at TBCT group (p < 0.05), but not in the Waitlist group (p > 0.05). Those reductions were associated with a large effect size. There was a significant reduction at fear of negative evaluation after Trial use, and reductions at cognitive distortions throughout the treatment as well (p < 0.05). There were no differences among the three groups regarding attentional bias at pre-test nor at post-test (p > 0.05). This study suggests that TBCT may be a new effective clinical approach to treat SAD associated with high rates of comorbidity, as there were significant reductions in the comorbid symptoms