We examined whether Cognitive-Behavioral Therapy (CBT) for social anxiety disorder (SAD) would modify self-reported negative emotion and functional magnetic resonance imaging brain responses when reacting to and reappraising social evaluation, and tested whether changes would predict treatment outcome in 59 patients with SAD who completed CBT or waitlist groups. For reactivity, compared to waitlist, CBT resulted in (a) increased brain responses in right superior frontal gyrus (SFG), inferior parietal lobule (IPL), and middle occipital gyrus (MOG) when reacting to social praise, and (b) increases in right SFG and IPL and decreases in left posterior superior temporal gyrus (pSTG) when reacting to social criticism. For reappraisal, compared to waitlist, CBT resulted in greater (c) reductions in self-reported negative emotion, and (d) increases in brain responses in right SFG and MOG, and decreases in left pSTG. A linear regression found that after controlling for CBT-induced changes in reactivity and reappraisal negative emotion ratings and brain changes in reactivity to praise and criticism, reappraisal of criticism brain response changes predicted 24% of the unique variance in CBT-related reductions in social anxiety. Thus, one mechanism underlying CBT for SAD may be changes in reappraisal-related brain responses to social criticism. (C) 2014 Elsevier Ltd. All rights reserved.

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 (C) 2014 Elsevier Ltd. All rights reserved.

Dysfunctional beliefs play an important role in the aetiology and maintenance of social anxiety disorder (SAD). Despite thisand the heightened salience of emotion in SADlittle is known about SAD patients' beliefs about whether emotions can be influenced or changed. The current study examined these emotion beliefs in patients with SAD and in non-clinical participants. Overall, patients were more likely to hold entity beliefs (i.e., viewing emotions as things that cannot be changed). However, this group difference in emotion beliefs varied by emotion domain. Specifically, SAD patients more readily held entity beliefs about their own emotions and anxiety than about emotions in general. By contrast, non-clinical participants more readily held entity beliefs about emotions in general than about their own. Results also indicated that even when controlling for social anxiety severity, patients with SAD differed in their beliefs about their emotions, and these beliefs explained unique variance in perceived stress, trait anxiety, negative affect, and self-esteem.

People differ in their implicit beliefs about emotions. Some believe emotions are fixed (entity theorists), whereas others believe that everyone can learn to change their emotions (incremental theorists). We extend the prior literature by demonstrating (a) entity beliefs are associated with lower well-being and increased psychological distress, (b) people's beliefs about their own emotions explain greater unique variance than their beliefs about emotions in general, and (3) implicit beliefs are linked with well-being/distress via cognitive reappraisal. These results suggest people's implicit beliefs—particularly about their own emotions—may predispose them toward emotion regulation strategies that have important consequences for psychological health.

IMPORTANCE Cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) is thought to enhance cognitive reappraisal in patients with SAD. Such improvements should be evident in cognitive reappraisal-related prefrontal cortex responses. OBJECTIVE To determine whether CBT for SAD modifies cognitive reappraisal-related prefrontal cortex neural signal magnitude and timing when implementing cognitive reappraisal with negative self-beliefs. DESIGN Randomized clinical trial of CBT for SAD vs wait-list control group during a study that enrolled patients from 2007 to 2010. SETTING University psychology department. PARTICIPANTS Seventy-five patients with generalized SAD randomly assigned to CBT or wait list. INTERVENTION Sixteen sessions of individual CBT for SAD. MAIN OUTCOME MEASURES Negative emotion ratings and functional magnetic resonance imaging blood oxygen-level dependent signal when reacting to and cognitively reappraising negative self-beliefs embedded in autobiographical social anxiety situations. RESULTS During reactivity trials, compared with wait list, CBT produced (1) greater reduction in negative emotion ratings and (2) greater blood oxygen-level dependent signal magnitude in the medial prefrontal cortex. During cognitive reappraisal trials, compared with wait list, CBT produced (3) greater reduction in negative emotion ratings, (4) greater blood oxygen level-dependent signal magnitude in the dorsolateral and dorsomedial prefrontal cortex, (5) earlier temporal onset of dorsomedial prefrontal cortex activity, and (6) greater dorsomedial prefrontal cortex-amygdala inverse functional connectivity. CONCLUSIONS AND RELEVANCE Modulation of cognitive reappraisal-related brain responses, timing, and functional connectivity may be important brain changes that contribute to the effectiveness of CBT for social anxiety. This study demonstrates that clinically applied neuroscience investigations can elucidate neurobiological mechanisms of change in psychiatric conditions. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00380731.

Social anxiety disorder is thought to be characterized by maladaptive self-views. This study investigated whether (a) patients with social anxiety disorder ( n = 75) differ at baseline from healthy controls ( n = 43) in negative and positive self-views, (b) cognitive-behavioral therapy (CBT) for social anxiety disorder versus wait-list control produces statistically and clinically significant changes in negative and positive self-views, (c) changes in self-views mediate the effect of CBT on social anxiety symptoms, and (d) changes in self-views during CBT related to social anxiety symptoms at 1-year post-CBT. As expected, patients endorsed more negative and fewer positive self-views than healthy controls at baseline. Compared to wait-list control, CBT yielded statistically and clinically significant changes, specifically, fewer negative and more positive self-views. Mediational analysis indicated that increased positive (but not reduced negative) self-views mediated the effect of CBT on social anxiety reduction. Correlational analyses determined that increased positive self-views were associated with social anxiety symptom reduction at 1-year post-CBT.

Mindfulness-based stress reduction (MBSR) is thought to reduce emotional reactivity and enhance emotion regulation in patients with social anxiety disorder (SAD). The goal of this study was to examine the neural correlates of deploying attention to regulate responses to negative self-beliefs using functional magnetic resonance imaging. Participants were 56 patients with generalized SAD in a randomized controlled trial who were assigned to MBSR or a comparison aerobic exercise (AE) stress reduction program. Compared to AE, MBSR yielded greater (i) reductions in negative emotion when implementing regulation and (ii) increases in attention-related parietal cortical regions. Meditation practice was associated with decreases in negative emotion and social anxiety symptom severity, and increases in attention-related parietal cortex neural responses when implementing attention regulation of negative self-beliefs. Changes in attention regulation during MBSR may be an important psychological factor that helps to explain how mindfulness meditation training benefits patients with anxiety disorders.

BACKGROUND:Social anxiety disorder (SAD) is widely thought to be characterized by heightened behavioral and limbic reactivity to socio-emotional stimuli. However, although behavioral findings are clear, neural findings are surprisingly mixed.METHODS:Using functional magnetic resonance imaging (fMRI), we examined behavioral and brain responses in a priori emotion generative regions of interest (amygdala and insula) in 67 patients with generalized SAD and in 28 healthy controls (HC) during three distinct socio-emotional tasks. We administered these socio-emotional tasks during one fMRI scanning session: 1) looming harsh faces (Faces); 2) videotaped actors delivering social criticism (Criticism); and 3) written negative self-beliefs (Beliefs).RESULTS:In each task, SAD patients reported heightened negative emotion, compared to HC. There were, however, no SAD versus HC differential brain responses in the amygdala and insula. Between-group whole-brain analyses confirmed no group differences in the responses of the amygdala and insula, and indicated different brain networks activated during each of the tasks. In SAD participants, social anxiety symptom severity was associated with increased BOLD signal in the left insula during the Faces task.CONCLUSIONS:The similar responses in amygdala and insula in SAD and HC participants suggest that heightened negative emotion responses reported by patients with SAD may be related to dysfunction in higher cognitive processes (e.g., distorted appraisal, attention biases, or ineffective cognitive reappraisal). In addition, the findings of this study emphasize the differential effects of socio-emotional experimental tasks.

BACKGROUND:Social anxiety disorder (SAD) is thought to involve deficits in emotion regulation, and more specifically, deficits in cognitive reappraisal. However, evidence for such deficits is mixed.METHODS:Using functional magnetic resonance imaging (fMRI) of blood oxygen-level dependent (BOLD) signal, we examined reappraisal-related behavioral and neural responses in 27 participants with generalized SAD and 27 healthy controls (HC) during three socio-emotional tasks: (1) looming harsh faces (Faces); (2) videotaped actors delivering social criticism (Criticism); and (3) written autobiographical negative self-beliefs (Beliefs).RESULTS:Behaviorally, compared to HC, participants with SAD had lesser reappraisal-related reduction in negative emotion in the Beliefs task. Neurally, compared to HC, participants with SAD had lesser BOLD responses in reappraisal-related brain regions when reappraising faces, in visual and attention related regions when reappraising criticism, and in the left superior temporal gyrus when reappraising beliefs. Examination of the temporal dynamics of BOLD responses revealed late reappraisal-related increased responses in HC, compared to SAD. In addition, the dorsomedial prefrontal cortex (DMPFC), which showed reappraisal-related increased activity in both groups, had similar temporal dynamics in SAD and HC during the Faces and Criticism tasks, but greater late response increases in HC, compared to SAD, during the Beliefs task. Reappraisal-related greater late DMPFC responses were associated with greater percent reduction in negative emotion ratings in SAD patients.CONCLUSIONS:These results suggest a dysfunction of cognitive reappraisal in SAD patients, with overall reduced late brain responses in prefrontal regions, particularly when reappraising faces. Decreased late activity in the DMPFC might be associated with deficient reappraisal and greater negative reactivity.TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT00380731.

Background: Social anxiety disorder (SAD) is characterized by distorted self-views. The goal of this study was to examine whether mindfulness-based stress reduction (MBSR) alters behavioral and brain measures of negative and positive self-views. Methods: Fifty-six adult patients with generalized SAD were randomly assigned to MBSR or a comparison aerobic exercise (AE) program. A self-referential encoding task was administered at baseline and post-intervention to examine changes in behavioral and neural responses in the self-referential brain network during functional magnetic resonance imaging. Patients were cued to decide whether positive and negative social trait adjectives were self-descriptive or in upper case font. Results: Behaviorally, compared to AE, MBSR produced greater decreases in negative self-views, and equivalent increases in positive self-views. Neurally, during negative self versus case, compared to AE, MBSR led to increased brain responses in the posterior cingulate cortex (PCC). There were no differential changes for positive self versus case. Secondary analyses showed that changes in endorsement of negative and positive self-views were associated with decreased social anxiety symptom severity for MBSR, but not AE. Additionally, MBSR-related increases in dorsomedial prefrontal cortex (DMPFC) activity during negative self-view versus case were associated with decreased social anxiety related disability and increased mindfulness. Analysis of neural temporal dynamics revealed MBSR-related changes in the timing of neural responses in the DMPFC and PCC for negative self-view versus case. Conclusion: These findings suggest that MBSR attenuates maladaptive habitual self-views by facilitating automatic (i.e., uninstructed) recruitment of cognitive and attention regulation neural networks. This highlights potentially important links between self-referential and cognitive-attention regulation systems and suggests that MBSR may enhance more adaptive social self-referential processes in patients with SAD.

OBJECTIVE:To examine whether changes in cognitive reappraisal self-efficacy (CR-SE) mediate the effects of individually administered cognitive-behavioral therapy (I-CBT) for social anxiety disorder (SAD) on severity of social anxiety symptoms.METHOD:A randomized controlled trial in which 75 adult patients (21-55 years of age; 53% male; 57% Caucasian) with a principal diagnosis of generalized SAD were randomly assigned to 16 sessions of I-CBT (n = 38) or a wait-list control (WL) group (n = 37). All patients completed self-report inventories measuring CR-SE and social anxiety symptoms at baseline and post-I-CBT/post-WL, and I-CBT completers were also assessed at 1-year posttreatment.RESULTS:Compared with WL, I-CBT resulted in greater increases in CR-SE and greater decreases in social anxiety. Increases in CR-SE during I-CBT mediated the effect of I-CBT on social anxiety. Gains achieved by patients receiving I-CBT were maintained 1-year posttreatment, and I-CBT-related increases in CR-SE were also associated with reduction in social anxiety at the 1-year follow-up.CONCLUSIONS:Increasing CR-SE may be an important mechanism by which I-CBT for SAD produces both immediate and long-term reductions in social anxiety.

OBJECTIVE:Effective treatments for social anxiety disorder (SAD) exist, but additional treatment options are needed for nonresponders as well as those who are either unable or unwilling to engage in traditional treatments. Mindfulness-based stress reduction (MBSR) is one nontraditional treatment that has demonstrated efficacy in treating other mood and anxiety disorders, and preliminary data suggest its efficacy in SAD as well.METHOD:Fifty-six adults (52% female; 41% Caucasian; age mean [M] ± standard deviation [SD]: 32.8 ± 8.4) with SAD were randomized to MBSR or an active comparison condition, aerobic exercise (AE). At baseline and post-intervention, participants completed measures of clinical symptoms (Liebowitz Social Anxiety Scale, Social Interaction Anxiety Scale, Beck Depression Inventory-II, and Perceived Stress Scale) and subjective well-being (Rosenberg Self-Esteem Scale, Satisfaction with Life Scale, Self-Compassion Scale, and UCLA-8 Loneliness Scale). At 3 months post-intervention, a subset of these measures was readministered. For clinical significance analyses, 48 healthy adults (52.1% female; 56.3% Caucasian; age [M ± SD]: 33.9 ± 9.8) were recruited. MBSR and AE participants were also compared with a separate untreated group of 29 adults (44.8% female; 48.3% Caucasian; age [M ± SD]: 32.3 ± 9.4) with generalized SAD who completed assessments over a comparable time period with no intervening treatment.RESULTS:A 2 (Group) x 2 (Time) repeated measures analyses of variance (ANOVAs) on measures of clinical symptoms and well-being were conducted to examine pre-intervention to post-intervention and pre-intervention to 3-month follow-up. Both MBSR and AE were associated with reductions in social anxiety and depression and increases in subjective well-being, both immediately post-intervention and at 3 months post-intervention. When participants in the randomized controlled trial were compared with the untreated SAD group, participants in both interventions exhibited improvements on measures of clinical symptoms and well-being.CONCLUSION:Nontraditional interventions such as MBSR and AE merit further exploration as alternative or complementary treatments for SAD.

Self-compassion refers to having an accepting and caring orientation towards oneself. Although self-compassion has been studied primarily in healthy populations, one particularly compelling clinical context in which to examine self-compassion is social anxiety disorder (SAD). SAD is characterized by high levels of negative self-criticism as well as an abiding concern about others' evaluation of one's performance. In the present study, we tested the hypotheses that: (1) people with SAD would demonstrate less self-compassion than healthy controls (HCs), (2) self-compassion would relate to severity of social anxiety and fear of evaluation among people with SAD, and (3) age would be negatively correlated with self-compassion for people with SAD, but not for HC. As expected, people with SAD reported less self-compassion than HCs on the Self-Compassion Scale and its subscales. Within the SAD group, lesser self-compassion was not generally associated with severity of social anxiety, but it was associated with greater fear of both negative and positive evaluation. Age was negatively correlated with self-compassion for people with SAD, whereas age was positively correlated with self-compassion for HC. These findings suggest that self-compassion may be a particularly important target for assessment and treatment in persons with SAD.

Anxiety arising during pain expectancy can modulate the subjective experience of pain. However, individuals differ in their sensitivity to pain expectancy. The amygdale and hippocampus were proposed to mediate the behavioral response to aversive stimuli. However, their differential role in mediating anxiety‐related individual differences is not clear. Using fMRI, we investigated brain activity during expectancy to cued or uncued thermal pain applied to the wrist. Following each stimulation participants rated the intensity of the painful experience. Activations in the amygdala and hippocampus were examined with respect to individual differences in harm avoidance (HA) personality trait, and individual sensitivity to expectancy, (i.e. response to cued vs. uncued painful stimuli). Only half of the subjects reported on cued pain as being more painful than uncued pain. In addition, we found a different activation profile for the amygdala and hippocampus during pain expectancy and experience. The amygdala was more active during expectancy and this activity was correlated with HA scores. The hippocampal activity was equally increased during both pain expectancy and experience, and correlated with the individual's sensitivity to expectancy. Our findings suggest that the amygdala supports an innate tendency to approach or avoid pain as reflected in HA trait, whereas the hippocampus mediates the effect of context possibly via appraisal of the stimulus value. Hum Brain Mapp, 2010. © 2009 Wiley‐Liss, Inc.

PURPOSE:To assess the applicability of T1-weighted images in the presence of a contrast agent for functional mapping free of susceptibility artifacts, in comparison to the blood oxygenation level-dependent (BOLD) imaging.MATERIALS AND METHODS:Six patients and five control subjects were scanned using BOLD and T1-weighted functional imaging, in the presence of a Gd-DTPA contrast-agent (TOFICA). In the control group, low- and high-resolution BOLD images were performed. Functional stimuli included motor and language activations.RESULTS:Both BOLD and TOFICA methods resulted in activations in the expected anatomical regions. The TOFICA mapping gave less distributed and with higher percent signal changes in comparison with the BOLD images. Gd-DTPA remained almost constant in the blood for at least 15 min post injection. In one patient with surgical clips, no signal was detected in the left cerebral hemisphere using BOLD imaging, but activation could be mapped using the TOFICA method.CONCLUSION:T1-weighted imaging in the presence of a contrast agent can be used for functional mapping. This method is insensitive to susceptibility artifacts, and is therefore advantageous in the evaluation of presurgical cases and in areas of the brain close to cavities in which the BOLD method cannot reliably be applied.