Literature Review - Psychology
Integrate and synthesize the below 6 peer-reviewed journal articles and how they relate to social anxiety.
References Below/Articles attached
Hajure, M., & Abdu, Z. (2020). Social Phobia and Its Impact on Quality of Life Among Regular Undergraduate Students of Mettu University, Mettu, Ethiopia. Adolescent health, medicine, and therapeutics, 11, 79–87. https://doi.org/10.2147/AHMT.S254002
Hakami, R. M., Mahfouz, M. S., Adawi, A. M., Mahha, A. J., Athathi, A. J., Daghreeri, H. H., Najmi, H. H., & Areeshi, N. A. (2018). Social anxiety disorder and its impact in undergraduate students at Jazan University, Saudi Arabia. Mental illness, 9(2), 7274. https://doi.org/10.4081/mi.2017.7274
Kampmann, I. L., Emmelkamp, P. M. G., Hartanto, D., Brinkman, W.-P., Zijlstra, B. J. H., & Morina, N. (2016). Exposure to virtual social interactions in the treatment of social anxiety disorder: A randomized controlled trial. Behaviour Research & Therapy, 77, 147–156. https://doi-org.ezp.waldenulibrary.org/10.1016/j.brat.2015.12.016
Kivity, Y., Cohen, L., Weiss, M., Elizur, J., & Huppert, J. D. (2021). The role of expressive suppression and cognitive reappraisal in cognitive behavioral therapy for social anxiety disorder: A study of self-report, subjective, and electrocortical measures. Journal of Affective Disorders, 279, 334–342. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jad.2020.10.021
Mesri, B., Niles, A. N., Pittig, A., LeBeau, R. T., Haik, E., & Craske, M. G. (2017). Public speaking avoidance as a treatment moderator for social anxiety disorder. Journal of behavior therapy and experimental psychiatry, 55, 66–72. https://doi.org/10.1016/j.jbtep.2016.11.010
Rosen, A. (2021). How Social Anxiety Impacts Higher Education and Career Choices - The Center for Treatment of Anxiety and Mood Disorders. Retrieved 27 August 2021, from https://centerforanxietydisorders.com/social-anxiety-impacts-higher-education-career-choices/
O R I G I N A L R E S E A R C H
Social Phobia and Its Impact on Quality of Life
Among Regular Undergraduate Students of Mettu
University, Mettu, Ethiopia
This article was published in the following Dove Press journal:
Adolescent Health, Medicine and Therapeutics
Mohammedamin Hajure
Zakir Abdu
Department of Psychiatry, Mettu
University, Mettu, Oromia, Ethiopia
Video abstract
Point your SmartPhone at the code above. If you have a QR
code reader the video abstract will appear. Or use:
https://youtu.be/ggViE65C2Fo
Background: Social anxiety disorder is a serious and disabling mental health problem that
begins before or during adolescence, with the potential to significantly interfere with an
individual’s daily functioning and overall quality of life.
Objective: The aims of this study were to assess the prevalence, severity, and quality of life
towards social anxiety disorder among students of Mettu University, Ethiopia.
Subjects and Methods: A cross-sectional study was conducted among a stratified sample
of 523 undergraduate students to identify the prevalence, correlates of social anxiety dis-
order, and impacts on quality life. All participants completed the Social Phobia Inventory,
Liebowitz Social Anxiety Scale, and World Health Organization Quality of Life-Brief Form,
Turkish Version (WHOQOL-BREF-TR). Of 523 students, 26% were screened positive for
social anxiety disorder. About 69.4% and 17.4% of the students had mild and moderate
symptoms of social anxiety disorder, respectively. WHOQOL BREF-TR scores showed that
students with social phobia had significantly lower quality of life quality than those without
social phobia. Being criticized by others or fear of parties was the most commonly feared
situations. Talking to strangers was the most commonly avoided situations. Being females,
current tobacco use, and family history of psychiatric illness were factors significantly
associated with social phobia symptoms using logistic regression analysis.
Conclusion: The current study shows high prevalence of social phobia among the university
students and its significant negative effects on quality of life which require prompt identi-
fication and treatment.
Keywords: social anxiety, university, quality of life
Background
Social phobia or social anxiety disorder is a serious and disabling mental health
problem that begins before or during adolescence, has a chronic course, is asso-
ciated with significant impairment in social functioning and work, and reduced
quality of life.1 Among university, social phobia symptoms arise in a great number
of students or existing symptoms increase.2 During this period, students go into the
effort of having himself or herself accepted by others as a self-governing person
and showing himself or herself. Performing or giving a talk in front of an audience
was the most commonly feared situations and also showed an association with
increased disability, and impaired quality of life.3,4
It is generally estimated that 13% of the population will meet the diagnostic criteria
for lifetime social phobia with onset typically occurring in adolescence or early
Correspondence: Mohammedamin
Hajure
Email [email protected]
Adolescent Health, Medicine and Therapeutics Dovepress
open access to scientific and medical research
Open Access Full Text Article
submit your manuscript | www.dovepress.com Adolescent Health, Medicine and Therapeutics 2020:11 79–87 79
http://doi.org/10.2147/AHMT.S254002
DovePress © 2020 Hajure and Abdu. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/
terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing
the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.
For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
http://orcid.org/0000-0002-4596-9611
http://orcid.org/0000-0001-5637-5651
http://www.dovepress.com
http://www.dovepress.com
https://www.facebook.com/DoveMedicalPress/
https://twitter.com/dovepress
https://www.linkedin.com/company/dove-medical-press
https://www.youtube.com/user/dovepress
http://www.dovepress.com/permissions.php
adulthood.5 However, recent studies suggest that lifetime
prevalence rates may be much higher.6,7 After major depres-
sion disorder and alcohol dependence, social anxiety disorder
is the third most common disorder in the general population
and it is also the most prevalent anxiety disorder.8
A cross-sectional study conducted in Swedish, Jordan
University, Saudi Arabia (2014), and University of
Parakuo students showed that about 9–16.1% of partici-
pants were positive of social phobia.9–12 Research con-
ducted in Nigeria shows SAD in about 9.4% which states
that there will be a significant difference in the phobic
health of adolescents in the selected private and public
Nigerian universities.13
In Ethiopia, research conducted on prevalence of social
phobia among high school students in Woldia, Gondar and
Hawassa was 27.5%, 31.2%, 32.8%.14–16 Factors have shown
to have an association include being the first or only child,17
medical science faculties,18,19 being female, younger age, reli-
gion, marital status (unmarried), the presence psychiatric ill-
ness, having a positive family history of mental disorder had
a significant role for development of social phobia.16,20
Evidence showed that social phobia was associated with sub-
stance use,21 low socioeconomic status, unemployment, low
level of education, and social support.22 Also decreased aca-
demic achievement, poor clinical exam performance,11 and
impaired quality of life23 also shown to have associated with
social phobia.
Despite the high worldwide burden of social phobia,
like shy, withdraw, unfriendly, and disinterested in social
activity and limited evidence is available, particularly in
developing countries. To the best of the author’s knowl-
edge, no study has investigated the effects of social phobia
on quality of life in Ethiopia. The present study aimed to
determine the prevalence of social phobia among univer-
sity students, its correlate, and impacts on quality of life.
Subjects and Methods
An institution based cross-sectional study conducted at Mettu
University from May to April, 2019. Mettu University is one
of the higher institutions in Ethiopia, which is a third
Generation University. It is located at 600 km southwest of
Addis Ababa. Mettu University established in 2011. Mettu
University currently has two campuses. Main campus was
study area containing 7 faculties. Those are faculty of health
science, faculty of natural and computational science, faculty
of social science and Humanity, school of law. The campus has
a total of 43 departments and 8290 regular undergraduate
students.
This study included 8290 undergraduate students at
Mettu University during the 2019–2020 academic years.
Using a confidence interval of 95%, 5% margin of error,
design effect of 2, the prevalence of social phobia of
19.9%16 and adding 10% non-response rate of 10%, mak-
ing a final number of participants to be 523. As such, 523
students were selected as the study group.
A study is part of a mega project undertaken in among
regular undergraduate students of Mettu University and
previously published study assessing suicidal behavior
among this population were also part of the project.24
Multistage stratified sampling technique was used to
select the study participants. Stratification was first done
on the faculty/college level, then by department and by
the year of study. Finally, taking students from registration
as a sampling frame a random selection was done. All
regular undergraduate students aged 18yrs old and above
were included, while critically ill students were excluded.
A self-administered structured questionnaire was used
to collect information. Questionnaires about demographic,
family and campus related and clinical factors were devel-
oped after an extensive review of literatures and similar
study tools. Rating instruments included the Social Phobia
Inventory to detect Social Phobia, the Liebowitz Social
Anxiety Scale to measure the severity of Social Phobia
and the WHO Quality of Life – BREF questionnaire to
assess Quality of Life. The questionnaire was translated to
Amharic and Afaan Oromo language, and then retranslated
back to English so as to see and keep the consistency.
Pretest was done on 26 students in Bedele agricultural
campus whose completed the questionnaires beforehand
and the questions were evaluated and re-arranged accord-
ingly before actual data collection.
Ethical clearance was obtained from the ethical review
board of Mettu University and permission was obtained
from the concerned body.
Rating Instruments
Social Phobia Inventory (SPIN, a 17-item self-rating scale
developed to measure social phobia). It shows the symp-
tom domains of social phobia (fear, avoidance, and phy-
siological arousal) and has reliable and valid psychometric
properties in screening social phobia in adolescents and
other populations. The Cronbach’s α in this study was
0.87. Subjects are asked to rate symptoms occurrences as
0 (not at all), 1 (a little bit), 2 (somewhat), 3 (very much),
or 4 (extremely during the past week) and the sum score
ranged from 0 to 68. A student with a score of 20 and
Hajure and Abdu Dovepress
submit your manuscript | www.dovepress.com
DovePress
Adolescent Health, Medicine and Therapeutics 2020:1180
http://www.dovepress.com
http://www.dovepress.com
above on SPIN will be considered as having social
phobia.25
Liebowitz Social Anxiety Scale is a self-rating scale
used to rate fear/anxiety and avoidance regarding com-
monly feared performance or social situations. The scale
includes 24 items and 2 subscales. The first subscale has
11 items and investigates social relationships. The second
subscale has 13 items and investigates performance. The
4-point Likert-type scale measures the intensity of fear and
avoidance behaviour during the previous week. It has
a good internal consistency and evaluates the severity of
fear and avoidance in common social situations. A score of
<55 suggests mild social anxiety disorder, 55–64 suggests
the moderate social anxiety disorder, 65–79 suggests
marked social anxiety disorder, 80–94 suggests severe
social anxiety disorder, and >95 suggests very severe
social anxiety disorder. It is validated in and reliable for
measuring the severity of social phobia26. The Cronbach’s
α in this study was 0.98.
World Health Organization Quality of Life Scale –
Brief version (WHOQOL – BREF) which is a 26-item self-
administered generic questionnaire. It produces a profile
with four domain scores: physical health (7 items), psy-
chological health (6 items), social relationships (3 items),
environmental domain (8 items) as well as two separately
scored items about the individuals‟ perception of their
quality of life (QI) and health (Q2). Each item was scored
in a Likert format from 1 (very dissatisfied) to 5 (very
satisfied) in a positive direction, which means that higher
scores indicate a higher quality of life. The scores of ques-
tions 3, 4 and 26 are reversed, so as to transform these
negatively framed questions to positively frame. The
Turkish version of the form had an internal validity score
of 0.83 (Cronbach’s alpha) in physical terms, 0.66 in men-
tal terms, 0.53 in social terms, and 0.73 in both environ-
mental and environment-national terms27. The Cronbach’s
α in this study was 0.82
Statistical Analysis
The data were analyzed using SPSS version 21. Descriptive
(frequency and percentage) and inferential statistics (chi
square test was used for categorical variables, and ANOVA
(analysis of variance) were used to compare groups in terms
of SPIN and LSAS scores).
An independent samples t-test was used to analyze the
difference between the two groups (students with/without
social anxiety disorder). Logistical regression analysis was
used to evaluate the significance of the relationship between
two dependent and independent variables. The Pearson cor-
relation coefficient was used for correlation analysis.
Result
Socio-Demographic Characteristics of
the Study Participants
A total of 523 participants were recruited for the study,
which makes the response rate 100%. The results show
that 270 (51.6%) of respondents were males and 253
(48.6%) were females. The mean age of students was
22.07 (SD = 2.36), with ages ranging from 18 to 32
years and the majority of them (61.0%) were at the age
of 22 years or below. The sample consisted of different
faculties with the highest number of engineering faculty
(110, 21.0%) and the lowest number from Institute of
education (42, 8.0%) which was proportionally recruited
from each stratum. Also the study has revealed that 351
(67.1%) of the participants had one of two siblings and
most perceived that their family income as bad (58.9%).
The majority of the participants 319 (61.0%) were from
rural backgrounds and first-year students comprises the
majority of participants (222, 42.4%) (Table 1).
Social Phobia
The regarding students’ reports of their social phobia
symptoms, the analysis (Table 2) showed that the mean
score for students in general was 13.08 (SD = 9.24), with
scores ranging from 0 to 43. About, 70% (n = 361) had
a score of 16 or less.
Further analysis using LSAS score, for the levels of
social anxiety symptoms showed that the majority of uni-
versity students had mild symptoms, 69.4% (n = 363)
followed by moderate symptoms 91 (17.4%), and those
with marked to severe represented about 13.2% (n = 69).
The Cronbach’s alpha for LSAS scale obtained in this
sample was 0.976.
As shown in Table 2, 25.8% of the subjects had a SPIN
score of 19 (Connor et al, 2000), and more which accounted
for about one-fourth of participants, ie, There was
a statistically significant difference in the prevalence of
SAD regarding the age category, birth order, faculties, family
history of mental illness. Being a younger age18–20 group was
associated with higher prevalence of SAD (26.7%) and being
in the age group of 21–23years was associated with lower
prevalence of SAD (9.6%) (X2= 0.24, P<0.05). There is
a higher prevalence of SAD among students in Engineering
Dovepress Hajure and Abdu
Adolescent Health, Medicine and Therapeutics 2020:11
submit your manuscript | www.dovepress.com
DovePress
81
http://www.dovepress.com
http://www.dovepress.com
faculties, while lower prevalence is seen in the faculty of
social science and humanities (X2=0.163, P<0.05).
The results of the present study show that significantly
more of the students without social phobia have a family
history of psychiatric illness than those with social phobia.
Table 1 The Basic Sociodemographic, Clinical and Substance
Use Characteristics of the Participants (n= 523)
Variables Categories Frequency Percentage
Sex Male 270 51.6
Female 253 48.6
Age 18–20 148 28.3
21–23 87 16.6
24–26 149 28.5
≥27 139 26.6
Ethnicity Oromo 321 61.4
Amhara 117 22.4
Gurage 41 7.8
Tigre 25 4.8
Others* 19 3.6
Faculty Engineering 110 21.0
Health sciences 97 18.5
Social science and
humanities
85 16.3
Natural and
computational
89 17.0
Business and
economics
52 9.9
School of Law 48 9.2
Institute of
education
42 8.0
Residence
before campus
Urban 204 39.0
Rural 319 61.0
Birth order Frist or only child 123 23.5
Middle 320 61.2
Last 80 15.3
Year of study First 130 24.9
Second 133 25.4
Third 107 20.5
Fourth 77 14.7
Fifth 76 14.5
Alcohol use Yes 299 57.4
No 127 42.5
Cigarette use Yes 78 14.9
No 53 67.9
Khat use Yes 98 18.3
No 67 68.4
Note: *Wolayta, Dawuro, Kefa, Sidama, Gurage, Silte.
Table 2 Comparing Social Phobia with Demographic and Clinical
Variables
Variables Categories Frequency Percentage
Sex Male 270 51.6
Female 253 48.6
Age 18–20 148 28.3
21–23 87 16.6
24–26 149 28.5
≥27 139 26.6
Ethnicity Oromo 321 61.4
Amhara 117 22.4
Gurage 41 7.8
Tigre 25 4.8
Others* 19 3.6
Faculty Engineering 110 21.0
Health sciences 97 18.5
Social science
and humanities
85 16.3
Natural and
computational
89 17.0
Business and
economics
52 9.9
School of Law 48 9.2
Institute of
education
42 8.0
Residence before
campus
Urban 204 39.0
Rural 319 61.0
No. of siblings Mean ±SD (1.98±1.16)
Birth order Frist or only
child
123 23.5
Middle 320 61.2
Last 80 15.3
Fathers education No formal
education
50 9.6
Primary school 217 41.5
Secondary
school
137 26.2
Above
secondary
119 22.8
Mothers’
education
No formal
education
62 11.9
Primary school 187 35.8
Secondary
school
235 44.9
Above
secondary
39 7.5
Perceived family
monthly income
Bad 308 58.9
Moderate 127 24.3
(Continued)
Hajure and Abdu Dovepress
submit your manuscript | www.dovepress.com
DovePress
Adolescent Health, Medicine and Therapeutics 2020:1182
http://www.dovepress.com
http://www.dovepress.com
However, with respect to gender, ethnicity, year of study,
family educational status, perceived family income, and
residency, there was no statistically significant difference
in the prevalence of SAD (all P values >0.05).
Using logistical regression analysis, three independent
variables that were significantly shown to have association
in the final model. The risk of social phobia was 1. Ninety-
five-fold higher among female students than male students, 1.
Eighty-four-fold higher among those with a family history of
psychiatric illness than those without, and 2. Ninety-five-fold
higher among students who smoked cigarettes in the past
3months compared to those who did not (Table 3).
Using item analysis to examine the items that had the
highest and lowest scores (Table 4), the analysis showed
that the mean items ranged from 0.56 (SD = 0.81) (item
13: Heart palpitations bother me when I am around peo-
ple) to 0.99 (SD = 1.07) (item 2: I am bothered by blush-
ing in front of people).
The highest three items in addition to item 2 were item
10 (M = 0.96, SD = 1.10: Talking to strangers scares me)
and item 7 (M = 0.85, SD = 1.009: Sweating in front of
people causes me distress). This also goes for the highest
three items that students reported being very much to
extremely experiencing social phobia symptoms over the
past week as items 2, 10, and 7 had the highest percentage
among all other items.
Table 2 (Continued).
Variables Categories Frequency Percentage
Good 88 16.8
Year of study First 130 24.9
Second 133 25.4
Third 107 20.5
Fourth 77 14.7
Fifth 76 14.5
Alcohol use Yes 299 57.4
No 127 42.5
Cigarette use Yes 78 14.9
No 53 67.9
Khat use Yes 98 18.3
No 67 68.4
Note: *Wolayta, Dawuro, Kefa, Sidama, Gurage, Silte.
Table 3 Logistical Regression Analysis Showing Factors
Associated with Social Phobia Among Students in Mettu Health
Science Students, Mettu, Ethiopia, 2019 (n=523)
Variables Category COR (95% CI) AOR (95% CI)
Sex Male
®
Female
1.78 (1.20–2.64) 2.04 (1.26–3.28)*
Previous history of
chronic physical
illness
No
®
Yes
1.83 (1.02–3.30) 1.84 (1.01–3.35)*
Current tobacco
use
No
®
Yes
1.27 (.74–2.2) 2.95 (1.36–6.40)**
Lifetime khat use No
®
Yes
1.99 (1.00–3.99) 1.52 (0.68–3.37)
Residence Urban
®
Rural
4.52 (2.69–7.7) 1.24 (.494–3.12)
Notes: *P value < 0.05, **P value < 0.01, VIF 1.06–2.10. Hosmer–Lemeshow -
goodness of fit test corresponding, P value = 0.77, Reference =
®
.
Abbreviations: COR, crude odds ratio; AOR, adjusted odds ratio.
Table 4 Item Analysis of SPIN Among University Student in
Mettu (n= 523)
Item Mean SD
1 I am afraid of people in authority. 0.68 0.976
2 I am bothered by blushing in front of people. 0.99 1.073
3 Parties and social events scare me. 0.82 0.957
4 I avoid talking to people I do not know. 0.75 0.961
5 Being criticized scares me a lot. 0.85 0.959
6 Fear of embarrassment causes me to avoid doing
things or speaking to people.
0.80 0.921
7 Sweating in front of people causes me distress. 0.85 1.009
8 I avoid going to parties. 0.79 0.892
9 I avoid activities in which I am the center of attention. 0.79 0.993
10 Talking to strangers scares me. 0.96 1.109
11 I avoid having to give speeches. 0.83 0.990
12 I would do anything to avoid being criticized. 0.65 0.925
13 Heart palpitations bother me when I am around
people.
0.56 0.811
14 I am afraid of doing things when people might be
Watching.
0.59 0.885
15 Being embarrassed or looking stupid is my worst
fears.
0.67 0.931
16 I avoid speaking to anyone in authority. 0.72 0.888
17 Trembling or shaking in front of others is distressing
to me.
0.78 0.955
Notes: Copyright ©, Jonathan Davidson. 1995, 2008, 2015. All rights reserved.
Permission to use the SPIN must be obtained from the copyright holder at
[email protected] The SPIN may not be reproduced or transmitted in any form,
or by any means, electronic or mechanical, or by any information storage or
retrieval system without permission in writing from the copyright holder.
Dovepress Hajure and Abdu
Adolescent Health, Medicine and Therapeutics 2020:11
submit your manuscript | www.dovepress.com
DovePress
83
http://www.dovepress.com
http://www.dovepress.com
The highest mean item scores varied among the two
subscales (more among physiological discomfort) and also,
two of lowest mean item scores (item 1,14) belong to fear of
the social situation subscale. The results do not strictly
support the mean scores of the subscales mentioned above
in Table 2 that physiological discomfort in social situation
was the lowest reported subscale among the three subscales.
The Cronbach’s alpha for SPIN scale obtained in this study
sample was 0.869. Generally, about one-fourth of the stu-
dents showed positive symptoms of social phobia (score of
>19) and the majority of them present with mild category.
Quality of Life of Students with and
Without Social Phobia
Study participants’ quality of life was assessed by the
world health organization quality of life brief version
scale (WHOQOL-BREF) and the mean total quality of
life score was found to be (70.87+16.22). The highest
QOL domain of the students with social phobia in the
current study was environmental health domain mean
score of (23.55 ± 3.46), followed by physical health
domain mean score of (22.34±3.76), psychological health
domain mean score of (17.67±2.62) and social relation-
ships domain mean score of (6.87±2.27). The WHOQOL-
BREF scale demonstrated a high internal consistency
reliability coefficient (Cronbach’s alpha=0.821).
WHOQOL-BREF-TR scores showed that students with-
out social phobia had significantly higher quality of life scores
in all areas than the students with social phobia (Table 5).
Correlating SPIN and LSAS with QOL
Scores
As seen in Table 6. Regarding correlation of LSAS scores
to QOL scores, they were negatively correlated with
respect to physical health, psychological health, social
relationship and environment, although not significant in
majority of the domains, except the psychological domain.
Again, SPIN scores were also negatively correlated
with QOL scores in all areas. Thus, social phobia was
associated with reported deterioration in physical, psycho-
logical health, social relationship and environmental func-
tioning. SPIN and LSAS scores were found to be more
strongly correlated with psychological domain scores and
SPIN score were more strongly correlated with physical
health domain compared to other domain (Table 6).
Discussion
This study aims on the prevalence of social phobia and its
impact on quality of life among university students in
Mettu, South western, Ethiopia. The prevalence of social
phobia varies widely among different countries. In this
study, social phobia was found in 26% of subjects, much
more than other studies among undergraduate university
students in different settings.18,28-31 Regarding the severity
of social phobia, using LSAS score, the majority of the
students have mild forms of social anxiety disorder. In
other words, levels of social anxiety symptoms show
about 17.4% of them had moderate symptoms, which is
in line with the study undertaken at the University of
Jordan (6.8%). However, the finding was lower than
study done in Woldia, Ethiopia (27.5%),15 Saudi Arabia,
Table 5 Mean Distribution of QOL of Students with and
Without Social Phobia at Mettu University, 2019
Areas Students with
Social Phobia
(χ ± SD)
Students
Without Social
Phobia (χ ± SD)
Analysis*
T P
Physical 22.34±3.76 21.55±4.49 −1.821 < 0.01
Psychological 17.67±2.62 16.03±4.03 −4.42 < 0.001
Social 6.87±2.27 5.59±2.93 −4.59 < 0.001
Environmental 23.55±3.46 22.01±5.02 −3.32 < 0.001
Notes: ANOVA, χ ± SD (arithmetic mean ± standard deviation). *For all analyses
the degree of freedom was 522.
Abbreviation: QOL, quality of life.
Table 6 Correlating SPIN and LSAS with QOL Scores
Instrument Domain of Quality of Life
Physical Health Psychological Health Social Relationship Environmental
LSAS score R −0.010 −0.168 −0.019 −0.053
P value 0.820 0.000 0.662 0.227
SPIN score r −0.199 −0.102 −0.082 −0.013
P value 0.000 0.020 0.062 0.768
Note: r = Pearson correlation coefficient.
Abbreviations: SPIN, Social Phobia Inventory; LSAS, Liebowitz Social Anxiety Scale; QOL, quality of life.
Hajure and Abdu Dovepress
submit your manuscript | www.dovepress.com
DovePress
Adolescent Health, Medicine and Therapeutics 2020:1184
http://www.dovepress.com
http://www.dovepress.com
Riyadh (24.3%).32 Different studies have shown an asso-
ciation of social phobia with gender. The results of the
current study, which showed higher social phobia scores of
female students compared to their counterparts. This was
in line with the international report of different countries
such as India,11 Turkey,33 German.3 However, in one study
social phobia prevalence is found to be higher in men in
studies of prevalence conducted with clinical samples.34
The current study shows an association of cigarette
smoking and social anxiety disorder. This finding was in
agreement with international report such as in the USA35
and Turkey.36 The reason behind might be related to
smoking, which used for its reinforcing effect, by socially
anxious people to elevated negative affect especially for
social interaction.37
In contrast to studies done in Australia18 and Swedish,9
SAD was more prevalent among students of engineering
faculties than students of social science and humanities
faculties. It may be related to the consequences of social
anxiety on academic performance during pre-engineering
years and career choices made thereafter, in addition to
a larger quota of students in the school, as this stage
greatly matters their life on the campus, particularly.
Considering birth order, SAD was more prevalent
among first or only child than being middle or last child.
Which was in agreement with study done in Egypt (birth
order).17 It was hypothesized that the first-born child will
have a higher level of social anxiety than a non-first born
child.38
In terms of age, the current study shows significant
association, with higher prevalence of SAD among stu-
dents in the age group of 18–20 years as compared to older
age groups. The finding was in accordance with many of
the prior studies, shown an early onset of social anxiety
symptoms.20
Family history of psychiatric illness was found to have
significant association with SAD. This could be explained
by studies showed association of social phobia and genetic
inheritability, although the underlying mechanisms remain
unclear.39
The most commonly reported feared social situations in
the target sample were being criticized by others or fear of
parties and social events, followed by doing things or speak-
ing to people and the most commonly avoided situations
were talking to strangers followed by being a center of
attention. These findings were consistent with result of earlier
studies.4 This is because college years are a critical period to
socialize themselves, particularly via social interaction.
Again their expectation matter the way they interact, they
may avoid such interaction because of negative evaluation.
The Effects of Social Phobia on Quality of
Life
To the best of the author’s knowledge, the present study is
the first to investigate the direct relationship between social
phobia and its impact on quality of life among university
students in Ethiopia. In the present study students with social
phobia had lower scores on all areas of life quality, including
physical and psychological health, social relationships, and
the environment than those without social phobia.
Results of an epidemiological study from report that
students with social phobia have reduced quality of life in
all domains as …
[page 42] [Mental Illness 2017; 9:7274]
Social anxiety disorder and its
impact in undergraduate stu-
dents at Jazan University,
Saudi Arabia
Ramzi M. Hakami,1
Mohamed S. Mahfouz,2
Abdulrahman M. Adawi,1
Adeebah J. Mahha,1 Alaa J. Athathi,1
Hadi H. Daghreeri,1 Hatim H. Najmi,1
Nuha A. Areeshi1
1Faculty of Medicine, Jazan University,
Jazan; 2Department of Family and
Community Medicine, Faculty of
Medicine, Jazan University, Jazan,
Saudi Arabia
Abstract
Although social anxiety disorder
(SAD) is a common mental disorder, it is
often under diagnosed and under treated.
The aim of this study is to assess the preva-
lence, severity, disability, and quality of life
towards SAD among students of Jazan
University, Saudi Arabia. A cross-sectional
study was conducted among a stratified
sample of 500 undergraduate students to
identify the prevalence of SAD, its corre-
lates, related disability, and its impact on the
quality life. All participants completed the
Social Phobia Inventory, Leibowitz Social
Anxiety Scale, Sheehan Disability Scale,
and the WHO Quality of Life – BREF ques-
tionnaire. Of 476 students, 25.8% were
screened positive for SAD. About 47.2% of
the students had mild symptoms, 42.3% had
moderate to marked symptoms, and 10.5%
had severe to very severe symptoms of
SAD. Students who resulted positive for
SAD reported significant disabilities in
work, social, and family areas, and this has
adversely affected their quality of life as
compared to those who screened negative
for SAD. Students reported several clinical
manifestations that affected their function-
ing and social life. Acting, performing or
giving a talk in front of an audience was the
most commonly feared situation. Blushing
in front of people was the most commonly
avoided situation. Since the present study
showed a marked prevalence of SAD
among students, increased disability, and
impaired quality of life, rigorous efforts are
needed for early recognition and treatment
of SAD.
Introduction
While most of us experience some level
of social unease when we feel scrutinized
by others, such as while speaking in public
or presenting at meetings, social anxiety
disorder (SAD) is defined as an excessive
and persistent fear of acting in a way that
will be embarrassing and humiliating. This
fear is almost invariably provoked by the
feared situations, which are avoided or
endured with severe distress, and interferes
significantly with personal, occupational,
and social functioning.1
Social anxiety disorder commonly
appears in the teenage years,2 and usually
affects 3 to 5% of youths.3 It is an extraor-
dinarily persistent condition if left untreated
and it may lead to a variety of comorbidi-
ties, such as other anxiety disorders, affec-
tive disorders, nicotine dependence, and
substance-use disorder,4-6 predicting poorer
treatment outcomes.7 Most of patients with
SAD have been reported to have at least
moderate impairment at some point in their
lives. Education, employment, family,
romantic relationships, friendships, social
networks, quality of life, and other areas of
life have been reported to be liable to
impairment in patients with SAD.8-12
Unfortunately, although it is the third most
common mental disorder in adults world-
wide,13 SAD is often under diagnosed and
undertreated.14 Furthermore, it has received
little attention by both clinicians and
researchers.8
In general, there is a lack of data on the
prevalence of SAD and the reported rates
vary widely between studies, with much of
the variability possibly being due to differ-
ent instruments used to determine diagno-
sis.10 However, SAD is obviously one of the
most common of all anxiety disorders.10 For
instance, Kesseler and colleagues (2005)
interviewed 9282 English-speaking partici-
pants aged 18 years and older and found
that SAD was the most common anxiety
disorder, with a lifetime prevalence of up to
12%15 and a 12-month prevalence of
6.8%.16
Studies looking at country-specific pop-
ulations of university students have pro-
duced quite variable results when it comes
to the prevalence of SAD. Many studies
have indicated that social anxiety is a preva-
lent disorder among university stu-
dents.11,12,17-20 For example, studies from
Sweden and India have reported the preva-
lence of SAD among university students to
be 16.1% and 19.5%, respectively.11,12 In
the Kingdome of Saudi Arabia, less is
known about SAD in general and among
undergraduate students. However, high
prevalence rates have been reported among
Saudis, especially adolescents and young
adults.21-25 Elhadad and colleagues (2017)
have carried out a study on 380 medical stu-
dents and found that as high as 59.5% of
them were screened positive for SAD. In
the same study, SAD was associated with
decreased academic achievement, weak
clinical exam performance, and avoidance
of oral presentation.22
The present study aims to investigate
SAD prevalence, severity, related disabili-
ties, and its impact in students from five
faculties at Jazan University, Saudi Arabia.
We expect that this study would be helpful
in bridging the gap in the local research of
SAD, and will be useful to the future studies
attempting to reduce the high prevalence of
this disorder and to prevent its long-term
consequences.
Materials and Methods
Study place, design and participants
Jazan University is situated in Jazan
region, southwest of the kingdom of Saudi
Arabia. It is the leading higher educational
institution in Jazan province. This is an
Mental Illness 2017; volume 9:7274
Correspondence: Ramzi Mohammed Hakami,
Faculty of Medicine, Jazan University, Jazan,
Saudi Arabia.
E-mail: [email protected]
Key words: Mental disorder; social phobia;
social anxiety disorder; Saudi Arabia; Social
Phobia Inventory.
Acknowledgements: the authors thank Dr.
Rashad Alsanosy (Substance Abuse Research
Center (SARC), Jazan University and the
Department of Family and Community
Medicine) for his assistance with the research
project.
Contributions: the authors contributed equally.
Conflict of interest: the authors declare no
potential conflict of interest.
Received for publication: 20 June 2017.
Revision received: 7 August 2017.
Accepted for publication: 8 August 2017.
This work is licensed under a Creative
Commons Attribution-NonCommercial 4.0
International License (CC BY-NC 4.0).
©Copyright R.M.Hakami et al., 2017
Licensee PAGEPress, Italy
Mental Illness 2017; 9:7274
doi:10.4081/mi.2017.7274
[Mental Illness 2017; 9:7274] [page 43]
observational cross-sectional survey target-
ing Jazan University students who are over
18 years and registered for the academic
year 2016/2017. The target colleges were
Applied Medical Sciences, Pharmacy,
Sciences, Computer sciences and Business
administration.
Sample size and sample design
A sample of 400 participants was esti-
mated for the purpose of this study. The
sample size was calculated using the formu-
la for a cross-sectional study, n=[(z2 * p *
q)]/d2. Sample size was calculated using the
following parameters: p=prevalence of
Knowledge 50%, Z=95% confidence inter-
val, d=error ≤5%, and a 25% non-response
rate. Probability proportional to size sam-
pling (PPS) was used to adjust the number
of students in each faculty.
Data collection
The structured questionnaire was writ-
ten in Arabic and distributed by six medical
students to the study population. After
explaining the purpose of the study and
obtaining verbal consents, data collectors
waited somewhere near for the completion
of the questionnaire to give the respondents
the opportunity to ask clarifying questions
regarding the interpretation of terms or
items in the questionnaire. All respondents
were asked to fill out the survey separately
to make sure that they do not duplicate each
other’s answers. The data collection process
took place in the period from November
2016 to January 2017.
Instruments
The questionnaire consisted of demo-
graphic information such as age, sex, facul-
ty type, family size, birth order, perceived
family income, marital status, and housing
type. Rating instruments included the Social
Phobia Inventory (SPIN) to detect social
anxiety disorder, the Leibowitz Social
Anxiety Scale (LSAS) to evaluate social
anxiety disorder severity, the Sheehan
Disability Scale (SDS) to assess disability
due to social anxiety disorder, and the WHO
Quality of Life – BREF questionnaire to
assess the quality of life. All study tools
were translated to simple Arabic by the
study authors. The questionnaire took about
15 to 20 minutes to complete.
Social Phobia Inventory
The SPIN is a short, self-rating scale
developed by Dr. K.M. Connor to capture
the social phobia symptoms.26 It consists of
17 items and each item is rated from 0 (not
at all) to 4 (extremely). The scale ranges
from 0-68. A score ≥19 suggests social anx-
iety disorder. It has good test-retest reliabil-
ity, internal consistency, convergent and
divergent validity and can be used for
screening of and detecting treatment
response to social anxiety disorder.
Regarding diagnosis of social anxiety disor-
der, it has a sensitivity of 73-85% and a
specificity of 69-84%. Although Shah and
Kataria12 used a cut-off point of 19 on this
scale in a similar study, Dogaheh27 reported
that the cut-off point of 29 resulted in bal-
anced sensitivity (0.96) and 1-specificity
(0.87), and it was more appropriate for this
study (a cut-off point of 19 resulted in an
oddly very high prevalence).
Liebowitz Social Anxiety Scale
The LSAS is self-rating scale developed
by Dr. Michael Liebowitz to rate fear/anxi-
ety and avoidance regarding 24 commonly
feared performance or social situations.28 It
consists of 13 performance-related items
and 11 social-related items which are rated
from 0 (none/never) to 3 (severe/usually). It
has a good internal consistency and evalu-
ates the severity of fear and avoidance in
common social situations. A score of <55
suggests mild social anxiety disorder, 55-64
suggests moderate social anxiety disorder,
65-79 suggests marked social anxiety disor-
der, 80-94 suggests severe social anxiety
disorder, and >95 suggests very severe
social anxiety disorder.
Sheehan Disability Scale
The SDS is a simple and commonly
used scale developed by David V.
Sheehan29 to evaluate functional impair-
ments/disabilities in the domains of work,
social life/leisure and family life/home
responsibility due to an anxiety disorder.
Each domain is rated on an 11-point, where
0=no impairment, 10=most severe, 1-
3=mild, 4-6=moderate, and 7-9=marked.
WHO Quality of Life – Bref
The WHOQOL-BREF is an abbreviated
version of the WHOQOL-100 developed by
the WHOQOL Group30 to assess the quality
of life in multiple dimensions, and it is
applicable cross-culturally. It consists of 26
items based on a four-domain structure:
Physical health (7 items), Psychological
health (6 items), Social relationships (3
items) and Environment (8 items), along
with a self-rating of general quality of life
Article
Table 1. Socio-demographic characteristics of participants.
Characteristics Male, n (%) Female, n (%) Total, n (%)
N=243 N=233 N=476
Age in years*
19 – 21 78 (32.1) 161 (70.9) 239 (50.8)
22 – 24 152 (62.6) 64 (28.2) 216 (45.9)
25 – 27 13 (5.3) 2 (0.9) 15 (3.2)
College
Applied Medical Sciences 44 (18.1) 41 (17.6) 85 (17.9)
Pharmacy 14 (5.8) 5 (2.1) 19 (4.0)
Business Administration 70 (28.8) 86 (36.9) 156 (32.7)
Computer Sciences 59 (24.3) 39 (16.7) 98 (20.6)
Sciences 56 (23) 62 (26.6) 118 (24.8)
Marital status*
Single 232 (95.9) 192 (83.8) 424 (90.0)
Married 8 (3.3) 31 (13.5) 39 (8.3)
Divorced 2 (0.8) 6 (2.6) 8 (1.7)
Family size*
<6 42 (17.3) 33 (14.4) 75 (15.9)
06-10 135 (55.6) 162 (70.7) 297 (62.9)
>10 66 (27.2) 34 (14.8) 100 (21.2)
Birth order*
First or only child 46 (18.9) 47 (20.5) 93 (19.2)
In the middle 159 (65.4) 144 (62.9) 303 (64.1)
Last baby 38 (15.6) 38 (16.6) 76 (16.1)
Perceived family income (SR/month)*
Very good 49 (20.3) 38 (17.4) 87 (19.0)
Good 117 (48.5) 98 (45.0) 215 (46.8)
Bad 75 (31.1) 82 (37.6) 157 (34.2)
Housing type*
Owning housing 191 (78.9) 207 (90.0) 398 (84.3)
Rent housing 51 (21.1) 23 (10.0) 74 (15.7)
*Because of missing responses, the total percentages do not add up to 100%.
(1 item) and general satisfaction with health
(1 item). It is self-administered and each
item is scaled from 1-5 in a positive direc-
tion, which means that higher scores indi-
cate a higher quality of life. Each domain
score (mean score of items within that
domain) is converted to a scale of 0-100 and
indicates an individual’s perception of qual-
ity of life in that domain. In the absence of
clear cut-off point for such study, a cut-off
point of 88.22 (70% of the total scores) was
used as suggested by Al-Fayez and Ohaeri31
and Xia et al.32
Statistical analysis
The data was analysed using SPSS ver-
sion 20. Descriptive (frequency and per-
centage) and inferential statistics (chi-
square test) were used to interpret the data.
An independent samples t-test was used to
analyse the difference between the two
groups (students with/without social anxi-
ety disorder). Pearson correlation coeffi-
cient was used for correlation analysis.
Ethical consideration
All participants were informed of their
rights to participate and that their informa-
tion would be kept anonymous and only
used for the purpose of this study. Ethical
approval was obtained from the University
Ethical Committee.
Results
Of 500 questionnaires, students com-
pleted 476 questionnaires giving a response
rate of 95.2%. Table 1 details the sociode-
mographic distribution of the study popula-
tion. The results show that 243 (51.1%) of
respondents were males and 233 (48.9%)
were females. The respondents’ age ranged
from 19 to 27 years. The mean, median, and
mode of students’ age were 21.49, 21, and
22 years, respectively (SD=1.57), which
indicates a fairly even distribution of partic-
ipants’ ages. The sample consisted of differ-
ent faculties with the highest number from
Business administration (156, 32.7%) and
the lowest number from Pharmacy (19,
4.0%). Most of the respondents (90%) were
single (N=424), 8.3% were married (N=39),
and 1.7% were divorced (N=8). Those who
lived in families consisted of 6-10 members
comprised the majority of the study popula-
tion (62.9%). Regarding birth order, a high
frequency of respondents (303, 64.1%)
reported that they were in the middle of
their families. Most of the study population
perceived their family income as very good
(19.0%) and good (46.8%), and lived in
their own household (84.3%).
Using a cut-off score of 29, participants
were screened positive for social anxiety
disorder if they scored 29 or higher on the
SPIN scale. Table 2 shows that 123 (25.8%)
students were screened positive for SAD,
71 of them (51.1%) were males and 52 were
females (42.3%). There was a statistically
significant difference in the prevalence of
SAD regarding the birth order. Being a first-
born child (or the only child) was associated
with least prevalence of SAD (15.6%) and
being a middle born child was associated
with higher prevalence of SAD (61.5%)
(X2=6.407, P<0.05). However, with respect
to gender, faculty type, family size, per-
ceived family income, and housing type,
there was no statistically significant differ-
ence in the prevalence of SAD (all P values
>0.05). In addition, as the range of age
groups was narrow, (i.e. most of students
were young adults, who are the target popu-
lation of this study) and as most of the stu-
dents were single, these two parameters
(age and marital status) were not signifi-
cantly associated (P=0.777 and P=0.511,
respectively) with the prevalence of SAD.
The Cronbach’s alpha for SPIN scale
obtained in this study sample was 0.85.
Using the LSAS scale to detect the
severity of SAD, 47.2% (N=58) had mild
symptoms, 42.3%, (N=52) had moderate to
marked symptoms, and 10.5% (N=13) had
severe to very severe symptoms. As shown
in Table 3, the descending ranking of com-
monly feared/avoided situations (LSAS
scale) was obtained. The most commonly
feared situations reported by students were
acting, performing or giving a talk in front
of an audience (75.0%, N=357), followed
by taking a test (74.0%, N=352). The most
commonly avoided situations reported by
students were blushing in front of people
(79.4%, N=377), followed by having to give
speeches (76.7%, N=365). The majority of
students (76.5%, N=364) reported that
being embarrassed or looking stupid is
among their worst fears. The Cronbach’s
alpha for LSAS scale obtained in this sam-
ple was (0.87) and (0.85) for the fear/anxi-
ety and avoidance domains, respectively.
An independent samples t-test was
employed to compare between students
with SAD and students without SAD in
their scores on the SDS and QOL scales. As
Table 4 shows, the difference between the
two groups was statistically significant.
Students who screened positive for SAD
reported significantly more disabilities in
the work (t(474)=6.596, P<0.01), social life
(t(473)=6.941, P<0.01), and home areas
Article
Table 2. Comparing social phobia with demographic variables of the participants.
Demographic variables SPIN score <29 SPIN score ≥29 X2 P value
n (%) n (%)
Study population 353 (74.2) 123 (25.8)
Gender 2.956 0.090
Male 172 (48.7) 71 (57.7)
Female 181 (51.3) 52 (42.3)
Age* 0.504 0.777
19 – 21 179 (51.1) 60 (50.0)
22 – 24 161 (46.0) 55 (45.8)
25 – 27 10 (2.9) 5 (4.2)
Faculty type 0.225 0.705
Health faculties 79 (22.4) 25 (20.3)
Others 274 (77.6) 98 (79.7)
Family size* 0.611 0.737
<6 53 (15.1) 22 (18.0)
06-10 223 (63.7) 74 (60.7)
>10 74 (21.1) 26 (21.3)
Birth order 6.407 0.041
First or only child 74 (21.1) 19 (15.6)
In the middle 228 (65.1) 75 (61.5)
Last baby 48 (13.9) 28 (23.0)
Perceived family income (SR/month)* 0.480 0.787
Very good 31 (9.2) 10 (8.3)
Good 104 (30.8) 34 (28.1)
Bad 203 (60.1) 77 (63.6)
Housing type* 1.985 0.192
Owning housing 300 (85.7) 98 (80.3)
Rent housing 50 (14.3) 24 (19.7)
SPIN, Social Phobia Inventory. *Because of missing responses, total percentages do not add up to 100%.
[page 44] [Mental Illness 2017; 9:7274]
[Mental Illness 2017; 9:7274] [page 45]
(t(474)=4.375, P<0.01). As well, students
who screened positive for SAD reported
significantly worse quality of life, that is,
they scored lower than students who
screened negative for SAD on the physical
health domain (t(473)=4.220, P<0.01), psy-
chological health domain (t(459)=3.970,
P<0.01), social relationship domain
(t(472)=1.999, P<0.05), and environment
domain (t(474)=2.297, P<0.05). The
Cronbach’s alpha for SDS scale obtained in
this sample was (0.74), and for QOL scale,
the Cronbach’s alpha for the respective
domains were 0.64 (physical health), 0.64
(psychological health), 0.55 (social rela-
tionships), and 0.72 (environment).
As shown in Table 5, both SPIN and
LSAS scores were positively correlated
with SDS scores. Thus, SAD and its severi-
ty were significantly associated with report-
ed disabilities in the areas of work, social
life, and home life. In contrast, both SPIN
and LSAS scores were negatively correlat-
ed with QOL score. This means that SAD
and its severity were significantly associat-
ed with deterioration in all domains of qual-
ity of life. In general, these results suggest
that students who screened positive for
SAD suffered more than students who
screened negative from deteriorated func-
tioning and quality of life.
Discussion
The main purpose of the present study
was to investigate SAD prevalence, severi-
ty, related disabilities, and its impact in
undergraduate students at Jazan University.
SAD symptoms may overlap with other dis-
eases making it challenging to recognize
and separate SAD from shyness or poor
social skills. Many studies of SAD from dif-
ferent countries and cultures reported wide-
ly varied estimates of the prevalence rang-
ing from 1.9% and 20.4% among the gener-
al population and depending on the diag-
nostic threshold.33 In the present study,
SAD was as high as 25.8% among the study
population, much higher than many other
studies among undergraduate stu-
dents.11,12,17,18,34 However, as SPIN, the
screening scale used in this study, has a
specificity of 0.84-0.94 and the analysis
using LSAS shows that 47.2% of those with
SAD have a mild degree of SAD, it can be
inferred that the prevalence might be lower
than identified. However, the prevalence
looks quite high even after this considera-
tion. Within the Saudi context, a few studies
have investigated SAD among university
students and most of them have been con-
ducted on medical students, making it diffi-
cult to compare our findings with a similar
study. However, consistently with the pres-
ent study, social anxiety have been revealed
to be a highly prevalent disorder in Saudi
Article
Table 3. Rank ordering of most commonly feared/avoided situations.
Rank Situation N (%)
Feared situations
1 Acting, performing or giving a talk in front of an audience 357 (75.0)
2 Taking a test 352 (74.0)
3 Speaking up at a meeting 326 (68.5)
4 Talking to people in authority 299 (62.8)
5 Meeting strangers 289 (60.7)
6 Working while being observed 289 …
lable at ScienceDirect
Behaviour Research and Therapy 77 (2016) 147e156
Contents lists avai
Behaviour Research and Therapy
journal homepage: www.elsevier.com/locate/brat
Exposure to virtual social interactions in the treatment of social
anxiety disorder: A randomized controlled trial
Isabel L. Kampmann a, *, Paul M.G. Emmelkamp c, d, Dwi Hartanto b,
Willem-Paul Brinkman b, Bonne J.H. Zijlstra e, Nexhmedin Morina a
a Department of Clinical Psychology, University of Amsterdam, Weesperplein 4, 1018 XA, Amsterdam, The Netherlands
b Interactive Intelligence Group, Delft University of Technology, Mekelweg 4, 2628 CD, Delft, The Netherlands
c Netherlands Institute for Advanced Study, Meijboomlaan 1, 2242 PR, Wassenaar, The Netherlands
d King Abdulaziz University, Abdullah Sulayman, 22254, Jeddah, Saudi Arabia
e Department of Educational Sciences, University of Amsterdam, Nieuwe Achtergracht 127, 1018 WS, Amsterdam, The Netherlands
a r t i c l e i n f o
Article history:
Received 4 September 2015
Received in revised form
19 December 2015
Accepted 23 December 2015
Available online 29 December 2015
Keywords:
Virtual reality
Exposure therapy
Social anxiety disorder
Social phobia
Social interaction
* Corresponding author.
E-mail address: [email protected] (I.L. Kampm
http://dx.doi.org/10.1016/j.brat.2015.12.016
0005-7967/© 2015 Elsevier Ltd. All rights reserved.
a b s t r a c t
This randomized controlled trial investigated the efficacy of a stand-alone virtual reality exposure
intervention comprising verbal interaction with virtual humans to target heterogeneous social fears in
participants with social anxiety disorder. Sixty participants (Mage ¼ 36.9 years; 63.3% women) diagnosed
with social anxiety disorder were randomly assigned to individual virtual reality exposure therapy
(VRET), individual in vivo exposure therapy (iVET), or waiting-list. Multilevel regression analyses
revealed that both treatment groups improved from pre-to postassessment on social anxiety symptoms,
speech duration, perceived stress, and avoidant personality disorder related beliefs when compared to
the waiting-list. Participants receiving iVET, but not VRET, improved on fear of negative evaluation,
speech performance, general anxiety, depression, and quality of life relative to those on waiting-list. The
iVET condition was further superior to the VRET condition regarding decreases in social anxiety symp-
toms at post- and follow-up assessments, and avoidant personality disorder related beliefs at follow-up.
At follow-up, all improvements were significant for iVET. For VRET, only the effect for perceived stress
was significant. VRET containing extensive verbal interaction without any cognitive components can
effectively reduce complaints of generalized social anxiety disorder. Future technological and psycho-
logical improvements of virtual social interactions might further enhance the efficacy of VRET for social
anxiety disorder.
© 2015 Elsevier Ltd. All rights reserved.
Social anxiety disorder (SAD) is defined as the fear of one or
more social situations in which one might behave embarrassingly
and be negatively evaluated by others (DSM-V; American
Psychiatric Association, 2013). SAD is one of the most common
mental disorders in the US population, with an estimated lifetime
prevalence of 12.1% (Ruscio et al., 2008). Individuals who suffer
from SAD can experience a reduced quality of life and significant
impairments in various areas of functioning, such as work and
interpersonal relationships (Wittchen, Fuetsch, Sonntag, Müller, &
Liebowitz, 2000). However, only about one third of individuals
with SAD seek treatment (Ruscio et al., 2008).
The most researched treatment for SAD is cognitive behavior
ann).
therapy (CBT). CBT aims at modifying maladaptive cognitions and
behavior using both cognitive (e.g., cognitive restructuring) and
behavioural (e.g., exposure) strategies (Hofmann & Smits, 2008;
Mayo-Wilson et al., 2014). During exposure therapy, participants
encounter feared stimuli in situations containing social interaction
until anxiety decreases and/or anxiety-related expectancies are
violated. Traditional exposure exercises are usually practiced dur-
ing therapy and as homework assignments. Interestingly, a meta-
analysis of treatment efficacy found exposure therapy alone to be
comparable to cognitive therapy and that the combination of both
was no more effective than either one delivered exclusively
(Powers, Sigmarsson, & Emmelkamp, 2008).
A relatively new form of exposure therapy is Virtual Reality
Exposure Therapy (VRET). During VRET, participants are confronted
with computer-generated stimuli (e.g. virtual social interaction)
that can elicit elevated subjective levels of social anxiety (Morina,
Delta:1_given name
Delta:1_surname
Delta:1_given name
Delta:1_surname
Delta:1_given name
Delta:1_surname
mailto:[email protected]
http://crossmark.crossref.org/dialog/?doi=10.1016/j.brat.2015.12.016&domain=pdf
www.sciencedirect.com/science/journal/00057967
http://www.elsevier.com/locate/brat
http://dx.doi.org/10.1016/j.brat.2015.12.016
http://dx.doi.org/10.1016/j.brat.2015.12.016
http://dx.doi.org/10.1016/j.brat.2015.12.016
I.L. Kampmann et al. / Behaviour Research and Therapy 77 (2016) 147e156148
Brinkman, Hartanto, & Emmelkamp, 2014; Powers et al., 2013).
Cumulative research suggests that VRET is effective in the treat-
ment of several anxiety disorders (Meyerbr€oker & Emmelkamp,
2010; Morina, Ijntema, Meyerbr€oker, & Emmelkamp, 2015; Opriş
et al., 2012; Parsons & Rizzo, 2008).
While VRET has been extensively studied in specific phobias,
research on the efficacy of VRET in the treatment of SAD is still
limited. Several studies suggest that VRET can reduce SAD symp-
toms (Anderson, Rothbaum, & Hodges, 2003; Anderson, Zimand,
Hodges, & Rothbaum, 2005; Klinger et al., 2005). However, only
three randomized controlled trials on the efficacy of VRET in SAD
have been conducted (Anderson et al., 2013; Bouchard et al., 2015;
Wallach, Safir, & Bar-Zvi, 2009). In the study by Wallach et al.
(2009), VRET for public speaking anxiety, a specific social anxiety
complaint, was combined with CBT and compared to CBT plus
imagery exposure, and waiting-list. Results revealed that VRET plus
CBT was effective in treating public speaking anxiety compared to
waiting-list and as effective as CBT plus imagery exposure. How-
ever, participants in this study were not screened for a clinical
diagnosis of SAD. Anderson et al. (2013) included participants with
a SAD diagnosis and compared the efficacy of CBT plus VRET with
CBT plus group exposure therapy. The authors reported that CBT
plus VRET was as effective as CBT plus group exposure therapy.
Nonetheless, the implications of the results of this study are rather
limited by the inclusion of participants who had reported public
speaking anxiety as their primary complaint and by the two
different formats of treatment (i.e., individual vs. group).
In both the above trials, exposure exercises solely targeted
public speaking-related anxiety and included only limited verbal
interaction (i.e., answering questions). However, although fear of
public speaking is the most common subtype of SAD, the majority
of individuals with SAD report more than one fear (Ruscio et al.,
2008), emphasizing the need for research on VRET targeting het-
erogeneous social fears. Moreover, a large number of feared social
situations reported by individuals with SAD (e.g., talking to
strangers or speaking up in a meeting) contain verbal interaction
(Ruscio et al., 2008). As a consequence, incorporating extensive
dialogues into VRET and thus going beyond answering a limited
number of questions might improve the efficacy of VRET for SAD. In
contrast to Anderson et al. (2013) and Wallach et al. (2009),
Bouchard et al. (2015) included virtual scenarios in VRET target-
ing several social fears. They found individual CBT plus VRET to be
effective compared to waiting-list and more effective than CBT plus
in vivo exposure. However, all three studies investigated VRET in
combination with CBT. Therefore, no conclusions can be drawn
regarding the efficacy of VRET as stand-alone treatment and the
possibility cannot be ruled out that the effects found were caused
by CBT rather than VRET.
In summary, previous research on VRET is limited by investi-
gating VRET only in combination with CBT, focussing mainly on fear
of public speaking and including only limited verbal interaction.
The incorporation of diverse virtual scenarios with social interac-
tion that resembles real life interaction into VRET might more
adequately target the idiosyncratic fears of participants with SAD.
The aim of the present study was to single out the effects of pure
VRET without any cognitive components and to adapt VRET to in-
dividuals with heterogeneous social fears by simulating social
verbal interaction in a variety of virtual social situations believed to
be relevant for treating individuals with SAD. In a randomized
controlled trial, we examined the efficacy of VRET and in vivo
exposure therapy (iVET) for adults with SAD and heterogeneous
social fears. These active treatments were compared to a waiting-
list control group. Both active treatments were administered in
an individual format and were exposure-based only. It was hy-
pothesized that relative to individuals in the waiting-list control
group, participants in active conditions would report fewer social
anxiety symptoms and would perform better on a behavioural
assessment task at postassessment. Treatment gains were expected
to be comparable for VRET and iVET at postassessment and 3-
month follow-up.
1. Method
1.1. Participants
Participants were recruited via online and newspaper adver-
tisements, the website of the ambulatory of the University of
Amsterdam, and the project's website. Sixty participants
(Mage ¼ 36.9 years, age range: 18e65 years) meeting the criteria for
a primary diagnosis of SAD according to the 4th edition of the
Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association, 2000) were included and randomly
assigned to one of three conditions (20 participants each; see Fig. 1
for an overview of the randomization procedure and Table 1 for
sample characteristics per condition). Exclusion criteria were a)
psychotherapy for SAD in the past year; b) current use of tran-
quilizers or change in dosage of antidepressants in the past 6
weeks; c) a history of psychosis, current suicidal intentions, or
current substance dependence; e) severe cognitive impairment; or
f) insufficient command of the Dutch language. The average num-
ber of completed sessions was 8.50 (SD ¼ 2.63) for VRET and 8.55
(SD ¼ 2.68) for iVET. All participants received free treatment and a
small monetary reward (22 Euro) for the completion of the follow-
up assessment.
1.2. Measures
1.2.1. Screening and diagnostic measures
The Social Interaction Anxiety Scale (SIAS; Mattick & Clarke,
1998) was used for screening purposes before the in-person
interview. The SIAS consists of 20 items assessing cognitive, affec-
tive, and behavioural responses to social interactions on a 5-point
Likert scale. The SIAS possesses a high internal consistency and
test-retest reliability (Cronbach's a ¼ .93 and r ¼ 0.92 respectively;
Mattick & Clarke,1998). Individuals scoring �29 were invited for an
in-person diagnostic interview with a psychologist. We choose a
slightly lower cut-off than reported in previous research to prevent
false-negatives in this early stage of screening where the in-person
intake was still to come (Heimberg, Mueller, Holt, Hope, &
Liebowitz, 1992).
To assess the diagnosis of SAD and potential comorbidity, the
Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-
I; First, Spitzer, Gibbon, & Williams, 1994) was administered prior
to inclusion. All assessors were psychologists with a master degree
in clinical psychology. These assessors were blind to treatment
condition and had received a SCID training in accordance with their
individual level of expertise. The assessor at preassessment was in
most cases a different person than the therapist (52/60). In a mi-
nority of cases (8/60), the assessor became also the patient's ther-
apist after the assessment. Note, however, that these assessors were
also blind to condition because condition allocation took place after
the preassessment. The number of administered SCID-I modules
depended on participants' responses to the SCID-I screening
questions (covering substance use disorders, anxiety disorders, and
eating disorders). The modules on social phobia, mood disorders,
psychotic disorders, post-traumatic stress disorder, and somato-
form disorders were assessed for all patients. The avoidant per-
sonality disorder section of the Structured Clinical Interview for
DSM-IV Axis II Personality Disorders (SCID-II; First, Gibbon,
Spitzer, Williams, & Benjamin, 1997) was also administered
Fig. 1. Participant flow chart. VRET ¼ Virtual Reality Exposure Therapy; iVET ¼ in Vivo Exposure Therapy.
I.L. Kampmann et al. / Behaviour Research and Therapy 77 (2016) 147e156 149
because research suggests that avoidant personality disorder and
SAD might be one disorder instead of two distinct disorders, with
avoidant personality disorder being the more severe form (Reich,
2009).
1.2.2. Primary outcome measures
Social anxiety symptoms were measured with the Liebowitz
Social Anxiety Scale-Self Report (LSAS-SR; Liebowitz, 1987). The
LSAS-SR is a 24-item questionnaire that assesses fear and avoidance
in social situations on a 4-point Likert scale. The 12-week test-
retest reliability of the LSAS-SR has been reported to be high
(r ¼ 0.83; Baker, Heinrichs, Kim, & Hofmann, 2002) and the internal
consistency in the present study was excellent (Cronbach's
a ¼ .90e0.97).
The subjective fear of being negatively evaluated by others in
social situations was assessed with the Fear of Negative Evaluation
Scale-Brief Form (FNE-B; Leary, 1983). The FNE-B is a 12-item in-
strument using a 5-point Likert scale for responses. Good psycho-
metric properties have been reported for the FNE-B in earlier
research (Weeks et al., 2005) and the internal consistency in the
present study was excellent (Cronbach's a ¼ .91e0.97).
1.2.3. Secondary outcome measures
We measured speech duration and speech performance during
a behavioural assessment task, in the form of a 5 min impromptu
speech, to evaluate levels of behavioural avoidance. The behav-
ioural assessment task was a modified version of a standardized
protocol (Beidel, Turner, & Jacob, 1989). This modified version has
been used in previous studies on social anxiety (Amir, Weber,
Beard, Bomyea, & Taylor, 2008). Although participants with
diverse social fears were included in the present study, this task
was chosen because public speaking anxiety is the most prevalent
Table 1
Demographic characteristics of participants per condition.
Characteristics VRET (n ¼ 20) iVET (n ¼ 20) WL (n ¼ 20)
Age, M (SD) 39.65 (11.77) 37.50 (11.27) 33.50 (11.44)
Gender (% female) 65 75 50
Native language, n (%)
Dutch 17 (85) 17 (85) 20 (100)
Spanish 1 (5) 0 (0) 0 (0)
Russian 1 (5) 0 (0) 0 (0)
Portuguese 0 (0) 1 (5) 0 (0)
Polish 0 (0) 1 (5) 0 (0)
Indonesian 0 (0) 1 (5) 0 (0)
Berber 1 (5) 0 (0) 0 (0)
Education, n (%)
High 8 (40) 10 (50) 11 (55)
Middle 11 (55) 8 (40) 9 (45)
Low 1 (5) 2 (10) 0 (0)
Employment status, n (%)
Paid employment 10 (50) 13 (65) 13 (65)
Trainee/student 1 (5) 1 (5) 5 (25)
Social welfare 1 (5) 1 (5) 0 (0)
Unemployed with voluntary work 1 (5) 0 (0) 0 (0)
Unemployed 7 (35) 5 (25) 2 (10)
Marital status, n (%)
Married or cohabitating 9 (45) 10 (50) 11 (55)
Long distance relationship 2 (10) 3 (15) 2 (10)
Single living with children 1 (5) 0 (0) 0 (0)
Single living without children 7 (35) 7 (35) 6 (30)
Widowed 1 (5) 0 (0) 1 (5)
Comorbidity, n (%)
Any anxiety disorder 3 (15) 4 (20) 0 (0)
Depressive disorder 4 (20) 0 (0) 2 (10)
Avoidant personality disorder 7 (35) 6 (30) 3 (15)
Session completed, n
1 20 20
2 20 20
3 19 19
4 19 19
5 18 17
6 15 17
7 15 17
8 15 16
9 15 16
10 14 14
Dropout, n (%) 5 (25) 3 (15) 4 (20)
Note. VRET ¼ Virtual Reality Exposure Therapy; iVET ¼ in Vivo Exposure Therapy; WL ¼ waiting-list; Low ¼ completed elementary school or lower vocational edu-
cation; Middle ¼ completed high school or middle-level vocational education; High ¼ completed pre-university, college, or university degree.
I.L. Kampmann et al. / Behaviour Research and Therapy 77 (2016) 147e156150
social fear. Speech duration was measured using a stop watch. To
assess speech performance, two independent judges, blind for
condition and assessment point, rated the videotaped speeches
using 17 items of a public speaking performance measure on a 5-
point Likert scale (Rapee & Lim, 1992). Higher scores on this mea-
sure indicated better speech performance. The internal consistency
of this scale was good in earlier research (r ¼ 0.84; Rapee & Lim,
1992) and the present study (r ¼ 0.81e0.87).
Symptoms of depression, general anxiety, and stress were
measured with the Depression Anxiety Stress Scale (DASS-21;
Lovibond & Lovibond, 1995). The DASS-21 is a 21-item self-report
questionnaire measuring depression, anxiety, and stress on a 4-
point Likert scale with higher scores representing higher levels of
depression, anxiety, or stress, respectively. The stress scale includes
items that measure subjective coping with stressful events, such as
tension, irritability, and a tendency to overreact to stressful events.
The DASS possesses good psychometric properties (Antony, Bieling,
Cox, Enns, & Swinson, 1998; Henry & Crawford, 2005) and in the
present study its internal consistency was excellent (Cronbach's
a ¼ .91e0.95).
Avoidant personality disorder related beliefs were assessed with
the Personality Disorder Belief Questionnaire (PDBQ; Dreessen &
Arntz, 1995). Research has shown that exposure therapy without
cognitive components can affect cognitions (Powers et al., 2008).
The avoidant subscale of the PDBQ contains 10 items to assess the
strength of beliefs assumed to be specific to avoidant personality
disorder. The internal consistency of this subscale was excellent in
the present study (Cronbach's a ¼ .90e0.97).
Subjective quality of life was measured using the Eurohis
Quality of Life Scale (EUROHIS-QOL 8-item index; Schmidt, Mühlan,
& Power, 2006). The EUROHIS-QOL 8-item index measures quality
of life on a 5-point Likert scale with higher scores indicating a
better quality of life. The psychometric properties of the EUROHIS-
QOL are reported to be satisfactory (Da Rocha, Power, Bushnell, &
Fleck, 2012; Schmidt et al., 2006) and the internal consistency in
the present study was good (Cronbach's a ¼ .83e0.93).
1.3. Procedure
The present study was approved by the Institutional Review
Board of the University of Amsterdam and registered
(NCT01746667; www.clinicaltrials.gov). Potential participants were
asked on the telephone about former SAD treatment and whether
attending treatment was logistically feasible. Afterwards, they filled
in the SIAS online. Participants who scored above the cut-off were
invited to an in-person intake (SCID), where they were screened for
http://www.clinicaltrials.gov
I.L. Kampmann et al. / Behaviour Research and Therapy 77 (2016) 147e156 151
exclusion criteria. After obtaining informed consent, eligible par-
ticipants underwent a preassessment comprising a battery of self-
report measures (LSAS-SR, FNE-B, DASS-21, PDBQ, EUROHIS-QOL)
and the behavioural assessment task. For the behavioural assess-
ment task, participants were told that they would give a 5 min
speech in front of a camera and a two-person jury rating the
speech. They were then asked to choose one out of seven topics
(nuclear power, gay marriage, euthanasia, republic or monarchy,
genetic selection, burqa ban, or mandatory organ donation) and
had 2 min to prepare the speech. Participants were allowed to make
notes during the preparation time but they could not use them
during the speech. Then, the jury entered the room and the par-
ticipants gave a speech for 5 min or until they indicated that they
wanted to stop. After the assessment, participants were random-
ized to one of the three conditions (VRET, iVET, or waiting-list)
using a computerized random number generator (http://www.
randomization.com). A person who was not involved in the pre-
sent study kept a list with the randomization sequence in a locked
office cupboard and prepared sealed envelopes containing the
condition allocation. The first author opened the envelopes after
participants were enrolled. Participants in the waiting-list condi-
tion received a second assessment after a waiting period of five
weeks (i.e. the same aimed length of time as the treatment) before
being randomized to one of the treatment conditions. After the last
treatment session, all participants completed a postassessment
identical to the preassessment. Three months after the post-
assessment, participants were invited to an in-person follow-up
assessment consisting of the battery of self-report measures (LSAS-
SR, FNE-B, DASS-21, PDBQ, EUROHIS-QOL).
1.4. Treatment
The treatment protocols for VRET and iVET were based on the
protocols of Scholing and Emmelkamp (1993) and Hofmann and
Otto (2008). Consistent with our aim of examining the potential
efficacy of exposure to virtual social interactions, only behavioural
exposure elements were used in both conditions and cognitive el-
ements were discarded. Both treatments comprised ten 90 min
sessions scheduled twice a week. In standard treatment, homework
is commonly added to therapy sessions. However, due to the
technical equipment necessary for VRET, virtual exposure could
only be implemented in the lab. Therefore, homework assignments
were not feasible in this condition. To keep the amount of exposure
equal in both conditions, no homework assignment was given in
either condition and therapists were instructed not to encourage
participants to practice exposure outside of therapy sessions.
Therapists involved in the present study were clinical psychologists
and students in their last semester of a clinical master's degree
program. They received training on VRET and iVET by the second
and last author prior to administering both treatments. To monitor
treatment adherence and competence, all therapy sessions and
exposure exercises were extensively discussed during supervision.
Furthermore, therapists were asked to complete a checklist
immediately after each session in which they indicated any possible
deviations from the protocol which were discussed during super-
vision. Moreover, therapy sessions were audio recorded (except for
in vivo exposure exercises) and parts of recordings were replayed
and discussed during supervision. Due to logistical reasons treat-
ment adherence and competence were not formally assessed.
Weekly supervision was provided to the therapists by the first,
second, and last author.
1.4.1. Virtual reality exposure therapy (VRET)
VRET took place in the virtual reality laboratory of the University
of Amsterdam. The laboratory consisted of two rooms separated by
a one-way mirror, through which the therapist could see the
participant during exposure exercises while controlling the com-
puter system, whereas the participant could not see the therapist.
The therapist and the participant had face-to-face contact before
and after exposure exercises and during exposure they communi-
cated via an intercom. The virtual situations covered one-to-one
and group situations designed to provoke anxiety in individuals
with SAD: giving a talk in front of an audience followed by ques-
tions from the audience, talking to a stranger, buying and returning
clothes, attending a job interview, being interviewed by journalists,
dining in a restaurant with a friend, and having a blind date (see
Appendix A for a detailed description of all virtual scenarios and
Figure 2 in Hartanto et al. (2014) for pictures of the virtual blind
date, virtual job interview, and neutral world).
For virtual exposure, we used the Delft Remote Virtual Reality
Exposure Therapy (DRVRET; Brinkman et al., 2012) system with
virtual worlds which were visualized using a Vizard v3.0 software
package. The setup consisted of three computers. The first com-
puter, a custom Dell T3400 workstation, was used to run the VR
server and the data logging system. The second computer, a custom
Dell T3600 workstation using Intel Quadcore E5 with NVIDIA
Quadro 5000, was used to run the VR engine and environment and
the therapist could see simultaneously what the participant could
see in the head mounted display. The video output of this computer
was split for both the head mounted display (participant) and real
time monitoring purpose (therapist). On the third computer, a
custom Dell T3400 workstation, the therapist controlled the virtual
situations. Participants wore a nVisor SX head mounted display
with 1280 � 1024 pixels, a stereographic projection, and a 60� di-
agonal field of view.
Semi-structured dialogues controlled by the therapist ensured a
certain length and difficulty level of interaction between the virtual
humans and the participant, as well as allowing for individual re-
sponses for each participant (Brinkman et al., 2012). To tailor
exposure exercises to the specific needs, anxiety level, and treat-
ment progress of the individual participant, the system allowed the
therapist to vary the following components depending on the vir-
tual situation: dialogue style (friendly or unfriendly), gender of
avatar, number of avatars present in the virtual world, dialogue
topic's degree of personal relevance, and avatar's gestures (i.e., gaze
direction and posture).
Treatment Sessions 1 and 2 focused on the conveyance of the
therapy rationale, the registration of participant's relevant social
situations, and creating a hierarchy of the available virtual social
situations according to the participants' anticipated anxiety level.
Moreover, participants were introduced to virtual reality and the
technological equipment by entering a virtual neutral situation
(Busscher, de Vliegher, Ling, & Brinkman, 2011), without any social
interaction, for a maximum of 5 min.
Sessions 3 through 9 contained two 30 min blocks of exposure
exercises separated by a 5 min break. The content of exposure ex-
ercises followed the previously made hierarchy in ascending order
with regards to individual anxiety level (i.e. gradual exposure).
Participants rated their anxiety level regarding three time points in
every exposure exercise: beginning, highest level during the exer-
cise, and end. Participants practiced every virtual world at least
once and until anxiety decreased. Yet, only a maximum of two
sessions were spent on exposure exercises focussing on presenta-
tion situations to limit the amount of practice in presentation
performance, given that the behavioural assessment task also
consisted of giving a speech. Session 10 was devoted to relapse
prevention and evaluation of the therapy.
1.4.2. In vivo exposure therapy (iVET)
The iVET consisted of gradual exposure therapy to real-life
http://www.randomization.com
http://www.randomization.com
I.L. Kampmann et al. / Behaviour Research and Therapy 77 (2016) 147e156152
situations. Similar to VRET, iVET comprised 10 sessions with 60 min
exposure in Sessions 3 through 9. As in the VRET condition, the
therapy rationale and anxiety hierarchy were discussed in Sessions
1 and 2. The hierarchy used in iVET comprised participants’ indi-
vidual social situations which were translated to exposure exercises
that could be implemented at the ambulatory of the University of
Amsterdam or in its neighbourhood (e.g., supermarkets, subway
stations, caf�es, etc.). If relevant social situations could not be
translated into exercises at the ambulatory or its nearby sur-
roundings (e.g., work-related social situations), participants could
substitute a regular session with a session in their personal envi-
ronment. In these cases, the therapist and the participant had
contact via the telephone before and after the exposure assign-
ment. Session 10 was identical to the last session in the VRET
condition.
1.5. Statistical analyses
Multilevel regression analyses were carried out to explore
within-group (Time), between-group (Condition), and interaction
(Time � Condition) effects. Only the fixed effects of the multilevel
models were reported because they model change at the group
level (in contrast to random effects, which model at the individual
level). To investigate treatment effects from pre-to postassessment,
each active treatment group was compared to waiting-list. The
estimated model (see Table 3a) consisted of two parameters for
each group: one parameter estimating the mean level of the
outcome variable at preassessment and a second parameter esti-
mating the rate of change from pre-to postassessment. For the
active treatment groups, the second parameter described the
change from pre-to postassessment relative to the change of the
waiting-list group. To investigate long term effects of the two active
treatments, the change from pre-to postassessment and the change
from preassessment to follow-up were compared between VRET
and iVET. The estimated model (see Table 3b) consisted of three
parameters for each group: the first parameter describes the mean
level of the outcome variable at preassessment, the …
Contents lists available at ScienceDirect
Journal of Affective Disorders
journal homepage: www.elsevier.com/locate/jad
Research paper
The role of expressive suppression and cognitive reappraisal in cognitive
behavioral therapy for social anxiety disorder: A study of self-report,
subjective, and electrocortical measures
Yogev Kivity⁎,1, Lior Cohen, Michal Weiss, Jonathan Elizur, Jonathan D. Huppert
Department of Psychology, The Hebrew University of Jerusalem, Jerusalem, Israel
A R T I C L E I N F O
Keywords:
Social Anxiety
Emotion Regulation
Cognitive Reappraisal
Expressive Suppression
Cognitive Behavioral Therapy
A B S T R A C T
Background: Contemporary models of cognitive behavioral therapy (CBT) for social anxiety disorder (SAD)
emphasize emotion dysregulation as a core impairment whose reduction may play a causal role in psy-
chotherapy. The current study examined changes in use of emotion regulation strategies as possible mechanisms
of change in CBT for SAD. Specifically, we examined changes in expressive suppression and cognitive reappraisal
during CBT and whether these changes predict treatment outcome.
Methods: Patients (n = 34; 13 females; Mean age = 28.36 (6.97)) were allocated to 16-20 sessions of CBT. An
electrocortical measure of emotion regulation and a clinician-rated measure of SAD were administered monthly.
Self-report measures of emotion regulation and social anxiety were administered weekly. Multilevel models were
used to examine changes in emotion regulation during treatment and cross-lagged associations between emotion
regulation and anxiety.
Results: CBT led to decreased suppression frequency, increased reappraisal self-efficacy, and decreased un-
pleasantness for SAD-related pictures (ps < .05). At post-treatment, patients were equivalent to healthy controls
in terms of suppression frequency and subjective reactivity to SAD-related stimuli. Gains were maintained at 3-
months follow-up. Decreases in suppression frequency and electrocortical reactivity to SAD-related pictures
predicted lower subsequent anxiety but not the other way around (ps < .05). Lower anxiety predicted greater
subsequent increases in reappraisal self-efficacy.
Limitations: The lack of a control group precludes conclusions regarding mechanisms specificity.
Conclusions: Decreased frequency of suppression is a potential mechanism of change in CBT for SAD.
1. Introduction
Recent models of anxiety, including social anxiety disorder (SAD),
emphasize impairments in emotion regulation (Hofmann, Sawyer,
Fang, & Asnaani, 2012; Morrison & Heimberg, 2013). Two regulation
strategies, cognitive reappraisal and expressive suppression, may be
particularly relevant for SAD (Morrison & Heimberg, 2013). In the
process model of emotion regulation (Gross, 2015), cognitive re-
appraisal is generally considered an adaptive strategy that involves
cognitive change to regulate one's emotion – for example, attempts to
reinterpret emotional stimuli in less threatening ways (Gross, 2015). On
the other hand, expressive suppression is an attempt to inhibit one's
expression of emotions and is generally considered maladaptive
(Gross, 2015).
In Heimberg's updated model (Morrison & Heimberg, 2013),
emotion dysregulation in SAD includes avoidance of anxiety (e.g.
avoidance or escape from stressful situations) and expressive suppres-
sion due to believing that expressing emotions will lead to rejection or
to excessive focus on oneself. The model further proposes that in-
dividuals with SAD are less effective in implementing reappraisal. Ac-
cordingly, decreased suppression and increased effective use of re-
appraisal are hypothesized to lead to symptom reduction, for example,
by outward shifting of attention and by reducing exaggerated prob-
ability and cost of rejection.
Recently, studies have examined suppression and reappraisal in SAD
(reviewed in Dryman & Heimberg, 2018). Cross-sectional and daily
diary studies typically focus on the frequency of use of a strategy and
self-efficacy (perceived success in implementation). Individuals with
SAD report an over-reliance on suppression and lower frequency and
self-efficacy of reappraisal (e.g., Farmer & Kashdan, 2012;
https://doi.org/10.1016/j.jad.2020.10.021
Received 10 May 2020; Received in revised form 16 August 2020; Accepted 11 October 2020
⁎ Corresponding author: Yogev Kivity, Department of Psychology, Bar Ilan University, Ramat Gan 5290002, Israel, Telephone: +972-3-5318715
E-mail address: [email protected] (Y. Kivity).
1 Yogev Kivity is now in the Department of Psychology, Bar Ilan University, Israel.
Journal of Affective Disorders 279 (2021) 334–342
Available online 14 October 2020
0165-0327/ © 2020 Elsevier B.V. All rights reserved.
T
http://www.sciencedirect.com/science/journal/01650327
https://www.elsevier.com/locate/jad
https://doi.org/10.1016/j.jad.2020.10.021
https://doi.org/10.1016/j.jad.2020.10.021
mailto:[email protected]
https://doi.org/10.1016/j.jad.2020.10.021
http://crossmark.crossref.org/dialog/?doi=10.1016/j.jad.2020.10.021&domain=pdf
Gaebler, Daniels, Lamke, Fydrich, & Walter, 2014). Impairments in
frequency seem to be larger than impairments in self-efficacy in sup-
pression while the opposite is true for reappraisal (Kivity &
Huppert, 2018, 2019), thus supporting the Heimberg model.
In addition, studies have also utilized subjective ratings during lab
tasks of emotion regulation to study reappraisal and suppression abil-
ities in SAD. These studies typically present SAD-related stimuli to
participants, such as pictures of rejecting faces (Goldin et al., 2009a),
pictures portraying scenes of rejection and embarrassment (Kivity &
Huppert, 2016, 2018, 2019) and idiographic statements of negative
self-beliefs (Goldin et al., 2009b) while asking participants to change
the way they interpret these stimuli in order to reduce the distress they
evoke in them. However, compared to questionnaires and daily diary
measures, these lab studies have shown intact emotion regulation
abilities in SAD compared to controls, even under social stress (e.g.,
Gaebler et al., 2014; Kivity & Huppert, 2016, 2018, 2019). Thus, self-
reported impairments are not reflected in lab performance. Among
other possibilities, this discrepancy may suggest a difficulty im-
plementing strategies in daily life despite an intact ability to implement
them upon instruction in controlled circumstances, low ecological va-
lidity of lab-based measures, or a bias in self-reports that does not exist
in lab-based measures. Examining the role that each of these aspects
(lab-based performance, self-reported frequency and self-reported self-
efficacy) plays in treatments for SAD may shed light on their relative
importance.
Several techniques of cognitive behavioral therapy (CBT) for SAD
seem relevant for improving emotion regulation. Psychoeducation and
exposures likely decrease suppression, as patients learn that hiding
their anxiety is futile and likely to backfire. Outward shifting of at-
tention (focusing on the task at hand instead of on how one is per-
ceived) presumably decreases suppression by decreasing patients’ pre-
occupation with their overt signs of anxiety. Furthermore, cognitive
restructuring can potentially increase the use of reappraisal by chan-
ging biased catastrophic cognitions. Finally, psychoeducation and in-
vivo exposure challenge biased cognitions and are expected to promote
reappraisal too.
Studies have shown that self-reported reappraisal (frequency and
self-efficacy) increases in CBT (Goldin et al., 2014a; Goldin, Morrison,
Jazaieri, Heimberg, & Gross, 2017; Kocovski, Fleming, Hawley, Huta, &
Antony, 2013; Moscovitch et al., 2012). However, findings regarding
self-reported suppression are inconclusive, with one study reporting a
decrease in frequency (Goldin et al., 2014a) and another reporting no
change (Moscovitch et al., 2012). Less is known regarding lab-based
measures: one study found improvements in reappraisal of negative
social evaluations and negative self-beliefs during CBT (Goldin et al.,
2013, 2014b).
Importantly, the best test of the importance of emotion regulation as
a treatment target for SAD is to examine its contribution to symptom
improvement (Nock, 2007). Changes in reappraisal and suppression
that predict treatment outcome would provide further support to
Heimberg's model. Several studies found that increases in self-reported
frequency and self-efficacy of reappraisal predicted subsequent
symptom reduction (Goldin et al., 2017; Kocovski, Fleming, Hawley,
Ho, & Antony, 2015; Moscovitch et al., 2012), although another study
found that only self-efficacy (but not frequency) of reappraisal pre-
dicted subsequent outcome (Goldin et al., 2014a). Decreases in self-
reported suppression frequency predicted contemporaneous, but not
subsequent, symptoms reduction in one study (Goldin et al., 2014a) and
did not predict outcome at all in another (Moscovitch et al., 2012). The
only examination of lab-based reappraisal (Goldin et al., 2014b) found
that greater changes in fMRI measures of reappraisal predicted greater
symptom change during CBT for SAD, although subjective task per-
formance did not. Thus, the self-report findings suggest that reappraisal
increases during CBT for SAD and may be driving symptom change,
with more consistent findings regarding self-efficacy than frequency.
Additional studies are needed regarding lab-based emotion regulation.
The present study examines changes in suppression and reappraisal
during CBT for SAD and their role in treatment outcome using data
from a previously completed study (Huppert, Kivity, Cohen, Strauss,
Elizur & Weiss, 2018). We collected weekly self-reports of the frequency
and self-efficacy of reappraisal and suppression, and monthly lab-based
measures of reappraisal and suppression in response to SAD-related
pictures. Given past findings, our primary focus was self-reported self-
efficacy of reappraisal and frequency of suppression. Frequency of re-
appraisal and self-efficacy of suppression were of secondary interest.
For the lab-based task, we focused on unpleasantness and event-
related potentials (ERP) during reappraisal and suppression of SAD-
related pictures. We focused on the late positive potential (LPP), an ERP
with a posterior midline distribution and an onset of 300 ms post-sti-
mulus (Proudfit, Dunning, Foti, & Weinberg, 2013). Larger LPP reflect
sustained attention to stimuli and elaborative engagement in order to
regulate the emotion (Proudfit et al., 2013). The LPP is sensitive to
emotional intensity and to emotion regulation, with higher amplitudes
for highly arousing stimuli that are reduced following instructions to
regulate, including reappraisal and suppression, even within several
seconds from the presentation of the stimuli (Proudfit et al., 2013). The
LPP shows less habituation over repeated exposure to stimuli compared
to other psychophysiological measures (Proudfit et al., 2013), which
allows for repetition of stimuli and attribution of changes in LPPs to the
same stimuli as due to regulation. The LPP has been utilized in SAD
(Kinney, Burkhouse, & Klump, 2019; Kivity & Huppert, 2018, 2019;
Yuan et al., 2014) but we are unaware of studies examining it during
CBT for SAD.
We examined these hypotheses: 1) CBT will result in significant
improvements in suppression and reappraisal, including reduced fre-
quency of suppression and increased self-efficacy, frequency, and suc-
cessful lab implementation of reappraisal. 2) Improvements in sup-
pression and reappraisal will play a potentially causal role in CBT:
improvements will predict subsequent improvements in anxiety and not
vice versa. 3) We examined whether patients reached an equivalent
level of emotion regulation to healthy controls (HCs) at post-treatment,
and whether gains were maintained at 3-months follow-up without an
a-priori hypothesis.
2. Method
2.1. Participants
Data were drawn from the CBT arm of a study of treatments for SAD
(Huppert et al., 2018)2. Patients were recruited via advertisements and
referrals. Participants were 34 patients who met DSM-IV-TR
(American Psychiatric Association, 2000) criteria for SAD and 40 HCs
with no history of psychiatric disorders, matched to patients on sex, age
and education. One patient decided not to enter treatment and 5 HCs
were removed because they did not have a continued low social anxiety
score between screening and participation. The final sample included
33 patients (13 females, Age: 18-53, M = 28.36, SD = 6.97) and 35
HCs (15 females, Age: 19-45, M = 28.49, SD = 6.28). Participants were
Hebrew speaking and family status was: single: CBT = 59%,
HC = 61%; in a relationship: CBT = 41%, HC = 35%; divorced:
CBT = 0%, HC = 4%. Education levels were: high school: CBT = 15%,
HC = 29%; post-high school: CBT = 21%, HC = 9%; undergraduate
degree/student: CBT = 42%, HC = 27%; graduate degree/student:
2 The original study also included participants receiving a computerized
treatment for SAD called Attention Bias Modification. This treatment was of
shorter duration compared to CBT, of a smaller sample size and only included
three measurements of lab-based emotion regulation. In addition, group as-
signment was random only for a subset of the CBT patients. Due to these rea-
sons, we decided not to include data from this treatment in the current study,
which a priori was designed to examine the role of ER in CBT.
Y. Kivity, et al. Journal of Affective Disorders 279 (2021) 334–342
335
CBT = 21%, HC = 26%. Groups did not differ on demographics (ps >
.05). Ten SAD participants (29.41%) had one comorbid disorder and
two (5.88%) had more than one. The most common comorbid disorders
were depression (n = 9; 26.47%) or other anxiety disorders (n = 4;
11.76%).
2.2. Measures
Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987). A 24-
item interviewer-rated measure of fear and avoidance of social inter-
actions and social performance. The Hebrew version (Levin, Marom,
Gur, Wechter, & Hermesh, 2002) was administered by trained clinical
psychology doctoral students, blind to hypotheses. Internal consistency
in all assessments was α = .90 – .96; interrater reliability for 15 ran-
domly chosen interviews was r = .94.
Social Phobia Inventory (SPIN; Connor et al., 2000). A valid and
reliable 17-item self-report measure of social anxiety symptoms,
translated and back translated to Hebrew for previous studies. Internal
consistency in all assessments was: α = .78 – .95.
Emotion Regulation Questionnaire – Self-Efficacy and
Frequency (ERQ; Gross & John, 2003). We used the reliable and valid
Hebrew version (Carthy, Horesh, Apter, Edge, & Gross, 2010). Fol-
lowing Goldin et al. (2009b), we measured both the frequency (ERQ-F)
and self-efficacy (ERQ-SE) in social situations instead of frequency only
(internal consistency of all subscales: α = .73 – .97). Items tap into
reappraisal (e.g., “When I want to feel less negative emotion, I change
the way I'm thinking about the situation”) and suppression (e.g., “I
control my emotions by not expressing them”) which participants en-
dorse using a 1 ("Seldom"/"Ineffectively") to 7 ("Often"/"Effectively")
scale.
Emotion Regulation Task. Full details are provided in supple-
mental material, section 1. We used a task that was developed by
Hajcak and Nieuwenhuis (2006) who presented emotionally-salient
pictures to participants and instructed them to either passively view the
picture or to reappraise the emotion it evokes in them while ERP ac-
tivity was recorded and unpleasantness ratings were collected. Hajcak
and Nieuwenhuis found that the amplitude of the LPP and the level of
subjective unpleasantness were decreased during reappraisal compared
to passive viewing. Thus, the task is validated and suitable for studying
the effects of emotion regulation on electrocortical activity and sub-
jective unpleasantness. In the current study, we adapted the task to
measure suppression in addition to reappraisal and used SAD-related
pictures rather than general pictures (Kivity & Huppert, 2018, 2019). In
selecting the stimuli for the task, we chose to focus on shame, embar-
rassment and rejection because these experiences are central in SAD
(Goldin et al., 2009b; Morrison & Heimberg, 2013; Moscovitch, 2009)3.
Twenty trials of each condition were included: viewing of SAD-related
pictures, viewing of neutral pictures, reappraisal of SAD-related pic-
tures and suppression of SAD-related pictures.
When viewing SAD-related pictures, participants imagined them-
selves as the character that is the focus of shame, rejection, and em-
barrassment. When viewing neutral pictures, participants responded
naturally. When reappraising, participants first imagined themselves as
the character and then changed the way they think of the picture to
decrease their unpleasantness (e.g., "This guy is not laughing at me, but
at someone else"). When suppressing, participants first imagined
themselves as the character and then concealed any expression of
emotions. To enhance the effect of the suppression manipulation, a web
camera was placed above the computer screen and participants were
told that a member of the research team would review the recordings.
Participants were instructed to avoid any expression of their emotions
such that it would be impossible to tell whether they were viewing
neutral pictures or concealing their emotions4.
After each trial, participants rated their unpleasantness on a Self-
Assessment Manikin (SAM; Lang, Bradley, & Cuthbert, 2008) scale (1
through 9; 5 being neutral; transformed such that higher ratings express
greater unpleasantness). We focused on unpleasantness ratings in order
to complement the LPP data (which is mostly correlated with arousal)
and arrive at a more complete picture of the participants’ emotional
experience that takes into account the two basic dimensions of emo-
tions – valence and arousal. After providing unpleasantness ratings,
participants were asked to indicate the instructions they followed
during that trial. In the reappraisal condition, participants were also
asked to record the new interpretation they came up with for the pic-
ture (results not reported here).
Ratings were averaged for each condition and a regulation score
(view – regulate; calculated on the transformed scores) was calculated
to capture the amount of reduction in unpleasantness. Higher scores
indicate larger regulation effects.
SAD-related pictures were collected from the internet5, normed and
shown to evoke moderate shame, embarrassment, rejection and un-
pleasantness (Kivity & Huppert, 2018, 2019). These depicted situations
of shame, rejection, and/or embarrassment such as scenes of people
pointed and laughed at, anxious people during a public speech, and
facial expressions of contempt. Neutral pictures were taken from the
International Affective Picture System (IAPS) database (Lang et al.,
2008).
Psychophysiological Recording, Data Reduction, and Analysis.
Full details are provided in section 2 of the supplement. ERPs were
constructed by averaging trials in each condition (view, suppression,
reappraisal and view neutral). Following Moser, Hartwig, Moran,
Jendrusina, & Kross (2014), the LPP was quantified as the average
voltage in 5 parietal electrodes (CPz, P1, Pz, P2, POz) in the entire
segment (400-2000 ms). A regulation change score (view – regulate)
was calculated to capture the amount of reduction in the LPP. Higher
scores indicate larger regulation effects. Trials in which participants
failed to use the instructed strategy were excluded (4.57% on average,
no group differences). Studies have shown that the LPP can be reliably
measured with as little as 8 trials and that it varies little beyond 12
trials (Moran, Jendrusina, & Moser, 2013). Assessments with fewer than
12 valid trials in each condition were removed from analyses (5%
across groups, no group differences).
2.3. Treatment and therapists
Individual CBT was delivered for up to 20 sessions using a manual
by Roth-Ledley, Foa, & Huppert (2006), based on Clark's (2005) CBT for
SAD. Components such as building an idiographic model, outward
shifting of attention, safety behaviors experiment, video feedback, be-
havioral experiments and exposures, and optional use of imaginal ex-
posure, assertiveness training, or social skills training are included.
Therapists were four clinical psychology doctoral students with 2-4
years of CBT experience. Videorecordings of sessions were used in
group supervision by the last author.
3 Shame, embarrassment and rejection are likely separate, but related, ex-
periences. Similar to previous studies (e.g., Goldin et al., 2009), when designing
and validating the task (Kivity & Huppert, 2018, 2019) we were not able to
examine these experiences separately due to a small number of stimuli that
purely fall into one of these categories. It remains for future studies to examine
these experiences separately.
4 It should be noted that although the view condition is not entirely a passive
one (as it includes perspective taking), it is still possible that it requires less
cognitive effort than the reappraisal and suppression conditions. However,
studies have shown that cognitive effort alone does not explain the down-reg-
ulatory effects of reappraisal (Foti & Hajack, 2008).
5 See a sample picture at https://tinyurl.com/ShameArousingPicture.
Y. Kivity, et al. Journal of Affective Disorders 279 (2021) 334–342
336
https://tinyurl.com/ShameArousingPicture
2.4. Procedure
The institutional review board approved the study. After providing
informed consent, participants were evaluated by trained independent
evaluators (blind to hypotheses) using the Mini-International
Neuropsychiatric Interview (Sheehan et al., 1998) and the LSAS. Par-
ticipants completed a baseline assessment and entered treatment. Pa-
tients completed the ERQ before and after each session (post-session
ratings were of secondary interest and are only reported in Supple-
mental Material, Section 4). Patients also completed in-lab assessments
at pre-treatment, every four sessions during treatment, at post-treat-
ment and at 3-months follow-up which included the LSAS, SPIN, ERQ,
and the lab task. Thus, each patient had up to seven assessments (pre-
treatment, sessions 4, 8, 12 and 16, post-treatment, and follow-up). HCs
only completed a single assessment and were not followed long-
itudinally. Thus, HCs were included only in analyses of equivalency.
2.5. Data Analyses
We used intent-to-treat linear multi-level models (assessments at
level 1 repeated within patients at level 2) implemented in R package
'nlme' (Pinheiro, Bates, DebRoy, Sarkar, & R Core Team, 2016). In-
cluding therapists as a third level showed negligible and non-significant
effects (ICCs: Med = .00, range: 0 – 0.049) and therefore this level was
removed. We used restricted maximum likelihood estimation, a first-
order autoregressive level 1 covariance structure and random intercepts
and slopes at level 2. For H1, linear rates of change were examined by
including session/assessment number as a level 1 predictor (centered at
pre-treatment). Intercepts represent estimated levels of the dependent
variable at pre-treatment and slopes represent estimated changes in the
dependent variable between two assessment points (one/four sessions,
depending on the measure). To examine changes from post-treatment to
follow-up we fitted a piece-wise model that examines changes during
treatment and from post-treatment to follow-up separately. This was
done by adding the follow-up data to the abovementioned model and
adding a dummy coded variable that captures post-treatment to follow-
up changes (coded “1” for follow-up assessment and “0” for all other
assessment). The fixed effect of the dummy variable expresses the
amount and significance of the change from post-treatment to follow-
up.
H2 was examined by modeling within-patient variation in the pre-
dictor following recommended procedures (Wang & Maxwell, 2015).
Monthly scores of the predictor (patient mean-centered) served as
within-patient scores in a cross-lagged (1-month) model. Within-subject
effects represent cross-lagged associations between the predictor and
the outcome. Per Wang and Maxwell (2015) we did not control for
linear time effects as we wished to model and explain these very effects.
Following Falkenström, Finkel, Sandell, Rubel, and Holmqvist (2017),
we did not include the lagged dependent variable as a predictor because
it introduces a dependency between the dependent variable and the
error, thus violating assumptions. However, the first auto-regressive
residual structure partly accounts for the effects of prior on current
levels of the outcome. For consistency, we only analyzed monthly
scores of the SPIN and ERQ. A cross-lagged association was interpreted
as significant only if effects were significant for clinician-rated and self-
reported anxiety.
For H3, comparisons were conducted using clinical equivalency
procedures (Kendall, Marrs-Garcia, Nath, & Sheldrick, 1999) through t
tests examining non-inferiority (i.e., < 1 SD difference) of post-treat-
ment scores compared to HCs. A significant effect in noninferiority tests
suggests that patients are non-inferior to HCs.
Effect sizes were calculated as semi-partial r (rs; Jaeger, Edwards,
Das, & Sen, 2016; Nakagawa & Schielzeth, 2013) using package
'r2glmm' in R (Jaeger & R Core Team, 2016). These represent the un-
ique contribution above and beyond the contribution of other pre-
dictors in the model and are presented in absolute values.
3. Results
3.1. Changes in regulation (H1) and equivalency to HCs (H3)
3.1.1. Change in self-reports
Descriptive statistics for all study variables are presented in sup-
plemental material, section 3. Changes are shown in Fig. 1.
Suppression. Consistent with hypotheses, the frequency of sup-
pression decreased during treatment (t467 = -3.98, p < .01, rs = .22
[.14, .30]) and did not change from post-treatment to follow-up
(b = -.10, t490 = -.62, p = .53, rs = .01 [.00, .10]). In contrast to
hypotheses, self-efficacy of suppression decreased during treatment
(t467 = -2.85, p < .01, rs = .14 [.05, .22]) and did not change from
post-treatment to follow-up (b = -.09, t490 = -.64, p = .52, rs = .01
[.00, .10]).
Reappraisal. Consistent with hypotheses, self-efficacy of reappraisal
increased during treatment (t467 = 3.67, p < .01, rs = .17 [.08, .25])
and did not change from post-treatment to follow-up (b = -.02,
t490 = -.10, p = .92, rs = .00 [.00, .10]). In contrast to hypotheses, no
changes in frequency of reappraisal were observed (t467 = .04, p = .97,
rs = .00 [.00, .10]) nor did they change from post-treatment to follow-
up (b = .08, t490 = .33, p = .74, rs = .01 [.00, .10]).
3.1.2. Change in lab-based measures
Changes are shown in Fig. 2 and Fig. 3.
View SAD-related pictures. As hypothesized, unpleasantness ratings
decreased during treatment (t115 = 4.49, p < .01, rs = .28 [.13, .42])
and did not change from post-treatment to follow-up (b = .08,
t138 = .70, p = .49, rs = .03 [.00, .18]). The LPP while viewing SAD-
related pictures did not change significantly during treatment (b = -.46,
t103 = -1.80, p = .07, rs = .14 [.01, .30]) or from post-treatment to
Fig. 1. Change in frequency and self-efficacy of reappraisal (top panel) and
suppression (bottom panel) during Cognitive Behavioral Therapy (CBT). Error
bars represent estimated standard errors. Only data from sessions 1-16 are
presented because only 5 patients received more than 16 sessions. b = esti-
mated weekly change in emotion regulation. ** p < .01
Y. Kivity, et al. Journal of Affective Disorders 279 (2021) 334–342
337
follow-up (b = 1.73, t126 = 1.11, p = .27, rs = .05 [.00, .20]).
View neutral pictures. Supporting our hypotheses, we found no
change in unpleasantness ratings during CBT or from post-treatment to
follow-up (during: t115 = -.43, p = .67, rs = .04 [.00, .20]; post-
treatment to follow-up: b = -.05, t138 = -.26, p = .79, rs = .02 [.00,
.17]) and in the LPP (during: b = -.29, t103 = -1.04, p = .30, rs = .09
[.00, .25]; post-treatment to follow-up: b = 1.86, t126 = 1.09, p = .28,
rs = .05 [.00, .20]) while viewing neutral pictures.
Suppression. Examining suppression-related reductions in un-
pleasantness (compared to viewing pictures) we found that reductions
were significantly different from zero at pre-treatment (b = .25,
t115 = 3.84, p < .01), indicating that suppression was effective in
down-regulating negativity. Consistent with hypotheses, regulation
scores did not change during treatment (t115 = -1.77, p = .08, rs = .16
[.02, .31]) or from post-treatment to follow-up (b = .03, t138 = .29,
p = .78, rs = .02 [.00, .18]). Reductions in LPP via suppression were
not different from zero at pre-treatment (b = .69, t103 = 1.00, p = .32),
suggesting that suppression was not effective in down regulating the
LPP. Also consistent with hypotheses, regulation scores …
Paper demonstrates an excellent understanding of all of the concepts and key points presented in the text(s) and Learning Resources. Paper provides significant detail including multiple relevant examples, evidence from the readings and other sources, and discerning ideas.
Paper is well organized, uses scholarly tone, follows APA Style, uses original writing and proper paraphrasing, contains very few or no writing and/or spelling errors, and is fully consistent with graduate-level writing style. Paper contains multiple, appropriate and exemplary sources expected/required for the Assignment.
CATEGORIES
Economics
Nursing
Applied Sciences
Psychology
Science
Management
Computer Science
Human Resource Management
Accounting
Information Systems
English
Anatomy
Operations Management
Sociology
Literature
Education
Business & Finance
Marketing
Engineering
Statistics
Biology
Political Science
Reading
History
Financial markets
Philosophy
Mathematics
Law
Criminal
Architecture and Design
Government
Social Science
World history
Chemistry
Humanities
Business Finance
Writing
Programming
Telecommunications Engineering
Geography
Physics
Spanish
ach
e. Embedded Entrepreneurship
f. Three Social Entrepreneurship Models
g. Social-Founder Identity
h. Micros-enterprise Development
Outcomes
Subset 2. Indigenous Entrepreneurship Approaches (Outside of Canada)
a. Indigenous Australian Entrepreneurs Exami
Calculus
(people influence of
others) processes that you perceived occurs in this specific Institution Select one of the forms of stratification highlighted (focus on inter the intersectionalities
of these three) to reflect and analyze the potential ways these (
American history
Pharmacology
Ancient history
. Also
Numerical analysis
Environmental science
Electrical Engineering
Precalculus
Physiology
Civil Engineering
Electronic Engineering
ness Horizons
Algebra
Geology
Physical chemistry
nt
When considering both O
lassrooms
Civil
Probability
ions
Identify a specific consumer product that you or your family have used for quite some time. This might be a branded smartphone (if you have used several versions over the years)
or the court to consider in its deliberations. Locard’s exchange principle argues that during the commission of a crime
Chemical Engineering
Ecology
aragraphs (meaning 25 sentences or more). Your assignment may be more than 5 paragraphs but not less.
INSTRUCTIONS:
To access the FNU Online Library for journals and articles you can go the FNU library link here:
https://www.fnu.edu/library/
In order to
n that draws upon the theoretical reading to explain and contextualize the design choices. Be sure to directly quote or paraphrase the reading
ce to the vaccine. Your campaign must educate and inform the audience on the benefits but also create for safe and open dialogue. A key metric of your campaign will be the direct increase in numbers.
Key outcomes: The approach that you take must be clear
Mechanical Engineering
Organic chemistry
Geometry
nment
Topic
You will need to pick one topic for your project (5 pts)
Literature search
You will need to perform a literature search for your topic
Geophysics
you been involved with a company doing a redesign of business processes
Communication on Customer Relations. Discuss how two-way communication on social media channels impacts businesses both positively and negatively. Provide any personal examples from your experience
od pressure and hypertension via a community-wide intervention that targets the problem across the lifespan (i.e. includes all ages).
Develop a community-wide intervention to reduce elevated blood pressure and hypertension in the State of Alabama that in
in body of the report
Conclusions
References (8 References Minimum)
*** Words count = 2000 words.
*** In-Text Citations and References using Harvard style.
*** In Task section I’ve chose (Economic issues in overseas contracting)"
Electromagnetism
w or quality improvement; it was just all part of good nursing care. The goal for quality improvement is to monitor patient outcomes using statistics for comparison to standards of care for different diseases
e a 1 to 2 slide Microsoft PowerPoint presentation on the different models of case management. Include speaker notes... .....Describe three different models of case management.
visual representations of information. They can include numbers
SSAY
ame workbook for all 3 milestones. You do not need to download a new copy for Milestones 2 or 3. When you submit Milestone 3
pages):
Provide a description of an existing intervention in Canada
making the appropriate buying decisions in an ethical and professional manner.
Topic: Purchasing and Technology
You read about blockchain ledger technology. Now do some additional research out on the Internet and share your URL with the rest of the class
be aware of which features their competitors are opting to include so the product development teams can design similar or enhanced features to attract more of the market. The more unique
low (The Top Health Industry Trends to Watch in 2015) to assist you with this discussion.
https://youtu.be/fRym_jyuBc0
Next year the $2.8 trillion U.S. healthcare industry will finally begin to look and feel more like the rest of the business wo
evidence-based primary care curriculum. Throughout your nurse practitioner program
Vignette
Understanding Gender Fluidity
Providing Inclusive Quality Care
Affirming Clinical Encounters
Conclusion
References
Nurse Practitioner Knowledge
Mechanics
and word limit is unit as a guide only.
The assessment may be re-attempted on two further occasions (maximum three attempts in total). All assessments must be resubmitted 3 days within receiving your unsatisfactory grade. You must clearly indicate “Re-su
Trigonometry
Article writing
Other
5. June 29
After the components sending to the manufacturing house
1. In 1972 the Furman v. Georgia case resulted in a decision that would put action into motion. Furman was originally sentenced to death because of a murder he committed in Georgia but the court debated whether or not this was a violation of his 8th amend
One of the first conflicts that would need to be investigated would be whether the human service professional followed the responsibility to client ethical standard. While developing a relationship with client it is important to clarify that if danger or
Ethical behavior is a critical topic in the workplace because the impact of it can make or break a business
No matter which type of health care organization
With a direct sale
During the pandemic
Computers are being used to monitor the spread of outbreaks in different areas of the world and with this record
3. Furman v. Georgia is a U.S Supreme Court case that resolves around the Eighth Amendments ban on cruel and unsual punishment in death penalty cases. The Furman v. Georgia case was based on Furman being convicted of murder in Georgia. Furman was caught i
One major ethical conflict that may arise in my investigation is the Responsibility to Client in both Standard 3 and Standard 4 of the Ethical Standards for Human Service Professionals (2015). Making sure we do not disclose information without consent ev
4. Identify two examples of real world problems that you have observed in your personal
Summary & Evaluation: Reference & 188. Academic Search Ultimate
Ethics
We can mention at least one example of how the violation of ethical standards can be prevented. Many organizations promote ethical self-regulation by creating moral codes to help direct their business activities
*DDB is used for the first three years
For example
The inbound logistics for William Instrument refer to purchase components from various electronic firms. During the purchase process William need to consider the quality and price of the components. In this case
4. A U.S. Supreme Court case known as Furman v. Georgia (1972) is a landmark case that involved Eighth Amendment’s ban of unusual and cruel punishment in death penalty cases (Furman v. Georgia (1972)
With covid coming into place
In my opinion
with
Not necessarily all home buyers are the same! When you choose to work with we buy ugly houses Baltimore & nationwide USA
The ability to view ourselves from an unbiased perspective allows us to critically assess our personal strengths and weaknesses. This is an important step in the process of finding the right resources for our personal learning style. Ego and pride can be
· By Day 1 of this week
While you must form your answers to the questions below from our assigned reading material
CliftonLarsonAllen LLP (2013)
5 The family dynamic is awkward at first since the most outgoing and straight forward person in the family in Linda
Urien
The most important benefit of my statistical analysis would be the accuracy with which I interpret the data. The greatest obstacle
From a similar but larger point of view
4 In order to get the entire family to come back for another session I would suggest coming in on a day the restaurant is not open
When seeking to identify a patient’s health condition
After viewing the you tube videos on prayer
Your paper must be at least two pages in length (not counting the title and reference pages)
The word assimilate is negative to me. I believe everyone should learn about a country that they are going to live in. It doesnt mean that they have to believe that everything in America is better than where they came from. It means that they care enough
Data collection
Single Subject Chris is a social worker in a geriatric case management program located in a midsize Northeastern town. She has an MSW and is part of a team of case managers that likes to continuously improve on its practice. The team is currently using an
I would start off with Linda on repeating her options for the child and going over what she is feeling with each option. I would want to find out what she is afraid of. I would avoid asking her any “why” questions because I want her to be in the here an
Summarize the advantages and disadvantages of using an Internet site as means of collecting data for psychological research (Comp 2.1) 25.0\% Summarization of the advantages and disadvantages of using an Internet site as means of collecting data for psych
Identify the type of research used in a chosen study
Compose a 1
Optics
effect relationship becomes more difficult—as the researcher cannot enact total control of another person even in an experimental environment. Social workers serve clients in highly complex real-world environments. Clients often implement recommended inte
I think knowing more about you will allow you to be able to choose the right resources
Be 4 pages in length
soft MB-920 dumps review and documentation and high-quality listing pdf MB-920 braindumps also recommended and approved by Microsoft experts. The practical test
g
One thing you will need to do in college is learn how to find and use references. References support your ideas. College-level work must be supported by research. You are expected to do that for this paper. You will research
Elaborate on any potential confounds or ethical concerns while participating in the psychological study 20.0\% Elaboration on any potential confounds or ethical concerns while participating in the psychological study is missing. Elaboration on any potenti
3 The first thing I would do in the family’s first session is develop a genogram of the family to get an idea of all the individuals who play a major role in Linda’s life. After establishing where each member is in relation to the family
A Health in All Policies approach
Note: The requirements outlined below correspond to the grading criteria in the scoring guide. At a minimum
Chen
Read Connecting Communities and Complexity: A Case Study in Creating the Conditions for Transformational Change
Read Reflections on Cultural Humility
Read A Basic Guide to ABCD Community Organizing
Use the bolded black section and sub-section titles below to organize your paper. For each section
Losinski forwarded the article on a priority basis to Mary Scott
Losinksi wanted details on use of the ED at CGH. He asked the administrative resident