Social anxiety and its maintaining factors : accounting for the role of neuroticism

Models of social anxiety disorder (SAD) and research indicate several cognitive and behavioural maintaining factors that perpetuate social anxiety (i.e., maladaptive social-evaluative beliefs, self-focus, attention towards threat in environment, anticipatory processing, post-event processing, safety behaviours). It is unknown whether these maintaining factors are exclusive to social anxiety or if they are also related to neuroticism – a tendency to experience negative emotions. A community sample of adults (N = 263) completed measures of relevant constructs (social anxiety, neuroticism, depression, aforementioned maintaining factors). Structural equation modelling was used to analyse the cross-sectional data. In a good fitting model which included depression, social anxiety had unique positive associations with all maintaining factors. Neuroticism had unique positive associations with social-evaluative beliefs, self-focus, and post-event processing, but not with any of the other maintaining factors. This model also had superior fit compared to a plausible competing model which did not include neuroticism. Certain maintaining factors may not be exclusive to social anxiety, in contrast to how they are conceptualised in models of SAD. Furthermore, neuroticism may play a role in social anxiety, highlighting the potential of interventions for social anxiety to be advanced through greater incorporation of emotion regulation strategies for negative affect

The effectiveness of a smartphone intervention targeting suicidal ideation in young adults : randomized controlled trial examining the influence of loneliness

Background: Loneliness is commonly reported by young people and has been shown to contribute to the rapid onset and escalation of depression and suicidal ideation during adolescence. Lonely people may also be particularly susceptible to disengaging from treatment early given the likelihood of their more complex clinical profiles leading to cognitive fatigue. While a smartphone intervention (LifeBuoy) has been shown to effectively reduce suicidal ideation in young adults, poor engagement is a well-documented issue for this therapeutic modality and has been shown to result in poorer treatment outcomes. Objective: This study aims to determine whether loneliness affects how young people experiencing suicidal ideation engage with and benefit from a therapeutic smartphone intervention (LifeBuoy). Methods: A total of 455 community-based Australian young adults (aged 18-25 years) experiencing recent suicidal ideation were randomized to use a dialectical behavioral therapy–based smartphone intervention (LifeBuoy) or an attention-matched control app (LifeBuoy-C) for 6 weeks. Participants completed measures of suicidal ideation, depression, anxiety, and loneliness at baseline (T0), post intervention (T1), and 3 months post intervention (T2). Piecewise linear mixed models were used to examine whether loneliness levels moderated the effect of LifeBuoy and LifeBuoy-C on suicidal ideation and depression across time (T0 to T1; T1 to T2). This statistical method was then used to examine whether app engagement (number of modules completed) influenced the relationship between baseline loneliness and suicidal ideation and depression across time. Results: Loneliness was positively associated with higher levels of overall suicidal ideation (B=0.75, 95% CI 0.08-1.42; P=.03) and depression (B=0.88, 95% CI 0.45-1.32; P<.001), regardless of time point or allocated condition. However, loneliness did not affect suicidal ideation scores across time (time 1: B=1.10, 95% CI –0.25 to 2.46; P=.11; time 2: B=0.43, 95% CI –1.25 to 2.12; P=.61) and depression scores across time (time 1: B=0.00, 95% CI –0.67 to 0.66; P=.99; time 2: B=0.41, 95% CI –0.37 to 1.18; P=.30) in either condition. Similarly, engagement with the LifeBuoy app was not found to moderate the impact of loneliness on suicidal ideation (B=0.00, 95% CI –0.17 to 0.18; P=.98) or depression (B=–0.08, 95% CI –0.19 to 0.03; P=.14). Conclusions: Loneliness was not found to affect young adults’ engagement with a smartphone intervention (LifeBuoy) nor any clinical benefits derived from the intervention. LifeBuoy, in its current form, can effectively engage and treat individuals regardless of how lonely they may be

Use of web conferencing technology for conducting online focus groups among young people with lived experience of suicidal thoughts : mixed methods research

Background: There is an increasing interest in engaging people with lived experience in suicide prevention research. However, young people with suicidal thoughts have been described as a “hard-to-include” population due to time, distance, stigma, and social barriers. Objective: This study aims to investigate whether conducting synchronous Web conferencing technology–based online focus groups (W-OFGs) is a feasible method to engage young people with lived experience of suicidal thoughts in suicide prevention research. Methods: Young people aged between 16 and 25 years and living in Sydney, Australia, were recruited through flyers, emails, and social media advertisements. The W-OFGs were established using a Web conferencing technology called GoToMeeting. Participants’ response rate, attendance, and feedback of the W-OFGs were analyzed to determine whether the W-OFG system is feasible for suicide prevention research. Researchers’ reflections about how to effectively implement the W-OFGs were also reported as part of the results. Results: In the pre–W-OFG survey, 39 (97.5%) young people (n=40) chose to attend the online focus group. Among the 22 participants who responded to the W-OFG invitations, 15 confirmed that they would attend the W-OFGs, of which 11 participants attended the W-OFGs. Feedback collected from the participants in the W-OFG and the post–W-OFG survey suggested that online focus groups are acceptable to young people in suicide prevention research. Considerations for selecting the Web conferencing platform, conducting the mock W-OFGs, implementing the risk management procedure, inviting participants to the W-OFGs, and hosting and moderating the W-OFGs as well as a few potential ethical and pragmatic challenges in using this method are discussed in this study. Conclusions: The Web conferencing technology provides a feasible replacement for conventional methods, particularly for qualitative research involving vulnerable populations and stigmatized topics including suicide prevention. Our results indicate that this modality is an optimal alternative to engage young people in the focus group discussion. Future studies should compare the data collected from the Web conferencing technology and conventional face-to-face methods in suicide prevention research to determine if these two methods are equivalent in data quality from a quantitative approach

Three-arm randomised controlled trial of an m-health app and digital engagement strategy for improving treatment adherence and reducing suicidal ideation in young people : study protocol

Introduction: Youth suicidal ideation and behaviour is concerning due to its widespread prevalence, morbidity and potentially fatal consequences. Digital mental health interventions have been found to improve access to low-cost and high-quality support for a range of mental health issues, yet there are few digital interventions available for suicide prevention in young people. In addition, no studies have examined how digital engagement strategies may impact the engagement and efficacy of digital interventions in suicide prevention. The current protocol describes a three-arm parallel randomised controlled trial. A therapeutic smartphone application (‘LifeBuoy’; intervention condition) will be tested against a condition that consists of the LifeBuoy application plus access to a digital engagement strategy (‘LifeBuoy+engagement’; intervention condition) to determine whether the addition of the digital strategy improves app engagement metrics. To establish the efficacy of the LifeBuoy application, both of these intervention conditions will be tested against an attention-matched control condition (a placebo app). Methods and analysis: 669 young Australians aged 17–24 years who have experienced suicidal ideation in the past 30 days will be recruited by Facebook advertisement. The primary outcomes will be suicidal ideation severity and level of app engagement. Primary analyses will use an intention-to-treat approach and compare changes from baseline to 30-day, 60-day and 120-day follow-up time points relative to the control group using mixed-effect modelling. A subset of participants in the intervention groups will be interviewed on their experience with the app and engagement strategy. Qualitative data will be analysed using an inductive approach, independent of a theoretical confirmative method to identify the group themes. Ethics and dissemination: The study has been approved by the University of New South Wales Human Research Ethics Committee (HC210400). The results of the trial will be disseminated via peer-reviewed publications in scientific journals and conferences. Trial registration number ACTRN12621001247864

A mobile health intervention (LifeBuoy App) to help young people manage suicidal thoughts : protocol for a mixed-methods randomized controlled trial

Background: Self-help smartphone apps offer a new opportunity to address youth suicide prevention by improving access to support and by providing potentially high fidelity and cost-effective treatment. However, there have been very few smartphone apps providing evidence-based support for suicide prevention in this population. To address this gap, we developed the LifeBuoy app, a self-help smartphone app informed by dialectical behavior therapy (DBT), to help young people manage suicidal thoughts in their daily life. Objective: This study describes the protocol for a randomized controlled trial to evaluate the efficacy of the LifeBuoy app for reducing suicidal thoughts and behaviors, depression, anxiety, and psychological distress, and improving general mental well-being in young adults aged 18 to 25 years. Methods: This is a randomized controlled trial recruiting 378 young adults aged between 18 and 25 years and comparing the LifeBuoy app with a matched attention control (a placebo app with the same display but no DBT components). The primary outcome is suicidal thoughts measured by the Suicidal Ideation Attributes Scale (SIDAS). The secondary outcomes are suicidal behavior, depression, anxiety, psychological distress, and general mental well-being. The changes in the levels of insomnia, rumination, suicide cognitions, distress tolerance, loneliness, and help seeking before and after using the app are evaluated in this study. The study also addresses risk factors and responses to the intervention. A series of items assessing COVID-19 experiences is included in the trial to capture the potential impact of the pandemic on this study. Assessments will occur on the following three occasions: baseline, postintervention, and follow-up at 3 months postintervention. A qualitative interview about user experience with the LifeBuoy app will take place within 4 weeks of the final assessment. Using linear mixed models, the primary analysis will compare the changes in suicidal thoughts in the intervention condition relative to the control condition. To minimize risks, participants will receive a call from the team clinical psychologist by clicking a help button in the app or responding to an automated email sent by the system when they are assessed with elevated suicide risks at the baseline, postintervention, and 3-month follow-up surveys. Results: The trial recruitment started in May 2020. Data collection is currently ongoing. Conclusions: This is the first trial examining the efficacy of a DBT-informed smartphone app delivered to community-living young adults reporting suicidal thoughts. This trial will extend knowledge about the efficacy and acceptability of app-based support for suicidal thoughts in young people

Concurrent and prospective associations between negative social-evaluative beliefs, safety behaviours, and symptoms during and following cognitive behavioural group therapy for social anxiety disorder

Background: Improving the delivery of cognitive-behavioural therapy (CBT) for social anxiety disorder (SAD) requires an in-depth understanding of which cognitive and behavioural mechanisms drive change in social anxiety symptoms (i.e., social interaction anxiety) during and after treatment. The current study explores the dynamic temporal associations between theory-driven cognitive and behavioural mechanisms of symptom change both during and following group CBT. Methods: A randomized controlled trial of imagery-enhanced CBT (n = 51) versus traditional verbal CBT (n = 54) for social anxiety was completed in a community mental health clinic setting. This study included data collected from 12-weekly sessions and a 1-month follow-up session. Mixed models were used to assess magnitude of change over the course of treatment. Cross-lagged panel models were fit to the data to examine temporal relationships between mechanisms (social evaluative beliefs, safety behaviours) and social interaction anxiety symptoms. Results: Participants in both CBT groups experienced significant improvements across all cognitive, behavioural, and symptom measures, with no significant differences in the magnitude of changes between treatments. During treatment, greater social-evaluative beliefs (fear of negative evaluation, negative self-portrayals) at one time point (T) were predictive of more severe SAD symptoms and safety behaviours at T+1. Social-evaluative beliefs (fear of negative evaluation, probability and cost of social failure) and safety behaviours measured at post-treatment were positively associated with SAD symptoms at the 1-month follow-up. Conclusions: The current study identifies social-evaluative beliefs that may be important targets for symptom and avoidance reduction during and following CBT. Assessment of these social-evaluative beliefs throughout treatment may be useful for predicting future SAD symptoms and avoidance, and for adapting treatment to promote optimal change for patients

A trial protocol for the effectiveness of digital interventions for preventing depression in adolescents : The Future Proofing Study

Background: Depression frequently first emerges during adolescence, and one in five young people will experience an episode of depression by the age of 18 years. Despite advances in treatment, there has been limited progress in addressing the burden at a population level. Accordingly, there has been growing interest in prevention approaches as an additional pathway to address depression. Depression can be prevented using evidence-based psychological programmes. However, barriers to implementing and accessing these programmes remain, typically reflecting a requirement for delivery by clinical experts and high associated delivery costs. Digital technologies, specifically smartphones, are now considered a key strategy to overcome the barriers inhibiting access to mental health programmes. The Future Proofing Study is a large-scale school-based trial investigating whether cognitive behaviour therapies (CBT) delivered by smartphone application can prevent depression. Methods: A randomised controlled trial targeting up to 10,000 Year 8 Australian secondary school students will be conducted. In Stage I, schools will be randomised at the cluster level either to receive the CBT intervention app (SPARX) or to a non-active control group comparator. The primary outcome will be symptoms of depression, and secondary outcomes include psychological distress, anxiety and insomnia. At the 12-month follow-up, participants in the intervention arm with elevated depressive symptoms will participate in an individual-level randomised controlled trial (Stage II) and be randomised to receive a second CBT app which targets sleep difficulties (Sleep Ninja) or a control condition. Assessments will occur post intervention (both trial stages) and at 6, 12, 24, 36, 48 and 60 months post baseline. Primary analyses will use an intention-to-treat approach and compare changes in symptoms from baseline to follow-up relative to the control group using mixed-effect models. Discussion: This is the first trial testing the effectiveness of smartphone apps delivered to school students to prevent depression at scale. Results from this trial will provide much-needed insight into the feasibility of this approach. They stand to inform policy and commission decisions concerning if and how such programmes should be deployed in school-based settings in Australia and beyond

Psychometric evaluation of the English version of the Extended Post-event Processing Questionnaire

Background: The importance of post-event processing (PEP) in prominent models of social anxiety disorder has led to the development of measures that tap this cognitive construct. The 17-item Extended Post-event Processing Questionnaire (E-PEPQ) is one of the most comprehensive measures of PEP developed to date. However, the measure was developed in German and the psychometric properties of the English version of the E-PEPQ have not yet been examined. Design: The current study examined the factor structure, internal consistency, and construct validity of the English version of the E-PEPQ. Methods: English-speaking participants (N = 560) completed the English version of the E-PEPQ, a measure of social anxiety and a measure of depression. Results: A 15-item version of the E-PEPQ with a correlated three-factor structure (referred to as the E-PEPQ-15) emerged as the best fitting model using confirmatory factor analyses, and the E-PEPQ-15 and its subscales demonstrated good internal consistency. The E-PEPQ-15 and two of its three subscales also had significantly stronger positive associations with the social anxiety measure than with the depression measure. Conclusions: The psychometric properties of the E-PEPQ-15 obtained in the current study justify the use of the measure in research, particularly in the domain of social anxiety

Anticipatory processing and post-event processing in social anxiety disorder : an update on the literature

Two repetitive thinking processes that have been proposed in prominent maintenance models of social anxiety disorder (SAD) are anticipatory processing and post-event processing. Research into these two processes has steadily increased over the last 20 years. This review highlights the main lines of existing research on anticipatory processing and post-event processing, including studies on the nature of these processes, their association with social anxiety, the predictors, and consequences of these processes, as well as how these processes respond to treatments for SAD. The review also highlights some of the conceptual and methodological issues that have prevented the literature on anticipatory processing and post-event processing from being more integrated and focused. Finally, the review draws together some new directions in terms of theory and research to further advance the field

The aetiology and maintenance of social anxiety disorder : a synthesis of complimentary theoretical models and formulation of a new integrated model

Background: Within maintenance models of social anxiety disorder (SAD), a number of cognitive and behavioural factors that drive the persistence of SAD have been proposed. However, these maintenance models do not address how SAD develops, or the origins of the proposed maintaining factors. There are also models of the development of SAD that have been proposed independently from maintenance models. These models highlight multiple factors that contribute risk to the onset of SAD, but do not address how these aetiological factors may lead to the development of the maintaining factors associated with SAD. Methods: A systematic review of the literature was conducted to identify aetiological and maintenance models of SAD. We then united key factors identified in these models and formulated an integrated aetiological and maintenance (IAM) model of SAD. A systematic review of the literature was then conducted on the components of the IAM model. Results: A number of aetiological and maintaining factors were identified in models of SAD. These factors could be drawn together into the IAM model. On balance, there is empirical evidence for the association of each of the factors in the IAM model with social anxiety or SAD, providing preliminary support for the model. Limitations: There are relationships between components of the IAM model that require empirical attention. Future research will need to continue to test the IAM model. Conclusions: The IAM model provides a framework for future investigations into the development and persistence of SAD