Publications by authors named "David M Clark"

131 Publications

Safety behaviours in social anxiety: An examination across adolescence.

Behav Res Ther 2021 Sep 15;144:103931. Epub 2021 Jul 15.

Department of Experimental Psychology, University of Oxford, Oxford, UK. Electronic address:

Background: Safety behaviours have been shown to be a key maintaining factor in Social Anxiety Disorder (SAD). In adults, a two-factor structure of safety behaviours reflecting 'avoidance' and 'impression-management' types has been identified. This has not yet been investigated in adolescents.

Aims: We set out to investigate the factor structure of safety behaviours in relation to adolescent social anxiety symptoms and SAD, the extent to which this varies by age, and then to examine the association between the derived factor scores and other social anxiety related phenomena.

Method: Questionnaire measures of social anxiety symptoms, cognitions and safety behaviours, peer relationship outcomes, general anxiety and depression were collected from a community sample of 584 younger (11-14 years) and 208 older (16-18 years) adolescents, and a clinical sample of 80 adolescents (11-18 years) with a primary diagnosis of SAD. Four hypotheses were investigated using exploratory and confirmatory factor analyses, regressions, correlations and path analyses.

Results: A two-factor structure reflecting 'avoidance' and 'impression-management' safety behaviours was supported in the community and clinical sample. Older adolescents were found to use 'impression-management' behaviours more than younger adolescents after controlling for overall safety behaviour score. Both types of safety behaviour were significantly positively associated with social anxiety symptoms and cognitions. Path analyses revealed an indirect effect of social anxiety symptoms on peer victimisation, social satisfaction and friendship quality via 'avoidance', but not 'impression-management' safety behaviours.

Conclusions: Both 'avoidance' and 'impression-management' safety behaviours are associated with social anxiety symptoms and cognitions in youth, with age-related differences in their frequency. 'Avoidance' behaviours are specifically associated with negative outcomes for quality of peer relationships.
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http://dx.doi.org/10.1016/j.brat.2021.103931DOI Listing
September 2021

Treating social anxiety disorder remotely with cognitive therapy.

Cogn Behav Therap 2020 Jul 16;13:e30. Epub 2020 Jul 16.

Department of Experimental Psychology, University of Oxford, Oxford, UK.

Remote delivery of evidence-based psychological therapies via video conference has become particularly relevant following the COVID-19 pandemic, and is likely to be an on-going method of treatment delivery post-COVID. Remotely delivered therapy could be of particular benefit for people with social anxiety disorder (SAD), who tend to avoid or delay seeking face-to-face therapy, often due to anxiety about travelling to appointments and meeting mental health professionals in person. Individual cognitive therapy for SAD (CT-SAD), based on the Clark and Wells (1995) model, is a highly effective treatment that is recommended as a first-line intervention in NICE guidance (NICE, 2013). All of the key features of face-to-face CT-SAD (including video feedback, attention training, behavioural experiments and memory-focused techniques) can be adapted for remote delivery. In this paper, we provide guidance for clinicians on how to deliver CT-SAD remotely, and suggest novel ways for therapists and patients to overcome the challenges of carrying out a range of behavioural experiments during remote treatment delivery.

Key Learning Aims: To learn how to deliver all of the core interventions of CT-SAD remotely.To learn novel ways of carrying out behavioural experiments remotely when some in-person social situations might not be possible.
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http://dx.doi.org/10.1017/S1754470X2000032XDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7411446PMC
July 2020

Is concentration an indirect link between social anxiety and educational achievement in adolescents?

PLoS One 2021 14;16(5):e0249952. Epub 2021 May 14.

Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.

Social anxiety is associated with reduced educational achievement. Given that concentration is a predictor of educational achievement, and social anxiety symptoms are associated with reduced concentration in class, this prospective study examined the possibility that social anxiety may impair educational achievement through reduced classroom concentration. A sample of 509 participants (53.8% female; M age: 12.77 years [SD = 0.81]) recruited from secondary schools completed questionnaires assessing social anxiety symptoms, depressive symptoms, and concentration in class. Educational achievement was assessed by internal grades within schools. An indirect effect of social anxiety on later educational achievement via concentration was observed, over and above baseline achievement and depression symptoms; adolescents with higher levels of social anxiety tend to have more difficulties concentrating in class, which in turn is associated with poorer academic outcomes. Findings underscore the challenges socially anxious adolescents will face trying to learn in school, and the need for education providers and clinicians to consider the effect of social anxiety symptoms on concentration and learning.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249952PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8121284PMC
May 2021

The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder.

Front Psychiatry 2021 16;12:602648. Epub 2021 Apr 16.

Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.

Working alliance has been shown to predict outcome of psychological treatments in multiple studies. Conversely, changes in outcome scores have also been found to predict working alliance ratings. To assess the temporal relationships between working alliance and outcome in 230 patients receiving trauma-focused cognitive behavioral treatment for posttraumatic stress disorder (PTSD). Ratings of working alliance were made by both the patient and therapist after sessions 1, 3, and 5 of a course of Cognitive Therapy for PTSD (CT-PTSD). Autoregressive, cross-lagged panel models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Linear regressions tested the relationship between alliance and treatment outcome. Both patients' and therapists' working alliance ratings after session 1 predicted PTSD symptom scores at the end of treatment, controlling for baseline scores. At each assessment point, higher therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance: higher therapists' alliance ratings predicted lower PTSD symptom scores at the next assessment point. Similarly, lower PTSD symptoms predicted higher therapist working alliance ratings at the next assessment point. Ruminative thinking was negatively related to therapists' alliance ratings. Working alliance at the start of treatment predicted treatment outcome in patients receiving CT-PTSD and may be an important factor in setting the necessary conditions for effective treatment. For therapists, there was a reciprocal relationship between working alliance and PTSD symptom change in their patients during treatment, suggesting that their alliance ratings predicted symptom change, but were also influenced by patients' symptom change.
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http://dx.doi.org/10.3389/fpsyt.2021.602648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085346PMC
April 2021

Development and Preliminary Validation of the Child & Adolescent Social Cognitions Questionnaire.

Child Psychiatry Hum Dev 2021 Apr 3. Epub 2021 Apr 3.

Department of Experimental Psychology, University of Oxford, Oxford, UK.

Negative cognitions play a central role in adolescent social anxiety, and yet there is a lack of empirically validated measures assessing these in detail. This study describes the adaptation of the Child & Adolescent Social Cognitions Questionnaire (CASCQ) from the adult version of the scale and its preliminary validation in a general adolescent school sample (N = 671). Exploratory and confirmatory factor analysis on split halves of the data indicated two factors, labelled 'negative self-concept' and 'anxious appearance', provided the best fit. Totals and subscales possessed good internal consistency and convergent validity. Findings suggest that the CASCQ is a reliable and valid measure of social anxiety-related cognitions in youth and may be useful for research and clinical purposes. Further examination of the scale with pre-adolescents and clinical samples is warranted.
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http://dx.doi.org/10.1007/s10578-021-01163-0DOI Listing
April 2021

The employment and mental health impact of integrated improving access to psychological therapies services: Evidence on secondary health care utilization from a pragmatic trial in three English counties.

J Health Serv Res Policy 2021 Mar 26:1355819621997493. Epub 2021 Mar 26.

Professor and Chair of Experimental Psychology, Department of Experimental Psychology, University of Oxford, UK.

Objective: Patients with a combination of long-term physical health problems can face barriers in obtaining appropriate treatment for co-existing mental health problems. This paper evaluates the impact of integrating the improving access to psychological therapies services (IAPT) model with services addressing physical health problems. We ask whether such services can reduce secondary health care utilization costs and improve the employment prospects of those so affected.

Methods: We used a stepped-wedge design of two cohorts of a total of 1,096 patients with depression and/or anxiety and comorbid long-term physical health conditions from three counties within the Thames Valley from March to August 2017. Panels were balanced. Difference-in-difference models were employed in an intention-to-treat analysis.

Results: The new Integrated-IAPT was associated with a decrease of 6.15 (95% CI: -6.84 to -5.45) [4.83 (95% CI: -5.47 to -4.19]) points in the Patient Health Questionnaire-9 [generalized anxiety disorder-7] and £360 (95% CI: -£559 to -£162) in terms of secondary health care utilization costs per person in the first three months of treatment. The Integrated-IAPT was also associated with an 8.44% (95% CI: 1.93% to 14.9%) increased probability that those who were unemployed transitioned to employment.

Conclusions: Mental health treatment in care model with Integrated-IAPT seems to have significantly reduced secondary health care utilization costs among persons with long-term physical health conditions and increased their probability of employment.
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http://dx.doi.org/10.1177/1355819621997493DOI Listing
March 2021

Cognitive therapy compared with CBT for social anxiety disorder in adolescents: a feasibility study.

Health Technol Assess 2021 Mar;25(20):1-94

Department of Experimental Psychology, University of Oxford, Oxford, UK.

Background: Social anxiety disorder (SAD) is common, typically starts in adolescence and has a low natural recovery rate. Existing psychological treatments for adolescent SAD are only moderately effective. It is possible that recovery rates for adolescents could be substantially improved by adapting a psychological therapy that is highly effective among adults with SAD.

Objectives: To train child and adolescent mental health services (CAMHS) therapists to deliver cognitive therapy for SAD in adolescents (CT-SAD-A) and assess therapist competence. To estimate the costs to the NHS of training therapists to deliver CT-SAD-A and the mean cost per adolescent treated. To examine the feasibility of a randomised controlled trial (RCT) to compare CT-SAD-A with the general form of cognitive-behavioural therapy that is more commonly used.

Design: During the training phase of the study, it became clear that the RCT would not be feasible because of high staff turnover and unfilled posts within CAMHS and changes in the nature of referrals, which meant that few young people with primary SAD were accessing some of the participating services. The study design was altered to comprise the following: a training case series of CT-SAD-A delivered in routine CAMHS, an estimate of the cost to the NHS of training therapists to deliver CT-SAD-A and of the mean cost per adolescent treated, and qualitative interviews with participating young people, parents, therapists and service managers/leads.

Setting: Five CAMHS teams within Berkshire Healthcare and Oxford Health NHS Foundation Trusts.

Participants: Eight therapists received training in CT-SAD-A. Twelve young people received CT-SAD-A, delivered by six therapists. Six young people, six parents, seven therapists and three managers participated in qualitative interviews.

Interventions: Cognitive therapy for social anxiety disorder in adolescents (CT-SAD-A).

Main Outcome Measures: Measured outcomes included social anxiety symptoms and diagnostic status, comorbid symptoms of anxiety and depression, social and general functioning, concentration in class and treatment acceptability. Patient level utilisation of the intervention was collected using clinicians' logs.

Results: Nine out of 12 participants achieved good outcomes across measures ( ≥ 0.60 across social anxiety measures). The estimated cost of delivering CT-SAD-A was £1861 (standard deviation £358) per person. Qualitative interviews indicated that the treatment was acceptable to young people, parents and therapists, but therapists and managers experienced challenges when implementing the training and treatment within the current CAMHS context.

Limitations: Findings were based on a small, homogeneous sample and there was no comparison arm.

Conclusions: CT-SAD-A is a promising treatment for young people with SAD, but the current CAMHS context presents challenges for its implementation.

Future Work: Further work is needed to ensure that CAMHS can incorporate and test CT-SAD-A. Alternatively, CT-SAD-A should be delivered and tested in other settings that are better configured to treat young people whose lives are held back by SAD. The new schools Mental Health Support Teams envisaged in the 2017 Children's Mental Health Green Paper may provide such an opportunity.

Funding: The National Institute for Health Research (NIHR) Health Technology Assessment programme. Individual funding was also provided for Cathy Creswell, David M Clark and Eleanor Leigh as follows: NIHR Research Professorship (Cathy Creswell); Wellcome Senior Investigator Award (Anke Ehlers and David M Clark); and the Wellcome Clinical Research Training Fellowship (Eleanor Leigh).
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http://dx.doi.org/10.3310/hta25200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020199PMC
March 2021

Delivering cognitive therapy for adolescent social anxiety disorder in NHS CAMHS: a clinical and cost analysis.

Behav Cogn Psychother 2021 Mar 1:1-13. Epub 2021 Mar 1.

Department of Experimental Psychology, University of Oxford, Oxford Centre for Anxiety Disorders and Trauma, The Old Rectory, Paradise Square, OxfordOX1 1TW, UK.

Background: Cognitive therapy, based on the Clark and Wells (1995) model, is a first-line treatment for adults with social anxiety disorder (SAD), and findings from research settings suggest it has promise for use with adolescents (Cognitive Therapy for Social Anxiety Disorder in Adolescents; CT-SAD-A). However, for the treatment to be suitable for delivery in routine clinical care, two questions need to be addressed.

Aims: Can therapists be trained to achieve good outcomes in routine Child and Adolescent Mental Health Services (CAMHS), and what are the costs associated with training and treatment?

Method: CAMHS therapists working in two NHS trusts received training in CT-SAD-A. They delivered the treatment to adolescents with SAD during a period of supervised practice. We examined the clinical outcomes for the 12 patients treated during this period, and estimated costs associated with treatment and training.

Results: Treatment produced significant improvements in social anxiety symptoms, general anxiety and depression symptoms, and reductions in putative process measures. Seventy-five per cent (9 out of 12) patients showed a reliable and clinically significant improvement in social anxiety symptoms, and 64% (7/11) lost their primary diagnosis of SAD. The total cost to the NHS of the CT-SAD-A treatment was £4047 (SD = £1003) per adolescent treated, of which £1861 (SD = £358) referred to the specific estimated cost of face-to-face delivery; the remaining cost was for training and supervising therapists who were not previously familiar with the treatment.

Conclusions: This study provides preliminary evidence that clinicians can deliver good patient outcomes for adolescents with SAD in routine CAMHS during a period of supervised practice after receiving a 2-day training workshop. Furthermore, the cost of delivering CT-SAD-A with adolescents appeared to be no more than the cost of delivering CT-SAD with adults.
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http://dx.doi.org/10.1017/S1352465821000035DOI Listing
March 2021

Delivering cognitive therapy for adolescent social anxiety disorder in NHS CAMHS: a qualitative analysis of the experiences of young people, their parents and clinicians-in-training.

Behav Cogn Psychother 2021 Mar 1:1-15. Epub 2021 Mar 1.

Department of Psychology, Aston Triangle, BirminghamB4 7ET, UK.

Background: Social anxiety disorder (SAD) is common. It usually starts in adolescence, and without treatment can disrupt key developmental milestones. Existing generic treatments are less effective for young people with SAD than with other anxiety disorders, but an adaptation of an effective adult therapy (CT-SAD-A) has shown promising results for adolescents.

Aims: The aim of this study was to conduct a qualitative exploration to contribute towards the evaluation of CT-SAD-A for adoption into Child and Adolescent Mental Health Services (CAMHS).

Method: We used interpretative phenomenological analysis (IPA) to analyse the transcripts of interviews with a sample of six young people, six parents and seven clinicians who were learning the treatment.

Results: Three cross-cutting themes were identified: (i) endorsing the treatment; (ii) finding therapy to be collaborative and active; challenging but helpful; and (iii) navigating change in a complex setting. Young people and parents found the treatment to be useful and acceptable, although simultaneously challenging. This was echoed by the clinicians, with particular reference to integrating CT-SAD-A within community CAMHS settings.

Conclusions: The acceptability of the treatment with young people, their parents and clinicians suggests further work is warranted in order to support its development and implementation within CAMHS settings.
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http://dx.doi.org/10.1017/S1352465821000047DOI Listing
March 2021

Self-focused attention and safety behaviours maintain social anxiety in adolescents: An experimental study.

PLoS One 2021 26;16(2):e0247703. Epub 2021 Feb 26.

Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.

Background: Self-focused attention and safety behaviours are both associated with adolescent social anxiety. In adults, experimental studies have indicated that the processes are causally implicated in social anxiety, but this hypothesis has not yet been tested in a youth sample.

Methods: This experiment explored this possibility by asking high and low socially anxious adolescents (N = 57) to undertake conversations under different conditions. During one conversation they were instructed to focus on themselves and use safety behaviours, and in the other they focused externally and did not use safety behaviours. Self-report, conversation partner report and independent assessor ratings were taken.

Results: Self-focus and safety behaviours increased feelings and appearance of anxiety and undermined performance for all participants, but only high socially anxious participants reported habitually using self-focus and safety behaviours.

Conclusions: The findings provide support for the causal role of self-focus and safety behaviours in adolescent social anxiety and point to the potential clinical value of techniques reversing them to treat the disorder.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247703PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909699PMC
February 2021

Catastrophic cognitions about coronavirus: the Oxford psychological investigation of coronavirus questionnaire [TOPIC-Q].

Psychol Med 2021 Jan 22:1-10. Epub 2021 Jan 22.

Department of Psychiatry, University of Oxford, Oxford, UK.

Background: Cognitive therapies are developed on the principle that specific cognitive appraisals are key determinants in the development and maintenance of mental health disorders. It is likely that particular appraisals of the coronavirus pandemic will have explanatory power for subsequent mental health outcomes in the general public. To enable testing of this hypothesis we developed a questionnaire assessing coronavirus-related cognitions.

Methods: 12 285 participants completed online a 46-item pool of cognitions about coronavirus and six measures of different mental health problems. The sample was randomly split into derivation and validation samples. Exploratory factor analyses determined the factor structure, selection of items, and model fit in the derivation sample. Confirmatory factor analysis (CFA) then tested this model in the validation sample. Associations of the questionnaire with mental health outcomes were examined.

Results: The 26-item, seven-factor, Oxford Psychological Investigation of Coronavirus Questionnaire [TOPIC-Q] was developed. CFA demonstrated a good model fit (χ2 = 2108.43, df = 278, p < 0.001, comparative fit index (CFI) = 0.950, Tucker-Lewis index (TLI) = 0.942, root mean square error of approximation (RMSEA) = 0.033, standardized root mean square residual (SRMR) = 0.038). The factors were: cognitions about (1) safety and vulnerability, (2) negative long-term impact, (3) having the virus, (4) spreading the virus, (5) social judgment, (6) negative self, and (7) being targeted. The questionnaire explained significant variance in depression (45.8%), social anxiety (37.3%), agoraphobia (23.2%), paranoia (27.3%), post-traumatic stress disorder (57.1%), and panic disorder (31.4%). Cognitions about negative long-term impact had the greatest explanatory power across disorders.

Conclusions: TOPIC-Q provides a method to assess appraisals of the pandemic, which is likely to prove helpful both in longitudinal studies assessing mental health outcomes and in delivery of psychological therapy.
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http://dx.doi.org/10.1017/S0033291721000283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884724PMC
January 2021

Cognitive predictors of adolescent social anxiety.

Behav Res Ther 2021 02 31;137:103801. Epub 2020 Dec 31.

Department of Experimental Psychology, University of Oxford, Oxford, UK. Electronic address:

Background: Identifying psychological processes that maintain social anxiety holds promise for improving treatment outcomes for young people. Experimental and prospective studies in adults suggest negative social cognitions, safety behaviours, self-focused attention, and pre- and post-event processing are all implicated in the maintenance of social anxiety. Despite social anxiety typically starting in adolescence, prospective studies examining these cognitive processes in youth are lacking. The current study examined prospective associations between these five cognitive processes and social anxiety in a sample of 614 participants (53% girls; aged 11-14 years).

Methods: Psychological processes, social anxiety symptoms, and depressive symptoms were assessed using self-report questionnaires at two time points.

Results: Negative social cognitions, safety behaviours, self-focused attention, and post-event processing predicted prospective levels of social anxiety over and above the effect of baseline levels of social anxiety. When these process variables were entered together in a regression model, three of them were independently associated with prospective social anxiety. Neither pre- nor post-event processing independently predicted later social anxiety over and above the effects of other psychological process variables.

Conclusions: The findings indicate that these psychological processes are promising targets for treatment in adolescent social anxiety.
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http://dx.doi.org/10.1016/j.brat.2020.103801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846721PMC
February 2021

Are young people with primary social anxiety disorder less likely to recover following generic CBT compared to young people with other primary anxiety disorders? A systematic review and meta-analysis.

Behav Cogn Psychother 2021 May 10;49(3):352-369. Epub 2020 Dec 10.

Department of Experimental Psychology, University of Oxford, Oxford, UK.

Background: Social anxiety disorder (SoAD) in youth is often treated with a generic form of cognitive behavioural therapy (CBT). Some studies have suggested that primary SoAD is associated with lower recovery rates following generic CBT compared with other anxiety disorders.

Aims: This systematic review and meta-analysis investigated recovery rates following generic CBT for youth with primary SoAD versus other primary anxiety disorders.

Method: Five databases (PsycINFO, Web of Science, PubMed, Embase, Medline) were searched for randomised controlled trials of generic CBT for child and/or adolescent anxiety.

Results: Ten trials met criteria for inclusion in the systematic review, six of which presented sufficient data for inclusion in the meta-analysis. Sixty-seven did not report data on recovery rates relative to primary diagnosis. While most individual studies included in the systematic review were not sufficiently powered to detect a difference in recovery rates between diagnoses, there was a pattern of lower recovery rates for youth with primary SoAD. Across the trials included in the meta-analysis, the post-CBT recovery rate from primary SoAD (35%) was significantly lower than the recovery rate from other primary anxiety disorders (54%).

Conclusions: Recovery from primary SoAD is significantly less likely than recovery from any other primary anxiety disorder following generic CBT in youth. This suggests a need for research to enhance the efficacy of CBT for youth SoAD.
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http://dx.doi.org/10.1017/S135246582000079XDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8293629PMC
May 2021

Prospective associations between peer functioning and social anxiety in adolescents: A systematic review and meta-analysis.

J Affect Disord 2021 01 29;279:650-661. Epub 2020 Oct 29.

Department of Experimental Psychology, University of Oxford, Oxford, UK. Electronic address:

Background: During adolescence, peer relationships take precedence and there is a normative increase in social anxiety. Although prospective studies have suggested peer functioning and social anxiety can influence each other, their findings have not been examined systematically. We performed a systematic review and meta-analysis of prospective studies to examine the bidirectional relationship between peer functioning and social anxiety in adolescence.

Methods: EMBASE, PsycINFO, Medline, and PubMed were searched to identify relevant articles. Meta-analysis was conducted to examine the mean effect sizes of prospective associations between social anxiety and four dimensions of peer functioning. Moderator analysis was performed, with age, gender, time interval between baseline and follow-up assessment, and publication year as moderators.

Results: Meta-analyses of 23 studies showed that friendship quality (r =-.11), peer rejection (r =-.06), and peer victimization (r =.23) were each associated with later social anxiety, but peer acceptance was not (r =-.11). Social anxiety at baseline was associated with prospective levels of friendship quality (r =-.11), peer rejection (r=.09), and peer victimization (r =.17), but not peer acceptance (r =-.14). Age moderated the association between friendship quality and prospective social anxiety. Other moderator effects were statistically non-significant.

Limitations: Limitations include different classifications of peer functioning, the use of self-report measures, heterogeneity between studies, and underrepresentation of clinical samples.

Conclusions: A significant bidirectional association was found with social anxiety across three dimensions of peer functioning. Psychological prevention and intervention targeting peer functioning and social anxiety are indicated.
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http://dx.doi.org/10.1016/j.jad.2020.10.055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758784PMC
January 2021

Treating posttraumatic stress disorder remotely with cognitive therapy for PTSD.

Eur J Psychotraumatol 2020 Jul 14;11(1):1785818. Epub 2020 Jul 14.

Department of Experimental Psychology, University of Oxford, Oxford, UK.

Delivering trauma-focused cognitive behavioural therapy to patients with PTSD during the COVID-19 pandemic poses challenges. The therapist cannot meet with the patient in person to guide them through trauma-focused work and other treatment components, and patients are restricted in carrying out treatment-related activities and behavioural experiments that involve contact with other people. Whilst online trauma-focused CBT treatments for PTSD have been developed, which overcome some of these barriers in that they can be delivered remotely, they are not yet routinely available in clinical services in countries, such as the UK. Cognitive therapy for PTSD (CT-PTSD) is a trauma-focused cognitive behavioural therapy that is acceptable to patients, leads to high rates of recovery and is recommended as a first-line treatment for the disorder by international clinical practice guidelines. Here we describe how to deliver CT-PTSD remotely so that patients presenting with PTSD during the COVID-19 pandemic can still benefit from this evidence-based treatment.
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http://dx.doi.org/10.1080/20008198.2020.1785818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7473124PMC
July 2020

Assessing panic disorder-specific competencies: evaluation of the Cognitive Therapy Competence Scale for panic disorder.

Behav Cogn Psychother 2021 Mar 8;49(2):197-205. Epub 2020 Sep 8.

Department of Experimental Psychology, University of Oxford, Oxford, UK.

Background: Evidence-based treatment for panic disorder consists of disorder-specific cognitive behavioural therapy (CBT) protocols. However, most measures of CBT competence are generic and there is a clear need for disorder-specific assessment measures.

Aims: To fill this gap, we evaluated the psychometric properties of the Cognitive Therapy Competence Scale (CTCP) for panic disorder.

Method: CBT trainees (n = 60) submitted audio recordings of CBT for panic disorder that were scored on a generic competence measure, the Cognitive Therapy Scale - Revised (CTS-R), and the CTCP by markers with experience in CBT practice and evaluation. Trainees also provided pre- to post-treatment clinical outcomes on disorder-specific patient report measures for cases corresponding to their therapy recordings.

Results: The CTCP exhibited strong internal consistency (α = .79-.91) and inter-rater reliability (ICC = .70-.88). The measure demonstrated convergent validity with the CTS-R (r = .40-.54), although investigation into competence classification indicated that the CTCP may be more sensitive at detecting competence for panic disorder-specific CBT skills. Notably, the CTCP demonstrated the first indication of a relationship between therapist competence and clinical outcome for panic disorder (r = .29-.35); no relationship was found for the CTS-R.

Conclusions: These findings provide initial support for the reliability and validity of the CTCP for assessing therapist competence in CBT for panic disorder and support the use of anxiety disorder-specific competence measures. Further investigation into the psychometric properties of the measure in other therapist cohorts and its relationship with clinical outcomes is recommended.
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http://dx.doi.org/10.1017/S1352465820000612DOI Listing
March 2021

Cognitive therapy for post-traumatic stress disorder following critical illness and intensive care unit admission.

Cogn Behav Therap 2020 Apr 29;13:e13. Epub 2020 Apr 29.

Department of Experimental Psychology, University of Oxford, Oxford, UK.

Around a quarter of patients treated in intensive care units (ICUs) will develop symptoms of post-traumatic stress disorder (PTSD). Given the dramatic increase in ICU admissions during the COVID-19 pandemic, clinicians are likely to see a rise in post-ICU PTSD cases in the coming months. Post-ICU PTSD can present various challenges to clinicians, and no clinical guidelines have been published for delivering trauma-focused cognitive behavioural therapy with this population. In this article, we describe how to use cognitive therapy for PTSD (CT-PTSD), a first line treatment for PTSD recommended by the National Institute for Health and Care Excellence. Using clinical case examples, we outline the key techniques involved in CT-PTSD, and describe their application to treating patients with PTSD following ICU.

Key Learning Aims: To recognise PTSD following admissions to intensive care units (ICUs).To understand how the ICU experience can lead to PTSD development.To understand how Ehlers and Clark's (2000) cognitive model of PTSD can be applied to post-ICU PTSD.To be able to apply cognitive therapy for PTSD to patients with post-ICU PTSD.
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http://dx.doi.org/10.1017/S1754470X2000015XDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251252PMC
April 2020

A randomised controlled trial of therapist-assisted online psychological therapies for posttraumatic stress disorder (STOP-PTSD): trial protocol.

Trials 2020 Apr 23;21(1):355. Epub 2020 Apr 23.

Department of Experimental Psychology, University of Oxford, Paradise Square, Oxford, OX1 1TW, UK.

Background: Over the last few decades, effective psychological treatments for posttraumatic stress disorder (PTSD) have been developed, but many patients are currently unable to access these treatments. There is initial evidence that therapist-assisted internet-based psychological treatments are effective for PTSD and may help increase access, but it remains unclear which of these treatments work best and are most acceptable to patients. This randomised controlled trial will compare a trauma-focussed and a nontrauma-focussed therapist-assisted cognitive behavioural Internet treatment for PTSD: Internet-delivered cognitive therapy for PTSD (iCT-PTSD) and internet-delivered stress management therapy (iStress-PTSD).

Methods/design: The study is a single-blind, randomised controlled trial comparing iCT-PTSD, iStress-PTSD and a 13-week wait-list condition, with an embedded process study. Assessors of treatment outcome will be blinded to trial arm. Two hundred and seventeen participants who meet DSM-5 criteria for PTSD will be randomly allocated by a computer programme to iCT-PTSD, iStress-PTSD or wait-list at a 3:3:1 ratio. The primary assessment point is at 13 weeks, and further assessments are taken at 6, 26, 39 and 65 weeks. The primary outcome measure is the severity of PTSD symptoms as measured by the PTSD Checklist for DSM-5 (PCL-5). Secondary measures of PTSD symptoms are the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the Impact of Event Scale-Revised (IES-R). Other symptoms and well-being will be assessed with the Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder Scale (GAD-7), WHO (Five) Well-Being Index, Work and Social Adjustment Scale (WSAS), Endicott Quality of Life Scale (QoL), and Insomnia Sleep Index (ISI). Health economics analyses will consider quality of life, productivity, health resource utilisation, employment status and state benefits, and treatment delivery costs. Process analyses will investigate candidate mediators and moderators of outcome. Patient experience will be assessed by interview and questionnaire.

Discussion: This study will be the first to compare the efficacy of a trauma-focussed and nontrauma-focussed therapist-assisted online cognitive behavioural treatment for people with posttraumatic stress disorder.

Trial Registration: ISRCTN16806208. Registered prospectively on 5 January 2018.
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http://dx.doi.org/10.1186/s13063-020-4176-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7181498PMC
April 2020

Accessing social media: Help or hindrance for people with social anxiety?

J Exp Psychopathol 2019 Apr 4;10(2):2043808719837811. Epub 2019 Apr 4.

University of Oxford, UK.

Despite increasing use of social media and the potential benefits for people with social anxiety (SA) disorder, little is known about the online experience of people with SA. Our study aimed to investigate the occurrence of cognitive and behavioral processes during a series of online and off-line Facebook (FB)-based tasks among individuals with high and low levels of SA. Sixty-one undergraduates with low or high SA were asked to use FB in a laboratory setting, to make an FB post, and to imagine three ambiguous FB scenarios. Participants with high SA reported higher anxiety throughout the study with an interaction effect, indicating greater relative increases in anxiety for those with high SA over low SA across tasks. The high SA group were more likely to negatively interpret the ambiguous FB scenarios than the low SA group. They also reported using more safety-seeking behaviors and having more negative thoughts. The findings suggest that the cognitive and behavioral processes that characterize socially anxious face-to-face interaction are also evident in online communication. Suggestions are made for the clinical implications of such findings.
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http://dx.doi.org/10.1177/2043808719837811DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7086304PMC
April 2019

The effects of modifying mental imagery in adolescent social anxiety.

PLoS One 2020 6;15(4):e0230826. Epub 2020 Apr 6.

Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.

Background: The identification of negative self-imagery as a maintenance factor in adult social anxiety has led to enhanced treatments for this population. Whilst intrusive negative imagery is commonly reported by socially anxious adolescents, no studies have demonstrated that it plays a causal role in maintaining symptoms. To assess this possibility, we undertook an experimental study manipulating social self-imagery in high socially anxious adolescents.

Methods: High socially anxious adolescents undertook two conversations under different conditions. During one conversation they held a negative social self-image in mind, and in the other they held a benign social self-image in mind. Self-report, conversation partner report and independent assessor ratings were taken.

Results: When participants held a negative self-image in mind, they reported feeling more anxious, and believed they looked more anxious and performed more poorly. Furthermore, they overestimated how anxious they looked compared to conversation partner ratings. As well as distorting participants' perception of their anxious appearance, holding a negative image in mind also had observable effects on the interaction. Participants were rated as looking more anxious and performing less well by their conversation partner when they held such images in mind, and the conversation was rated more critically by conversation partners and independent observers. Finally, a preliminary mediation analysis suggested that the detrimental effect of negative imagery on the social interaction may be partly due to the spontaneous use of avoidant safety behaviours.

Conclusions: The findings provide support for a causal role of negative self-imagery in adolescent social anxiety and point to the potential clinical value of techniques targeting imagery to treat the disorder.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0230826PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7135232PMC
July 2020

Cognitive processes associated with sudden gains in cognitive therapy for posttraumatic stress disorder in routine care.

J Consult Clin Psychol 2020 May 5;88(5):455-469. Epub 2020 Mar 5.

Department of Experimental Psychology.

Objective: Although most studies investigating sudden gains in treatments for posttraumatic stress disorder (PTSD) report a positive association between sudden gains and outcomes at the end of treatment, less is known about sudden gains in routine clinical care and the processes involved in their occurrence. This study investigated changes in cognitive factors (negative appraisals, trauma memory characteristics) before, during, and after sudden gains in PTSD symptom severity.

Method: Two samples (₁ = 248, ₂ = 234) of patients who received trauma-focused cognitive therapy for PTSD in routine clinical care were analyzed. Mahalanobis distance matching, including the propensity score, was used to compare patients with sudden gains and similar patients without sudden gains. Estimates from both samples were meta-analyzed to obtain pooled effects.

Results: Patients with sudden gains (₁ = 76, ₂ = 87) reported better treatment outcomes in PTSD symptom severity, depression, and anxiety at the end of therapy and follow-up than those without sudden gains. No baseline predictors of sudden gains could be reliably identified. During sudden gains, those with sudden gains had greater changes in both cognitive factors than matched patients. Meta-analyses of the two samples showed that negative appraisals had already decreased in the session prior to sudden gains compared with matched patients.

Conclusions: The pooled estimates suggest that changes in negative trauma-related appraisals precede sudden gains in PTSD symptoms. The results suggest that interventions that promote change in appraisals may also facilitate sudden gains in therapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/ccp0000488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144503PMC
May 2020

Disrupted joint action accounts for reduced likability of socially anxious individuals.

J Behav Ther Exp Psychiatry 2020 09 5;68:101512. Epub 2019 Sep 5.

Department of Experimental Psychology, University of Oxford, United Kingdom. Electronic address:

Background And Objectives: Motivated by their fear of disapproval, individuals with social anxiety continually monitor their own behaviour during social interactions hoping to prevent dreaded negative outcomes. Ironically, they do evoke less positive reactions from others. This study investigated whether lower engagement in the interpersonal process of joint action by socially anxious individuals leads them to attract less positive ratings by their conversation partners.

Method: High socially anxious (HSA; N = 36) and low socially anxious individuals (LSA; N = 36) had separate conversations with a naïve conversation partner (N = 36). Conversations were filmed and analysed for joint action using the conventional manual way and a more exploratory automated way. Conversation partners rated the quality of the interaction and the person they talked to.

Results: Conversation partners rated HSA participants less positively than LSA participants. The conventional manual method showed less joint action in conversations with LSA participants and crucially, joint action served as mediator between social anxiety status and general impression, quality of interaction and desire to meet again. These results were not replicated with the automated method.

Limitations: The study used an analogue sample and future research should investigate whether these findings also apply to a clinical sample. Future studies should further explore the utility of automated techniques to measure joint action.

Conclusion: Reduced joint action may explain why socially anxious individuals tend to be perceived less positively by others. The findings emphasise the importance of taking an interpersonal and holistic approach to understanding aspects of social anxiety disorder.
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http://dx.doi.org/10.1016/j.jbtep.2019.101512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7232015PMC
September 2020

Online Social anxiety Cognitive therapy for Adolescents (OSCA): protocol for a randomised controlled trial.

Trials 2019 Oct 7;20(1):574. Epub 2019 Oct 7.

Department of Experimental Psychology, University of Oxford, OxCADAT, The Old Rectory, Paradise Square, Oxford, OX1 1TW, UK.

Background: Adolescent social anxiety disorder (SAD) is common, impairing and persistent. There is a need to intervene early to avert its long-term consequences. Cognitive Therapy for SAD is the leading treatment for adults and shows promise for adolescents. However, given the scale of the problem of adolescent SAD and the limited availability of psychological therapists in child and adolescent mental health services, there is a substantial gap in service provision. Delivering therapy via the Internet may provide part of the solution to this problem. An Internet version of adult Cognitive Therapy for SAD has been developed, with outcomes similar to face-to-face therapy. We have recently adapted this treatment for use with adolescents with SAD. Here, we describe a randomised controlled trial designed to test the efficacy of Internet Cognitive Therapy for adolescent SAD compared to waitlist.

Methods/design: Forty adolescents aged 14-18 years with a diagnosis of SAD will be recruited via schools. Participants will be randomly allocated to Internet Cognitive Therapy or to waitlist. All participants will be assessed three times during the study-at baseline (pretreatment/wait), midtreatment/wait (week 8) and posttreatment/wait (week 15). Participants in the experimental arm will also complete weekly measures as part of the online program and they will be assessed at 3 and 6 months. Postwait, participants in the waitlist arm will be offered Internet Cognitive Therapy, and weekly and posttreatment data will also be collected for them. The trial aims to test whether Internet Cognitive Therapy is superior to waitlist in reducing social anxiety symptoms and in reducing the proportion of adolescents meeting criteria for SAD. Other outcomes of interest include depression and general anxiety symptoms. Acceptability of the online treatment will also be evaluated.

Discussion: This randomised controlled trial will provide preliminary evidence on whether this intervention, requiring relatively low levels of therapist input, is safe and clinically effective. If this is shown to be the case, Internet Cognitive Therapy for adolescents has the potential to provide a service to the large population of adolescents with untreated SAD.

Trial Registration: ISRCTN Registry, ISRCTN15079139 . Version 1 registered on 06/02/2019.
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http://dx.doi.org/10.1186/s13063-019-3651-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6781376PMC
October 2019

Sub-types of safety behaviours and their effects on social anxiety disorder.

PLoS One 2019 1;14(10):e0223165. Epub 2019 Oct 1.

Oxford Centre for Anxiety Disorders and Trauma, University of Oxford, Oxford, United Kingdom.

Cognitive models suggest that social anxiety disorder (SAD) is maintained through the use of safety behaviours. Previous reports propose that these safety behaviours can be subdivided into two main categories: avoidance and impression management. Study 1 investigates whether certain safety behaviours are specific to SAD. The social behaviour questionnaire was administered to individuals with SAD (N = 106), post-traumatic stress disorder (N = 28) and non-patient controls (N = 59). A factor analysis (N = 164) replicated the previously reported avoidance and impression management subtypes. Scores for both subtypes were significantly higher in individuals with SAD than in individuals with post-traumatic stress disorder or non-patient controls. Study 2 investigated the causal role of such safety behaviours using an experimental design in a non-clinical population (N = 96). Pairs of participants each engaged in two conversations. In one of the conversations, a randomly selected participant performed either avoidance or impression management safety behaviours. In the other conversation, neither participant was instructed to use safety behaviours. Each participant rated their own anxiety and performance as well as rating the other person. Videos of the conversations were also rated. Both types of safety behaviour increased anxiety in the person performing the safety behaviour. The avoidance subtype also had broader effects on the other person that were largely absent from the impression management subtype. Taken together the studies provide support for the distinction between safety behaviour subtypes and have implications for the treatment of SAD.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0223165PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773421PMC
March 2020

Cognitive paths from trauma to posttraumatic stress disorder: a prospective study of Ehlers and Clark's model in survivors of assaults or road traffic collisions.

Psychol Med 2020 10 11;50(13):2172-2181. Epub 2019 Sep 11.

University of Oxford, Oxford, UK.

Background: Individual differences in cognitive responses to trauma may represent modifiable risk factors that could allow early identification, targeted early treatment and possibly prevention of chronic posttraumatic stress disorder (PTSD). Ehlers and Clark's cognitive model of PTSD suggests that negative appraisals, disjointed trauma memories, and unhelpful coping strategies maintain PTSD. These are thought to be influenced by cognitive processing during trauma. The aim of this study was to test this model prospectively with path analyses.

Methods: Participants (N = 828) were recruited from an emergency department following injury in a violent assault or road traffic collision and 700 participated in the 6-month assessments. Cognitive processing was assessed shortly after the event, negative appraisals, disjointed memories, and unhelpful coping strategies at 1 month, persistent PTSD symptom severity at 6 months, and early PTSD symptom severity at 2 weeks.

Results: Cognitive variables, with trauma type and gender, explained 52% of the variance in PTSD symptom severity at 6 months. Including early symptom severity in the model did not explain more variance (53%). Early PTSD symptom severity, with trauma type and gender, only predicted 40%. Negative appraisals and disjointed memories predicted persistent symptom severity both directly and indirectly via unhelpful strategies. Peritraumatic processing predicted persistent symptom severity mainly indirectly. The effects of trauma type and gender were fully mediated by the cognitive factors.

Conclusions: The results are consistent with theoretically derived predictions and support cognitive factors as indicators of risk for chronic PTSD and as a target for the treatment and prevention of PTSD.
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http://dx.doi.org/10.1017/S0033291719002253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557160PMC
October 2020

Automated virtual reality (VR) cognitive therapy for patients with psychosis: study protocol for a single-blind parallel group randomised controlled trial (gameChange).

BMJ Open 2019 08 27;9(8):e031606. Epub 2019 Aug 27.

Department of Psychiatry, University of Oxford, Oxford, UK.

Introduction: Many patients with psychosis experience everyday social situations as anxiety-provoking. The fears can arise, for example, from paranoia, hallucinations, social anxiety or negative-self beliefs. The fears lead patients to withdraw from activities, and this isolation leads to a cycle of worsening physical and mental health. Breaking this cycle requires highly active treatment directly in the troubling situations so that patients learn that they can safely and confidently enter them. However patients with psychosis seldom receive such life-changing interventions. To solve this problem we have developed an automated psychological treatment delivered in virtual reality (VR). It allows patients to experience computer simulations of the situations that they find anxiety-provoking. A virtual coach guides patients, using cognitive techniques, in how to overcome their fears. Patients are willing to enter VR simulations of anxiety-provoking situations because they know the simulations are not real, but the learning made transfers to the real world.

Methods And Analysis: 432 patients with psychosis and anxious avoidance of social situations will be recruited from National Health Service (NHS) secondary care services. In the gameChange trial, they will be randomised (1:1) to the six-session VR cognitive treatment added to treatment as usual or treatment as usual alone. Assessments will be conducted at 0, 6 (post-treatment) and 26 weeks by a researcher blind to allocation. The primary outcome is avoidance and distress in real-life situations, using a behavioural assessment task, at 6 weeks. The secondary outcomes are psychiatric symptoms, activity levels and quality of life. All main analyses will be intention-to-treat. Moderation and mediation will be tested. An economic evaluation will be conducted.

Ethics And Dissemination: The trial has received ethical approval from the NHS South Central - Oxford B Research Ethics Committee (19/SC/0075). A key output will be a high-quality automated VR treatment for patients to overcome anxious avoidance of social situations.

Trial Registration Number: ISRCTN17308399.
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http://dx.doi.org/10.1136/bmjopen-2019-031606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6720451PMC
August 2019

Internet-Based Cognitive Therapy for Social Anxiety Disorder in Hong Kong: Therapist Training and Dissemination Case Series.

JMIR Form Res 2019 May 15;3(2):e13446. Epub 2019 May 15.

Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.

Background: Guided internet-based psychological interventions show substantial promise for expanding access to evidence-based mental health care. However, this can only be achieved if results of tightly controlled studies from the treatment developers can also be achieved in other independent settings. This dissemination depends critically on developing efficient and effective ways to train professionals to deliver these interventions. Unfortunately, descriptions of therapist training and its evaluation are often limited or absent within dissemination studies.

Objective: This study aimed to describe and evaluate a program of therapist training to deliver internet-based Cognitive Therapy for social anxiety disorder (iCT-SAD). As this treatment was developed in the United Kingdom and this study was conducted in Hong Kong with local therapists, an additional objective was to examine the feasibility, acceptability, and initial efficacy of iCT-SAD in this cultural context, based on data from a pilot case series.

Methods: Training in iCT-SAD was provided to 3 therapists and included practice of the face-to-face format of therapy under clinical supervision, training workshops, and treating 6 patients with the iCT-SAD program. Training progress was evaluated using standardized and self-report measures and by reviewing patient outcomes. In addition, feedback from patients and therapists was sought regarding the feasibility and acceptability of the program.

Results: The training program was effective at increasing therapists' iCT-SAD knowledge and skills, resulting in levels of competence expected of a specialist Cognitive Behavioral Therapy practitioner. The 6 patients treated by the trainees all completed their treatment and achieved a mean pre- to posttreatment change of 53.8 points (SD 39.5) on the primary patient outcome measure, the Liebowitz Social Anxiety Scale. The within-group effect size (Cohen d) was 2.06 (95% CI 0.66-3.46). There was evidence to suggest that the patients' clinical outcomes were sustained at 3-month follow-up. These clinical results are comparable to those achieved by UK patients treated by the developers of the internet program. Patient and therapist feedback did not identify any major cultural barriers to implementing iCT-SAD in Hong Kong; some modest language suggestions were made to assist understanding.

Conclusions: The therapist training implemented here facilitated the successful dissemination of an effective UK-developed internet intervention to Hong Kong. The treatment appeared feasible and acceptable in this setting and showed highly promising initial efficacy. A randomized controlled trial is now required to examine this more robustly. As therapist training is critical to the successful dissemination of internet interventions, further research to develop, describe, and evaluate therapist training procedures is recommended.
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http://dx.doi.org/10.2196/13446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6540721PMC
May 2019

The Dunn Worry Questionnaire and the Paranoia Worries Questionnaire: new assessments of worry.

Psychol Med 2020 04 5;50(5):771-780. Epub 2019 Apr 5.

Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK.

Background: The cognitive process of worry, which keeps negative thoughts in mind and elaborates the content, contributes to the occurrence of many mental health disorders. Our principal aim was to develop a straightforward measure of general problematic worry suitable for research and clinical treatment. Our secondary aim was to develop a measure of problematic worry specifically concerning paranoid fears.

Methods: An item pool concerning worry in the past month was evaluated in 250 non-clinical individuals and 50 patients with psychosis in a worry treatment trial. Exploratory factor analysis and item response theory (IRT) informed the selection of scale items. IRT analyses were repeated with the scales administered to 273 non-clinical individuals, 79 patients with psychosis and 93 patients with social anxiety disorder. Other clinical measures were administered to assess concurrent validity. Test-retest reliability was assessed with 75 participants. Sensitivity to change was assessed with 43 patients with psychosis.

Results: A 10-item general worry scale (Dunn Worry Questionnaire; DWQ) and a five-item paranoia worry scale (Paranoia Worries Questionnaire; PWQ) were developed. All items were highly discriminative (DWQ a = 1.98-5.03; PWQ a = 4.10-10.7), indicating small increases in latent worry lead to a high probability of item endorsement. The DWQ was highly informative across a wide range of the worry distribution, whilst the PWQ had greatest precision at clinical levels of paranoia worry. The scales demonstrated excellent internal reliability, test-retest reliability, concurrent validity and sensitivity to change.

Conclusions: The new measures of general problematic worry and worry about paranoid fears have excellent psychometric properties.
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http://dx.doi.org/10.1017/S0033291719000588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7168652PMC
April 2020

Multi-professional IAPT CBT training: clinical competence and patient outcomes.

Behav Cogn Psychother 2019 Nov 28;47(6):672-685. Epub 2019 Mar 28.

Department of Experimental Psychology, University of Oxford, Oxford, UK.

Background: There is international interest in the training of psychological therapists to deliver evidence-based treatment for common mental health problems. The UK Improving Access to Psychological Therapies (IAPT) programme, one of the largest training initiatives, relies on competent therapists to successfully deliver cognitive behaviour therapy (CBT) and promote good patient outcome.

Aims: To evaluate an IAPT CBT training course by assessing if trainees' clinical skills improve during training and reach competency standards, and to report patient outcome for submitted training cases. To investigate a possible relationship between trainee competence and patient outcome. To explore professional differences during training.

Method: CBT trainee (n = 252) competence was assessed via audio recordings of therapy sessions at the beginning, middle and end of training. Patient pre- to post-treatment outcomes were extracted from submitted training cases (n = 1927). Differences in professional background were examined across competence, academic final grade and tutorial support.

Results: CBT trainees attained competence by the end of the course with 77% (anxiety recordings) and 72% (depression recordings) improving reliably. Training cases reported pre- to post-treatment effect sizes of 1.08-2.26 across disorders. CBT competence predicted a small variance in clinical outcome for depression cases. Differences in professional background emerged, with clinical psychologists demonstrating greater competence and higher academic grades. Trainees without a core professional background required more additional support to achieve competence.

Conclusions: Part of a new CBT therapist workforce was successfully trained to deliver relatively brief treatment effectively. Trainees without a core profession can be successfully trained to competence, but may need additional support. This has implications for workforce training.
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http://dx.doi.org/10.1017/S1352465819000201DOI Listing
November 2019

Understanding Social Anxiety Disorder in Adolescents and Improving Treatment Outcomes: Applying the Cognitive Model of Clark and Wells (1995).

Clin Child Fam Psychol Rev 2018 09;21(3):388-414

Department of Experimental Psychology, University of Oxford, Oxford, UK.

Social anxiety disorder is a condition characterised by a marked and persistent fear of being humiliated or scrutinised by others. Age-of-onset data point to adolescence as a developmentally sensitive period for the emergence of the condition, at a time when the peer group becomes increasingly important. Social anxiety in adolescence is associated with considerable impairment that persists through to adulthood. There are clear potential benefits to delivering effective interventions during adolescence. However, there is limited evidence on the specific efficacy of available therapies. This is in contrast to adults, for whom we have interventions with very specific treatment effects. One such treatment is individual cognitive therapy. Cognitive therapy is based on the cognitive model of social anxiety proposed by Clark and Wells (in: Heimberg, Leibowitz, Hope, Scheiber (eds) Social phobia: diagnosis, assessment and treatment, The Guilford Press, New York, 1995). The present review examines the potential application of this adult cognitive model to the understanding of adolescent social anxiety and considers additional adolescent-specific factors that need to be accommodated. It is suggested that a developmentally sensitive adoption of the cognitive model of social anxiety disorder (Clark and Wells 1995) for adolescents may lead to better treatment outcomes.
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http://dx.doi.org/10.1007/s10567-018-0258-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6447508PMC
September 2018
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