Fear and missing out : internet-treatment for social anxiety disorder in youth

Abstract

Background: Social anxiety disorder (SAD) is common, highly impairing and associated with severe effects on functioning and with increased monetary costs for the society. The disorder typically emerges during childhood and tends to follow a persistent and chronic course if left untreated. Currently, a minority of individuals with SAD have access to effective treatment and new approaches to treatment delivery are needed. In addition, the current covid-19 pandemic crisis further highlights the need for remotely delivered therapies. Internet-delivered cognitive behavioral therapy (ICBT) could increase availability of evidence-based treatment but little is known about its efficacy and cost-effectiveness for youth with SAD. Further knowledge is also needed regarding maintaining factors of SAD in youth. Attention bias has been suggested as one of those factors but studies evaluating attention bias in youth with SAD have showed mixed results.

Aims and methods: The overall aim of this thesis was twofold. First, to develop and evaluate an ICBT program for children and adolescent with SAD. Second, to examine attention bias in adolescents with SAD. Three specific research questions were: 1) to examine if ICBT is feasible, acceptable and potentially efficacious, 2) to examine if ICBT is efficacious and cost-effective and, 3) to examine if adolescents with SAD show attention bias to social threat. These research questions were examined in three studies: Study I being a feasibility trial where ICBT (supplemented with three group-exposure sessions) was offered to 30 adolescents with SAD, Study II being a randomized controlled trial comparing ICBT (supplemented with three video-call sessions) with an active control treatment, ISUPPORT, for 103 children and adolescents and, Study III being an eye-tracking study examining attention bias in 25 adolescents with SAD compared to 22 non-anxious controls from the general population.

Results: Study I showed that the vast majority of the participants were satisfied with ICBT, found the treatment easy to understand and would recommend it to a friend with similar problems. On average, participants completed two thirds of the ICBT modules and attended most of the group-exposure sessions. Child-, parent- and clinician-reported measures of social anxiety showed symptom reduction with large within-group effects sizes (Cohen’s d=0.85, 0.79 and 1.17, respectively). Study II showed significantly more reduction of social anxiety in the ICBT group compared to the ISUPPORT group corresponding to a moderate between-group effect size (Cohen’s d=0.66). Significant improvement in favor of ICBT was also observed on most secondary outcomes such as depressive symptoms and functional impairment, with moderate between-group effect sizes. Participants completed on average 75% of ICBT modules and participated in 85% of the video call sessions. ICBT was deemed more cost-effective than ISUPPORT with societal cost savings mainly driven by reduction in medication use and increased school productivity. Study III found support for a vigilant and avoidant gaze pattern to angry faces, compared to neutral or happy faces, in youth with SAD as well as in controls. Adolescents with SAD who showed more avoidance of social stimuli improved more after ICBT.

Conclusions: The studies included in this thesis support ICBT as a feasible, efficacious and cost-effective treatment for youth with SAD. Treatment completion was high and participants found ICBT to be a credible treatment. These results build on and further extend results from previous studies that have shown promising results for ICBT for youth with SAD. Further evaluations are needed to determine how clinical outcomes can be improved for youth who do not respond to ICBT. Youth with SAD show attention bias to social threat and similar patterns are shown in non-anxious controls. These results are in line with previous eye-tracking studies that have examined attention bias in children but is partly inconsistent with those found for adolescents. Future eye-tracking studies with larger samples of youth with SAD are needed to determine if aspects of attention bias are specific to SAD. In summary, ICBT could increase access to evidence-based treatment for youth with SAD and further knowledge about attention bias could generate hypotheses about the maintenance of social anxiety as well as how psychological treatment for social anxiety could be improved to target those maintaining factors.