A novel CBT informed
intervention for social anxiety
in people recovering from
psychosis.
Ruth Turner, Richard White,
Rebecca Lower, Lina Gega,
David Fowler
Acknowledgements
• Everyone who has helped to make
the Social Anxiety Research Clinic
successful: Tony Reilly,Timothy
Clarke, Felicity Waite, Evelina
Medin, Kevin Lloyd, Rose
Christopher, Emily Drake all of our
participants,and the case
managers within Central Norfolk
Early Intervention Team
Social Anxiety Research Clinic
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Describe participants
Brief description of intervention
Describe findings
Discussion of use of virtual environments
Background
• Up to 70% of people recovering
from psychosis experience social
anxiety.
• This is a significant barrier to social
recovery.
• Social anxiety appears to be
independent of the experience of
positive symptoms
Screen referred cases
for eligibility
Enrollment and Consent Procedure
Study
outline
Baseline Assessment (N = 48)
Social anxiety
Cognitive bias assessment
Schema, low-level psychotic symptoms
Qualitative interview
Treatment Group
(N=24)
Allocated to
immediate standard
CBT (N = 12)
Randomisation by
randomly ordered
sealed envelopes
Allocated to
immediate enhanced
CBT (N = 12)
Exclude non-consenters and
cases not meeting inclusion
criteria
Waitlist control
(N=24)
Allocated to
delayed standard
CBT (N = 12)
Allocated to
delayed enhanced
CBT (N = 12)
Wait for 12 weeks
Assess primary/secondary outcomes at the
end of the intervention period (12 weeks)
Assess primary/secondary outcomes at
the end of the 12 week wait
Assess primary outcome at 18 weeks
Assess primary outcome 6 weeks
following end of intervention (18 weeks)
Assess primary outcome 12 weeks following
end of intervention (24 weeks)
Assess primary/secondary outcomes at 24 weeks
Receive standard CBT
for 8-12 sessions
Receive enhanced CBT
for 8-12 sessions
Description of sample at
baseline
• Demographics: ; 17 male, 5 female; Average age = 26 (S.D. 6)
• PANSS (data for 13 participants) average score on positive sub-scale =
10.9 (S.D. = 3.0). 46% (n = 6) of participants scored 4 or more on one
or more items of the sub-scale.
• BDI average score = 26.6 (S.D. 15.8)
• SIAS:
SIAS
M (S.D.)
SARC
55.6 (10.7)
Social Phobia Comparison
34.6 (16.4)
Non-Clinical Comparison
18.8 (11.8)
Description of
sample at baseline
SSI
SARC
Psychosis Comparison
Non-Clinical
SSI SA
M (S.D.)
17.4 (4.7)
8.6 (6.7)
4.4 (5.1)
SSI P
M (S.D.)
11.5 (7.6)
6.0 (6.4)
2.9 (3.6)
SSI AE
M (S.D.)
8.4 (5.5)
4.1 (5.7)
2.3 (3.4)
SSI total
M (S.D.)
37.2 (15.0)
18.7 (15.7)
9.5 (9.2)
BCSS
Positive
Positive Self Negative Self Other
M (S.D.)
M (S.D.)
M (S.D.)
SARC
6.8 (6.4)
9.2 (7.0)
8.6 (6.5)
Psychosis Comparison 10.3 (6.4)
7.2 (5.9)
10.3 (6.0)
Non-clinical
10.2 (4.2)
3.5 (3.5)
10.4 (4.5)
Negative
Other
M (S.D.)
9.0 (7.7)
9.1 (6.8)
4.0 (4)
Formulation
Based on Clarke
and Wells model
Trigger
People talking
Performance/
expectations on me
Activates Beliefs and
Assumptions
I am inadequate
I have to be on guard or I will be
hurt
Others are judgemental
Perceived Social Danger
Others might be talking about
me
I will be found out and punished
Processing self as
social object
Focus on own anxiety
Image – self sweating
Safety Behaviour
Avoid social and
performance situations
Listen in to others’
conversations
Anxiety
Sweating
Heart racing
Could not
concentrate
Intervention
• The intervention is an assisted self-help intervention which
follows four stages:
– first stage included an assessment of social anxiety, goal setting and
psycho-education about social anxiety.
– Stage two helped patients develop an individualised CBT formulation.
Patients identified their own idiosyncratic safety behaviours.
– Stage three involved repeated exposure to anxiety provoking social
situations in the format of behavioural experiments
– The final stage focussed on maximising patients’ gains by planning
further exposure-based behavioural experiments which were done
either independently by the patient or with support from the care team.
• Additional interventions were piloted using computerised
cognitive bias modification and virtual environments.
Outcomes - SIAS
• Baseline SIAS scores were
compared to those at the 12, 18
and 24 week follow up points.
Baseline
12 weeks
18 weeks
24 weeks
Therapy
60.2 (11.19)
49.7 (12.23)
42.9 (8.15)
40.4 (10.95)
Waitlist
52.4 (9.19)
52.1 (13.69)
52.1 (12.76)
50.6 (13.09)
Outcome - SIAS
Therapy
Waitlist
12 week
18 week
24 week
N
10
7
8
Mean change score (SD)
-10.50 (8.90)
-17.29 (4.86)
-16.75 (13.75)
Reliable improvement (n)
6
7
6
Reliable deterioration (n)
0
0
0
Clinically significant reliable
change (n)
2
1
4
N
11
9
8
Mean change score (SD)
-.27 (11.34)
-.56 (7.45)
-1.0 (10.52)
Reliable improvement (n)
3
1
3
Reliable deterioration (n)
3
1
3
Clinically significant reliable
change (n)
2
1
1
Additional pilot
interventions
• Preliminary evidence that CBM-I sentence
completion task can be used to train a
more positive interpretation bias in this
group.
• Virtual environments are being used to
provide additional situations in which
behavioural experiments can be conducted.
CAFÉ
“sitting down waiting to order”
Conclusions
• Preliminary evidence that an assisted selfhelp intervention may help to reduce the
level of social anxiety in people recovering
from psychosis.
• Psychoeducation about social anxiety and
the active engagement in behavioural
experiments seems to be key.
Any questions?
• Ruth.turner@nwmhp.nhs.uk