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Social Anxiety – There’s An App for That?

When I first heard about studies using smartphones to treat anxiety with cognitive therapy I was intrigued, to say the least. However, I had a misconception about what that actually meant. My assumption was that the smartphone app would be automating some basic cognitive therapy, a virtual therapist that could give some reflective feedback and also give basic cognitive tools to deal with anxiety. That sounded like it might be useful, at least for mild cases, and I hoped that the app was designed to refer severe cases to an actual therapist.

I had already been very interested in the concept of online, virtual, or computer-based therapy. It seems like this is coming, but of course it needs to be researched to see how it works and for which patients.

But that is not what the smartphone app is at all. Rather it has to do with a treatment technique called cognitive bias modification (CBM). This therapy is based on research that finds that those with social anxiety have a cognitive bias which makes them attend more than others to signs of threat or to negative emotions. Further, they have a cognitive bias to interpret ambiguous social cues as hostile or negative. This raises a cause and effect question – are they anxious because they have these cognitive biases, or does the anxiety make them attend to negative emotions and interpret emotions negatively. Perhaps it is both, in a reinforcing feedback loop.

There is some evidence from prospective studies that cognitive biases predict future anxiety, suggesting (but not proving) a cause and effect. Another way to address this question, and perhaps to develop a treatment for social anxiety, is to target these cognitive biases directly, rather than addressing possible underlying causes of the biases. That is where the smartphone app comes in. There are two computer-based treatments designed to directly treat these cognitive biases: CBM-Attentional and CBM-Interpretive (CBM-A and CBM-I respectively).

For CBM-A subjects are made to look at a computer screen (or now a smartphone screen) with two faces displayed, one neutral and one disgusted or angry. They are told to note and remember the letters that appear on the screen. A letter than appears where the neutral face was located, drawing their attention toward the neutral face and away from the face displaying a negative emotion. This is supposed to train their brain away from attending to negative emotions – modifying their cognitive bias for attention.

For CBM-I subjects are asked to interpret word-sentence associations, and are given positive feedback for benign interpretations and negative feedback for negative interpretations. Again this is supposed to modify their bias away from negative interpretations.

As always, we like to evaluate any new treatment paradigm on two basic criteria – is it plausible, and does it work better than placebo. Plausibility is a little challenging to assess. There are certainly no laws of physics, chemistry, or basic biology involved. Plausibility depends on whether or not you think this top-down approach to brain training can have a significant and lasting effect on our thinking and emotions. Personally I am not convinced that this approach has much value. It all seems like the “magic wand” approach to therapy – rather than addressing a complex behavior with an approach that reasonably addresses that complexity, it focuses on one perhaps superficial aspect of something as complex as social anxiety.

I have not been impressed with the whole “brain training” approach to cognitive therapy, such as EMDR (eye movement desensitization and reprocessing). At best it seems like treating the symptom of a disease rather than the disease itself. But I could be wrong. Sometimes the symptoms are the disease. In some chronic pain conditions, for example, the pain is the problem, and treating the symptom of the pain may be a reasonable and effective approach. Perhaps at its core social anxiety is being driven by some flaw or bias in brain function that can be tweaked by simple training.

My personal bias, therefore, is that this kind of approach has low (but not very low) plausibility but I am willing to be convinced by reasonable clinical evidence. So what does the clinical evidence show?

There are many pilot studies of CBM (both CBM-A and CBM-I and a couple with combined treatments). A review published in February 2011 concluded:

Although the potential clinical utility of CBM is quite exciting, the existing data do not address a number of limitations. First, the majority of the evidence of CBM’s effect on cognitive bias and anxiety relies on analogue samples and brief (one session) experiments. The field is in need of RCTs to test treatment protocols in clinical samples. A related issue is that all existing RCTs represent researchers’ initial pilot studies rather than large-scale RCTs. Therefore, they comprise of relatively small samples (subject numbers ranging from 29 to 44). Effect sizes from small studies are unreliable [93]; thus we await the results of larger, definitive trials.

While positive, the evidence is still preliminary and there needs to be more rigorous trial design before we can conclude that there is a real specific effect here. My concern with the research to far is that we are just seeing the non-specific effects of treatment intervention, rather than specific effects of CBM.

In a recent New York Times article on the topic, one specifically discussing the smartphone app for administering CBM, the results of perhaps the largest study to date are discussed. The study is yet to be published, but the researchers reported their results so far as:

Participants who got the treatment improved their scores on a questionnaire measuring anxiety, dropping by an average of 22 points, compared with an 8-point drop among people in a “waiting list” group, who got no computer games to play. However, a placebo group in the study practiced with a two-face video program not intended to shift the eyes from one face or the other, and their anxiety levels as measured on questionnaires also fell by about 22 points, just as they had for those who got the treatment.

The comparison to a waiting group showed a significant difference, but to a more rigorous and blinded control showed no difference at all. While the article indicated that these results were “confusing” I don’t find them confusing at all – they are dead negative. The only comparison that matters is the blinded one to a reasonable placebo treatment.

Further the article refers to a review from the University of Pennsylvania that found evidence of publication bias:

The authors noted that there was evidence of what scientists call a “file drawer” problem — in which studies finding no effect are filed away or ignored, while encouraging ones are published. “I think in this field the standards for publishing positive studies are lower than for negative ones,” Dr. Van der Does said in an e-mail.

To summarize: preliminary evidence is mixed but tending toward the positive, but has acknowledged serious limitations and evidence of publication bias. Preliminary results from a large and well-controlled study are negative.

I agree with various reviewers who conclude that this treatment is interesting and deserves more research. I would like to see some rigorous large studies – the kind that are really definitive. I sense a great deal of excitement among researchers. For example, from a recent pilot study the authors write:

Excitingly, these procedures have been shown to reduce bias in attention to threat (CBM-A), and to promote a positive interpretive bias (CBM-I) in anxious populations; furthermore, these modifications are associated with reductions in anxiety. We believe that these techniques have the potential to create a real clinical impact for people with anxiety.

The excitement may be premature, however. I hope this therapy is found to have potential, because it can result in a cheap and convenient treatment method. All the more reason to move beyond pilot studies are perform some rigorous studies that can really answer the question as to whether or not the specific elements of CBM-I and CBM-A, alone or in combination, can have long lasting benefits for social or other forms of anxiety.

Posted in: Neuroscience/Mental Health, Science and Medicine

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13 thoughts on “Social Anxiety – There’s An App for That?

  1. mdstudent says:

    Dr. Novella, do you know of any studies that examine the potential benefits of CBM compared to such drugs as benzodiazepines and ssris in treating anxiety disorders?

  2. Shelley says:

    I’ve read a little bit about this but have not found the evidence particularly compelling. On the other hand, CBT does have good evidence for efficacy in treating social anxiety. It does two things: it targets the cognitive biases directly through cognitive restructuring and uses exposure techniques to address the behavioural/avoidance issues. There’s even a pretty good website out of Australia that delivers CBT online (see: http://moodgym.anu.edu.au/welcome).

    In response to mdstudent, I would say that in my practice (I’m a cognitive behavioural therapist), I’ve found that SSRIs or SNRIs can be helpful initially particularly when the anxiety is very severe or if there is comorbid depression. This is not always true, however. SSRIs and SNRIs can have some unpleasant side effects, sometimes don’t work at all, and when discontinued, the patient is still left with no skills for dealing with his/her anxiety (particularly if they attribute any improvement to the medication alone).

    Benzodiazepines reduce anxiety alright, but both physical and psychological dependence issues are a significant problem and simply a means of avoiding the anxious feelings rather than dealing with them or learning coping strategies. I rarely recommend them and they frequently interfere with treatment because the patient is so motivated to avoid the anxiety that they prefer to take the pill (and gain quick relief) rather than doing the work to get rid of the anxious thoughts and behaviours. They are best used very very short term IMO.

  3. mdstudent says:

    @ Shelley

    I completely understand your reservations in using drugs alone to treat anxiety disorders, especially as far as benzodiazepines are concerned.

    If, however, CBM does end up showing some benefit over a placebo I think it would also be wise to compare it against other standards of care.

  4. Curious. How is this not Apple practicing medicine without a license?

  5. Purenoiz says:

    @nobodyyouknow

    Was the app created by apple? Most apps are 3rd party creations, that is akin to saying, “is your therapists chair a licensed therapist?”

  6. nobodyyouknow has a great question.
    there are a couple ways to look at this.
    if i read diet advice via an ‘app,’ or some stop-smoking app, is apple practicing medicine?
    if i buy a diet book, is the author, or the bookstore, practicing medicine?
    sound info and advice about how to prevent or treat medical problems are all over the place – literally and figuratively.
    there is a place for this. ‘medicine’ does the same things, but also does something unique: prescribes a formulary that can only be prescribed by them. i guess, ‘medicine’ more importantly considers whether to whip out the Rx pad upon diagnosis, and that judgment is what you pay for, as well as the judgment of which med, if a med is deemed to be helpful or necessary. along with deciding whether the Rx is worthwhile, it seems perfectly fitting for the physician to add in other directives: get some rest, exercise, whatever. that simply accompanies the med as the reasonable comprehensive treatment plan. that does not make the advice to rest, or eat more fiber, ‘medicine.’

    so, the rest of us are free to learn and judge and discuss whether or not we should eat more fiber. michellle obama is dispensing such advice right now.

    that is one way to look at this.

    the other way is this:
    from my point of view, as a clinical psychologist, i have in my world-view this category of problems that are ‘psychological’ problems, and not ‘medical’ problems.

    in my opinion, ‘social anxiety,’ at mild or more serious ‘diagnosable’ level, is a ‘psychological’ problem.

    sure, we could find cases where the anxiety level is due to some physical problem, some thyroid disorder or brain tumor, but those cases of medical-problems-masquerading-as-psychological-problems aside, 95% of social anxiety is a ‘psychological’ problem.

    if it is a ‘psychological’ problem, it ought to receive a ‘psychological’ intervention to correct it.

    social anxiety does have these unsupported thoughts/interpretations/predictions at its heart. if you change those, you greatly reduce the social anxiety.

    this has been done a million times. no pills necessary.

    physicians mostly do not recognize how profound this is – in my opinion, a physician, upon discovering ‘social anxiety,’ in a decent world where a physician was able to conceive that he or she was not the top dog of all things clinical, would direct the patient to a decent mental health professional who was trained in recognizing and treating ‘social anxiety’ properly.

    instead, the ‘medical model’ is applied to the problem. and, the drug reps and thought leaders convince physicians that drugs are a reasonable intervention.

    shelley’s answer is brief, but spot-on.

    so: consider that we have this ‘psychological’ learning aspect to our existences. and through that aspect of our life, we can have circumstances lead us to have a ‘psychological disorder.’

    and, consider that the intervention is to identify, examine, and change the faulty, off-base mis-interpretations, substituting more sound, accurate ones. plus, accompany that with some physiological relaxation stuff, and some cognitive ‘tricks,’ such as ‘distraction,’ ‘grounding,’ and ‘imagine-the-audience-in-their-underwear.’

    mix in some skills training. do some role-plays. hold some mock social-anxiety-provking sessions.

    now, this intervention does not sound so much like ‘practicing medicine,’ but sounds more like how we professionals get coached to handle ‘public speaking,” if we happen to be a bit scared of messing up, being judged, and so on. or, consider how you may have encouraged and helped a colleague to better handle getting pimped in rounds, or some other fitting example.

    it is largely the same. these are psychological challenges. not medical.

    if you believe some minority group has a quality of being inherently ‘lazy,’ you are probably wrong. you probably discount counter-examples such as a successful minority, and certainly don’t seek them out, and you probably allow one case example of laziness-by-this-minority-member to, in your mind, ‘prove’ your misguided belief.

    that is not a ‘medical disorder.’ that is just a cognitive mistake. prejudice. pre-judge.

    once you recognize it and admit it, and strive to actively ‘think’ different things, and act accordingly – such as being willing to hire a person from that group, and treat them like you would another employee, things will work out for you.

    there, we don’t even call the problem a ‘psychological’ problem. the issue has social and political dimensions, so we stick it into a political category. not psychological or medical.

    some people do try to psychologize or medicalize these ideas. the ‘authoritarian personality’ idea is one example from history.

    so, some problems, to me, are ‘psychological.’ ideally, in ‘health care,’ these problems should be diagnosed by a psychologist, who should decide if there is a call for medication, in which case the psychologist would direct the patient to a psychiatrist, who would be an ancillary provider.

    instead, because we as a society, and we psychologists also, have bought in to the ‘medical model,’ a primary care physician is allowed to play ‘psychiatrist,’ and decide what the problem is, and treat, or the primary care doc can recognize something ‘psychiatric,’ and direct the patient to the psychiatrist, just as he or she would direct an orthopedic problem to the orthopedist.

    for some reason, we psychologists don’t even realize we have been cut out of the game by trying to be ‘in’ on the game.

    partly because we have sold out: if we choose to buy into the ‘medical model,’ the reward is that we can ‘bill for services’ from ‘third-party payers.’

    the medical model sez: figure out THE diagnosis, then apply one of the recognized treatments per practice standards and evidence basis, then get reimbursed per hour of service delivery.

    myself, i have been more successful in therapy when i can get the ‘patient’ to give up on believing that the ‘diagnosis’ is relevant.

    what is relevant? the functional assessment of the problem – the thoughts of social anxiety, the emotional dimension (sympathetic activiation, etc.), and the behavioral dimension. plus my commitment to earnestly understanding the problem and devoting myself to working toward a solution.

    for each person, in my experience, there are general patterns, but specifics have been unique, and have to be tailored, and all this often a committed profesisonal.

    that is what you pay for.

    the social anxiety app might really work – if it is regular ‘social anxiety,’ and you use self-help or an app to rcognize the ‘dysfunctional,’ not-accurate thoughts, calm yourself down, change your thoughts, you may overcome the problem.

    maybe a little, maybe a lot. if it gets you through the ‘public speaking,’ or the ‘asking-out-on-a-date,’ or ‘asking-for-a-raise,’ or being-able-to-ask-to-sit-next-to-another-third-grader-in-the-school-cafeteria,’ then you are successful.

    ^that is what a ‘cure’ looks like to a psychological ‘problem.’ to play the ‘research’ game, though, we have to also include “reduced Beck Anxiety Inventory scores,” and ‘increased generic social involvement’ as outcomes.

    if a person fears flying, they are cured either: 1. when they decide they are sufficently cured, or 2. when they are satisfied with their ability to get on a plane and take that trip. -if they are a little panicky or not panicky at all, or avoid some discretionalry flying and are ‘cured’ enought to handle work-required flying, then that is the tailored, individual outcome for that pt. <no two pts have the same outcome goal. <that makes 'research' difficult, since a study will require treatment to some researcher's pre-defined goal to count as 'success' versus no-success.'

    how can you specify the outcome of a study when you have not even met the patient? well, an issue for another day, i guess.

    myself, i don't care if this intervention is done by a school nurse, a psychologist, a physician, an app, a self-help book, or a PDA.

    so what do i get paid for? i am way better at finely detecting and discovering the thoughts, the physiological impact, differential diagnosis, and for guiding a person through the fairly clear, but challenging, process of changing long-standing, entrenched habitual thought patterns, recognizing indicators of normal progress, and not minimizing progress because results are desired by a patient overnite.

    an app can do some of this, but will only fit for the low-hanging fruit. this is like getting coaching on a golf swing – you can only really benefit from a person who knows how to hit a golf ball and really knows how to teach this to other people. a 'natural' golfer might benefit from a video, or a 'tip' in a golf mag.

    to be really good at CBT, you cannot be an 'app' – i believe you have to have a strong foundation in theory as well as practice. for the golf swing analogy, this is 'fundamentals:' you won't fail as a coach as long as you start with the fundamentals: stance, etc.

    master's level mental health professionals, psychologists, some pastoral counselors, and some social workers get trained in this.

    you can 'pick up' a fair amount, and maybe by some good natural 'grasp' and adhering to some good guidelines or rules-of-thumb, do pretty good for a fair portion of patients without a solid background. some physicians really do this stuff well without being encyclopedic on the entire background of CBT.

    i have been side-by-side in the 'psychiatry' setting as docs-in-training get trained in Dx and CBT. I know what your training consists of. is it bad? no. is is minimal? yes. quite.

    so, docs get this training, but don't perform counseling a lot – some are hesitant because they correctly recognize that not all pts are low-hanging fruit, and the case could end up being more challenging than they can handle. i respect that a lot. some simply don't have the time to properly perform the delivery of cognitive behavioral therapy – identifying 'automatic dysfunctional thoughts' goes quick with some ppl, but takes forever with others. and probably, most docs realize that it is simply a betetr world all around if thy do what they are good at, and accordingly get paid the best to do – reimbursement for a half-day clinic of counseling does not 'pay' like a half-day clinic of practicing their practice – this is why psychiatrists don't do 'counseling,' and mostly do med-checks.

    why do i think meds are so bad?

    some problems do call for meds. schizophrenia. some depressions. bipolar, if it realy is bipolar. some 'depression' needs a kick-start, and some is more 'biological' than 'psychological.'

    anxiety disorders? for the great portion, almost never are meds 'needed.' if so, i believe this is only an occasional-use deal. som OCD, and a handful of other relatively infrequent conditions, can (but not always will) go better with meds. you can give meds to some hoarders and they hoard less; others, no diff. so d/c the meds.

    but 10% of us or more are Rx SSRIs, and there simply is not the burden of disease to call for that. at all.

    a huge portion of us are Rx klonopin, xanax, etc.

    nearly all of this would be unwarranted if only 1. we did not have the 'medical model' view, and 2. the health care system could actually deliver/support/provide decent psychotherapy. hey, the MRI is ubiquitous, so nothing is impossible.

    when you help someone change their thought patterns, they have that ability forever. a pill wears off, and also can deliver the message that the patient has a problem and needs outside help – not coaching to build skills and esteem, but needs 'professional help.' this further dis-empowers the person, and can contribute to more self-defeating thoughts.

    meds for anxiety also entrench the idea that a 'psychological' problem is a 'medical' problem. this is very damaging to our entire society. now, unruly children who are unruly because their parents do not practice discipline are diagnosed as having a 'mental illness.'

    when we 'buy into' the medical model, those things happen. i have 'cured' these 'mental illnesses' in children by having the parent change – i don't even need the child in my office. how can the child's 'mental illness' disappear if I only 'treat' the parent?

    does 'adhd' exist? yes. -but sometimes the problem is a lack of parenting/appropriate discipline plus appropriate attention and guidance.

    'medicalizing' psychological problems, in my opinion, is tragic and dangerous.

    sure, i can see physicians having a medical model view – but it has been relly bad for us psychologists to buy the medical model – now, we sit in our offices and wait for the physicians to decide when it is fitting for us to be involved in care, when we should be the ones to assess the problems and decide when a psychiatrist should provide ancillary care.

    there is a lot of talk about integrating behavioral health into primary care. this will happen. the 'medical home' movement will make this happen. the ACO movement will make this happen. get ready.

    but we will do it wrong. a doc will decide what roles the mental health people get to play, when, where, how much, and we mental health people will be thrilled to be in one the game. there will be no psychologist who will say, 'who the flip are you to decide what the person's mental disorder diagnosis is, and how much time they get with me?'

  7. now, for this CBM-A and CBM-I by smartphone:

    sure, it could happen. i am skeptical. i think a proper ‘attention control’ group would reveal that there is not a unique ‘ingredient.’

    also, this kind of ‘mental priming’ stuff sure sounds like ‘neurolinguistic programming.’ <– of which i am skeptical, and which really fits the pseudoscience/sCAM format: take a tiny, limited, but true observation, and build an entire treatment system around it.

    at the same time, there is an amazing burst of research coming out on internet-based psychotherapy, and it is very promising. also, some canned (not real therapists) web portals with some good outcomes for some problems.

    i think this is the low-hanging fruit, and we should reap it where we can.

    sevreal years ago, a student of mine did an extensive lit review of internet-based psychotherapy trials – as a thesis (assessing a few more issues and dimensions along the way, but an evidence review was integral).

    there were only a handful of fairly conducted studies. now there are a lot, and they are coming out regularly. i am excited that 'we' in the health care delivery biz may be able to accomodate the great portion of need with this, and leave the more-intensive care to the in-person heavily tailored modality.

  8. BillyJoe says:

    Cripes! MVT’s comment is longer than the post.

  9. Ha– I would LOVE to be given benzos for my anxiety issues! But I know it would only cause me more problems in the long run. I get by with SSRIs and a mood stabilizer, and while those take the edge off, I wouldn’t be able to function in society, much less in my oftentimes quite stressful career, if not for cognitive coping strategies.

    One of the most effective coping strategies I’ve found is simple distraction. Having podcasts or a DVD playing in the background helps me get work done without stressing about the product. Similarly, having light comedies playing while I pack for a big show allows me to ignore my panic at interacting with the public. Based on my personal experience, n=1, anecdote =/= proof and all that, I suspect Angry Birds would work about as well on many cases of social anxiety as this proposed social anxiety app. I’d definitely like to see trials before they start making claims that it works better than placebo.

  10. “Cripes! MVT’s comment is longer than the post.”
    –I had insomnia. MVTh

  11. mousethatroared says:

    Very informative post! As someone with SA I particularly like this observation “Further, they have a cognitive bias to interpret ambiguous social cues as hostile or negative. This raises a cause and effect question – are they anxious because they have these cognitive biases, or does the anxiety make them attend to negative emotions and interpret emotions negatively. Perhaps it is both, in a reinforcing feedback loop.”

    The concept of a feedback loop is quite descriptive of what I experience. The most helpful thing for me has been to recognize two things. Firstly that the anxiety I feel is the result of my brains conditioned response to social contact, developed since childhood.  Secondly, that the conditioned response can change if I break into that loop by responding to my anxiety differently than has been my habit.

    I have heard about the research on folks with SA and facial expressions, but personally, I suspect that inaccurately identifying facial expressions is only a very small component within the social interaction, much of the problem is the story that one builds around the facial expression or tone of voice…

    Thanks for the interesting article.

  12. mousethatroared says:

    Perky Skeptic “One of the most effective coping strategies I’ve found is simple distraction. Having podcasts or a DVD playing in the background helps me get work done without stressing about the product. Similarly, having light comedies playing while I pack for a big show allows me to ignore my panic at interacting with the public. Based on my personal experience, n=1, anecdote =/= proof and all that, I suspect Angry Birds would work about as well on many cases of social anxiety as this proposed social anxiety app. I’d definitely like to see trials before they start making claims that it works better than placebo.”

    This is so true! I know I’m posting a bit late, but I didn’t get a chance to read the comments before commenting on SN’s articles.

    I’ve grown accustomed to thinking of my brain as a particularly busy breed of dog (ex. border collie). Like a border collie, I’ve found if I give my brain more things to do (interesting reading, radio programs or absorbing projects) and more physical exercise, my brain has less of a tendency to chew my up the figurative sofa in my mental decor.

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