Acceptance and commitment therapy for generalized social ...

[Pages:121]Acceptance and Commitment Therapy for Generalized Social Anxiety Disorder: A Pilot Study A Thesis

Submitted to the Faculty Of

Drexel University by

Kristy L. Dalrymple in partial fulfillment of the requirements for the degree

of Doctor of Philosophy

September 2005

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ACKNOWLEDGEMENTS I would like to thank my dissertation chair and graduate advisor, Dr. James Herbert, for his invaluable guidance and support during this study and my graduate career. I am particularly indebted to my colleagues who assisted in data collection and served as therapists for this study: Elizabeth Nolan, LeeAnn Cardaciotto, Meagan Parmley, Heather Murray, Angela Gorman, Peter Yeomans, and Ethan Moitra. My committee members were extremely helpful during the course of this study: Dr. Lamia Barakat, Dr. Evan Forman, Dr. Martin Franklin, and Dr. Pamela Geller. I would also like to thank Dr. Brandon Gaudiano for his helpful feedback and constant support throughout the course of this study. I would like to acknowledge those whose work formed the basis for this study: Dr. Steven Hayes, Dr. Kirk Strosahl, and Dr. Kelly Wilson, who developed Acceptance and Commitment Therapy (ACT); and Dr. Jennifer Block-Lerner and Dr. Edelgard Wulfert, who first investigated the efficacy of ACT for Social Anxiety Disorder. Finally, I am truly grateful for my family and friends, who provided unyielding support and helped to make this project possible.

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TABLE OF CONTENTS LIST OF TABLES..................................................................................vii LIST OF FIGURES................................................................................viii ABSTRACT..........................................................................................ix 1. INTRODUCTION.................................................................................1

1.1. Cognitive Behavior Therapies for SAD.................................................2 1.2. Pharmacotherapy...........................................................................4 1.3. Combined Pharmacotherapy and CBT...................................................6 1.4. Acceptance and Commitment Therapy....................................................9 1.5. Empirical Evidence for ACT............................................................16 1.6. Efficacy of ACT for Anxiety Disorders................................................21 1.7. Summary and Study Rationale..........................................................26 2. METHOD........................................................................................30 2.1. Participants.................................................................................30 2.2. Measures....................................................................................31

2.2.1. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P)............................................................................31

2.2.2. Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II)....................................................31

2.2.3. Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV)............32 2.2.4. Social Phobia and Anxiety Inventory (SPAI).................................32 2.2.5. Liebowitz Social Anxiety Scale (LSAS).......................................32 2.2.6. Beck Depression Inventory-2nd Edition (BDI-II).............................33

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2.2.7. Fear Questionnaire (FQ).........................................................33 2.2.8. Brief Version of the Fear of Negative Evaluation Scale (Brief FNE)......33 2.2.9. Sheehan Disability Scale (SDS).................................................34 2.2.10. Quality of Life Inventory (QOLI)...............................................34 2.2.11. Acceptance and Action Questionnaire (AAQ)................................35 2.2.12. Valued Living Questionnaire (VLQ)...........................................35 2.2.13. Automatic Thoughts Questionnaire (ATQ)....................................36 2.2.14. Anxiety Control Questionnaire (ACQ).........................................36 2.2.15. Thought Control Questionnaire (TCQ).........................................37 2.2.16. Willingness Scale (WS)..........................................................37 2.2.17. Social Interaction Self-Statement Test (SISST)..............................37 2.2.18. Demographics Questionnaire....................................................38 2.2.19. Clinical Global Impression Scales (CGI)......................................38 2.2.20. Behavioral assessment............................................................39 2.3. Treatment..................................................................................40 2.3.1. Acceptance and Commitment Therapy (ACT)................................40 2.4. Procedure...................................................................................41 2.5. Statistical Analyses........................................................................43 2.5.1. Statistical Power...................................................................43 2.5.2. Preliminary Analyses.............................................................43 2.5.3. Primary Analyses..................................................................44 2.5.4. Analysis of Clinical Significance...............................................45 2.5.5. Secondary Analyses...............................................................46

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2.6. Design and Data Collection Considerations...........................................47 3. RESULTS........................................................................................50

3.1. Sample Description..........................................................................50 3.2. Preliminary Analyses.....................................................................51

3.2.1. Dropouts............................................................................51 3.2.2. Baseline Period....................................................................51 3.2.3. Exploratory Demographic Comparisons.......................................52 3.3. Primary Analyses..........................................................................52 3.3.1. Outcome Measures.................................................................52 3.3.2. Process Measures..................................................................54 3.3.3. Clinician-rated Measures.........................................................56 3.3.4. Behavioral Assessment...........................................................56 3.3.5. Intention-to-Treat Analyses......................................................57 3.4. Analyses of Clinical Significance......................................................58 3.5. Secondary Analyses.......................................................................60 3.5.1. Effect Size Comparisons..........................................................60 3.5.2. Correlation Analyses..............................................................61 4. DISCUSSION...................................................................................64 4.1. Summary of Results.......................................................................64 4.2. Support for Hypotheses..................................................................64 4.2.1. Hypothesis #1.....................................................................64 4.2.2. Hypothesis #2......................................................................65 4.2.3. Hypothesis #3......................................................................69

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4.2.4. Hypothesis #4......................................................................71 4.2.5. Hypothesis #5......................................................................72 4.3. Comparison and Contrast to Block (2002)...............................................73 4.4. Limitations.................................................................................75 4.5. Implications and Future Directions.....................................................77 LIST OF REFERENCES...........................................................................82 VITA................................................................................................111

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LIST OF TABLES 1. Assessment Schedule for Current Study......................................................94 2. Demographic Characteristics of the Sample.................................................95 3. Means (Standard Deviations), Effect Sizes, and p-Values of Baseline, Pre-, Mid-, and

Post-Treatment Measures for Completers Only and Intention to Treat Analyses..........................................................................................96

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LIST OF FIGURES 1. Participant Flow Diagram for Study Phases...............................................101 2. Baseline, Pre-, Mid-, and Post-Treatment Mean Scores on the SPAI-SP.............102 3. Baseline, Pre-, Mid-, and Post-Treatment Mean Scores on the Brief FNE............103 4. Baseline, Pre-, Mid-, and Post-Treatment Mean Scores on the FQ-SP................104 5. Baseline, Pre-, Mid-, and Post-Treatment Mean Scores on the LSAS Fear and

Avoidance Subscales.........................................................................105

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