Advertisement

Fear of Negative Evaluation and Rapid Response to Treatment During Cognitive Behaviour Therapy for Social Anxiety Disorder

  • Karen AuyeungEmail author
  • Lance L. Hawley
  • Kevin Grimm
  • Randi McCabe
  • Karen Rowa
Original Article
  • 33 Downloads

Abstract

Cognitive behavioural therapy (CBT) for Social Anxiety Disorder (SAD) is an effective intervention for SAD, however, many individuals with SAD remain symptomatic at the end of CBT. Therefore, it is important to understand variables that influence patients’ responses to treatment. The present study investigated temporal changes in SAD symptoms as related to fear of negative evaluation (FNE) in a clinical sample of individuals with SAD who completed CBT. Participants with SAD (N = 175) completed self-report measures of SAD symptoms and FNE weekly across 12 weeks of group CBT. We used latent difference score dynamic modelling to explore the relationship between SAD symptom scores and FNE during CBT. Reductions in FNE were associated with subsequent reductions in SAD symptoms for individuals who showed a rapid response to treatment. The coupling of FNE and subsequent reductions in SAD symptoms was not seen in individuals not showing a rapid response. This study provides further support for the phenomenon of rapid response in CBT for SAD and suggests that mechanisms of change may be different for rapid responders as compared to non-rapid responders. The results of the current study may have implications for understanding the mechanisms underlying treatment response during CBT for SAD and for whom particular mechanisms are relevant.

Keywords

Social anxiety Cognitive behavior therapy Fear of negative evaluation Rapid response 

Notes

Funding

There are no sources of funding to declare.

Compliance with Ethical Standards

Conflict of Interest

Karen Auyeung, Lance L. Hawley, Kevin Grimm, Randi McCabe, and Karen Rowa declares that there are no potential conflicts of interest

Ethical Approval

All procedures performed in current study were in accordance with the Ethical Standards of the Ethical Committee of Ghent University and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Animal Rights

This article does not contain any studies with animals performed by any of the authors.

Supplementary material

10608_2020_10077_MOESM1_ESM.docx (24 kb)
Supplementary file1 (DOCX 24 kb)

References

  1. Acarturk, C., Cuijpers, P., van Straten, A., & de Graaf, R. (2009a). Psychological treatment of social anxiety disorder: A meta-analysis. Psychological Medicine,39(2), 241–254.  https://doi.org/10.1017/S0033291708003590.CrossRefPubMedGoogle Scholar
  2. Acarturk, C., Smit, F., de Graaf, R., van Straten, A., ten Have, M., & Cuijpers, P. (2009b). Economic costs of social phobia: A population-based study. Journal of Affective Disorders,115(3), 421–429.  https://doi.org/10.1016/j.jad.2008.10.008.CrossRefPubMedGoogle Scholar
  3. Aderka, I. M., Hofmann, S. G., Nickerson, A., Hermesh, H., Gilboa-Schechtman, E., & Marom, S. (2012). Functional impairment in social anxiety disorder. Journal of Anxiety Disorders,26(3), 393–400.  https://doi.org/10.1016/j.janxdis.2012.01.003.CrossRefPubMedGoogle Scholar
  4. Akaike, H. (1973). Information theory and an extension of the maximum likelihood principle. In B. N. Petrov, & F. Csaki (Eds.), Proceedings of the 2nd international symposium on information theory (pp. 267–281). Budapest: Akademiai Kiado.Google Scholar
  5. Antony, M. M., & Swinson, R. P. (2000). The shyness and social anxiety workbook: Proven techniques for overcoming your fears. Oakland, CA: New Harbinger Publications.Google Scholar
  6. Antony, M. M., & Swinson, R. P. (2008). The shyness and social anxiety workbook: Proven techniques for overcoming your fears (2nd ed.). Oakland, CA: New Harbinger Publications.Google Scholar
  7. Antony, M. M., Coons, M. J., McCabe, R. E., Ashbaugh, A., & Swinson, R. P. (2006). Psychometric properties of the Social Phobia Inventory: Further evaluation. Behaviour Research and Therapy,44(8), 1177–1185.  https://doi.org/10.1016/j.brat.2005.08.013.CrossRefPubMedGoogle Scholar
  8. Arbuckle, J. L. (2016). Amos (Version 24.0) [Computer Program]. Chicago, IL: SPSS.Google Scholar
  9. Barkowski, S., Schwartze, D., Strauss, B., Burlingame, G. M., Barth, J., & Rosendahl, J. (2016). Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders,39, 44–64.  https://doi.org/10.1016/j.janxdis.2016.02.005.CrossRefPubMedGoogle Scholar
  10. Bentler, P. M. (1990). Comparative fit indexes in structural models. Psychological Bulletin,107, 238–246.  https://doi.org/10.1037//0033-2909.107.2.238.CrossRefPubMedGoogle Scholar
  11. Bohn, C., Aderk, I. M., Schreiber, F., Stangier, U., & Hofmann, S. G. (2013). Sudden gains in cognitive therapy and interpersonal therapy for social anxiety disorder. Journal of Counselling and Clinical Psychology,81(1), 177–182.  https://doi.org/10.1037/a0031198.CrossRefGoogle Scholar
  12. Browne, M. W. (2000). Cross-validation methods. Journal of Mathematical Psychology,44, 108–132.  https://doi.org/10.1006/jmps.1999.1279.CrossRefPubMedGoogle Scholar
  13. Browne, M. W., & Cudeck, R. (1993). Alternative ways of assessing model fit. In K. A. Bollen & J. S. Long (Eds.), Testing structural equation models (pp. 136–162). Newbury Park, CA: Sage.Google Scholar
  14. Buchholz, J. L., Abramowitz, J. S., Blakey, S. M., Reuman, L., & Twohig, M. P. (2019). Sudden gains: How important are they during exposure and response prevention for obsessive-compulsive disorder? Behavior Therapy,50, 672–681.  https://doi.org/10.1016/j.beth.2018.10.004.CrossRefPubMedGoogle Scholar
  15. Burham, K. P., & Anderson, D. R. (2002). Model selection and multimodel inferences: A practical theoretic approcach (2nd ed.). New York, NY: Springer.Google Scholar
  16. Burton, M., Schmertz, S. K., Price, M., Masuda, A., & Anderson, P. L. (2013). The relation between mindfulness and fear of negative evaluation over the course of cognitive behavioral therapy for social anxiety disorder. Journal of Clinical Psychology,69, 222–228.  https://doi.org/10.1002/jclp.21929.CrossRefPubMedGoogle Scholar
  17. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review,26(1), 17–31.  https://doi.org/10.1016/j.cpr.2005.07.003.CrossRefPubMedGoogle Scholar
  18. Byrne, B. M. (2004). Testing for multigroup invariance using AMOS graphics: A road less traveled. Structural Equation Modeling,11, 272–300.  https://doi.org/10.1207/s15328007sem1102_8.CrossRefGoogle Scholar
  19. Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A., & Hofman, S. G. (2018). Cognitive behaviour therapy for anxiety and related disorders: A mata-analysis of randomized placebo-controlled trials. Depression and Anxiety,35(6), 502–514.  https://doi.org/10.1002/da.22728.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In M. Liebowitz & R. G. Heimberg (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69–93). New York, NY: Guilford Press.Google Scholar
  21. Clark, D. M., Ehlers, A., Hackmann, A., McManus, F., Fennell, M., Grey, N., et al. (2006). Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychlogy,74(3), 568–578.  https://doi.org/10.1037/0022-006X.74.3.568.CrossRefGoogle Scholar
  22. Clerkin, E. M., Teahman, B. A., & Smith-Janik, S. B. (2008). Sudden gains in group cognitive-behavioral therapy for panic disorder. Behaviour Research and Therapy,46(11), 1244–1250.  https://doi.org/10.1016/j.brat.2008.08.002.CrossRefPubMedPubMedCentralGoogle Scholar
  23. Collins, K. A., Westra, H. A., Dozois, D. J. A., & Stewart, S. H. (2005). The validity of the brief version of the Fear of Negative Evaluation Scale. Anxiety Disorders,19, 345–359.  https://doi.org/10.1016/j.janxdis.2004.02.003.CrossRefGoogle Scholar
  24. Connor, K. M., Davidson, J. R., Churchill, L. E., Sherwood, A., Foa, E., & Weisler, R. H. (2000). Psychometric properties of the Social Phobia Inventory (SPIN): New self-rating scale. British Journal of Psychiatry: The Journal of Mental Science,176, 379–386.  https://doi.org/10.1192/bjp.176.4.379.CrossRefGoogle Scholar
  25. DeWall, N., Buckner, J. D., Lambert, N. M., Cohen, A. S., & Fincham, F. D. (2010). Bracing for the worst, but behaving the best: Social anxiety, hostility, and behavioral aggression. Journal of Anxiety Disorders,24, 260–268.  https://doi.org/10.1016/j.janxdis.2009.12.002.CrossRefPubMedGoogle Scholar
  26. Dogaheh, E. R., Mohammadkhani, P., & Dolatshahi, B. (2011). Comparison of group and individual cognitive-behavioral therapy in reducing fear of negative evaluation. Psychological Reports,108, 955–962.  https://doi.org/10.2466/02.21.PR0.108.3.955-962.CrossRefPubMedGoogle Scholar
  27. Erwin, B. A., Heimberg, R. G., Schneier, F. R., & Liebowitz, M. R. (2003). Anger experience and expression in social anxiety disorder: Pretreatment profile and predictors of attrition and response to cognitive-behavioral treatment. Behavior Therapy,34, 331–350.  https://doi.org/10.1016/S0005-7894(03)80004-7.CrossRefGoogle Scholar
  28. Farrell, N. R., Ouimet, A. J., Rowa, K., Soreni, N., Swinson, R. P., & McCabe, R. E. (2016). Who gets better when? An investigation of change patterns in group cognitive behavioral therapy for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders,10, 35–41.  https://doi.org/10.1016/j.jocrd.2016.05.003.CrossRefGoogle Scholar
  29. Gatignon, H. (2010). Confirmatory factory analysis. In Statistical analysis of management data. New York, NY: Springer.Google Scholar
  30. Goldin, P. R., Ziv, M., Jazaieri, H., Werner, K., Kraemer, H., Heimberg, R. G., et al. (2012). Cognitive reappraisal self-efficacy mediates the effects of individual cognitive-behavioral therapy for social anxiety disorder. Journal of Consulting and Clinical Psychology,80(6), 1034–1040.  https://doi.org/10.1037/a0028555.CrossRefPubMedPubMedCentralGoogle Scholar
  31. Grilo, C. M., White, M. A., Wilson, G. T., Gueorguieva, R., & Masheb, R. M. (2012). Rapid response predicts 12-month post-treatment outcomes in binge-eating disorder: Theoretical and clinical implications. Psychological Medicine,42(4), 807–817.  https://doi.org/10.1017/S0033291711001875.CrossRefPubMedGoogle Scholar
  32. Hamagami, F., & McArdle, J. J. (2001). Advanced studies for individual differences linear dynamic models for longitudinal data analysis. In G. A. Marcoulides & R. E. Schumacker (Eds.), New developments and techniques in structural equation modeling (pp. 203–246). Mahwah, NJ: Erlbaum.Google Scholar
  33. Hawley, L. L., Ho, M. R., Zuroff, D. C., & Blatt, S. J. (2006). The relationship of perfectionism, depression and therapeutic alliance during treatment for depression: Latent difference score analysis. Journal of Consulting and Clinical Psychology,74, 930–942.  https://doi.org/10.1037/0022-006x.74.5.930.CrossRefPubMedGoogle Scholar
  34. Hawley, L. L., Ho, M. R., Zuroff, D. C., & Blatt, S. J. (2007). Stress reactivity following brief treatment for depression: Differential effects of psychotherapy and medication. Journal of Consulting and Clinical Psychology,75, 244–256.  https://doi.org/10.1037/0022-006X.75.2.244.CrossRefPubMedGoogle Scholar
  35. Heimberg, R. G., & Becker, R. E. (2002). Cognitive behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. New York, NY: Guilford Press.Google Scholar
  36. Heinrichs, N., & Hofmann, S. G. (2001). Information processing in social phobia: A critical review. Clinical Psychology Review,21(5), 751–770.  https://doi.org/10.1016/S0272-7358(00)00067-2.CrossRefPubMedGoogle Scholar
  37. Hilbert, A., Hildebrandt, T., Agras, W. S., Wilfley, D. E., & Wilson, G. T. (2015). Rapid response in psychological treatments for binge eating disorder. Journal of Consulting and Clinical Psychology,83(3), 649–654.  https://doi.org/10.1037/ccp0000018.CrossRefPubMedPubMedCentralGoogle Scholar
  38. Hofmann, S. G. (2004). Cognitive mediation of treatment change in social phobia. Journal of Consulting and Clinical Psychology,72(3), 392–399.CrossRefGoogle Scholar
  39. Hofmann, S. G. (2007). Cognitive factors that maintain social anxiety disorder: A comprehensive model and its treatment implications. Cognitive Behaviour Therapy,36, 193–209.  https://doi.org/10.1080/16506070701421313.CrossRefPubMedPubMedCentralGoogle Scholar
  40. Hofmann, S. G., & Bögels, S. M. (2006). Recent advances in the treatment of social phobia: Introduction to the special issue. Journal of Cognitive Psychotherapy,20(1), 3–5.CrossRefGoogle Scholar
  41. Hofmann, S. G., & Smits, J. A. J. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry,69(4), 621–632.CrossRefGoogle Scholar
  42. Hofmann, S. G., Schulz, G., Meuret, S. M., Moscovitch, D. A., & Suvak, M. (2006). Sudden gains during therapy of social phobia. Journal of Consulting and Clinical Psychology,74(4), 687–697.CrossRefGoogle Scholar
  43. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology,59(1), 12–19.CrossRefGoogle Scholar
  44. Joreskog, K. G., & Sorbom, D. (1979). Advances in factor analysis and structural equation models. Cambridge, MA: Abt Books.Google Scholar
  45. Kashdan, T. B., Elhai, J. D., & Breen, W. E. (2008). Social anxiety and disinhibition: An analysis of curiosity and social rank appraisals, approach-avoidance conflicts, and disruptive risk-taking behaviour. Journal of Anxiety Disorders,22, 925–939.  https://doi.org/10.1016/j.janxdis.2007.09.009.CrossRefPubMedGoogle Scholar
  46. Kelly, M. A. R., Roberts, J. E., & Ciesla, J. A. (2005). Sudden gains in cognitive behavioral treatment for depression: When do they occur and do they matter? Behaviour Research and Therapy,43(6), 703–714.  https://doi.org/10.1016/j.brat.2004.06.002.CrossRefPubMedGoogle Scholar
  47. Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey replication. Archives of General Psychiatry,62(6), 617–627.  https://doi.org/10.1001/archpsyc.62.6.617.CrossRefPubMedPubMedCentralGoogle Scholar
  48. Kocovski, N. L., Fleming, J. E., Hawley, L. L., Huta, V., & Antony, M. M. (2013). Mindfulness and acceptance-based group therapy versus traditional cognitive behavioral group therapy for social anxiety disorder: A randomized controlled trial. Behaviour Research and Therapy,51, 88–898.  https://doi.org/10.1016/j.brat.2013.10.007.CrossRefGoogle Scholar
  49. Kocovski, N. L., Fleming, J. E., Hawley, L. L., Ho, M.-H. R., & Antony, M. M. (2015). Mindfulness and acceptance-based group therapy and traditional cognitive behavioral group therapy for social anxiety disorder: Mechanisms of change. Behaviour Research and Therapy,70, 11–22.  https://doi.org/10.1016/j.brat.2015.04.005.CrossRefPubMedGoogle Scholar
  50. Leary, M. R. (1983). A brief version of the Fear of Negative Evaluation Scale. Personality and Social Psychology Bulletin,9, 371–376.CrossRefGoogle Scholar
  51. Ledley, D. R., Heimberg, R. G., Hope, D. A., Hayes, S. A., Zaider, T. I., Van Dyke, M., et al. (2009). Efficacy of a manualized and workbook-driven individual treatment for social anxiety disorder. Behavior Therapy,40(4), 414–424.  https://doi.org/10.1016/j.beth.2008.12.001.CrossRefPubMedGoogle Scholar
  52. Linardon, J., Brennan, L., & Xochitl de la Piedad, G. (2016). Rapid response to eating disorder treatment: A systematic review and meta-analysis. International Journal of Eating Disorders,49(10), 905–919.  https://doi.org/10.1002/eat.22595.CrossRefPubMedGoogle Scholar
  53. Linett, A., Monforton, J., MacKenzie, M. B., McCabe, R. E., Rowa, K., & Antony, M. M. (2019). The Social Suspiciousness Scale: Development, validation, and implications for understanding social anxiety disorder. Journal of Psychopathology and Behavioral Assessment,41(2), 280–293.  https://doi.org/10.1007/s10862-019-09724-3.CrossRefGoogle Scholar
  54. MacCallum, R. C., Browne, M. W., & Sugawara, H. M. (1996). Power analysis and determination of sample size for covariance structure modeling. Psychological Methods,1(2), 130–149.  https://doi.org/10.1037/1082-989X.1.2.130.CrossRefGoogle Scholar
  55. Maresh, E. L., Teachman, B. A., & Coan, J. A. (2017). Are you watching me? Interacting effects of fear of negative evaluation and social context on cognitive performance. Journal of Experimental Psychopathology,8(3), 303–319.  https://doi.org/10.5127/jep.059516.CrossRefGoogle Scholar
  56. Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., et al. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: A systematic review and network meta-analysis. The Lancet Psychiatry,1(5), 368–376.  https://doi.org/10.1016/S2215-0366(14)70329-3.CrossRefPubMedPubMedCentralGoogle Scholar
  57. McArdle, J. J. (2001). A latent difference score approach to longitudinal dynamic analysis. In R. Cudeck, S. Toit, & D. Sörbum (Eds.), Structural equation modeling: Present and future (pp. 341–380). Lincolnwood, IL: Scientific Software International.Google Scholar
  58. McArdle, J. J., & Hamagami, F. (2001). Latent difference score structural models for linear dynamic analyses with incomplete longitudinal data. In L. M. Collins & A. G. Sayer (Eds.), New methods for the analysis of change (pp. 139–175). Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  59. McArdle, J. J., & Nesselroade, J. R. (2002). Growth curve analysis in contemporary psychological research. In J. Schinka & W. Velicer (Eds.), Comprehensive handbook of psychology: Vol 2. Research methods in psychology. Hoboken, NJ: Wiley.Google Scholar
  60. Meredith, W., & Tisak, J. (1990). Latent curve analysis. Psychometrika,55, 107–122.  https://doi.org/10.1007/bf02294746.CrossRefGoogle Scholar
  61. Moscovitch, D. A., McCabe, R. E., Antony, M. M., Rocca, L., & Swinson, R. P. (2007). Anger experience and expression across the anxiety disorders. Depression and Anxiety,25(2), 107–113.  https://doi.org/10.1002/da.20280.CrossRefGoogle Scholar
  62. Moscovitch, D. A., Gavric, D. L., Senn, J. M., Santesso, D. L., Miskovic, V., Schmidt, L. A., et al. (2012). Changes in judgment biases and use of emotion regulation strategies during cognitive-behavioral therapy for social anxiety disorder: Distinguishing treatment responders from Nonresponders. Cognitive Therapy and Research,36(4), 261–271.  https://doi.org/10.1007/s10608-011-9371-1.CrossRefGoogle Scholar
  63. Norton, P. J., & Price, E. C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. Journal of Nervous and Mental Disease,195, 521–531.CrossRefGoogle Scholar
  64. Otto, M. W., Pollack, M. H., Maki, K. M., Gould, R. A., Worthington, J. J., Smoller, J. W., et al. (2001). Childhood history of anxiety disorders among adults with social phobia: Rates, correlates, and comparisons with patients with panic disorder. Depression and Anxiety,14(4), 209–213.  https://doi.org/10.1002/da.1068.CrossRefPubMedGoogle Scholar
  65. Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy,35(8), 741–756.  https://doi.org/10.1016/S0005-7967(97)00022-3.CrossRefPubMedGoogle Scholar
  66. Rodebaugh, T. L., Holaway, R. M., & Heimberg, R. G. (2004). The treatment of social anxiety disorder. Clinical Psychology Review,24(7), 883–908.  https://doi.org/10.1016/j.cpr.2004.07.007.CrossRefPubMedGoogle Scholar
  67. Steiger, J. H., & Lind, J. C. (1980, June). Statistically-based tests for the number of factors. Paper presented at the meeting of the Psychometric Society, Iowa City, IA.Google Scholar
  68. Stein, M. B., & Kean, Y. M. (2000). Disability and quality of life in social phobia: Epidemiologic findings. American Journal of Psychiatry,157(10), 1606–1613.  https://doi.org/10.1176/appi.ajp.157.10.1606.CrossRefPubMedGoogle Scholar
  69. Tang, T. Z., & DeRubeis, R. J. (1999). Sudden gains and critical sessions in cognitive-behavioral therapy for depression. Journal of Consulting and Clinical Psychology,67(6), 894–904.  https://doi.org/10.1037//0022-006x.67.6.894.CrossRefPubMedGoogle Scholar
  70. Thorisdottir, S., Tryggvadottir, A., Saevarsson, S. T., & Bjornsson, A. S. (2018). Brief report: Sudden gains in cognitive behavioral group therapy and group psychotherapy for social anxiety disorder among college students. Cognitive Behaviour Therapy,47, 462–469.  https://doi.org/10.1080/16506073.2018.1466909.CrossRefPubMedGoogle Scholar
  71. Vassilopoulos, S. (2005). Social anxiety and the vigilance-avoidance pattern of attentional processing. Behavioural and Cognitive Psychotherapy,33, 13–24.  https://doi.org/10.1017/S1352465804001730.CrossRefGoogle Scholar
  72. Versalla, M. V., Piccirillo, M. L., Potter, C. M., Olino, T. M., & Heimberg, R. G. (2016). Anger profiles in social anxiety disorder. Journal of Anxiety Disorders,37, 21–29.  https://doi.org/10.1016/j.janxdis.2015.10.008.CrossRefGoogle Scholar
  73. Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and Clinical Psychology,33(4), 448–457.  https://doi.org/10.1037/h0027806.CrossRefPubMedGoogle Scholar
  74. Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995). Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behavior Therapy, 26, 153–161.  https://doi.org/10.1016/S0005-7894(05)80088-7.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Anxiety Treatment and Research ClinicSt. Joseph’s HealthcareHamiltonCanada
  2. 2.Sunnybrook Health Sciences CentreTorontoCanada
  3. 3.Department of PsychiatryUniversity of TorontoTorontoCanada
  4. 4.Department of PsychologyArizona State UniversityArizonaUSA
  5. 5.Department of Psychiatry and Behavioural NeurosciencesMcMaster UniversityHamiltonCanada
  6. 6.North Shore Stress and Anxiety ClinicNorth VancouverCanada

Personalised recommendations