Neurophysiological Effects of Cognitive Behavioral
     Therapy in Social Anxiety: An ERP Study
     Sutao Song  (  sutao.song@sdnu.edu.cn )
      Shandong Normal University
     Ting Jiang 
      Southwest University
     Shimeng Zhao 
      University of Jinan
     Mingxian Zhang 
      University of Jinan
     Jing Feng 
      University of Jinan
     Yuanjie Zheng 
      Shandong Normal University
     Ruiyang Ge 
      University of British Columbia
     Research Article
     Keywords: dot-probe, cognitive behavioral therapy, social anxiety disorder, ERPs
     Posted Date: August 8th, 2022
     DOI: https://doi.org/10.21203/rs.3.rs-1921460/v1
     License:   This work is licensed under a Creative Commons Attribution 4.0 International License.  
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    Abstract
    Background: Social anxious individuals show attention bias towards emotional stimuli, this phenomenon
    is considered to be an important cause of anxiety generation and maintenance. Cognitive-behavioral
    therapy (CBT) is a standard psychotherapy for social anxiety disorder. CBT decreases attention biases by
    correcting the maladaptive beliefs of socially anxious individuals, but it is not clear whether CBT alters
    neurophysiological features of socially anxious individuals at early automatic and/or late cognitive
    strategy stage of attentional processing.
    Method: To address this knowledge gap, we collected pre-treatment event-related potential data of
    socially anxious individuals while they performed a dot-probe task. These participants then received eight
    weeks of CBT, and post-treatment ERP data were collected after completion of CBT treatment.
    Results: Participants’ social anxiety level was signicantly alleviated with CBT. ERP results revealed that
    (1) compared to pre-treatment phase, P1 amplitudes induced by probes signicantly decreased at post-
    treatment phase, whereas P3 amplitudes increased at post-treatment phase; (2) amplitude of
    components elicited by face pairs did not change signicantly between pre-treatment and post-treatment
    phases; (3) changes of Liebowitz Social Anxiety Scale were positively correlated with changes of P1
    amplitude, and negatively correlated with changes of N1 amplitude.
    Limitations: Our sample was university students, which limits the generalizability of the results.
    Conclusion: The present results demonstrated that CBT alters ERPs appeared in probe-presenting stage
    for social anxiety, which suggested that key to the effective intervention was the adjustment of cognitive
    strategies in the later stage of attentional processing.
    1. Introduction
    Social anxiety disorder (SAD) is characterized by an intense fear of negative evaluation and avoidance of
    interpersonal environments [1]. The onset of SAD is at a young age with a lifetime prevalence rate of
    approximately 10% [2, 3]. Social anxiety is linked to substantial personal, family and economic burden [4,
    5].
    According to the cognitive theory of social anxiety, the attentional bias and emotional response to
    potentially threatening stimuli are important factors contributing to formation and maintenance of social
    anxiety [6]. Attentional bias refers to the automatic attention to potentially threatening stimuli [7, 8].
    Previous studies have reported that socially anxious individuals exhibited dysfunctional reaction to
    negative stimuli [9–11] as well as positive stimuli [12–16].
    Cognitive Behavioral Therapy (CBT) is an effective therapeutic approach for the treatment of SAD [17,
    18]. In a CBT treatment course, patients are trained to engage repeatedly in socially feared situations, and
    to perform alternative learning in these situations to reduce threat avoidance behavior. CBT focuses on
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    the learning of cognitive strategies, including exposure, applied relaxation, social skills training, and
    cognitive restructuring [19, 20]. Neurophysiological studies have demonstrated that CBT normalizes
    neural system dysfunctions that are associated with emotional processing and regulation which enrolls
    prefrontal cortex, anterior cingulate and insula in patients with anxiety disorders [21, 22]. A recent event-
    related potential Egger, Konnopka [23] study using passive visual detection paradigm found that with
    group CBT, SAD patients showed decreased P1 responses to faces, and this phenomenon may reect the
    altered early processing of faces: CBT regulates early selective attention to social information in SAD
    patients [1]. However, this study cannot explore the effect of CBT on sustained attention when individuals
    process specic stimuli. In addition, this study only used neutral faces, therefore the effect of CBT on
    attention to different facial expressions can not be explored. CBT is ecient in the intervention of SAD
    probably because CBT promotes patients’ concentration, modies patients’ attentional bias, exibly shifts
    attention between neutral and threatening stimuli [19], and turns vigilance for threatening faces into
    avoidance [24]. However, it is not clear whether CBT alters neurophysiological features of socially anxious
    individuals at early automatic and/or late cognitive strategy stage of attentional processing to more
    social information, like emotional faces.
    To bridge this knowledge gap, we used dot-probe paradigm and ERP technique to investigate the
    neurophysiological effect of CBT in social anxious individuals. Using the superior temporal resolution of
    ERPs, researchers can investigate threat-related attentional bias and its components because these
    measures allow for the examination of the time course of attention to threat with millisecond
    resolution[25]. The facial expression-based dot-probe paradigm is commonly used in studies of attention
    bias [7, 26], which is sensitive to clinical change in social anxiety [27]. This paradigm can be used to
    detect individual's early automatic attention to facial expressions in face-pairs presentation stage, and
    sustained attention to the location of the emotional faces in probe presentation stage which reects the
    adjustment of individual's cognitive strategies.
    We hypothesized that CBT can effectively normalize the abnormal attention bias of socially anxious
    individuals in two attention stages: the early automatic attention and late cognitive strategy. At face
    processing stage, we expected that CBT reduces automatic attention to threatening faces, decreases
    attentional resources to face processing, and the amplitude of ERP components (e.g., P1, P2, N1, and
    N170) [28–30] elicited by face-pairs would decrease with CBT treatment. At probe processing stage, we
    expected CBT increases attention to task-related stimuli, reduces the constant attention to the position of
    various emotional faces, and the amplitude of ERP components (e.g. P1, N1, and P3) [14, 29] elicited by
    the probes would decrease with CBT treatment.
    2. Materials And Methods
    2.1 Participants
    University students with social anxiety were screened using Liebowitz Social Anxiety Scale (LSAS) and
    Beck Depression Scale (BDI-II) [31, 32]. There were two criteria for inclusion into the social anxiety group,
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    i.e., with patients’ LSAS ≥ 50 and BDI-II ≤ 8 [33] (One of the subjects had an LSAS score of 45. After being
    interviewed by DSM-V, he was also included in the social anxiety group). Additional exclusion criteria
    included no corrected-normal eyesight, no color blindness or weakness, no harmful drinking, no
    substance abuse or dependence, no history of neurological illness. A structured interview based on DSM-
    V was conducted by a therapist with clinical psychological qualications to clarify that the participants
    had high social anxiety symptoms. Finally, 30 participants who met the criteria were enrolled to
    participate in the present study. All participants gave written informed consent before the experiment.
    They received monetary compensation for participating in the study. Overall, a total of 22 subjects (mean
    age [SD]: 19.09 [1.07] years; 20 females) completed the entire experiment.This study was approved by the
    ethics committee of the School of Education and Psychology, University of Jinan.
    2.2 Clinical measures
    The 24-item self-report LSAS was used to assess fear and avoidance of 24 different social situations,
    including 11 social subscale items and 13 performance situation items. The 21-item self-report BDI-II was
    used to assess participants’ depressive symptoms. The Chinese version of LSAS and BDI-II both have
    high reliability and validity [34].
    2.3 Dot-probe task
    The stimuli consisted of 160 pictures of faces with 4 different expressions (i.e., happy, angry, fear,
    neutral), half of them were male faces and half were female faces. The picture was taken from the
    Chinese Affective Picture System (CAPS) [35]. After excluding non-facial contours and hair, the face
    stimuli were chromatic photographs (3 cm × 4 cm), subtending a visual angle of 4.5°×6.8°. There were
    four types of face pairs: 40 angry-neutral, 40 fear-neutral, 40 happy-neutral, and 40 neutral-neutral, and
    the position of the emotional faces (on the left or the right side of the screen) was equivalent within each
    block. Each face pair was repeated 6 times.
    As shown in Fig. 1(b), each trial began with a 500 ms "+" xation followed by the face pairs for 100ms or
    500ms on the left or right side of the screen. Next, the face pairs were followed by a xation screen which
    lasted for 100 ~ 300 ms. Then the probe "*" appeared in the prior location of emotional or neutral face for
    200 ms. The location of the probe equally distributed across trial types and the presentation order was
    randomized throughout the test. Participants were asked to determine the position of the probe by
    pressing a button as accurately and quickly as possible. Participants were given a window of 1200 ms
    from the onset of the probe to respond. There were 9 blocks of 80 trials, which were separated by short-
    time breaks. The xation "+" was always shown in the center of the screen. The experiment had a
    duration of about 40 min. Before the formal task, participants were asked to practice a few trials to
    understand the experiment procedure.The face pairs used in this stage did not appear in the formal task.
    2..4 Cognitive Behavioral Therapy
    Cognitive-behavioral therapy was administered by an experienced clinical psychotherapist, assisted by an
    assistant psychological Counselor. Therapist followed Beck [36] CBGT manual for SAD. Treatment focus
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