Exploring the temporal associations between avoidance behavior and cognitions during the course of cognitive behavioral therapy for clients with symptoms of social anxiety disorder.

Objectives: In cognitive behavioral therapy (CBT) for social anxiety disorder (SAD), avoidance behavior (AB) and cognitions (COG) are two important targets of intervention, but so far no studies have directly examined their relative importance. By means of cross-lagged panel models (CLPM), we examined their temporal associations and impacts on outcome in clients with symptoms of SAD while addressing typical methodological challenges.

Method: We used data from the first six therapy sessions in a sample of 428 primary care clients (mean [SD] age = 34.6 [12.2], 34.3% men), participating in the Prompt Mental Health Care trial. Session-by-session data was collected on AB, COG, depression and general anxiety. Competing multiple indicator CLPMs were tested.

Results: The Random Intercept-CLPM provided best fit, and indicated that AB predicted COG at subsequent time points (.39 ≤   ≤ .42 for T2-T5,   < .05), but not vice versa. In addition, AB, but not COG, predicted clients' general anxiety score at subsequent time points. Results were both robust to the inclusion of depressive symptoms as a within-level covariate, and sensitivity tests for stationarity and missing data assumptions.

Conclusion: Targeting avoidance behavior for primary care clients with symptoms of SAD may be more vital for the optimal effect of CBT than targeting cognitions. Methodological considerations and limitations of the study are discussed. ClinicalTrials.gov identifier: NCT03238872.