Augmentation of Exposure Therapy for High Levels of Social Anxiety Using Post-exposure Naps
Condition: Social Anxiety Disorder; Sleep Laboratory
MeSH terms: Anxiety Disorders; Phobia, Social
Study type: Interventional

Summary: 
      Investigators will examine whether post-exposure naps can be used to strengthen therapeutic
      extinction memories formed during exposure therapy for extreme social anxiety. Thirty-two
      individuals with high levels of social anxiety, evidenced by scores of 60 or greater on the
      Liebowitz Social Anxiety Scale, by self-report during a clinical interview and by
      demonstrated enhanced psychophysiological reactivity when imagining a socially stressful
      scenario, will be enrolled as one of four participants in one of eight successive offerings
      of a validated 5-session exposure-based group treatment for extreme social anxiety. The third
      and fourth sessions conclude with each participant delivering a speech on a topic
      individually chosen to elicit significant social anxiety. Following these sessions,
      participants will go to the sleep laboratory where two will be given a 2-hour sleep
      opportunity with polysomnographic (PSG) monitoring and two will be similarly instrumented but
      undergo 2 hours of monitored quiet wakefulness. Before and after treatment, participants will
      be individually assessed for social anxiety symptoms using standardized self-report
      instruments and a Trier Social Stress Test (TSST) modified for continuous psychophysiological
      monitoring. Ambulatory monitoring of home sleep will also be obtained using actigraphy and
      sleep diaries. The investigators hypothesize that, post treatment, those individuals who
      napped will show greater questionnaire-based clinical improvement as well as lesser
      psychophysiological reactivity during the modified TSST compared to those who remained
      quietly awake. The investigators further hypothesize that characteristics of sleep quality
      and architecture during naps, specifically durations of total sleep, REM and slow-wave sleep,
      as well as REM continuity, will predict greater clinical improvement and lesser
      psychophysiological reactivity to the TSST in those who napped following their third and
      fourth therapy sessions. Positive results will provide the first proof-of-principle for sleep
      augmentation of exposure therapy for clinically significant extreme social anxiety.
    

Detailed description: 
      Widely replicated studies demonstrate that sleep can enhance memory consolidation. Potential
      clinical applications of such findings have only begun to be explored. The investigators have
      recently shown that nocturnal sleep following simulated exposure therapy for high levels of
      spider fear reduced both psychophysiological and self-reported reactivity when participants
      were re-exposed to the same and to novel spider stimuli. The proposed research will extend
      these findings to the more debilitating and clinically important condition of extreme social
      anxiety. The investigators will examine whether post-exposure naps can be used to strengthen
      therapeutic extinction memories formed during exposure exercises used in the behavioral
      treatment of extreme social anxiety. A total of 32 individuals with high levels of social
      anxiety, evidenced by scores of 60 or greater on the Liebowitz Social Anxiety Scale,
      self-report during a clinical interview and demonstrated enhanced psychophysiological
      reactivity when imagining a socially stressful scenario, will be enrolled in an
      exposure-based group treatment for extreme social anxiety. Eight successive therapy groups of
      4 patients each will be offered during the 2-year funding period. The third and fourth
      sessions of this validated 5-week/5-session treatment will involve each participant
      delivering a speech on a topic individually chosen to elicit significant social anxiety.
      Following both of these sessions, all 4 participants will go to the nearby Massachusetts
      General Hospital sleep laboratory where 2 will be given a 2-hour sleep opportunity with
      polysomnographic (PSG) monitoring and the other 2 will be similarly instrumented but undergo
      2 hours of monitored quiet wakefulness (prior to session 3 participants will be randomized to
      the sleep or wakefulness arm). Before beginning treatment and within several days following
      the final treatment session, all participants will be individually assessed for social
      anxiety symptoms using standardized self-report instruments. At these same times, they will
      undergo a Trier Social Stress Test (TSST) modified for continuous psychophysiological
      monitoring that also includes repeated Subjective Units of Distress (SUDS) self report and
      sampling for salivary cortisol. In addition to laboratory PSG, ambulatory monitoring of home
      sleep with actigraphy and sleep diaries will take place at pre-treatment baseline and during
      the last 3 weeks of treatment. The investigators hypothesize that those individuals allowed a
      2-hour sleep opportunity following exposure sessions, compared to those who remained quietly
      awake, will show greater questionnaire-based clinical improvement as well as lesser
      psychophysiological and SUDS reactivity during the modified TSST. The investigators further
      hypothesize that characteristics of sleep quality and architecture during naps, specifically
      durations of total sleep, REM sleep and slow-wave sleep as well as REM continuity, will
      predict clinical improvement and diminished TSST reactivity in those who napped. To help
      ensure that observed sleep effects are attributable to the two 2-hour sleep opportunities,
      the investigators will control for actigraph and diary-measured sleep quality during
      treatment. Positive results will provide the first proof-of-principle for sleep augmentation
      of exposure therapy for a clinically significant extreme social anxiety.
    

Intervention name(s): Sleep-enhancement of extinction memory
Intervention type(s): Behavioral
Intervention description(s): Recent reports show that sleep promotes memory consolidation. The investigators' preliminary findings suggest sleep may enhance the therapeutic extinction memories acquired during exposure therapy. For sleep-enhancement of extinction memory, the current intervention uses post-exposure naps as a means to provide sleep in close temporal proximity to the encoding of memory for the extinction social exposure fears in individuals with severe social anxiety symptoms.
Allocation: Randomized
Intervention model: Single Group Assignment
Masking: Single (Care Provider)
Primary purpose: Treatment
Keywords: social anxiety; exposure therapy; extinction; sleep-dependent memory consolidation