Augmentation of Exposure Therapy for High Levels of Social Anxiety Using Post-exposure Naps

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.

Inclusion Criteria:

Inclusion Criteria:

1. Treatment-seeking individuals diagnosed with Social Anxiety Disorder using the
Structured Clinical Interview for DSM-IV56 (DSM-5 SCID once available)

2. A score > 60 on the Liebowitz Social Anxiety Scale (LSAS)13

3. 18-40 years of age

4. Proficient in English

5. Normal or corrected to normal vision

6. Able to give informed consent

7. Willingness and ability to comply with the requirements of the study protocol

8. Meets psychophysiological screening criteria for inclusion carried out as follows:

- During a 5-min. baseline period, the candidate participant will sit quietly with
skin conductance and orbicularis oculi EMG levels being recorded.

- Toward the end of this period a loud acoustic stimulus will be presented several
times and blink startle EMG and SCR will be recorded.

- The candidate subject will then be asked to describe, for 2 min., their most
fearful and upsetting past social experience.

- They will then be instructed to silently reimagine this experience as vividly as
possible.

- During this imagination period, the loud acoustic stimulus will again be
presented several times and blink startle EMG and SCR will be recorded.

- Participants for whom mean SCR and blink startle EMG during the imagining period
measurably exceed the means of these measures during baseline will be retained in
the study whereas those for whom these measures do not change or are reduced will
be excluded.

- This procedure will help ensure that those included in the study will show
potentiation of physiological reactivity while anticipating exposure to public
speaking.

Exclusion Criteria:

1. Any potentially confounding medical illness

2. Lifetime history of any neurological illness or injury including neurodegenerative
disorders or dementia, stroke, seizure disorders, neurosurgical procedures, head
injury resulting in loss of consciousness for greater than 5 min.

3. Lifetime history, diagnosed by DSM-IV criteria (or DSM-5 once its SCID available), of
bipolar disorder, schizophrenia or other psychotic disorder, pervasive developmental
disorder, chronic mental disorder due to a medical condition or other potentially
confounding chronic mental disorder.

4. Current major depressive, dysthymic or anxiety disorder other than Social Anxiety
Disorder or other potentially confounding current mental disorder diagnosed by DSM-IV
criteria (or DSM-5 once its SCID available).

5. DSM-IV substance abuse or dependence within the last year, lifetime history of
hospitalization for substance abuse (determined at clinical interview) or positive
urine toxicology screen at the time of the clinical interview

6. Any evidence of suicidal ideation, violent behavior or psychosis at the clinical
interview

7. Use of psychiatric medication within 4 weeks of study (with the exception of 6 weeks
for fluoxetine)

8. Current psychotherapy for Social Anxiety Disorder

9. Any indication of a sleep disorder, particularly sleep-disordered breathing, on the
Pittsburgh Structured Clinical Interview for Sleep Disorders

10. Sleep onset latency > 1 hr, total sleep time < 5 hr or typical bed time later than 3
AM

11. Overnight shift work or recent travel across multiple time zones

12. > 4 caffeinated beverages per day or > 11 alcoholic beverages per week

13. Nicotine use