Social Anxiety Disorder Dr. Candice Esposito 17 June 2013 Social Anxiety Disorder - Integrative strategies for an under-recognized and undertreated problem. By: Candice Esposito ND Algoma Natural Healing Clinic 45 Grace Street, Sault Ste. Marie, ON. P6A 2S7 www.calmlivingblueprint.com Jump to: Part 1 Part 2Part 3Part 4 Part I: What is Social Anxiety Disorder? Approximately 13% of the population experience social anxiety over the course of their lifetime,(1) the most common form of all anxiety disorders.(2) After alcohol abuse and depression it is the most common psychiatric illness. Many questions and controversies surrounding its diagnosis and treatment still remain. Currently, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines social anxiety disorder (SAD) as a persistent and debilitating fear of embarrassment or humiliation in social situations. People with SAD often completely avoid these social situations or endure them with significant distress.(3) Revisions to this definition have been proposed for several reasons: (4) • The difference between shyness and SAD is ambiguous • No clear causes for SAD have been validated • Contradicting views as to whether SAD is under-recognized and undertreated or over-diagnosed.(5) One of the most common screening tools for SAD used in doctors’ offices is the “mini SPIN.” This screening device asks the patient to rate the following statements on a scale of 0 “not at all” to 4 “extremely present:” • Fear of embarrassment causes me to avoid doing things or speaking to people. • I avoid activities in which I am the center of attention. • Being embarrassed or looking stupid are among my worst fears. A score of six or higher suggests further evaluation is warranted. The mini SPIN has been shown to be 89% accurate in detecting cases of SAD.(6) One possible reason for poor detection rates of SAD may lie with the very nature of the disorder itself. Due to fears that others may judge them, people with SAD may be embarrassed to talk about their concerns and rather avoid the anxiety than face it. As a result, these individuals are less likely to seek help or state this specific type of anxiety as a concern to their doctor.(5) Typically, the disorder begins early in life and remains over a lifetime if untreated. People may mistake symptoms of SAD as part of their personality, something that cannot be changed. The term “social anxiety disorder” was not introduced until 1994 and some researchers theorize that the lack of media attention it has received in comparison to depression and other anxiety disorders has contributed to SAD being under-recognized.(5) Social anxiety can interrupt education and job success, cause financial dependence, and impair relationships .(8) Sufferers of social anxiety have more difficulty dating,(9) are less often married,(10) record more sick days,(11) experience reduced work productivity (12) and rely more on social assistance in comparison to those without the disorder.(11) People with SAD are also more prone to depression and substance abuse.(13) Regardless of the reasons for it being under-recognized, it’s clear that SAD decreases the quality of life of its sufferers (14) and there is a strong need to improve screening for this disorder in the primary care setting. Individuals who suspect they may suffer from social anxiety can complete the Web-Based Depression and Anxiety Test (http://www.wb-dat.net) and either print out the results to bring to their doctor or email the results directly to their doctor. This test is a clinically accepted screening tool (15) that may help make it easier to initiate conversation with a health professional. References 1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602. 2. Davidson JRT, Hughes DL, George LK, Blazer DG. The epidemiology of social phobia: findings from the Duke Epidemiological Catchment Area Study. Psychol Med. 1993;23(3):709-718. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington: American Psychiatric Association; 1994. 4. Bogels SM, Alden L, Beidel DC, Clark LA, Pine DS, Stein MB, et al. Social anxiety disorder: questions and answers for the DSM-V. Depress Anxiety. 2010;27:168-189. 5. Dalrymple KL. Issues and controversies surrounding the diagnosis and treatment of social anxiety disorder. Expert Rev Neurother. 2012;12(8):993-1009. 6. Connor KM, Kobak KA, Churchill LE, Katzelnick D, Davidson JR. Mini-SPIN: a brief screening assessment for generalized social anxiety disorder. Depress Anxiety. 2001;14:137-140. 7. Vermani M, Marcus M, Katzman MA. Rates of detection of mood and anxiety disorders in primary care: a descriptive, cross-sectional study. Prim Care Companion CNS Disord. 2011;13(2). 8. Valente S. Social phobia. J Am Psychiatric Nurses Assoc. 2002;8:67-75. 9. Lader M. The clinical relevance of treating social phobia. J Affect Disord. 1998;50:S29-S34. 10. Lepine JP, Pelissolo A. Why take social anxiety disorder seriously? Depress Anxiety. 2000;11:87-92. 11. Dupont RL, Rice DP, Miller LS, Shiraki SS, Rowland CR, Harwood HJ. Economic costs of anxiety disorders. Anxiety. 1996;2:167-172. 12. Wittchen HU, Fuetsch M, Sonntag H, Muller N, Liebowitz M. Disability and quality of life in pure and comorbid social phobia: findings from a controlled study. Eur Psychiatry. 1999;14:118-131. 13. Den Boer JA, Baldwin D, Bobes J, Katschnig H, Westenberg H, Wittchen HU. Social anxiety disorder – our current understanding. Intl J Psychiatry ClinPract. 1999;3:S3-S12. 14. Wong N, Sarver DE, Beidel DC. Quality of life impairments among adults with social phobia: the impact of subtype. J Anxiety Disord. 2012;26(1):50-57. 15. Farvolden P, McBride C, Bagby RM, Ravitz P. A web-based screening instrument for depression and anxiety disorders in primary care. J Med Internet Res. 2003;5(3):e23. Social Anxiety Disorder - Integrative strategies for an under-recognized and undertreated problem. Part II Conventional and integrative treatment for SAD by: Candice Esposito, ND Algoma Natural Healing Clinic 45 Grace Street, Sault Ste. Marie, ON. P6A 2S7 www.calmlivingblueprint.com Not only is social anxiety disorder (SAD) under-recognized, but it is also undertreated. One study screened a large population of people for several mental health concerns. Only 7.9% of people meeting criteria for SAD were receiving treatment, a lower percentage of people receiving treatment than any other condition examined.(1) On average, individuals with SAD experience a longer delay (166 months) between the first onset of symptoms and receiving specific treatment for anxiety, compared to individuals with panic disorder (79 months) and generalized anxiety disorder (84 months).(2) Although undertreated, effective treatments do exist for SAD. The two most studied options are cognitive behaviour therapy (CBT) and pharmaceuticals. Prescription medications such as selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs) and benzodiazepines reduce symptoms faster than CBT; however the effects of these medications are generally short-lived.(3) Considering the chronic nature of SAD it makes sense to emphasize treatments that will benefit individuals over a long term period. Due to the dietary restrictions and adverse effects of MAOIs, and the potential for abuse and physical dependence inherent with benzodiazepines, SSRIs are considered the first-line pharmaceutical option for SAD.(4, 5) The fact that there has been a 400% increase in antidepressant prescriptions over the past few years (6) unfortunately suggests a greater reliance on short term symptom reduction over addressing underlying psychosocial factors to effect long-term behavioural changes and healing; however, mounting evidence for the effectiveness of natural therapies in treating anxiety provides hope for a shift in approach. St. John’s Wort is the only herb that has been looked at as treatment specifically for SAD .(7) St. John’s Wort showed no benefit, but it’s important to consider that this herb has traditionally been used for depression; individuals with both SAD and depression were excluded from this study. Perhaps St. John’s Wort may be more suited to treating individuals that have mild to moderate depression in addition to SAD. Strong evidence supports the use of Kava kava for reducing generalized anxiety(8,9) and initial research suggests Ginkgo,(10,11) Passion flower,(12) Chamomile,(13) Scullcap,(14) Lemon balm (15) and Bacopa (16) may be beneficial. Further studies are needed to explore their effects specifically for SAD. However, due to their positive effects on generalized anxiety and their strong safety profiles, it seems reasonable to consider incorporating these herbs as part of a holistic treatment plan. Magnesium, when combined in an herbal formula, was shown to significantly decrease anxiety in individuals diagnosed with mild to moderate generalized anxiety.(17) Inositol, a substance naturally found in fibre-rich foods like beans and brown rice, has been shown to decrease the frequency and severity of panic attacks, as well as the severity of agoraphobia (fear of being in an environment which is perceived to be difficult to escape) when taken at a dose of 12 grams per day.(18) One study showed inositol being more effective than a SSRI in reducing panic attacks.(19) Although the evidence supporting the use of omega-3 polyunsaturated fatty acids (fish oil, for example) for anxiety isn’t as clear cut as their use for mood disorders like depression, studies do confirm that patients suffering from SAD often have lower omega-3 levels.(20) Omega-3s have been shown to reduce some symptoms related to anxiety and are thought to inhibit activation of the hypothalamic-pituitary-adrenal (HPA) axis. In other words, omega-3s calm the body’s “stress system”.(21) One of the goals inherent in integrative and naturopathic medicine is to treat the whole person by addressing the underlying root causes specific to the individual. Therefore, holistic practitioners will often use a combination of interventions. One study compared a naturopathic therapy protocol consisting of 300mg twice daily of the herb Ashwagandha (Withaniasomnifera), dietary counselling, breathing relaxation techniques and a standard multivitamin, to a control group that received psychotherapy, deep breathing exercises and a placebo pill. The patients who received naturopathic care showed significantly greater benefit in mental health, concentration, fatigue, social functioning, vitality and overall quality of life.(22) Although the sample size was small, the results are definitely encouraging and support the need for a holistic approach to anxiety disorders like SAD. More research devoted specifically to the use of natural therapies for SAD is needed; however evidence supporting the use of herbs like kava and nutrients like magnesium and omega 3s for general anxiety suggests it’s reasonable to consider these as part of a holistic treatment plan. Part III of this article series will look at how diet and nutrition play a role in social anxiety. References 1. Messias E, Eaton W, Nestadt G, Bienvenu OJ, Samuels J. Psychiatrists’ ascertained treatment needs for mental disorders in a population-based sample. Psychiatr Serv. 2007;58(3):373-377. 2. Wagner R, Silove D, Marnane C, Rouen D. Delays in referral of patients with social phobia, panic disorder and generalized anxiety disorder attending a specialist anxiety clinic. J Anxiety Disord. 2006;20(3):363-371. 3. Dalrymple KL. Issues and controversies surrounding the diagnosis and treatment of social anxiety disorder. Expert Rev Neurother. 2012;12(8):993-1009. 4. Davidson JRT. Pharmacotherapy of social phobia. ActaPsychiatr Scand. 2003;108(Suppl 417):65-71. 5. Fedoroff IC, Taylor S. Psychological and pharmacological treatments of social phobia: a meta-analysis. J ClinPsychopharmacol. 2001;21(3):311-324. 6. Pratt LA, Brody DJ, Gu Q. Antidepressant use in persons aged 12 and over: United States, 2005 – 2008. MD, USA: National Center for Health Statistics; 2011. 7. Kobak KA, Taylor LV, Warner G, Futterer R. St. John’s wort versus placebo in social phobia: results from a placebo-controlled pilot study. J ClinPsychopharmacol. 2005;25(1):51-8. 8. Pittler MH, Ernst E. Kava extract for treating anxiety. Cochrane Database Syst Rev. 2003;(1):CD003383. 9. Witte S, Loew D, Gaus W. Meta-analysis of the efficacy of the acetonic kava-kava extract WS1490 in patients with non-psychotic anxiety disorders. Phytother Res. 2005;19(3)183-8. 10. Sarris J, Panossian A, Schweitzer I, Stough C, Scholey A. Herbal medicine for depression, anxiety and insomnia: a review of psychopharmacology and clinical evidence. EurNeuropsychopharmacol. 2011;21(12):841-860. 11. Woelk H, Arnoldt KH, Kieser M, Hoerr R. Ginkgo biloba special extract EGb 761 in generalized anxiety disorder and adjustment disorder with anxious mood: a randomized, double-blind, placebo-controlled trial. J Psychiatr Res. 2007;41(6):472-480. 12. Akhondzadeh S, Naghavi HR, Vazirian M, Shayeganpour A, Rashidi H, Khani M. Passionflower in the treatment of generalized anxiety: a pilot double-blind randomized controlled trial with oxazepam. J Clin Pharm Ther. 2001;26(5):363-367. 13. Amsterdam JD, Li Y, Soeller I, Rockwell K, Mao JJ, Shults J. A randomized, double-blind, placebo-controlled trial of oral matricariarecutita (chamomile) extract therapy for generalized anxiety disorder. J ClinPsychopharmacol. 2009;29(4):378-382. 14. Wolfson PE, Hoffmann DL. An investigation into the efficacy of Scutellarialateriflora in healthy volunteers. AlternTher Health Med. 2003;9(2):74-78. 15. Kennedy DO, Little W, Scholey AB. Attenuation of laboratory-induced stress in humans after acute administration of Melissa officinalis (lemon balm). Psychosom Med. 2004;66(4):607-613. 16. Sathyanarayanan V, Thomas T, Einother SJ, Dobriyal R, Joshi MK, Krishnamachari S. Brahmi for the better? New findings challenging cognition and anti-anxiety effects of Brahmi (Bacopamonniera) in healthy adults. Psychopharmacology (Berl). 2013 [Epub ahead of print]. 17. Hanus M, Lafon J, Mathieu M. Double-blind, randomized, placebo-controlled study to evaluate the efficacy and safety of a fixed combination containing two plant extracts (Crataegusoxyacantha and Eschscholtziacalifornica) and magnesium in mild-to-moderate anxiety disorders. Curr Med Res Opin. 2004;20(1):63-71. 18. Benjamin J, Levine J, Fux M, Aviv A, Levy D, Belmaker RH. Double-blind, placebo-controlled, crossover trial of inositol treatment for panic disorder. Am J Psychiatry. 1995;152(7):1084-1086. 19. Palatnik A, Frolov K, Fux M, Benjamin J. Double-blind, controlled, crossover trial of inositol versus fluvoxamine for treatment of panic disorder. J ClinPsychopharmacol. 2001;21(3):335-339. 20. Green P, Hermesh H, Monselise S, Marom S, Presburger G, Weizman A. Red cell membrane omega-3 fatty acids are decreased in non-depressed patients with social anxiety disorder. EurNeuropsychopharmacol. 2006;16(2):107-113. 21. Ross BM. Omega-3 polyunsaturated fatty acids and anxiety disorders. Prostaglandins LeukotEssent Fatty Acids. 2009;81(5-6):309-12. 22. Cooley K, Szczurko O, Perri D, Mills EJ, Bernhardt B, Zhou Q et al. Naturopathic care for anxiety: a randomized controlled trial ISRCTN78958974. PLoS ONE. 2009;4(8):e6628. Social Anxiety Disorder - Integrative strategies for an under-recognized and undertreated problem. Part III Diet and SAD by: Candice Esposito, ND Algoma Natural Healing Clinic 45 Grace Street, Sault Ste. Marie, ON. P6A 2S7 www.calmlivingblueprint.com More and more research indicates that diet affects mental health. Like in the case of herbs and natural supplements (see Part II of this article series), research examining diet has focused more on its effect on generalized anxiety than social anxiety specifically, but there are some lessons we can gleam from these studies. Studies have shown that individuals consuming a “traditional” diet consisting of vegetables, fruits, and lean, non-processed meats had a decreased likelihood of anxiety.(1) And, likewise, individuals consuming a “Western diet” high in processed meats, pizza, chocolates, sweets, soft drinks, margarine, French fries, beer, coffee, cake and ice cream, had a significantly increased likelihood of anxiety.(2) Researchers theorize that increased stress levels cause us to reach for “highly palatable” foods found in a typical Western diet, which have short term protective effects, but negative long term consequences.(3) Processed foods increase reactive oxygen species, causing oxidative stress that may contribute to the development of anxiety.(4) The link between anxiety and the misuse of caffeine and alcohol is well established. Individuals with social anxiety disorder (SAD) are particularly vulnerable to the negative effects of caffeine.(5) Long term alcohol use can reduce levels of critical nutrients needed for brain function, such as B vitamins. Treatment of alcohol use in patients with SAD has been shown to reduce anxiety levels.(6) Therefore, screening for abuse of these substances is especially important in individuals with SAD and the avoidance of these substances should be recommended as part of a treatment plan. There seems to be a higher prevalence of SAD in individuals who have celiac disease or a food allergy to gluten.(7) Greater rates of anxiety are also seen in people suffering from irritable bowel syndrome (IBS), a condition that has also been linked to food allergies .(8) Therefore, ruling out the possibility of food allergies and intolerances is a reasonable step to take when investigating underlying causes of SAD. In conclusion, a reasonable nutritional approach to treating SAD may involve recommending a diet rich in lean protein, vegetables and omega-3 fatty acids, while avoiding refined carbohydrates, processed foods, alcohol and caffeine. Investigation into possible food allergies or intolerances is warranted, along with ruling out the possibility of vitamin B6 and zinc nutritional deficiencies. References 1. Jacka FN, Pasco JA, Mykletun A, Williams LJ, Hodge AM, O’Reilly SL, et al. Association of Western and traditional diets with depression and anxiety in women. Am J Psychiatry. 2010;167(3):305-11. 2. Jacka FN, Mykletun A, Berk M, Bjelland I, Tell GS. The association between habitual diet quality and the common mental disorders in community-dwelling adults: the hordaland health study. Psychosom Med. 2011;73(6):483-490. 3. Finger BC, Dinan TG, Cryan JF. High-fat diet selectively protects against the effects of chronic social stress in the mouse. Neuroscience. 2011;192:351-360. 4. Salim S, Asghar M, Chugh G, Taneja M, Xia Z, Saha K. Oxidative stress: a potential recipe for anxiety, hypertension and insulin resistance. Brain Res. 2010;1359:178-185. 5. Charney DS, Heninger GR, Jatlow PI. Increased anxiogenic effects of caffeine in panic disorders. Arch Gen Psychiatry. 1985;42(3):233-243. 6. Hobbs JDJ, Kushner MG, Lee SS, Reardon SM, Maurer EW. Meta-analysis of supplemental treatment for depressive and anxiety disorders in patients being treated for alcohol dependence. Am J Addict. 2011;20(4):319-329. 7. Addolorato G, Mirijello A, D’Angelo C, Leggio L, Ferrulli A, Vonghia L, et al. Social phobia in coeliac disease. Scand J Gastroenterol. 2008;43(4):410-5. 8. Addolorato G, Marsigli L, Capristo E, Caputo F, Dall’Aglio C, Baudanza P. Anxiety and depression: a common feature of health care seeking patients with irritable bowel syndrome and food allergy. Hepatogastroenterology. 1998;45(23):1559-64. 9. Scott T. The antianxiety food solution: how the foods you eat can help you calm your anxious mind, improve your mood and end cravings. New York: New Harbinger Publications; 2011. 10. McGinnis WR, Audhya T, Walsh WJ, Jackson JA, McLaren-Howard J, Lewis A, et al. Discerning the Mauve Factor. AlternTher Health Med. 2008;14(2):40-50. Social Anxiety Disorder - Integrative strategies for an under-recognized and undertreated problem. Part IV More integrative strategies for helping SAD by: Candice Esposito, ND Algoma Natural Healing Clinic 45 Grace Street, Sault Ste. Marie, ON. P6A 2S7 www.calmlivingblueprint.com Perhaps more than any other intervention, lifestyle changes and mindfulness-based approaches offer the greatest potential to effect long term benefits for individuals with social anxiety disorder (SAD). Exercise has been shown to be a protective factor against all causes of disease,(1) so it seems logical that physical activity would be beneficial for SAD as well. Surprisingly, there is little research to draw on from large scale studies even though an association between lack of physical activity and social phobia does seem to exist.(2) One smaller study showed beneficial effects of a home-based walking program,(3) while another study showed benefits of exercise in combination with group cognitive behavioural therapy.(4) Interestingly, individuals with SAD are significantly more likely than those with panic or generalized anxiety disorder to follow through with an exercise program,(5) suggesting greater compliance and potential benefit in this population. Distorted self-views, such as viewing oneself as socially awkward, inadequate or flawed, are a key element of SAD. Mindfulness-based stress reduction (MBSR) has been shown to positively impact the areas of the brain responsible for producing these self-views; thereby significantly decreasing the number of negative self-views an individual with SAD experiences.(6) The beneficial effects of MBSR in reducing social anxiety have been replicated in multiple studies.(7,8) Mindfulness involves being aware and in the present moment, free of judgement. MBSR is an eight to 10 week program where individuals are taught mindful awareness via weekly group meetings, a one-day workshop and daily individual practice at home .(9) A relatively recent offshoot of cognitive behaviour therapy (CBT), Acceptance and Commitment Therapy (ACT), has also shown promise in the treatment of SAD.(10,11) The goal of ACT is to create a rich and meaningful life while accepting the pain that inevitably goes with it. So, unlike CBT which teaches individuals to reduce or eliminate negative thoughts, ACT teaches individuals how to accept those negative thoughts.(12) A CBT therapist theorizes that it’s the negative thoughts themselves that cause anxiety, whereas an ACT therapist suggests that it’s the struggle with the negative thoughts that causes anxiety. The nature of SAD can sometimes make one-on-one personal interactions with therapists difficult. Media like the Internet have the potential to reach individuals who might not seek out treatment through face to face encounters. This makes the positive results, seen from a study where acceptance-based behaviour therapy was provided via the online virtual world of Second Life, so encouraging. Significant improvements in social anxiety symptoms, as well as depression, disability and quality of life were experienced by participants.(13) Meditation and mindfulness techniques work to change the perception of a negative thought to viewing it as just that – a thought, words without value that come and go. This change in perception reduces the potential for triggering a reaction to the thought. This is important because it’s the reaction that causes distress.(14) As mentioned earlier, neuroimaging studies have shown that mindfulness is powerful enough to actually change the structure of the brain, including increasing its thickness in areas thought to be affected by anxiety.(15) Meditation may also influence the release of neurotransmitters in the brain.(16) In conclusion, although SAD is currently under-recognized and undertreated, awareness of the disorder is growing. Simple screening tools like the mini-SPIN and WB-DAT make it easier to detect and help initiate conversations between patient and doctor. Research related to the treatment of SAD is still in its infancy and reliance upon the short-term symptom reduction of pharmaceuticals is still too great; however mounting evidence showing benefit from dietary and lifestyle changes, herbs and natural supplements, and mindfulness-based behavioural therapies provide hope towards a more holistic, long-term approach to the treatment of SAD. References 1. Talbot LA, Morrell CH, Fleg JL, Metter EJ. Changes in leisure time physical activity and risk of all-cause mortality in men and women: the Baltimore longitudinal study of aging. Prev Med. 2007;45(2-3):169-176. 2. Goodwin RD. Association between physical activity and mental disorders among adults in the United States. Prev Med. 2003;36(6):698-703. 3. Merom D, Phongsavan P, Wagner R, Chey T, Marnane C, Steel Z, et al. Promoting walking as an adjunct intervention to group cognitive behavioural therapy for anxiety disorders – a pilot group randomized trial. J Anxiety Disord. 2008;22(6):959-68. 4. Jayakody K, Gunadasa S, Hosker C. Exercise for anxiety disorders: systematic review. Br J Sports Med. 2013;[Epub ahead of print]. 5. Phongsavan P, Merom D, Wagner R, Chey T, von Hofe B, Silove D, et al. Process evaluation in an intervention designed to promote physical activity among adults with anxiety disorders: evidence of acceptability and adherence. Health Promot J Austr. 2008;19(2):137-43. 6. Goldin P, Ziv M, Jazaieri H, Gross JJ. Randomized controlled trial of mindfulness-based stress reduction versus aerobic exercise: effects on the self-referential brain network in social anxiety disorder. Front Hum Neurosci. 2012;6:295. 7. Koszycki D, Benger M, Shlik J, Bradwejn J. Randomized trial of a meditation-based stress reduction program and cognitive behaviour therapy in generalized social anxiety disorder. Behav Res Ther. 2007;45(10):2518-2526. 8. Vollestad J, Sivertsen B, Nielsen GH. Mindfulness-based stress reduction for patients with anxiety disorders: evaluation in a randomized controlled trial. Behav Res Ther. 2011;49(4):281-288. 9. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits: a meta-analysis. J Psychosom Res. 2004;57(1):35-43. 10. Dalrymple KL, Herbert JD. Acceptance and commitment therapy for generalized social anxiety disorder: a pilot study. BehavModif. 2007;31(5):543-68. 11. Ossman WA, Wilson KG, Storaasli RD, McNeill JW. A preliminary investigation of the use of acceptance and commitment therapy in group treatment for social phobia. Rev IntPsicolTerPsicol. 2006;6(3):397-416. 12. Harris R. Embracing your demons: an overview of acceptance and commitment therapy. Psychotherapy in Australia. 2006;12(4):2-7. 13. Yuen EK, Herbert JD, Forman EM, Goetter EM, Comer R, Bradley JC. Treatment of social anxiety disorder using online virtual environments in second life. BehavTher. 2013;44(1):51-61. 14. Roemer L, Orsillo SM, Salters-Pedneault K. Efficacy of an acceptance-based behaviour therapy for generalized anxiety disorder: evaluation in a randomized controlled trial. J Consult Clin Psychol. 2008;76(6):1083-1089. 15. Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893-7. 16. Yu X, Furmoto M, Nakatani Y, Sekiyama T, Kikuchi H, Seki Y, et al. Activation of the anterior prefrontal cortex and serotonergic system is associated with improvements in mood and EEG changes induced by Zen meditation practice in novices. Int J Psychophysiol. 2011;80(2):103-11.