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The effectiveness of mindfulness-based cognitive therapy for social anxiety symptoms in people living with alopecia areata: a single-group case-series design

Published online by Cambridge University Press:  08 August 2023

Connor Heapy
Affiliation:
Department of Psychology, University of Sheffield, Sheffield, UK
Paul Norman
Affiliation:
Department of Psychology, University of Sheffield, Sheffield, UK
Sarah Cockayne
Affiliation:
Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
Andrew R. Thompson*
Affiliation:
Department of Psychology, University of Sheffield, Sheffield, UK South Wales Clinical Psychology Training Programme, Cardiff University and Cardiff and Vale University Health Board, School of Psychology, Tower Building, Park Place, Cardiff, UK
*
Corresponding author: Andrew R. Thompson; Email: thompsona18@cardiff.ac.uk
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Abstract

Background:

Alopecia areata (AA) is an immunological disorder characterised by hair loss. Individuals with AA report high levels of social anxiety. One intervention that holds potential for reducing social anxiety in individuals with AA is mindfulness-based cognitive therapy (MBCT).

Aims:

Our key aim was to investigate whether MBCT reduces social anxiety in individuals with AA. The study also investigated whether MBCT reduces depression, general anxiety, and increases quality of life and increases trait mindfulness in individuals with AA.

Method:

Five participants with AA took part in an 8-session in-person MBCT intervention. A multiple-baseline single-group case series design was adopted. Idiographic measures of social anxiety were measured each day from baseline, through intervention, to follow-up. Standardised questionnaires of trait mindfulness, social anxiety, depression, anxiety, and quality of life were completed at baseline, post-intervention, and at 4-week follow-up.

Results:

All participants completed the MBCT course, but one participant was excluded from the idiographic analysis due to a high amount of missing data. The remaining four participants demonstrated reductions in idiographic measures of social anxiety from baseline to follow-up. These effects were larger between baseline and follow-up, than between baseline and post-intervention. Two participants demonstrated significant improvement in standardised measures of wellbeing from baseline to follow-up – they also practised mindfulness most regularly at home between sessions.

Conclusion:

MBCT may be effective in reducing social anxiety and improving wellbeing in individuals with AA, although this might be dependent on the extent to which participants regularly practise mindfulness exercises.

Type
Empirically Grounded Clinical Interventions
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2023. Published by Cambridge University Press on behalf of British Association for Behavioural and Cognitive Psychotherapies

Introduction

Alopecia areata (AA) is an immunological disorder that affects around 0.1–0.2% of people worldwide (Sibbald, Reference Sibbald2023). AA is characterised by small patches of non-scarring hair loss, and in more severe forms leads to total hair loss on the scalp (alopecia totalis) or total hair loss of the entire body (alopecia universalis). There have been recent advances in treatment for alopecia, nevertheless the full range of treatments are not yet widely available and are in any event not currently curative (Sibbald, Reference Sibbald2023).

While the physical effects of AA are limited, the psychological effects can be profound. Hair is a central aspect of appearance and self-image for many people, and can express a person’s gender, age, ethnicity, and social or political beliefs (Freedman, Reference Freedman1994). Indeed, AA has a significant negative impact on quality of life (Rencz et al., Reference Rencz, Gulácsi, Péntek, Wikonkál, Baji and Brodszky2016) and individuals with AA experience higher levels of anxiety and depression than controls (Hunt and McHale, Reference Hunt and McHale2005; Ruiz-Doblado et al., Reference Ruiz-Doblado, Carrizosa and García-Hernández2003). Hair loss can also negatively impact an individual’s sense of identity and self-esteem – particularly for groups of individuals whose hair is given high importance by sociocultural norms (Tucker, Reference Tucker2009). For example, sexuality, attractiveness and personality are more symbolically linked to a woman’s hair than a man’s hair (Hunt and McHale, Reference Hunt and McHale2005), and women report that problems adjusting to their condition are exacerbated because baldness in women is not socially acceptable (Hunt and McHale, Reference Hunt and McHale2004). Consequently, the psychosocial impact of AA is typically more severe in women than men (Aukerman and Jafferany, Reference Aukerman and Jafferany2022).

When considering the social importance often placed on hair, it is perhaps unsurprising that one particularly prevalent difficulty for individuals with AA is social anxiety. In one of the largest surveys conducted into the psychosocial impact of AA, almost half of participants (47.5%) reported clinically significant levels of social anxiety, compared with around a third of participants reporting clinically significant levels of depression (29%) and general anxiety (35.5%) (total n = 338; Montgomery et al., Reference Montgomery, White and Thompson2017). People living with AA have reported unhelpful reactions from others, such as negative comments, staring, and comparisons with people undergoing chemotherapy treatment (Montgomery et al., Reference Montgomery, White and Thompson2017; Wiggins et al., Reference Wiggins, Moore-Millar and Thomson2014). For some people, fear of negative reactions from others can lead to use of concealment strategies such as wearing a wig or avoidance of social situations altogether (Montgomery et al., Reference Montgomery, White and Thompson2017; Wiggins et al., Reference Wiggins, Moore-Millar and Thomson2014). Avoiding social contact likely increases an individual’s sense of loneliness, which in turn increases feelings of depression and general anxiety (Beutel et al., Reference Beutel, Klein, Brähler, Reiner, Jünger, Michal and Tibubos2017). Reducing social anxiety in individuals with AA will therefore likely have a broad and significant positive impact on their lives.

Cognitive models of social anxiety disorder emphasise the role of self-focused attention and rumination in the maintenance of symptoms (Clark and Wells, Reference Clark, Wells, Heimberg, Biebowitz, Hope and Schneider1995; Rapee and Heimberg, Reference Rapee and Heimberg1997). Social situations trigger anxiety, with individuals viewing their audience as critical observers. Attention is biased towards threat-related social cues that the individual interprets as indicators of negative evaluation which, in turn, increases anxiety (Hirsch and Clark, Reference Hirsch and Clark2004; Morrison and Heimberg, Reference Morrison and Heimberg2013).

Whilst people with AA experience negative reactions from people, research suggests that they display a stigmatisation bias, in the form of increased attention towards disease-related cues (Van Beugen et al., Reference Van Beugen, Maas, van Laarhoven, Galesloot, Rinck, Becker and Evers2016). Interventions which aim to reduce engagement in negative appearance-related thoughts, and attentional bias towards negative self-referential information, may be helpful for people with AA.

One group of interventions that may be helpful are based on mindfulness principles.

Mindfulness is defined as ‘paying attention in a particular way: on purpose in the present moment and non-judgementally’ (Kabat-Zinn, Reference Kabat-Zinn1994; p. 4). Higher levels of trait mindfulness are related to lower levels of social anxiety in individuals diagnosed with social phobia (Schmertz et al., Reference Schmertz, Masuda and Anderson2012) and individuals with skin conditions (Montgomery et al., Reference Montgomery, Norman, Messenger and Thompson2016). Mindfulness-based stress reduction (MBSR) – a structured group intervention based on mindfulness principles – has been shown to reduce negative self-referential processing and emotional reactivity, and increase self-esteem, in people with social phobia (Goldin et al., Reference Goldin, Ramel and Gross2009; Goldin et al., Reference Goldin, Ziv, Jazaieri and Gross2012; Goldin et al., Reference Goldin, Ziv, Jazaieri, Hahn and Gross2013). In addition, in a pilot study of individuals with AA, MBSR reduced distress and increase quality of life (Gallo et al., Reference Gallo, Chiorri, Gasparini, Signori, Burroni and Parodi2017).

Mindfulness-based cognitive therapy (MBCT) is a similar intervention to MBSR but draws on elements of cognitive therapy and places more importance on understanding cognitions and psychological processes. The National Institute of Clinical Excellence recommends MBCT for reducing relapse risk in depression (National Institute of Clinical Excellence, 2009), and the processes involved in maintaining depression, such as rumination and attention bias towards negative stimuli, are also relevant to social anxiety (Clark and Wells, Reference Clark, Wells, Heimberg, Biebowitz, Hope and Schneider1995). In the only study to compare MBCT with cognitive behavioural therapy (CBT) for social anxiety, Piet et al. (Reference Piet, Hougaard, Hecksher and Rosenberg2010) allocated 26 adults with a diagnosis of social phobia to group MBCT or group CBT in a crossover design. Both MBCT and CBT showed pre–post improvements in a composite measure of social anxiety. Moreover, no differences were found in social anxiety between MBCT and CBT following therapy at 6-month follow-up, or at 12-month follow-up.

However, whilst both CBT and MBCT hold promise for reducing social anxiety in individuals with AA, there are several benefits to investigating the impact of MBCT. First, although CBT is effective for social anxiety, approximately 40–50% of people referred for therapy show little or no improvement, and alternative options are therefore needed (Hofmann and Bögels, Reference Hofmann and Bögels2006; Rodebaugh et al., Reference Rodebaugh, Woods, Thissen, Heimberg, Chambless and Rapee2004). Second, developing the evidence-base for MBCT – a relatively under-researched intervention – could increase client choice, which in turn could increase client engagement and outcomes (Constantino et al., Reference Constantino, Bosweell, Coyne, Barkham, Lutz and Castonguay2021). Finally, drop-out rates may be lower in MBCT than CBT, indicating MBCT is preferred by clients and may be more cost-effective. For example, a review of mindfulness and acceptance-based interventions for anxiety disorders found a mean attrition rate of 15% (Vøllestad et al., Reference Vøllestad, Nielsen and Nielsen2012); whereas a review of CBT for anxiety disorders found a mean attrition rate of 24% (Carpenter et al., Reference Carpenter, Andrews, Witcraft, Powers, Smits and Hofmann2018).

Despite the potential benefits of investigating whether MBCT reduces social anxiety in individuals with AA, no studies have been conducted to answer this question. However, Fordham et al. (Reference Fordham, Nelson, Griffiths and Bundy2014, Reference Fordham, Griffiths and Bundy2015) investigated the effectiveness of MBCT in another dermatology sample – individuals with psoriasis. Although the study did not assess social anxiety, interviews following the intervention found participants reported feeling calmer, more confident, and more sociable. This finding suggests that MBCT may improve self-efficacy in dealing with social interactions, in turn reducing social anxiety.

The current study is the first to investigate the effectiveness of MBCT for people with AA in reducing social anxiety. The study also aimed to examine whether MBCT reduces depression and general anxiety, and improves quality of life and trait mindfulness, in individuals with AA. This group intervention is an adapted version of MBCT for depression (Segal et al., Reference Segal, Williams and Teasdale2013), with sessions including psychoeducation on social anxiety, experiential practice of mindfulness meditation, and group discussion. The study will adopt a multiple-baseline single-group case series design, whereby wellbeing and mindfulness variables are assessed before, during and after the intervention. Single-case designs are commonly used in clinical research, particularly in the preliminary stages of investigation (Morley, Reference Morley2018). Adopting this design also enables the measurement of idiographic targets – deemed as important to individual participants – each day.

Unlike randomised controlled trials, this design ensures that the impact of the intervention on key individual problems is assessed in detail over time (Morley, Reference Morley2018). Accordingly, we were most interested in the impact of the MBCT intervention on participants’ idiographic measures of social anxiety.

Method

Design

This study adopted an A-B multiple-baseline, single-group case series design, with a follow- up period. Phase A was a 2- to 4-week baseline period. Phase B was an eight-session group intervention run over 9 weeks (mindfulness-based cognitive therapy; MBCT). The follow-up period lasted 4 weeks during which participants were encouraged to continue to practise mindfulness regularly. A single follow-up intervention session was run during the fourth week of the follow-up period. Outcome variables were assessed at frequencies typical of single-case designs (Morley, Reference Morley2018). That is, the main outcome variable was two daily idiographic questions assessing social anxiety. Secondary outcome variables were standardised measures of the following variables, administered at three time-points: mindfulness, social anxiety, general anxiety, depression, and quality of life.

Participants

Seven participants were recruited to the study from social media, out-patient dermatology clinics, and an alopecia charity event. One participant dropped out before the first session due to practical reasons. One participant attended the MBCT intervention but was excluded from the analyses due to not having a diagnosis of alopecia areata, leaving a total of five participants in the study. Inclusion criteria were (i) aged 16 or over, (ii) primary health concern was alopecia areata (including alopecia totalis, and alopecia universalis), (iii) self-identified as experiencing social anxiety, and (iv) English language speaker. Exclusion criteria were (i) active thoughts of suicide or self-harm, (ii) experienced psychotic episode in the last 12 months, or (iii) currently engaged with other psychological talking therapies or due to start during the study period. No participants dropped out from the study after attending the first session. Participants’ demographic information is included in Table 1. The MBCT intervention was free for participants and travel costs were reimbursed.

Table 1. Demographic and clinical information of participants

Measures

Demographic and medical

Demographic and medical information was collected at the start of the study. Participants reported their gender, age, ethnicity, diagnosis, and duration of AA (see Table 1).

Idiographic measures of social anxiety and mindfulness practice

Social anxiety was assessed by two idiographic questions that were chosen by the participants and completed each day. These questions represented areas of social anxiety that participants wanted to address. Question 1 was decrease-framed (i.e. something the participant wanted to decrease; e.g. ‘How affected have you been today by people looking at your head/hair?’) and question 2 was increase-framed (i.e. something the participant wanted to increase; e.g. ‘How brave have you felt today (e.g. when in social situations and around others)?’). Questions were rated on a scale from 0 (‘not at all’) to 100 (‘extremely’). Idiographic questions were completed by participants each day from baseline until the follow-up session.

Participants were also asked to indicate how many minutes they had spent practising mindfulness each day, from the start of the intervention period until the follow-up session.

Standardised measures

Participants completed measures of the following constructs at three time-points (pre- intervention, post-intervention, follow-up): mindfulness, social anxiety, depression, general anxiety, and quality of life.

Mindfulness was assessed using the the Five Facet Mindfulness Questionnaire (FFMQ: Baer et al., Reference Baer, Smith, Hopkins, Krietemeyer and Toney2006). This 39-item self-report questionnaire assesses five facets of mindfulness: observing, describing, act with awareness, non-judgement of inner experience, and non-reactivity to inner experience. Items are rated on a 5-point Likert scale and responses are summed. The FFMQ has demonstrated good psychometric properties in non-clinical samples and individuals with anxiety disorders (Baer et al., Reference Baer, Smith, Hopkins, Krietemeyer and Toney2006; Bohlmeijer et al., Reference Bohlmeijer, Ten Klooster, Fledderus, Veehof and Baer2011).

Social anxiety was assessed using the Brief Fear of Negative Evaluation, Straightforward items (BFNE-S: Carleton et al., Reference Carleton, Collimore, McCabe and Antony2011; Rodebaugh et al., Reference Rodebaugh, Woods, Thissen, Heimberg, Chambless and Rapee2004; Weeks et al., Reference Weeks, Heimberg, Fresco, Hart, Turk, Schneier and Liebowitz2005). This 8-item self-report questionnaire assesses social anxiety as a single factor. Items are rated on a 5-point Likert scale and responses are summed. Scores of 25 or over suggest clinical levels of social anxiety (Carleton et al., Reference Carleton, Collimore, McCabe and Antony2011). The BFNE-S has demonstrated good psychometric properties in individuals with anxiety disorders (Carleton et al., Reference Carleton, Collimore, McCabe and Antony2011), and has previously been used to assess social anxiety in individuals with AA (Montgomery et al., Reference Montgomery, Norman, Messenger and Thompson2016). This brief measure of social anxiety was chosen to limit participant burden.

Depression was assessed using the Patient Health Questionnaire (PHQ-9; Spitzer et al., Reference Spitzer, Kroenke and Williams1999). This 9-item self-report questionnaire measures symptoms of depression over the previous 2 weeks. Items are rated on a 4-point Likert scale and responses are summed. Scores of 10 or more suggest clinical levels of depression (Kroenke et al., Reference Kroenke, Spitzer and Williams2001). The PHQ-9 has demonstrated good psychometric properties in primary care patients (Kroenke et al., Reference Kroenke, Spitzer and Williams2001).

General anxiety was assessed using the Generalised Anxiety Disorder Questionnaire (GAD-7; Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006). This 7-item self-report questionnaire measures symptoms of generalised anxiety over the previous 2 weeks. Items are rated on a 4-point Likert scale and responses are summed. Scores of 8 or more suggest clinical levels of anxiety (Kroenke et al., Reference Kroenke, Spitzer, Williams, Monahan and Löwe2007). The GAD-7 has demonstrated good psychometric properties in primary care patients (Kroenke et al., Reference Kroenke, Spitzer and Williams2001).

Quality of life was assessed using the Dermatology Life Quality Index (DLQI: Finlay and Khan, Reference Finlay and Khan1994). This 10-item self-report questionnaire assesses the impact of a skin condition on quality of life over the last week. The DLQI has been adapted to refer to hair loss specifically, rather than skin conditions more generally. Items are rated on a 4-point Likert scale and responses are summed. Higher scores suggest poorer quality of life. The DLQI has demonstrated good psychometric properties in individuals with a range of skin conditions, including alopecia areata (Basra et al., Reference Basra, Fenech, Gatt, Salek and Finlay2008).

Procedure

Participants were first interviewed in-person for their eligibility. Those that were eligible were randomly allocated to a 2-, 3- or 4-week baseline period. During the eligibility interview, participants were asked to identify two target idiographic measures of social anxiety that were sent to them each day using an online text message service (ConnectTxt). Participants responded to the questions with numerical scores by replying to the text message. Participants completed paper copies of the standardised questionnaires. Participants attended the MBCT groups in-person at the University of Sheffield.

Intervention description

The MBCT intervention followed the protocol outlined by Segal et al. (Reference Segal, Williams and Teasdale2013), with adaptations to psychoeducation material to focus on social anxiety rather than depression. The group consisted of eight sessions and one follow-up session. Each session lasted two-and-a-half hours and participants were taught how to apply mindfulness to their lives. Participants were encouraged to carry out home practice each week based on the content of each session. Each session involved a review of home practice (e.g. mindful movement meditation), a formal meditation practice (e.g. breathing meditation), and group discussion around a theme (e.g. ‘thoughts are not facts’; see Supplementary material for a full outline).

Treatment fidelity

The intervention was led by an accredited mindfulness teacher with experience of running MBCT groups, and experience of working with people with social anxiety. The mindfulness teacher received clinical supervision as part of his existing NHS role. One session was video-recorded at random for fidelity review using the Mindfulness-Based Interventions Teaching Assessment Criteria (MBI:TAC; Crane et al., Reference Crane, Eames, Kuyken, Hastings, Williams, Bartley and Surawy2013) by another experienced mindfulness teacher. Six elements of the mindfulness teaching were assessed using criteria ranging from 1 (‘incompetent’) to 6 (‘advanced’).

Data analysis

Daily responses to idiographic measures were graphed in Microsoft Excel and inspected for change (in means), trend, and variability across phases (Morley, Reference Morley2018).

Idiographic data were analysed with Tau-U (Parker et al., Reference Parker, Vannest, Davis and Sauber2011) using an online calculator (Vannest et al., Reference Vannest, Parker, Gonen and Adiguzel2016). Tau-U examines percentage of data non-overlap between each of the study phases (baseline, intervention, follow-up). Baseline scores were first assessed for trend, using the calculator, and any significant trend was corrected. Missing values were imputed using the expectation–maximisation procedure (Dempster et al., Reference Dempster, Laird and Rubin1977; Smith et al., Reference Smith, Borckardt and Nash2012). Weighted averages were also calculated for each idiographic measure using the same online calculator. One participant was excluded from the idiographic data analysis due to a high amount of missing data.

Changes in scores on secondary outcome measures (BFNE-S, FFMQ subscales, PHQ–9, GAD-7, DLQI) between pre-intervention, post-intervention and follow-up were investigated using Jacobson’s reliable change index (Jacobson and Truax, Reference Jacobson and Truax1991). This method demonstrates statistically reliable improvement or deterioration in standardised questionnaires. Reliable change criteria were calculated using means and standard deviations of the measures found in existing research data. The analyses were carried out using the Leeds Reliable Change Calculator (Morley and Dowzer, Reference Morley and Dowzer2014).

Results

Participant characteristics can be seen in Table 1.

Idiographic measures

Visual analysis

See Fig. 1 for the graphs of each parent’s responses to the decrease-framed and increase-framed idiographic social anxiety measures. Mean weekly scores were calculated from daily responses over the course of the study (see Supplementary material for daily graphs).

Figure 1. Weekly averages of daily scores for decrease-framed (on the left) idiographic (‘How affected have you been today by people looking at your head/hair?’) and increased-frame (on the right) social anxiety questions (‘How brave have you felt today – e.g. when in social situations?’).

Question 1: Decrease-framed idiographic social anxiety

Participant 1 demonstrated a slight reduction, and downward trend, in their decrease-framed idiographic measure of social anxiety in the intervention and follow-up phases, relative to the baseline phase. They also showed low variability in social anxiety across baseline, intervention, and follow-up phases.

Participant 2 demonstrated a slight reduction in their decrease-framed idiographic measure of social anxiety in the intervention and follow-up phases, relative to the baseline phase. They demonstrated a slight upward trend in social anxiety across the baseline phase, but this trend levelled out during the intervention phase and reversed in the follow-up phase. Participant 2 showed high variability in scores in the baseline and intervention phase, but this reduced in the follow-up phase.

Participant 3 showed a large reduction in their decrease-framed idiographic measure of social anxiety in the intervention and follow-up phases, relative to the baseline phase. They also demonstrated a prominent downward trend in social anxiety across the intervention phase, and this levelled out in the follow-up phase. Participant 3 showed moderate variability in scores across phases.

Participant 4 showed a large reduction, and downward trend, in their decrease-framed idiographic measure of social anxiety in the intervention and follow-up phases, relative to the baseline phase. They showed moderate variability in scores across phases.

Question 2: Increase-framed idiographic social anxiety

Participant 1 showed no noticeable change, or trend, in their increase-framed idiographic measure of social anxiety across phases.

Participant 2 demonstrated a slight improvement in their increase-framed idiographic measure of social anxiety in the follow-up phase, relative to baseline phase. They showed some downward trend in social anxiety during the baseline phase, but this reversed to a positive trend in the intervention phase, and then levelled out during the follow-up phase. Participant 2 showed moderate variability across phases.

Participant 3 showed a moderate increase in their increase-framed idiographic measure of social anxiety in the intervention and follow-up phases, relative to the baseline phase. Participant 3 also showed a slight downward trend in social anxiety during the baseline phase, but this was reversed in the intervention phase and continued as a positive trend in the follow-up phase. They showed moderate variability in scores across all phases.

Participant 4 showed a moderate increase, and upward trend, in their increase-framed idiographic measure of social anxiety in the intervention and follow-up phases, relative to the baseline phase. They showed low variability in scores across all phases.

Tau-U analysis

All four participants demonstrated significant improvements in their decrease-framed (question 1) idiographic measure of social anxiety from baseline to intervention, and from baseline to follow-up. Weighted average of all participants also demonstrated overall significant improvement in social anxiety (question 1) from baseline to intervention, and baseline to follow-up (see Table 2).

Table 2. Tau-U results for decrease- and increase-framed questions for each participant

* Baseline corrected.

Only two of the participants (3 and 4) demonstrated significant improvements in their increase-framed (question 2) idiographic measure of social anxiety from baseline to intervention, and from baseline to follow-up. Weighted average of all participants showed overall significant improvement in social anxiety (question 2) from baseline to intervention, and baseline to follow-up (see Table 2).

Standardised measures

Jacobson reliable change

The following scores were considered as reliable change for each measure: BFNE-S = 5;

FFMQ O = 7; FFMQ D = 6; FFMQ AwA = 6; FFMQ NJ = 7; FFMQ NR = 7; PHQ-9 = 6; GAD-7 = 4; DLQI = 6 (see Table 3).

Table 3. Scores at three time-points, across the intervention, on standardised measures of social anxiety, mindfulness (all five facets), depression, general anxiety, and quality of life

I Reliable improvement from baseline score; Dreliable deterioration from baseline score.

Two participants (3 and 4) showed reliable improvement in social anxiety from baseline to post-intervention and follow-up. Three participants (3, 4 and 5) showed reliable improvement in at least one mindfulness facet from baseline to post-intervention or follow-up. Three participants (3 and 4) showed reliable improvement in depression or anxiety from baseline to post-intervention or follow-up. Two participants (3 and 4) showed reliable improvement in quality of life from baseline to post-intervention or follow-up.

Home practice

Participant 5 practised mindfulness at home the least (M = 3 minutes per day), followed by participants 1 and 2 (M = 12 minutes per day), and participant 3 (M = 20 minutes per day). Participant 4 practised the mindfulness at home the most (M = 25 minutes; see Table 1).

Treatment fidelity

The mindfulness teacher scored 4 (‘competent’) or higher in each domain, confirming treatment fidelity.

Discussion

We investigated the effectiveness of MBCT for people with AA in reducing social anxiety, depression, general anxiety, and improving quality of life. To achieve this, we used a multiple-baseline single-group case series design and measured wellbeing variables across a baseline, intervention and follow-up period. All participants showed improvements in idiographic measures of social anxiety from baseline to post-intervention, and baseline to follow-up. In addition, two of the five participants showed improvement in at least one wellbeing measure from baseline to post-intervention or follow-up. Finally, two of the participants showed an increase in trait mindfulness from baseline to follow-up. Overall, our adaptation of MBCT shows promise in reducing distress associated with AA.

Our key finding was that the MBCT intervention reduced scores on idiographic measures of social anxiety in individuals with AA. Participants in the group intervention likely developed a range of mindfulness skills that contributed to reduced social anxiety. For example, by viewing thoughts as ‘just thoughts’, participants may have begun to disengage from negative appearance-related thoughts. By paying close, non-judgemental attention to internal and external stimuli, participants may have reduced their attentional bias towards negative-self-referential information. Indeed, participants who reported practising mindfulness most between sessions also saw the largest reductions in social anxiety. Encouragingly, reductions in social anxiety were larger at the end of the follow-up period than at the end of the intervention period, as indicated by larger Tau scores. This finding suggests the positive effects of MBCT developed beyond the last formal teaching session.

Not all participants showed increases in trait mindfulness from baseline to follow-up, suggesting additional mechanisms may explain reduced social anxiety. One possibility is that MBCT developed skills or knowledge that were not captured by the questionnaire used to measure trait mindfulness. For example, the intervention included psychoeducation and participants learnt about the contributing role of self-focused attention on maintaining anxiety – knowledge that could lead to reduced social anxiety but not necessarily an increase in trait mindfulness. Another mechanism we believe likely contributed to reductions in social anxiety is regular, weekly exposure to the other group participants. Cognitive behavioural approaches for social anxiety highlight the benefit of exposure to social situations for reducing social anxiety (e.g. Clark and Wells, Reference Clark, Wells, Heimberg, Biebowitz, Hope and Schneider1995). The three mechanisms described here – increased mindfulness, increased knowledge of social anxiety, increased exposure to social situations – are likely to be contributory, rather than mutually exclusive.

We were also interested in the impact of the MBCT intervention on other aspects of the participants’ wellbeing. Two of four participants showed improvements in quality of life from baseline to follow-up. These two participants also reported practising mindfulness most regularly at home, compared with other members of the group. The two participants who did not show improvements in quality of life, however, showed relatively little impairment at baseline, leaving little room for improvement through the intervention. Indeed, one participant scored so low on the quality of life measure that there was no room for reliable improvement. The effect of MBCT on depression and general anxiety was minimal, with only one participant showing a decrease in depression, and no participants showing a decrease in general anxiety, from baseline to follow-up, and this is perhaps unsurprising given that we focused on adapting MBCT to tackle social anxiety-type symptoms. In summary, MBCT appears beneficial in improving quality of life and social anxiety in those with AA who have particularly impaired quality of life.

Limitations and future directions

The generalisability of the findings is limited due to the small sample size. Nevertheless, it was appropriate to adopt a single-group experimental design in this early stage of investigating the effectiveness of MBCT with individuals with AA. Future studies should aim to investigate the feasibility and acceptability of MBCT compared with CBT in larger samples of individuals with AA through a pilot randomised controlled trial. Allocating individuals with AA to a second control group, involving a weekly group discussion, would help to separate the benefits of mindfulness from the benefits of social exposure. Outcomes in the trial could include social anxiety, depression, anxiety, and quality of life. Attrition rates and cost-effectiveness could also be monitored, and qualitative methods could be used to explore client views of MBCT and CBT. The intervention could also be improved by acknowledging that participants’ difficulties lie within a broader societal context. That is, many people with AA do receive negative reactions from others, such as staring and insults (e.g. Davey et al., Reference Davey, Clarke and Jenkinson2019), and this could be acknowledged and discussed in an early session to reduce self-blame in the group members.

Recruitment to the current study was difficult, despite receiving support from a local dermatology clinic, relevant national charities, and local wig stores. This difficulty is understandable when considering that individuals experiencing social anxiety were invited to attend a regular group meet-up with people they do not know – meaning those who were most socially anxious may not have attended. That the intervention was run in-person may have also prevented people with disabilities or lack of transport from attending (although travel costs were reimbursed). Despite recruitment difficulties, the benefits of the group format (e.g. more cost-effective than individual therapy, shared experiences with other members, exposure to social situations) warrant further investigation. A pilot randomised controlled trial would therefore benefit from a multi-site approach with more targeted recruitment to potential participants, to clarify whether a large-scale RCT would be feasible. Collecting data after a longer follow-up period would clarify whether the benefits of the intervention are long lasting. In addition, further single-group experimental designs would be useful in demonstrating the effectiveness of MBCT in more diverse samples of individuals with AA, such as men or individuals from minority ethnic backgrounds. The lack of diversity in mindfulness-based intervention studies is a broader issue, with samples typically consisting of white, educated, middle-aged females (Eichel et al., Reference Eichel, Gawande, Acabchuk, Palitsky, Chau, Pham and Britton2021). Diversifying samples may be achieved by increasing diversity within the research team (including the intervention facilitators), collaborating with marginalised communities, and carefully considering the intervention setting (e.g. running the group in a community centre, rather than at a university; Eichel et al., Reference Eichel, Gawande, Acabchuk, Palitsky, Chau, Pham and Britton2021). Finally, the importance of home practice should be emphasised to future participants, both during the screening process and during the mindfulness sessions, perhaps with a more focused discussion on potential obstacles and ways of overcoming them.

In conclusion, MBCT appears beneficial in reducing social anxiety and improving wellbeing in some individuals with AA, particularly those who practise mindfulness at home regularly between sessions. Idiographic measures of social anxiety continued to reduce beyond formal MBCT teaching, suggesting the intervention may provide benefits beyond the final session.

Supplementary material

The supplementary material for this article can be found at https://doi.org/10.1017/S1352465823000292

Data availability statement

Data are available upon reasonable request from the corresponding author.

Acknowledgements

The research team acknowledges the support of the National Institute for Health Research Clinical Research Network (NIHR CRN). We would also like to thank Andrew Chester for delivering the mindfulness-based cognitive therapy intervention, and Ann–Marie Mason for conducting therapist fidelity checks.

Author contribution

Connor Heapy: Data curation (equal), Formal analysis (equal), Investigation (equal), Project administration (equal), Writing – original draft (equal), Writing – review & editing (equal); Paul Norman: Conceptualization (equal), Data curation (equal), Formal analysis (equal), Funding acquisition (equal), Investigation (equal), Methodology (equal), Project administration (equal), Supervision (equal), Writing – original draft (equal), Writing – review & editing (equal); Sarah Cockayne: Project administration (equal), Resources (equal), Supervision (equal), Writing – review & editing (equal); Andrew Thompson: Conceptualization (equal), Data curation (equal), Formal analysis (equal), Funding acquisition (equal), Investigation (equal), Methodology (equal), Project administration (equal), Resources (equal), Supervision (equal), Writing – original draft (equal), Writing – review & editing (equal).

Financial support

The research team would like to thank Alopecia UK for funding this study.

Competing interests

The authors declare none.

Ethical standard

Ethical approval was granted by the Psychology Department, University of Sheffield ethics committee. Authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS.

References

Aukerman, E. L., & Jafferany, M. (2022). The psychological consequences of androgenetic alopecia: a systematic review. Journal of Cosmetic Dermatology. https://doi.org/10.1111/jocd.14983 Google ScholarPubMed
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, 2745. https://doi.org/10.1177/1073191105283504 CrossRefGoogle ScholarPubMed
Basra, M. K. A., Fenech, R., Gatt, R. M., Salek, M. S., & Finlay, A. Y. (2008). The Dermatology Life Quality Index 1994–2007: a comprehensive review of validation data and clinical results. British Journal of Dermatology, 159, 9971035. https://doi.org/10.1111/j.1365-2133.2008.08832.x Google ScholarPubMed
Beutel, M. E., Klein, E. M., Brähler, E., Reiner, I., Jünger, C., Michal, M., … & Tibubos, A. N. (2017). Loneliness in the general population: prevalence, determinants and relations to mental health. BMC Psychiatry, 17, 17. https://doi.org/10.1186/s12888-017-1262-x CrossRefGoogle ScholarPubMed
Bohlmeijer, E., Ten Klooster, P. M., Fledderus, M., Veehof, M., & Baer, R. (2011). Psychometric properties of the Five Facet Mindfulness Questionnaire in depressed adults and development of a short form. Assessment, 18, 308320. https://doi.org/10.1177/1073191111408231 CrossRefGoogle ScholarPubMed
Carleton, R. N., Collimore, K. C., McCabe, R. E., & Antony, M. M. (2011). Addressing revisions to the Brief Fear of Negative Evaluation scale: measuring fear of negative evaluation across anxiety and mood disorders. Journal of Anxiety Disorders, 25, 822828. https://doi.org/10.1016/j.janxdis.2011.04.002 CrossRefGoogle Scholar
Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: a meta-analysis of randomized placebo-controlled trials. Depression and Anxiety, 35, 502514. https://doi.org/10.1002/da.22728 CrossRefGoogle ScholarPubMed
Clark, D., & Wells, A. (1995). A cognitive model of social phobia. In Heimberg, R., Biebowitz, M., Hope, D., & Schneider, F. (eds), Social Phobia: Diagnosis, Assessment and Treatment (pp. 6993). New York: Guilford Press.Google Scholar
Constantino, M. J., Bosweell, J. F., & Coyne, A. E. (2021). Patient, therapist, and relational factors. In Barkham, M., Lutz, W., & Castonguay, L. G. (eds), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (pp. 225263). Wiley.Google Scholar
Crane, R. S., Eames, C., Kuyken, W., Hastings, R. P., Williams, J. M. G., Bartley, T., … & Surawy, C. (2013). Development and validation of the mindfulness-based interventions–teaching assessment criteria (MBI: TAC). Assessment, 20, 681688. https://doi.org/10.1177/1073191113490790 CrossRefGoogle Scholar
Davey, L., Clarke, V., & Jenkinson, E. (2019). Living with alopecia areata: an online qualitative survey study. British Journal of Dermatology, 180, 13771389. https://doi.org/10.1111/bjd.17463 CrossRefGoogle ScholarPubMed
Dempster, A., Laird, N., & Rubin, D. B. (1977). Maximum likelihood from incomplete data via the EM algorithm. Journal of the Royal Statistical Society: Series B, 39, 138. https://doi.org/10.1111/j.2517-6161.1977.tb01600.x Google Scholar
Eichel, K., Gawande, R., Acabchuk, R. L., Palitsky, R., Chau, S., Pham, A., … & Britton, W. (2021). A retrospective systematic review of diversity variables in mindfulness research, 2000–2016. Mindfulness, 12, 25732592. https://doi.org/10.1007/s12671-021-01715-4 CrossRefGoogle Scholar
Finlay, A. Y., & Khan, G. (1994). Dermatology Life Quality Index (DLQI) – a simple practical measure for routine clinical use. Clinical and Experimental Dermatology, 19, 210216. https://doi.org/10.1111/j.1365-2230.1994.tb01167.x CrossRefGoogle ScholarPubMed
Fordham, B., Griffiths, C. E., & Bundy, C. (2015). A pilot study examining mindfulness-based cognitive therapy in psoriasis. Psychological Health and Medicine, 20, 121127. https://doi.org/10.1080/13548506.2014.902483 CrossRefGoogle ScholarPubMed
Fordham, B. A., Nelson, P., Griffiths, C. E., & Bundy, C. (2014). The acceptability and usefulness of Mindfulness Based Cognitive Therapy (MBCT) for people living with psoriasis: a qualitative study. British Journal of Dermatology, 172, 823825. https://doi.org/10.1111/bjd.13333 CrossRefGoogle Scholar
Freedman, T. G. (1994). Social and cultural dimensions of hair loss in women treated for breast cancer. Cancer Nursing, 17, 334341. https://doi.org/10.1097/00002820-199408000-00006 CrossRefGoogle ScholarPubMed
Gallo, R., Chiorri, C., Gasparini, G., Signori, A., Burroni, A., & Parodi, A. (2017). Can mindfulness-based interventions improve the quality of life of patients with moderate/severe alopecia areata? A prospective pilot study. Journal of the American Academy of Dermatology, 76, 757759. https://doi.org/10.1152/ajplegacy.1931.98.4.636 CrossRefGoogle ScholarPubMed
Goldin, P., Ramel, W., & Gross, J. (2009). Mindfulness meditation training and self-referential processing in social anxiety disorder: behavioral and neural effects. Journal of Cognitive Psychotherapy, 23, 242257. https://doi.org/10.1891/0889-8391.23.3.242 CrossRefGoogle ScholarPubMed
Goldin, P., Ziv, M., Jazaieri, H., & Gross, J. (2012). Randomized controlled trial of mindfulness-based stress reduction versus aerobic exercise: effects on the self-referential brain network in social anxiety disorder. Frontiers in Human Neuroscience, 6, 295. https://doi.org/10.3389/fnhum.2012.00295 CrossRefGoogle ScholarPubMed
Goldin, P., Ziv, M., Jazaieri, H., Hahn, K., & Gross, J. J. (2013). MBSR aerobic exercise in social anxiety: fMRI of emotion regulation of negative self-beliefs. Social Cognitive and Affective Neuroscience, 8, 6572. https://doi.org/10.1093/scan/nss054 CrossRefGoogle ScholarPubMed
Hirsch, C. R., & Clark, D. M. (2004). Information-processing bias in social phobia. Clinical Psychology Review, 24, 799825. https://doi.org/10.1016/j.cpr.2004.07.005 CrossRefGoogle ScholarPubMed
Hofmann, S. G., & Bögels, S. M. (2006). Recent advances in the treatment of social phobia: introduction to the special issue. Journal of Cognitive Psychotherapy, 20(1), 35. https://doi.org/10.1891/jcop.20.1.3 CrossRefGoogle Scholar
Hunt, N., & McHale, S. (2004). Reported experiences of persons with alopecia areata. Journal of Loss and Trauma, 10, 3350. https://doi.org/10.1080/15325020490890633 CrossRefGoogle Scholar
Hunt, N., McHale, S. (2005). The psychological impact of alopecia. BMJ, 331, 951953. https://doi.org/10.1136/bmj.331.7522.951 CrossRefGoogle ScholarPubMed
Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal Consulting and Clinical Psychology, 59, 1219. https://doi.org/10.1037/0022-006x.59.1.12 CrossRefGoogle ScholarPubMed
Kabat-Zinn, J. (1994). Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. New York: Hyperion.Google Scholar
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001) The PHQ-9. Journal of General Internal Medicine, 16, 606613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x CrossRefGoogle ScholarPubMed
Kroenke, K., Spitzer, R. L., Williams, J. B. W., Monahan, P. O., & Löwe, B. (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine, 146, 317325. https://doi.org/10.7326/0003-4819-146-5-200703060-00004 CrossRefGoogle ScholarPubMed
Montgomery, K., Norman, P., Messenger, A. G., & Thompson, A. R. (2016). The importance of mindfulness in psychosocial distress and quality of life in dermatology patients. British Journal of Dermatology, 175, 930936. https://doi.org/10.1111/bjd.14719 CrossRefGoogle ScholarPubMed
Montgomery, K., White, C., & Thompson, A. (2017). A mixed methods survey of social anxiety, anxiety, depression and wig use in alopecia. BMJ Open, 7, 16. http://doi.org/10.1136/bmjopen-2016-015468 CrossRefGoogle ScholarPubMed
Morley, S. (2018). Single Case Methods in Clinical Psychology: A Practical Guide. In C. Masterson and C. J. Main (eds), Routledge: Routledge/Taylor & Francis Group.Google Scholar
Morley, S., & Dowzer, C. N. (2014). Manual for the Leeds Reliable Change Indicator: Simple ExcelTM Applications for the Analysis of Individual Patient and Group Data. University of Leeds, Leeds, UK.Google Scholar
Morrison, A. S., & Heimberg, R. G. (2013). Social anxiety and social anxiety disorder. Annual Review of Clinical Psychology, 9, 249274. https://doi.org/10.1146/annurev-clinpsy-050212-185631 CrossRefGoogle ScholarPubMed
National Institute for Health and Clinical Excellence (2009). Depression in Adults: Recognition and Management. UK: NICE.Google Scholar
Parker, R. I., Vannest, K. J., Davis, J. L., & Sauber, S. B. (2011). Combining nonoverlap and trend for single-case research: Tau-U. Behavior Therapy, 42, 284299. https://doi.org/10.1016/j.beth.2010.08.006 CrossRefGoogle ScholarPubMed
Piet, J., Hougaard, E., Hecksher, M. S., & Rosenberg, N. K. (2010). A randomized pilot study of mindfulness based cognitive therapy and group cognitive behavioral therapy for young adults with social phobia. Scandinavian Journal of Psychology, 51, 403410. https://doi.org/10.1111/j.1467-9450.2009.00801.x Google ScholarPubMed
Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35, 741756. https://doi.org/10.1016/s0005-7967(97)00022-3 CrossRefGoogle ScholarPubMed
Rencz, F., Gulácsi, L., Péntek, M., Wikonkál, N., Baji, P., Brodszky, V. (2016). Alopecia areata and health-related quality of life: a systematic review and meta-analysis. British Journal of Dermatology, 175, 561571. https://doi.org/10.1111/bjd.14497 CrossRefGoogle ScholarPubMed
Rodebaugh, T. L., Woods, C. M., Thissen, D., Heimberg, R. G., Chambless, D. L., & Rapee, R. M. (2004). More information from fewer questions: the factor structure and item properties of the original and brief fear of negative evaluation scales. Psychological Assessment, 16, 169181. https://doi.org/10.1037/1040-3590.16.2.169 CrossRefGoogle Scholar
Ruiz-Doblado, S., Carrizosa, A., & García-Hernández, M.J. (2003) Alopecia areata: psychiatric comorbidity and adjustment to illness. International Journal of Dermatology, 42, 434437. https://doi.org/10.1046/j.1365-4362.2003.01340.x CrossRefGoogle ScholarPubMed
Schmertz, S. K., Masuda, A., & Anderson, P. L. (2012) Cognitive processes mediate the relation between mindfulness and social anxiety within a clinical sample. Journal of Clinical Psychology, 63, 362371. https://doi.org/10.1002/jclp.20861 CrossRefGoogle Scholar
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-Based Cognitive Therapy for Depression (2nd edn). New York: Guilford Press.Google Scholar
Sibbald, C. (2023). Alopecia Areata: An Updated Review for 2023. Journal of cutaneous medicine and surgery, 27(3), 241259. https://doi.org/10.1177/12034754231168839 CrossRefGoogle ScholarPubMed
Smith, J., Borckardt, J., & Nash, M. (2012). Inferential precision in single-case time-series data streams: how well does the EM procedure perform when missing observations occur in autocorrelated data? Behavior Therapy, 43, 679685. https://doi.org/10.1016/j.beth.2011.10.001 CrossRefGoogle ScholarPubMed
Spitzer, R. L., Kroenke, K., & Williams, J. B. (1999) Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA, 282, 17371744. https://doi.org/10.1001/jama.282.18.1737 CrossRefGoogle Scholar
Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine, 166(10), 10921097. https://doi.org/10.1001/archinte.166.10.1092 CrossRefGoogle ScholarPubMed
Tucker, P. (2009). Bald is beautiful? The psychosocial impact of alopecia areata. Journal of Health Psychology, 14, 142151. https://doi.org/10.1177/1359105308097954 CrossRefGoogle ScholarPubMed
Van Beugen, S., Maas, J., van Laarhoven, A. I., Galesloot, T. E., Rinck, M., Becker, E. S., … & Evers, A. W. (2016). Implicit stigmatization-related biases in individuals with skin conditions and their significant others. Health Psychology, 35, 861. https://doi.org/10.1037/hea0000404 CrossRefGoogle ScholarPubMed
Vannest, K. J., Parker, R. I., Gonen, O., & Adiguzel, T. (2016). Single Case Research: web based calculators for SCR analysis (version 2.0) [web-based application]. College Station, TX: Texas A&M University. Available at: singlecaseresearch.org Google Scholar
Vøllestad, J., Nielsen, M. B., & Nielsen, G. H. (2012). Mindfulness-and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis. British Journal of Clinical Psychology, 51, 239260. https://doi.org/10.1111/j.2044-8260.2011.02024.x CrossRefGoogle ScholarPubMed
Weeks, J. W., Heimberg, R. G., Fresco, D. M., Hart, T. A., Turk, C. L., Schneier, F. R., & Liebowitz, M. R. (2005). Empirical validation and psychometric evaluation of the Brief Fear of Negative Evaluation Scale in patients with social anxiety disorder. Psychological Assessment, 17, 179190. https://doi.org/10.1037/1040-3590.17.2.179 CrossRefGoogle ScholarPubMed
Wiggins, S., Moore-Millar, K., & Thomson, A. (2014). Can you pull it off? Appearance modifying behaviours adopted by wig users with alopecia in social interactions. Body Image, 11, 156166. https://doi.org/10.1016/j.bodyim.2014.01.004 CrossRefGoogle ScholarPubMed
Figure 0

Table 1. Demographic and clinical information of participants

Figure 1

Figure 1. Weekly averages of daily scores for decrease-framed (on the left) idiographic (‘How affected have you been today by people looking at your head/hair?’) and increased-frame (on the right) social anxiety questions (‘How brave have you felt today – e.g. when in social situations?’).

Figure 2

Table 2. Tau-U results for decrease- and increase-framed questions for each participant

Figure 3

Table 3. Scores at three time-points, across the intervention, on standardised measures of social anxiety, mindfulness (all five facets), depression, general anxiety, and quality of life

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