Breathe Hard to Breathe Easy: Online Breathwork-Assisted Therapy for Social Anxiety

Liebowitz Social Anxiety Scale

The LSAS (25) is a widely recognized instrument designed to assess the severity of SA. The LSAS measures both the fear and avoidance associated with social and performance situations. It consists of 24 items, divided into two subscales: 13 items addressing social interaction situations and 11 items focusing on performance situations. Each item is rated on a Likert scale from 0 (none) to 3 (severe) for fear, and from 0 (never) to 3 (usually) for avoidance, yielding a total possible score range of 0 to 144. The scale's dual focus allows for a comprehensive assessment of SA, making it a valuable tool for both therapy settings and research. The LSAS has demonstrated strong psychometric properties, including high internal consistency and test-retest reliability (26). It is also sensitive to changes in symptomatology, which makes it useful for evaluating treatment outcomes (27). The scale's validity has been established through correlations with other

Getting Acquainted Task

The GAT is an assessment tool used to evaluate SA by observing how an individual performs in a structured social interaction (29). The participant will be paired with a confederate and asked to engage in a conversation to get to know each other. This scenario is designed to elicit behaviors and responses indicative of SA, such as difficulty initiating conversation, discomfort, or avoidance behaviors. The task will involve different confederates at the two assessment timepoints to reduce habituation effects and will be video recorded and analyzed later for social performance assessment (29, 30). The assessment will be carried out by blinded raters on two dimensions: anxious appearance (fidgeting, blushing, laughing nervously and feelings of nervousness) and social behavior (making eye contact, completing of sentences, coherence, silences, listening, showing interest, responding) (29).

Heart Rate Variability

During the GAT heart-rate variability (HRV) will be assessed through the use of an ECG device.

Salivary Cortisol

Before, immediately after and 30 minutes after the end of the GAT, saliva samples will be collected to measure the concentration of salivary cortisol (SC).

State and Trait Anxiety

State and Trait Anxiety Inventory (STAI) The State-Trait Anxiety Inventory (STAI; 66) is a widely used psychological instrument designed to measure two distinct types of anxiety: state anxiety (temporary, situational anxiety) and trait anxiety (a general tendency to experience anxiety across situations). The STAI consists of 40 self-report items, divided equally into two subscales: the State Anxiety Scale (S-Anxiety) and the Trait Anxiety Scale (T-Anxiety). Each item is rated on a 4-point Likert scale, with scores ranging from 20 to 80 for each subscale, where higher scores indicate greater levels of anxiety.

Empathy

The Interpersonal Reactivity Index (IRI) (51) is a 28-item questionnaire consisting of 4 discrete seven-item scales i.e. 'Fantasy' (tendency to imaginatively transpose oneself into fictional situations), 'Perspective-Taking' (tendency to spontaneously adopt the psychological viewpoint of others), 'Empathic Concern' (taps the respondents' feelings of warmth, compassion, and concern for others), and 'Personal Distress' (assesses self-oriented feelings of anxiety and discomfort resulting from tense interpersonal settings).

Well-Being

The World Health Organisation - Well-Being Index (WHO-5) (52) is a short, self-reported measure designed to evaluate subjective well-being. The WHO-5 is widely used in therapy and research settings to assess general emotional well-being and screen for depression. The index consists of five items, each reflecting a positive aspect of mental health, such as feeling cheerful, calm, active, rested, and interested in daily life. Respondents rate each item on a 6-point Likert scale ranging from 0 (at no time) to 5 (all of the time), based on their experiences over the past two weeks. The total score of the WHO-5 ranges from 0 to 25, with higher scores indicating better well-being. A score below 13 suggests poor well-being. The WHO-5 is valued for its simplicity, brevity, and strong psychometric properties, including high internal consistency and sensitivity to change (52).

Resilience

The Resilience Scale (RS) is a well-validated instrument designed to measure the resilience levels of individuals, reflecting their ability to cope with stress and adversity (53). The RS aims to quantify the personal qualities that enable individuals to thrive despite challenging circumstances. The scale consists of 25 items and respondents rate each item on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).