Self-focused attention and safety behaviors across group therapies for social anxiety disorder

Background: Self-focused attention (SFA) and safety behaviors are two variables implicated in the maintenance of social anxiety disorder (SAD).

Design: The present study examined SFA and safety behaviors across two therapies for SAD, cognitive behavioral group therapy (CBGT) and mindfulness and acceptance-based group therapy (MAGT).

Method: Participants with symptoms meeting criteria for SAD (N?=?137) were randomly assigned to the 12-week-treatment groups (n?=?53 for each condition) or a waitlist control (n?=?31). Variables were assessed at baseline, midtreatment, posttreatment, and a 3-month follow-up.

Results: Both treatment conditions reported significantly lower SFA and safety behaviors compared to control, but did not differ from one another at posttreatment. Mediation analyses supported the following models: (1) safety behaviors mediating the relationship between SFA and social anxiety, and (2) SFA mediating the relationship between safety behaviors and social anxiety. These models were supported for both treatment groups.

Conclusions: Both treatments may have the potential to reduce the SFA and safety behaviors that serve to maintain SAD.     

The effects of safety behaviors on health anxiety: an experimental investigation

The present study examined the extent to which safety behaviors exacerbate symptoms of hypochondriasis (severe health anxiety). Participants were randomized into a safety behavior (n = 30) or control condition (n = 30). After a baseline period, participants in the safety behavior condition spent one week actively engaging in a clinically representative array of health-related safety behaviors on a daily basis, followed by a second week-long baseline period. Participants in the control condition monitored their normal use of safety behaviors. Compared to control participants, those in the safety behavior condition reported significantly greater increases in health anxiety, hypochondriacal beliefs, contamination fear, and avoidant responses to health-related behavioral tasks after the safety behavior manipulation. In contrast, general anxiety symptoms did not significantly differ between the two groups as a function of the manipulation. Mediational analyses were consistent with the hypothesis that changes in the frequency of health-related thoughts mediated the effects of the experimental manipulation on health anxiety. These findings suggest that safety behaviors are associated with increases in health anxiety, perhaps by fostering catastrophic thoughts about health. The implications of these findings for the conceptualization of hypochondriasis as an anxiety disorder are discussed.     

Sleep-Related Safety Behaviors and Dysfunctional Beliefs Mediate the Efficacy of Online CBT for Insomnia: A Randomized Controlled Trial

Several trials have demonstrated the efficacy of online cognitive behavioral therapy (CBT) for insomnia. However, few studies have examined putative mechanisms of change based on the cognitive model of insomnia. Identification of modifiable mechanisms by which the treatment works may guide efforts to further improve the efficacy of insomnia treatment. The current study therefore has two aims: (1) to replicate the finding that online CBT is effective for insomnia and (2) to test putative mechanism of change (i.e., safety behaviors and dysfunctional beliefs). Accordingly, we conducted a randomized controlled trial in which individuals with insomnia were randomized to either online CBT for insomnia (n = 36) or a waiting-list control group (n = 27). Baseline and posttest assessments included questionnaires assessing insomnia severity, safety behaviors, dysfunctional beliefs, anxiety and depression, and a sleep diary. Three- and six-month assessments were administered to the CBT group only. Results show moderate to large statistically significant effects of the online treatment compared to the waiting list on insomnia severity, sleep measures, sleep safety behaviors, and dysfunctional beliefs. Furthermore, dysfunctional beliefs and safety behaviors mediated the effects of treatment on insomnia severity and sleep efficiency. Together, these findings corroborate the efficacy of online CBT for insomnia, and suggest that these effects were produced by changing maladaptive beliefs, as well as safety behaviors. Treatment protocols for insomnia may specifically be enhanced by more focused attention on the comprehensive fading of sleep safety behaviors, for instance through behavioral experiments.     

Online attention modification for social anxiety disorder: replication of a randomized controlled trial

Social anxiety disorder (SAD) models posit vigilance for external social threat cues and exacerbated self-focused attention as key in disorder development and maintenance. Evidence indicates a modified dot-probe protocol may reduce symptoms of SAD; however, the efficacy when compared to a standard protocol and long-term maintenance of treatment gains remains unclear. Furthermore, the efficacy of such protocols on SAD-related constructs remains relatively unknown. The current investigation clarified these associations using a randomized control trial replicating and extending previous research. Participants with SAD (n = 113; 71% women) were randomized to complete a standard (i.e. control) or modified (i.e. active) dot-probe protocol consisting of 15-min sessions twice weekly for four weeks. Self-reported symptoms were measured at baseline, post-treatment, and 4-month and 8-month follow-ups. Hierarchical linear modeling indicated significant self-reported reductions in symptoms of social anxiety, fear of negative evaluation, trait anxiety, and depression, but no such reductions in fear of positive evaluation. Symptom changes did not differ based on condition and were maintained at 8-month follow-up. Attentional biases during the dot-probe task were not related to symptom change. Overall, our results replicate support for the efficacy of both protocols in reducing symptoms of SAD and specific related constructs, and suggest a role of exposure, expectancy, or practice effects, rather than attention modification, in effecting such reductions. The current results also support distinct relationships between fears of negative and positive evaluation and social anxiety. Further research focused on identifying the mechanisms of change in attention modification protocols appears warranted.     

The Impact of Brief Mindfulness Training on Postevent Processing Among Individuals With Clinically Elevated Social Anxiety

Postevent processing (PEP), the engagement in detailed and repetitive self-focused review of one’s performance in social situations, is theorized to maintain pathological social anxiety. However, little is known about interventions that may impact this maintenance factor. The current study examined the impact of brief mindfulness training (BMT) on PEP among socially anxious individuals. There were 77 participants (75.32% female, 63.64% non-Hispanic/Latinx White) with clinically elevated social anxiety who attended one appointment in the laboratory during which they were randomized to receive a brief mindfulness-based training (n = 37) or no training (i.e., thinking as usual control group; n = 40). After the training period, participants underwent a 3-minute social anxiety induction task, after which they were instructed to apply their thinking strategy. Participants were then asked to complete 2 weeks of daily online surveys that included a PEP induction task, instructions to use their thinking strategy following PEP induction, and a measure of state PEP. Individuals in the BMT condition reported a significant reduction in state anxiety posttraining compared to individuals in the control condition. Conditions did not differ on state PEP after the social anxiety induction task. However, compared to those in the control condition, participants in the BMT condition reported significantly greater decreases in state PEP over the 14-day follow-up period. Thus, this brief mindfulness-based strategy may be useful for individuals with clinically elevated social anxiety who engage in PEP, a cognitive vulnerability factor implicated in the maintenance of social anxiety.     

Mediators in psychological treatment of social anxiety disorder: Individual cognitive therapy compared to cognitive behavioral group therapy

According to cognitive-behavioral models of social anxiety disorder (SAD), four of the important maintaining mechanisms are avoidance, self-focused attention, anticipatory processing and post-event cognitive processing. Individual cognitive therapy (ICT) and cognitive behavioral group therapy (CBGT) both have substantial empirical support. However, it is unclear whether they achieve their effects by similar or different mechanisms. The aim of this study was to investigate whether changes in the four maintenance processes mediate clinical improvement in ICT and CBGT for SAD. We analyzed data from participants (N = 94) who received either ICT or CBGT in two separate RCTs. The results showed that ICT had larger effects than CBGT on social anxiety and each of the four potential mediators. More pertinently, moderated mediation analyses revealed significant between-treatment differences. Whereas improvement in ICT was mainly mediated by reductions in avoidance and self-focused attention, improvement in CBGT was mediated by changes in self-focused attention and in anticipatory and post-event processing. These results support the importance of the putative mediators, but suggest that their relative weights are moderated by treatment type.     

Nicotine exposure effects on ADHD in young adults with Attention Deficit Hyperactive Disorder (ADHD)

This study investigated whether ingestion of nicotine could enhance cognitive performance in people with ADHD. Participants with ADHD (n = 17) and without ADHD (n = 22) were contrasted for nicotine use. Cognitive performance was measured using selected subtests of the Cambridge Neuropsychological Test Automated Battery (CANTAB). Baseline cognitive performance data were collected prior to experimental nicotine exposure. The ADHD group with nicotine exposure performed significantly better than the non-exposure group post-intervention. Nicotine exposure appears to boost cognitive performance in subjects with ADHD.     

Effects of safety behaviors on fear reduction during exposure

The use of safety behaviors has been considered one of the primary maintaining mechanisms of anxiety disorders; however, evidence suggests that they are not always detrimental to treatment success (Milosevic & Radomsky, 2008). This study examined the effects of safety behaviors on behavioral, cognitive, and subjective indicators of fear during exposure for fear of spiders. A two-stage design was used to examine fear reduction and approach distance during an in vivo exposure task for participants (N = 43) assigned to either a safety behavior use (SBU) or no safety behavior use (NSB) condition. Overall, both groups reported significant and comparable reductions in self-reported anxiety and negative beliefs about spiders at posttest and 1-week follow-up. Participants in the SBU group approached the spider more quickly than did participants in the NSB condition; however, participants in the SBU condition showed a small but significant decrease in approach distance at follow-up. These results call for a reconceptualization of the impact of safety behaviors on in vivo exposure.     

An experimental analysis of hypochondriasis

Hypochondriasis (HC) involves preoccupation with fears of having a serious medical illness based on the misinterpretation of benign bodily perturbations. Individuals with HC also perform behaviors such as checking and reassurance-seeking presumably to reduce health-related fears. Experimental behavioral analyses of HC symptoms, however, are lacking. In the present study, 27 patients with HC were exposed to personally relevant health-related stimuli under one of two conditions: (a) subsequently performing safety-seeking behaviors (e.g., checking) (n=14) or (b) subsequently being instructed not to perform such behaviors (n=13). In both groups, subjective anxiety and urges to perform safety behaviors were monitored for 1h. Results indicated that exposure to the personally relevant health trigger provoked anxiety and urges to perform safety behaviors. For patients who performed such behaviors, these feelings were reduced. For patients who did not, a more gradual reduction of anxiety and urges was observed. Findings are discussed in terms of the conceptualization and treatment of HC behavior, and are relevant to HC's possible relationship to panic and obsessive-compulsive disorder.     

Adaptive and Maladaptive Self-Focus: A Pilot Extension Study With Individuals High and Low in Fear of Negative Evaluation

Previous research in depressed participants has supported the differentiation of self-focus into distinct modes of self-attention with distinct functional effects. In particular, Rimes and Watkins (2005) investigated the effects of self-focused rumination on overgeneral thinking and found that analytical, evaluative self-focus increased global negative self-judgments, whereas self-focus low in analytical thinking decreased such judgments in depressed participants. Given that self-focused attention and rumination have been implicated in the maintenance of social anxiety, the present study investigated the effects of these two distinct forms of self-focused attention on global negative self-judgments in an analogue sample for social anxiety (high and low fear of negative evaluation, FNE). Individuals high and low in FNE (n = 41 per group) were randomly allocated to analytic (abstract, evaluative) or experiential (concrete, process-focused) self-focused manipulations. As predicted, in high FNE individuals, the experiential self-focus condition decreased ratings of the self as worthless and incompetent pre- to post-manipulation, whereas the analytical self-focus condition maintained such negative self-judgments. Analytical and experiential self-focus did not differ in their effects on mood. The results suggest that an experiential mode of self-focused rumination may be adaptive in social anxiety.     

Ruminative coping and post-event processing in social anxiety

Cognitive models of social anxiety implicate various factors in the initiation and maintenance of socially anxious states, including anticipatory processing, self-focused attention and post-event processing. The present study focused on post-event processing, which is a post-mortem analysis following a social event that is described as ruminative in nature and serves to maintain social anxiety. Participants (N=112; 64 women, 48 men) were presented with vignettes that involved making mistakes in public and were instructed to record their thoughts to allow for the examination of the content of post-event processing. Ruminative coping and distraction were assessed via self-report. Results indicated that participants high in social anxiety (n=55) were more likely to ruminate and less likely to distract when faced with socially anxious stressors compared to those low in social anxiety (n=57). Further, as hypothesized, participants high in social anxiety recorded more negative thoughts and more upward counterfactual thoughts ('if only' type thoughts on how things could have been better; associated with negative affect) compared to those low in social anxiety. These results are discussed in terms of cognitive models of social anxiety.     

Computerized attention retraining for individuals with elevated health anxiety

Background and Objectives: Current cognitive-behavioral theorists conceptualize hypochondriasis as excessive health anxiety (HA). Growing evidence suggests that elevated HA is associated with attentional bias (AB) toward potential health-threat information. Design: This study aimed to examine the effects of attention retraining among individuals with elevated HA, using the established attention modification programs (AMP) designed to train participants to disengage attention from ideographically chosen health-threat words. Methods: Thirty-six randomly assigned individuals with elevated HA completed eight twice-weekly sessions of the AMP (n = 18) or the attention control condition (ACC; n = 18). Results: Despite using the well-established AMP protocol widely used within the field of anxiety disorders, we did not find evidence for change in AB following training. Further, AMP did not outperform ACC in reducing HA and other relevant emotional symptoms. However, both AMP and ACC evidenced overall significant symptom reduction in most of the outcome measures, including overall HA, anxiety sensitivity, general depression and anxiety, and somatic complaints. Conclusions: Further research is needed to better understand the effects and mechanisms of AMP as a possible cognitive intervention for HA.     

How to reverse the vicious cycle of low self-esteem: The importance of attentional focus

Recent research suggests that the cognitive processes of low self-esteem people (low SEs) perpetuate low self-esteem and its undesirable emotional and behavioral correlates. For instance, it has been suggested that low SEs are more “self-conscious” than high self-esteem people (high SEs) and that self-consciousness can impair task performance. It was reasoned that if low SEs were led to focus their attention away from themselves and onto the task, performance would improve relative to high SEs. In a 2 × 3 between-subjects factorial design, subjects high and low in chronic self-esteem performed a concept formation task under three conditions: (1) in the presence of an audience, where self-focused attention is presumably high; (2) in a control group, in which attention was not manipulated; and (3) with instructions to concentrate on the task diligently. A significant interaction effect was obtained, indicating that low SEs performed worse than high SEs in the audience condition (p < .025), no differently in the control, and better than high SEs (p < .01) when instructed to concentrate on the task. Although the latter results are unusual in the context of self-esteem research, they are strikingly parallel to recent findings in the study of test anxiety.     

Consequences of anticipatory processing on cognitive symptoms of social anxiety

Anticipatory processing is an anxious style of repetitive negative thought associated with social anxiety (SA) that was proposed by Clark and Wells. Considerable research has examined factors of Clark and Wells' cognitive model of SA (e.g. attention, interpretation), but few studies have examined anticipatory processing, which is hypothesized to interact with other components in the model. In the current study, individuals high in social anxiety symptoms (HSA; N = 56) and control participants [Normal Control (NC); N = 52] engaged in an anticipation or distraction task prior to a threatened social interaction. HSAs who anticipated had higher self-focused attention than NCs who anticipated and HSAs in the distraction condition, suggesting an important relationship between anticipation and self-focus that is specific to HSAs. Those who anticipated endorsed more negative interpretations than those who engaged in distraction, regardless of SA status. However, this relationship was mediated by self-focus. Implications in the context of Clark and Wells' model and future directions are discussed.     

The effect of attentional focus on social anxiety

The aim of the present study was to examine the effect of attentional focus on social anxiety in a group of high and low blushing-anxious subjects. One hundred and fourteen psychology undergraduate students were screened using the Fear of Blushing subscale of the Blushing Questionnaire [B?gels, S. M., & Reith, W. (1999). Validity of two questionnaires to assess social fears: The Dutch social phobia and anxiety questionnaire and the blushing, trembling and sweating questionnaire. Journal of Psychopathology and Behavioral Assessment, 21, 51-66]. Those with the most extreme scores in the top and bottom 20% of the distribution were selected to form a high (n=22) and a low (n=22) blushing-anxious group. Subjects were randomly allocated to either a self-focused attention (SFA) condition or a task-focused attention (TFA) condition. They were asked to engage in a 5 min conversation with the first author, and were instructed to either self-focus (SFA condition) or task-focus (TFA condition). Levels of social anxiety and self-awareness were measured using visual analogue scales. Results suggest that the there was a significant condition by group interaction, with high blushing individuals showing considerably higher levels of social anxiety in the SFA condition compared to the TFA condition while low blushing individuals showed no significant difference across the two conditions.     

Not self-focused attention but negative beliefs affect poor social performance in social anxiety: An investigation of pathways in the social anxiety-social rejection relationship

Patients with social anxiety disorder (SAD) not only fear negative evaluation but are indeed less likeable than people without SAD. Previous research shows social performance to mediate this social anxiety-social rejection relationship. This study studied two pathways hypothesized to lead to poor social performance in social anxiety: increased self-focused attention and negative beliefs. State social anxiety was experimentally manipulated in high and low-blushing-fearful individuals by letting half of the participants believe that they blushed intensely during a 5 min getting-acquainted interaction with two confederates. Participants rated their state social anxiety, self-focused attention, and level of negative beliefs. Two confederates and two video-observers rated subsequently likeability (i.e., social rejection) and social performance of the participants. In both groups, the social anxiety-social rejection relationship was present. Although state social anxiety was related to heightened self-focused attention and negative beliefs, only negative beliefs were associated with relatively poor social performance. In contrast to current SAD models, self-focused attention did not play a key-role in poor social performance but seemed to function as a by-product of state social anxiety. Beliefs of being negatively evaluated seem to elicit changes in behavioral repertoire resulting in a poor social performance and subsequent rejection.     

Looking at me,appreciating you: Self-focused attention distinguishes between gratitude and indebtedness

We provide evidence that self-focused attention (both dispositional and situationally induced) affects the evaluation of a benefactor. Specifically, self-focused attention distinguishes between gratitude and indebtedness. In Study 1, gratitude correlated negatively with dispositional public self-focused attention and social anxiety, whereas indebtedness correlated positively with public self-focused attention and social anxiety. In Study 2, participants recalled a recent benefit under either high self-focused attention, induced via a mirror, or low self-focused attention. Highly self-focused individuals recalled increased indebtedness, but not gratitude, toward a benefactor, relative to those in the control condition. Self-focused individuals also felt less commitment and closeness to the benefactor. The implications for the link between self-focus and social emotions (and thus social life) are discussed.     

How to remain neutral: An experimental analysis of neutralization

Many patients with obsessive-compulsive problems engage in neutralizing activity to reduce or “cancel out” the effects of the obsession. In many cases, neutralization is covert and therefore difficult to assess or manipulate experimentally. We hypothesize that neutralization resembles overt compulsions. In particular, it was predicted that: (i) neutralization reduces the anxiety evoked by unacceptable thoughts, and (ii) if neutralization is delayed, anxiety and the urge to neutralize will decay naturally. To test the hypothesis, 63 Ss prone to a cognitive bias known to be associated with obsessional complaints (thought-action fusion) were asked to write a sentence that would evoke anxiety. Measures of anxiety (and other variables of interest such as guilt, responsibility and the likelihood of harm) were taken. Subjects were then instructed to either immediately neutralize (n = 29) or delay for 20 min (n = 34), after which time anxiety and urge to neutralize were re-assessed. The Ss who had neutralized were then instructed to delay, and the Ss who had delayed were now instructed to neutralize, after which time the final assessments were taken. The results confirmed the predictions and supported the hypothesis that neutralization resembles overt compulsions. Of note, there were no differences between anxiety reduction after a 20-min delay, and after immediate neutralization. The problems involved in designing and conducting experiments on covert phenomena are discussed, and the clinical implications of the study are considered.     

Mirror gazing in body dysmorphic disorder and healthy controls: effects of duration of gazing

Cognitive-behavioural models of body dysmorphic disorder (BDD) suggest that mirrors can act as a trigger for individuals with BDD, resulting in a specific mode of cognitive processing, characterised by an increase in self-focussed attention and associated distress. The aim of the current study was to investigate these factors experimentally by exposing participants with BDD (n = 25) and without BDD (n = 25) to a mirror in a controlled setting. An additional aim was to ascertain the role of duration of mirror gazing in the maintenance of distress and self-consciousness by manipulating the length of gazing (short check vs. long gazing). Findings demonstrated that contrary to what was predicted, not only participants with BDD, but also those without BDD experienced an increase in distress and self-focused attention upon exposure to the mirror. In addition, people without BDD, unlike those with BDD, experienced more distress when looking in the mirror for a long period of time as opposed to a short period of time. This lends some support to the idea that, for people with BDD, gazing in a mirror, regardless of duration, might act as an immediate trigger for an abnormal mode of processing and associated distress, and that this association has developed from past excessive mirror gazing. Further theoretical implications of these findings, as well as subsidiary research questions relating to additional cognitive factors are discussed.