Social phobia and interpretation of social events

It has been suggested that social phobia may be characterized by two interpretation biases. First, a tendency to interpret ambiguous social events in a negative fashion. Second, a tendency to interpret unambiguous but mildly negative social events in a catastrophic fashion. To assess this possibility, patients with generalized social phobia, equally anxious patients with another anxiety disorder, and non-patient controls were presented with ambiguous scenarios depicting social and non-social events, and with unambiguous scenarios depicting mildly negative social events. Interpretations were assessed by participants' answers to open-ended questions and by their rankings and belief ratings for experimenter-provided, alternative explanations. Compared to both control groups, patients with generalized social phobia were more likely to interpret ambiguous social events in a negative fashion and to catastrophize in response to unambiguous, mildly negative social events.     

Recurrent images and early memories in social phobia

A recent model [Clark, D. M. & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D. A. Hope & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment and treatment (pp. 69-93). New York: Guildford Press] suggests that a distorted image of one's public self lies at the heart of social phobia. A previous study of spontaneous imagery [Hackmann, A., Surawy, C. & Clark, D. M. (1998) Seeing yourself through others' eyes: a study of spontaneously occurring images in social phobia. Behavioural and Cognitive Psychotherapy, 26, 3-12] confirmed that patients with social phobia frequently report experiencing negative, distorted, observer-perspective images when in anxiety provoking social situations. In the present study, 22 patients with social phobia were given a semistructured interview which aimed to further explore the nature of social phobic imagery. All participants were able to identify negative spontaneous images that were recurrent in the sense that their content appeared to be relatively stable over time and across different feared social situations. Most recurrent images involved several sensory modalities. Most recurrent images were linked to memories of adverse social events that clustered in time around the onset of the disorder. Taken together, the results suggest that in patients with social phobia, early unpleasant experiences may lead to the development of excessively negative images of their social selves that are repeatedly activated in subsequent social situations and fail to update in the light of subsequent, more favourable experiences. Implications of the findings for the understanding and treatment of social phobia are discussed.     

Social interpretation bias and generalized social phobia: the influence of developmental experiences

Patients with generalized social phobia (N = 42) and non-phobic community controls (N = 42) engaged in a social interaction with an experimental assistant whose behavior was used to create either a positive or an ambiguous social environment. Participants then rated their own performance and their partner's behavior. As a group, social phobic patients displayed negatively biased self-judgments, but failed to display biased social interpretations. Among the social phobia group, a social developmental history marked by parental hostility was associated with negative interpretations of partner behavior and a history of parental overprotection was associated with less sensitivity to partner behavior. The results supported cognitive models of social phobia, which implicate negative learning experiences in the development of information processing biases.     

Interpretation and judgmental biases in social phobia

Previous research demonstrated that social phobia is characterized by content-specific interpretation and judgmental biases. The present study investigated whether this interpretation bias occurs not only in ambiguous, but also in positive and negative social events, and whether social phobic patients (SPs) are more characterized by a judgmental bias in costs than in probability. Besides, we argued that the judgmental bias observed in former studies could also be attributed to accurate estimations of SPs (of, for example, stuttering). Therefore, we assessed judgmental bias by the ratings of probability and costs of a negative evaluation (e.g. ‘people dislike me’) and not, as in previous studies, of negative social events (e.g. ‘stuttering’). SPs (n=228) and normal controls (n=33) were presented social and non-social events ranging from positive to profoundly negative. They ranked four different interpretations on likelihood to assess interpretation bias, and rated the profoundly negative interpretation on probability and cost to assess judgmental bias. SPs demonstrated content-specific interpretation and judgmental biases that also occurred in positive and negative social events. In contrast with expectations, SPs were characterized by a judgmental bias in both costs and probability.     

Cognitive processes as mediators of the relation between mindfulness and change in social anxiety symptoms following cognitive behavioral treatment

The present study examined whether pretreatment mindfulness exerts an indirect effect on outcomes following cognitive-behavioral therapy (CBT). Cognitive processes of probability and cost bias (i.e., overestimations of the likelihood that negative social events will occur, and that these events will have negative consequences when they do occur) were explored as potential mediators of the relation between mindfulness and social anxiety symptom change. People with higher levels of mindfulness may be better able to benefit from treatments that reduce biases because mindfulness may aid in regulation of attention. Sixty-seven individuals with a primary diagnosis of social phobia identifying public speaking as their greatest fear received eight sessions of one of two types of exposure-based CBT delivered according to treatment manuals. Participants completed self-report measures of mindfulness, probability bias, cost bias, and social anxiety symptoms. Mediation hypotheses were assessed by a bootstrapped regression using treatment outcome data. Pretreatment mindfulness was not related to change in social anxiety symptoms from pre- to posttreatment. However, mindfulness had an indirect effect on treatment outcome via its association with probability bias, but not cost bias, at midtreatment. These findings were consistent across three metrics of social anxiety symptoms. Mindfulness may play a role in response to CBT among individuals with social phobia through its relation with probability bias – even when the treatment does not target mindfulness.     

Phenomenal characteristics of autobiographical memories for social and non-social events in social phobia

Previous studies failed to show clear differences between people with social phobia and non-anxious individuals regarding the specificity and affective intensity of their autobiographical memories for social events. However, these studies did not assess the subjective experience associated with remembering. In this study, people with social phobia and non-anxious control participants recalled social and non-social events, and rated the phenomenal characteristics of their memories. The memories of people with social phobia for social events contained fewer sensorial details but more self-referential information than controls' memories. In addition, people with social phobia remembered social situations from an observer perspective, viewing themselves as if from outside, to a greater extent than controls. By contrast, the two groups did not differ concerning their memories for non-social events. These findings are discussed in relation to cognitive models of social phobia.     

Interpretations for anxiety symptoms in social phobia

This study explored the ways in which people interpret visible physical symptoms of anxiety. A group of participants with social phobia (SP) and a nonclinical control (NCC) group completed either the Actor version or the Observer version of the Symptom Interpretation Scale (SIS), designed for the purposes of this study. The SIS asks participants to rate the extent to which each of eight interpretations is a likely explanation for a number of visible symptoms of anxiety. On the Actor version of the SIS, participants are asked to judge how their own anxiety symptoms are interpreted by others. On the Observer version of the SIS, participants are asked how they typically interpret anxiety symptoms that they notice in others. When participants were asked about anxiety symptoms that they themselves exhibit, people with social phobia were more likely than nonclinical controls to think that others interpreted these symptoms as being indicative of intense anxiety or a psychiatric condition and were less likely to think that others interpreted these symptoms as being indicative of a normal physical state. Data also suggested that people with social phobia have a more flexible cognitive style when asked to interpret anxiety symptoms exhibited by others than when asked about how others view their own anxiety symptoms. These findings are discussed in the context of recent psychological models of social anxiety and social phobia.     

Interpretation of facial expressions and social anxiety: Specificity and source of biases

Cognitive-behavioural models of social phobia (Clark & Wells, 1995; Rapee & Heimberg, 1997) propose that biased information processing contributes to the maintenance of social phobia. Given the importance of facial expressions in social interactions, recent investigations of these information-processing biases have increasingly used facial stimuli. The current study utilised schematic faces of emotional expressions to investigate interpretations of facial expressions and specific facial features in individuals with high and low social anxiety. Individuals with elevated social anxiety demonstrated biases in their perceptions of negative valence from the faces, whereas group differences were not observed for perceptions of activity or potency. Further, although the two groups generally utilised the same facial features to interpret facial expressions, the results suggested that individuals with high social anxiety may be more lenient in perceiving threat in faces than individuals without social anxiety.     

When ambiguity hurts: social standards moderate self-appraisals in generalized social phobia

Thirty-nine individuals with generalized social phobia (social anxiety disorder) and 39 nonclinical controls performed a public speech after receiving cues about social standards. Using a novel video manipulation paradigm, one third of participants received cues indicating that standards for performance were high, one third received cues that standards were low, and the remaining third were given no explicit information about expected standards (i.e., standards were ambiguous). Individuals with social phobia performed objectively worse than controls in all conditions, but rated their performance as being worse only in the high and ambiguous standards conditions. These results suggest that in social phobia, negative self-perception is context-dependent. Implications for the cognitive model and treatment are discussed.     

Framing social information and generalized social phobia

Patients with generalized social phobia (GSP, N=33) and matched community controls (N=31) engaged in a social interaction that was constructed to go well, and then received feedback that framed social cues reflecting either the absence of negative outcomes or the presence of positive outcomes. Following feedback that framed positive social cues, the GSP group predicted they would experience more anxiety in a subsequent interaction than did non-phobic controls. In contrast, following feedback framing the absence of negative outcomes, the GSP group did not differ from controls in their anxiety predictions. The results demonstrated that framing paradigms and methods can be usefully applied to the study of cognitive processes in social phobia and indicated that research to examine how GSP patients process specific types of social information is needed.     

Self-images play a causal role in social phobia

Patients with social phobia often experience negative self-images in social situations. The current study investigated whether negative self-images have a causal role in maintaining social phobia. Patients with social phobia participated twice in a conversation with a stranger, once whilst holding their usual negative self-image in mind and once whilst holding a less negative (control) self-image in mind, with order counterbalanced across participants. Compared to the control image condition, when participants held the negative image in mind they experienced greater anxiety, rated their anxiety symptoms as being more visible, and rated their performance as poorer. An assessor who did not know which image was being held also rated participants' anxiety as more evident and their behaviour as less positive when the negative image was being held in mind. Finally, when participant and assessor ratings were compared, participants underestimated their performance and overestimated the visibility of their anxiety to a significantly greater extent in the negative imagery condition. Taken together, these results support the hypothesis that negative self-imagery has a causal role in maintaining social phobia.     

Imagery and interpretations in social phobia: support for the combined cognitive biases hypothesis

Cognitive-behavioral models of clinical problems typically postulate a role for the combined effects of different cognitive biases in the maintenance of a given disorder. It is striking therefore that research has tended to examine cognitive biases in isolation rather than assessing how they work together to maintain psychological dysfunction. The combined cognitive biases hypothesis presented here suggests that cognitive biases influence each another and can interact to maintain a given disorder. Furthermore, it is proposed that the combined effects of cognitive biases may have a greater impact on sustaining a given disorder than if the biases operated in isolation. The combined cognitive biases hypothesis is examined in relation to imagery and interpretation in social phobia. Individuals with social phobia experience negative images of themselves performing poorly in social situations, and they also interpret external social information in a less positive way than those without social anxiety. Evidence of a reciprocal relationship between imagery and interpretations is presented, and the mechanisms underlying the combined effects are discussed. Clinical implications and the potential utility of examining the combined influence of other cognitive biases are highlighted.     

Social anxiety and interpersonal perception: a social relations model analysis

Cognitive models of social phobia posit that an individual's negative beliefs about the way he or she is perceived by others (metaperceptions) are a core feature of the disorder. The social relations model () was used to analyze interpersonal perception data collected following unstructured social interactions in 62 socially anxious (SA) and 62 not socially anxious (NSA) individuals. Using this model, the interpersonal perceptions were analyzed to evaluate whether pathological levels of social anxiety are associated with self-perceptions, metaperceptions, and perceptions from others. SA participants saw themselves negatively and believed others saw them negatively. Although seen as more nervous by others, SA participants were not seen as less likeable. A mediational model demonstrated that the negative metaperceptions of SA individuals were more a function of their own self-perceptions than the negative perceptions of others. These findings were not attributable to depressive symptoms. Implications for theory and treatment of social phobia are discussed.     

Self-perception and rumination in social anxiety

The present study examined the relationship between perceptions of performance and post-event processing (PEP) following task feedback in individuals with social phobia and matched control participants. Groups of high and low socially anxious participants engaged in a structured 5-min conversation in groups of four people. Following the conversation, false feedback (given in the form of either high scores or moderate scores) was given and self-appraisals of performance, levels of positive and negative mood, and levels of PEP were assessed. Results showed that participants' perceptions of their own performance and levels of positive affect significantly predicted the degree to which they engaged in negative rumination about the task. The moderate score condition was found to be detrimental for socially anxious individuals' self-appraisals and PEP, whereas controls showed no significant difference in self-appraisal and PEP, regardless of feedback. The results are discussed in relation to current cognitive models of social phobia and both treatment implications and directions for future research are explored.     

Frequency and comorbidity of social phobia and social fears in adolescents.

This report presents findings on the frequency, comorbidity and psychosocial impairment of social phobia and social fears among 1035 adolescents, aged 12-17 years. The adolescents were randomly selected from 36 schools in the province of Bremen, Germany. Social phobia and other psychiatric disorders were coded based on DSM-IV criteria using the computerized Munich version of the Composite International Diagnostic Interview. Seventeen (1.6%) of the adolescents met the DSM-IV criteria for social phobia sometimes in their life. More girls than boys received the diagnosis of social phobia and the frequency of the disorder increased with age. The lifetime frequency of social fears were much higher than that of social phobia. The most common types of feared social situations were fear of doing something in front of other people, followed by public speaking. Social phobia comorbid highly with depressive disorders, somatoform disorders and substance use disorders. Despite the high level of psychosocial impairment experienced by cases with social phobia and those with any social fears, only a small portion of them did receive professional help.     

Effects of varying levels of anxiety within social situations: relationship to memory perspective and attributions in social phobia

Cognitive-behavioral theorists (Clark & Wells, 1995: Clark, D. M. & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69-93). New York: Guilford Press; Rapee & Heimberg, 1997: Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35, 741-756.) propose that individuals with social phobia form mental images of themselves as if from an external point of view. Research by Wells and colleagues has shown that, when recalling anxiety-provoking social situations, individuals with social phobia are more likely to take an observer perspective (seeing oneself as if from an external point of view) whereas control subjects are more likely to take a field perspective (as if looking out through one's own eyes). Furthermore, this pattern is specific to social events, as both groups recall non-social events from a field perspective (see Wells, Clark & Ahmad, 1998: Wells, A., Clark, D. M., & Ahmad, S. (1998). How do I look with my minds eye: perspective taking in social phobic imagery. Behaviour Research and Therapy, 36, 631-634; Wells & Papageorigou, 1999: Wells, A. & Papageorgiou, C. (1999). The observer perspective: Biased imagery in social phobia, agoraphobia, and blood/injury phobia. Behaviour Research and Therapy, 37, 653-658). In the current study, individuals with social phobia took more of an observer perspective than non-anxious controls when recalling high anxiety social situations. However, both groups took a predominantly field perspective for memories of medium or low anxiety social situations. As memory perspective has also been shown to be related to causal attributions, we examined this relationship in our sample. Memories of low, medium, and high anxiety social situations were differentially related to attributions for each group. Patients' attributions for their performance became more internal, stable, and global as the anxiety level of the situation increased, while the attributions of control subjects showed the opposite pattern.     

Self-focused attention before and after treatment of social phobia

It has been hypothesized that effective psychological treatment for social phobia changes the person's representation of the self in a more positive direction. In order to test this hypothesis, we analyzed 506 thoughts that were endorsed by 23 social phobic individuals while anticipating socially stressful situations before and after exposure therapy. Treatment efficacy was assessed with the Social Phobia and Anxiety Inventory (SPAI) [Turner, S. M., Beidel, D. C., Dancu, C. V., & Stanley M. A. (1989) An empirically derived inventory to measure social fears and anxiety: the Social Phobia and Anxiety Inventory. Psychological Assessment, 1, 35-40)]. Subjects endorsed significantly fewer negative self-focused thoughts after treatment (on average 8.7% of the thoughts) than before treatment (26.5%, p < 0.005). These changes were highly correlated with pre-post difference scores in the social phobia subscale of the SPAI (r = 0.74, p < 0.0001). Implications of the results for the cognitive model of social phobia will be discussed.