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.     

Social anxiety and interpretation biases for facial displays of emotion: emotion detection and ratings of social cost

The current study assessed the processing of facial displays of emotion (Happy, Disgust, and Neutral) of varying emotional intensities in participants with high vs. low social anxiety. Use of facial expressions of varying intensities allowed for strong external validity and a fine-grained analysis of interpretation biases. Sensitivity to perceiving negative evaluation in faces (i.e., emotion detection) was assessed at both long (unlimited) and brief (60 ms) stimulus durations. In addition, ratings of perceived social cost were made indicating what participants judged it would be like to have a social interaction with a person exhibiting the stimulus emotion. Results suggest that high social anxiety participants did not demonstrate biases in their sensitivity to perceiving negative evaluation (i.e. disgust) in facial expressions. However, high social anxiety participants did estimate the perceived cost of interacting with someone showing disgust to be significantly greater than low social anxiety participants, regardless of the intensity of the disgust expression. These results are consistent with a specific type of interpretation bias in which participants with social anxiety have elevated ratings of the social cost of interacting with individuals displaying negative evaluation.     

Cognitive assessment of social anxiety: a comparison of self-report and thought listing methods

The goal of the present study was to compare 2 cognitive assessment methods for social anxiety: a thought listing and a self-report method. The focus of this study was on the convergent and divergent validity of these methods using a multi-trait multi-method approach. Furthermore, treatment sensitivity was explored. Fifty-eight patients with social phobia completed thought listings followed by 2 different social stress tasks before and after an exposure group treatment (n = 33), or following a waiting period (n = 25). One task consisted of speaking in front of 2 confederates while the other task involved initiating a conversation with an opposite-sex confederate. Two questionnaires measuring positive and negative self-statements regarding public speaking and social interactions were also completed. To compare the balance of positive and negative thoughts, the State of Mind ratio [positive thoughts/(positive+negative thoughts)] was calculated for both cognitive assessment methods. Results demonstrate that methods related to social interaction anxiety showed better convergent validity than methods related to public speaking anxiety; however, public speaking methods captured treatment effects better than methods related to social interaction anxiety. This study questions the common assumption that different cognitive assessment methods measure the same construct.     

Examining the Role of Implicit Emotional Judgments in Social Anxiety and Experiential Avoidance

This study sought to examine the relationship of implicit emotional judgments with experiential avoidance (EA) and social anxiety. A sample of 61 college students completed the Emotional Judgment – Implicit Relational Assessment Procedure (EJ-IRAP) as well as a public speaking challenge. Implicit judgments were related to greater self-reported EA, anxiety sensitivity, emotional judgments and social anxiety as well as lower performance ratings and willingness in the public speaking challenge. Effects differed by trial type with “Anxiety is bad” biases related to greater EA/anxiety, while “calm is bad” biases related to lower EA/anxiety (“Good” biases were generally unrelated to outcomes). Implicit emotional judgments moderated the relationship of heart rate during the speech with speech time and willingness, such that increases in heart rate were only related to lower speech time and willingness among those high in implicit judgments. Implicit judgments predicted social anxiety above and beyond self-report EA measures. Implicit emotional judgments appear to have a functional role in EA and anxiety that warrants further research.     

Change Processes in Residential Cognitive and Interpersonal Psychotherapy for Social Phobia: A Process-Outcome Study

The purpose of this study was to test cognitive and interpersonal models for improving social phobia. Eighty patients with social phobia were randomized to 10-week residential cognitive (RCT) or residential interpersonal psychotherapy (RIPT). They completed process measures every Thursday and a sub-outcome measure every Monday. The ratings were analyzed with mixed models. Weekly changes in the process variables derived from the cognitive model (self-focus, estimated probability and estimated cost of negative social events, safety behaviors) predicted subsequent weekly changes in social anxiety. Changes in the interpersonal variable perceived acceptance by others also predicted subsequent changes in social anxiety. On the other hand, changes in social anxiety predicted changes in the four cognitive variables. There were no interactive effects of process with treatment. The cognitive variables decreased during treatment to a similar degree in both treatments. The results indicate that, to reduce social anxiety, therapy should target self-focus, estimated probability and cost of feared social events, safety behaviors, and perceived acceptance by others. The process of improvement may involve positive cycles in that a reduction of social anxiety, in turn, appeared to impact self-focus, probability, cost, and safety behaviors.     

Performance and interaction anxiety: specific relationships with other- and self-evaluation concerns

This study examines whether performance anxiety (PA) is specifically associated with other-evaluation concerns and interaction anxiety (IA) with self-evaluation concerns. Individuals with public speaking fears and high levels of PA or IA were distinguishable from nonanxious controls on measures taken during a public speaking challenge. In addition, high PA individuals exhibited more observer-rated negative speech characteristics in an Other-Evaluation condition compared to a Self-Evaluation condition, but high IA individuals and nonanxious individuals did not. These results provide some evidence for the distinctiveness of these dimensions of social anxiety.     

Usability and Utility of a Computerized Cognitive-Behavioral Self-Help Program for Public Speaking Anxiety

This study describes the use of a cognitive-behavioral computer-administered self-help program with minimal therapist contact for public speaking anxiety. Participants (N = 10) with social phobia, as measured by a structured clinical interview, completed the self-help program in an open clinical trial. The program was delivered via a CD-ROM during individual sessions at an outpatient clinic, including 4 sessions of psychoeducation/cognitive therapy and 4 sessions of exposure therapy using a virtual audience presented on a computer screen. A therapist was available in another room to answer questions and to debrief for up to 10 minutes after each session. Participants completed standardized self-report questionnaires assessing social anxiety at pretreatment, posttreatment, and 3-month follow-up. Participants also completed measures of computer usability. Results showed decreases on all self-report measures of social anxiety from pre- to posttreatment, which were maintained at follow-up (n = 8). Participants also reported that they were satisfied with treatment, that they felt improved after treatment, and that the computer program was user-friendly. This study provides preliminary evidence that a computer-administered cognitive-behavioral-based program that includes minimal therapist contact may reduce public speaking anxiety and suggests that further research with a controlled design is needed.     

Social Anxiety and Content Specificity of Interpretation and Judgemental Bias in Children

Previous research with adult samples has demonstrated that social anxiety disorder is associated with content‐specific interpretation and judgemental biases. The present study extends our understanding of the specificity of cognitive biases in childhood social anxiety. A sample of non‐clinical children aged 11–12 years completed social anxiety and depression scales and was presented with scenarios depicting hypothetical events varying along two dimensions: relevance to self (event occurs to self or to other) and domain of activity (event is social or non‐social). Partial support for the content‐specificity hypothesis was found. Children's social anxiety symptoms were positively associated with negative interpretation ratings for ambiguous self‐referent and other‐referent events, but only when these events were in the social domain. Further, children's social anxiety symptoms were positively associated with emotional cost judgements for ambiguous social and non‐social events, but only when these events referred to the self. Both patterns of results remained significant even after controlling for concurrent depressive symptoms. Implications of the results for our understanding of maintaining factors in childhood social anxiety are discussed. Copyright © 2011 John Wiley & Sons, Ltd.     

Modelling relationships between cognitive variables during and following public speaking in participants with social phobia

Cognitive models of social phobia predict that several cognitive processes will mediate the relationship between trait levels of social anxiety and the extent of anxiety experienced in a specific social-evaluative situation. The current study aimed to provide a test of these relationships. Over 200 clinical participants with social phobia completed measures of their general social anxiety and a week later performed a brief impromptu speech. They completed a measure of state anxiety in response to the speech as well as questionnaires assessing several cognitive constructs including focus of perceived attention, perceived performance, and probability and cost of negative evaluation. A week later, they completed measures of negative rumination experienced over the week, as well as a measure of the recollection of their perceived performance. Path analysis provided support for a model in which the cognitive factors mediated between general social anxiety and the degree of anxiety experienced in response to the speech. A second model supported the theory that negative rumination mediated between characteristic social anxiety and negative bias in the recollection of performance.     

Comparison of group and individual cognitive-behavioral therapy in reducing fear of negative evaluation

Previous studies have established the efficacy of group and individual formats of cognitive-behavioral therapy in reducing fear of negative evaluation in social anxiety disorder, but the effectiveness of the group and individual therapies has not been widely assessed. This study was conducted to compare the effectiveness of cognitive-behavior group therapy to individual cognitive-behavioral therapy in social anxiety disorder. 28 patients were randomly allocated to two groups of 14. Each group participated in 12 weekly sessions. The final sample was 22 participants after drop-out. Pretest and posttest data were collected using the Brief Fear of Negative Evaluation Scale and the Beck Depression Inventory-II. Controlling for pretest fear of negative evaluation and depression, cognitive-behavioral group therapy was more effective than individual cognitive-behavioral therapy in reducing fear of negative evaluation, but the clinical significance and improvement rates of the two treatment formats were equivalent.     

The interpretation of negative social events in social phobia: changes during treatment and relationship to outcome

Catastrophic interpretations of negative social events are considered to be an important factor underlying social phobia. This study investigated the extent to which these interpretative biases change during cognitive-behavioural treatment for social phobia, and examined whether within-treatment changes in different types of interpretations predict longer-term treatment outcome. Results showed that treatment was associated with decreases in various types of maladaptive interpretations of negative social events, but that social phobia symptoms 3 months after treatment were independently predicted only by within-treatment reductions in the degree to which individuals personally believed that negative social events were indicative of unfavourable self-characteristics. These findings are discussed in relation to cognitive models of the maintenance of social anxiety, and implications for treatment are considered.     

Virtual reality therapy versus cognitive behavior therapy for social phobia: a preliminary controlled study.

Social phobia is one of the most frequent mental disorders and is accessible to two forms of scientifically validated treatments: anti-depressant drugs and cognitive behavior therapies (CBT). In this last case, graded exposure to feared social situations is one of the fundamental therapeutic ingredients. Virtual reality technologies are an interesting alternative to the standard exposure in social phobia, especially since studies have shown its usefulness for the fear of public speaking. This paper reports a preliminary study in which a virtual reality therapy (VRT), based on exposure to virtual environments, was used to treat social phobia. The sample consisted of 36 participants diagnosed with social phobia assigned to either VRT or a group-CBT (control condition). The virtual environments used in the treatment recreate four situations dealing with social anxiety: performance, intimacy, scrutiny, and assertiveness. With the help of the therapist, the patient learns adapted cognitions and behaviors in order to reduce anxiety in the corresponding real situations. Both treatments lasted 12 weeks, and sessions were delivered according to a treatment manual. Results showed statistically and clinically significant improvement in both conditions. The effect-sizes comparing the efficacy of VRT to the control traditional group-CBT revealed that the differences between the two treatments are trivial.     

Interpretation bias and social anxiety: does interpretation bias mediate the relationship between trait social anxiety and state anxiety responses?

Two studies aimed to examine whether high socially anxious individuals are more likely to negatively interpret ambiguous social scenarios and facial expressions compared to low socially anxious individuals. We also examined whether interpretation bias serves as a mediator of the relationship between trait social anxiety and state anxiety responses, in particular current state anxiety, bodily sensations, and perceived probability and cost of negative evaluation pertaining to a speech task. Study 1 used ambiguous social scenarios and Study 2 used ambiguous facial expressions as stimuli to objectively assess interpretation bias. Undergraduate students with high and low social anxiety completed measures of state anxiety responses at three time points: baseline, after the interpretation bias task, and after the preparation for an impromptu speech. Results showed that high socially anxious individuals were more likely to endorse threat interpretations for ambiguous social scenarios and to interpret ambiguous faces as negative than low socially anxious individuals. Furthermore, negative interpretations mediated the relationship between trait social anxiety and perceived probability of negative evaluation pertaining to the speech task in Study 1 but not Study 2. The present studies provide new insight into the role of interpretation bias in social anxiety.     

The generality of cognitive bias in acute stress disorder

Cognitive bias was investigated in acutely traumatised civilians with either acute stress disorder (ASD; n = 26) or no ASD (n = 24). Participants completed the Acute Stress Disorder Interview, the Beck Depression Inventory, the Beck Anxiety Inventory (BAI), the Impact of Event Scale (IES), and an Event Probability Questionnaire and an Event Cost Questionnaire that comprised items pertaining to (a) external harm, (b) somatic sensations and (c) social events. ASD participants exaggerated both the probability of negative external harm, somatic and social events occurring, and the adverse cost of those events more than non-ASD participants. Elevated probability and cost estimates were predicted by BAI and IES-Avoidance scores, respectively. These findings are discussed in the context of different patterns observed in other anxiety disorders, and interpreted in terms of network theories of posttraumatic stress.     

Interpretations and judgments regarding positive and negative social scenarios in childhood social anxiety

The present study extended our understanding of cognitive biases in childhood social anxiety. A non-clinical sample of 11-13-year olds completed social anxiety and depression scales and were presented with scenarios depicting positive and mildly negative social events. Social anxiety was associated with tendencies to interpret positive social events in a discounting fashion, to catastrophize in response to mildly negative social events, and to anticipate more negative emotional reactions to the negative events. Implications for understanding and treating social anxiety are discussed.     

Patterns of Metaperception in Adolescents with Social Anxiety: Mind Reading in the Classroom

Socially anxious adults display an interpretation bias toward anticipating threat such as a high probability of audience criticism even in nonthreatening social situations. They may also expect more negative audience reactions to self than to others acknowledging anxiety. Few studies have examined such biases in adolescents. We examined negative and positive metaperceptions (i.e., others’ perceived responses) in 13–16-year-old adolescents (n?=?655) with high vs. normal social anxiety in a hypothetical classroom scenario, in which the participants predicted the frequency of negative and positive classmate responses when imagining either themselves (self-referent metaperceptions) or a classmate (other-referent metaperceptions) with visible symptoms of social anxiety as the target persons giving a speech. We assessed social anxiety with the Social Anxiety Scale for Adolescents and metaperception using the Classroom Questionnaire of Social Anxiety and Interpersonal Cognition. Social anxiety was associated with negative self-referent metaperceptions to a greater degree than with negative other-referent metaperceptions. Compared with adolescents with normal social anxiety, those with high social anxiety (both boys and girls) predicted a broader range of negative classmate responses toward self, as compared with their predictions of negative responses toward a classmate. These group differences were observed specifically with regard to audience’s predicted covert negative responses (i.e., negative thoughts and feelings) toward self, indicating that socially anxious adolescents tend to mind-read. Minimal group differences in positive metaperceptions were observed. The results reveal target and content specificity in socially anxious adolescents’ negative metaperceptions.     

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.     

Influence of expressed emotion and perceived criticism on cognitive-behavioral therapy for social phobia

This study examined significant others' expressed emotion (EE) and a closely related construct, perceived criticism, as predictors of cognitive-behavioral therapy outcome in a sample of 40 patients with social phobia (social anxiety disorder). Patients enrolled in group therapy for social phobia completed pre- and post-treatment questionnaire measures of perceived criticism and anxious and depressive symptoms. Designated significant others were assessed for the components of high EE (criticism, hostility and emotional overinvolvement) using the Camberwell Family Interview. It was hypothesized that these high-EE components and patients' perceived criticism would be associated with poorer treatment outcome, and results ran counter to these expectations. Controlling for initial social phobia severity, lower levels of perceived criticism predicted treatment dropout. There was also a nonsignificant trend for participants with a significant other rated as high in emotional overinvolvement to show less change on a composite symptom measure. Findings from this study suggest that close relationships impact the outcome of cognitive-behavioral interventions for social phobia.     

The efficacy of remote video-based behavioral skills training and awareness training on public speaking performance

This study evaluated the efficacy of (a) remote video-based behavioral skills training (BST) with added speech outlines on teaching public speaking behaviors and (b) remote video-based awareness training (AT) on speech-disfluency rates. A multiple-baseline design across speech behaviors was used to evaluate the training. Remote video-based BST and AT were effective at teaching public speaking behaviors and reducing speech disfluencies, respectively, for both participants. In addition, performance generalized to increased audience size. Although expert ratings of perceived public speaking effectiveness improved following BST, the ratings did not improve and some worsened following AT. Both participants reported satisfaction with video-based BST and AT. One participant reported greater comfort, confidence, overall ability, and less anxiety as a public speaker following BST. Both participants reported greater improvements in those categories following AT. Our results suggest that public speaking behaviors can be taught using remote video-based BST and speech disfluencies can be reduced using remote video-based AT.     

Cognitive-behavioral therapy for social anxiety disorder: supporting evidence and future directions

The present paper examines the role of cognitive-behavioral therapy (CBT) in the treatment of social anxiety disorder (SAD). A cognitive-behavioral model of SAD is first presented. Different modalities of CBT for SAD are then described, including exposure, cognitive restructuring, relaxation training, and social skills training, and evidence supporting their efficacy is reviewed. The comparative and combined impact of CBT and pharmacotherapeutic interventions is also explored. CBT appears to be an efficacious treatment for SAD. However, the overall efficacy CBT may be increased by closer examination of the active ingredients of treatment. Such analyses may also enable more successful integration of the different CBT techniques and of CBT and pharmacotherapy in the treatment of SAD.