Bree Gregory

Changes in the self during cognitive behavioural therapy for social anxiety disorder : a systematic review

A consistent feature across cognitive-behavioural models of social anxiety disorder (SAD) is the central role of the self in the emergence and maintenance of the disorder. The strong emphasis placed on the self in these models and related empirical research has also been reflected in evidence-based treatments for the disorder. This systematic review provides an overview of the empirical literature investigating the role of self-related constructs (e.g., self-beliefs, self-images, self-focused attention) proposed in cognitive models of SAD, before examining how these constructs are modified during and following CBT for SAD. Forty-one studies met the inclusion criteria. Guided by Stopas (2009a, b) model of self, most studies examined change in self-related content, followed by change in self-related processing. No study examined change in self-structure. Pre- to post-treatment reductions were observed in self-related thoughts and beliefs, self-esteem, self-schema, self-focused attention, and self-evaluation. Change in self-related constructs predicted and/or mediated social anxiety reduction, however relatively few studies examined this. Papers were limited by small sample sizes, failure to control for depression symptoms, lack of waitlist, and some measurement concerns. Future research directions are discussed.

Development and validation of the Core Beliefs Questionnaire in a sample of individuals with social anxiety disorder

BACKGROUND Prominent cognitive models of social anxiety have consistently emphasised the importance of beliefs about the self in the aetiology and maintenance of social anxiety. The present study sought to develop and validate a new measure of core beliefs about the self for SAD, the Core Beliefs Questionnaire (CBQ). METHODS Three versions of the CBQ were developed: a Trait version (fundamental absolute statements about the self), a Contingent version (statements about the self related to a specific social-evaluative situation), and an Other version (statements about how others view the self in social-evaluative situations generally). The psychometric features of the scales were examined in clinical (n=269) and non-clinical (n=67) samples. RESULTS Exploratory factor analysis yielded a one factor model for all three versions of the questionnaire. Total scores differentiated individuals with SAD from individuals without a psychiatric condition, and demonstrated excellent internal consistency. The three CBQ versions had positive associations with social anxiety while controlling for depression, although zero-order correlations indicated the Trait version was more strongly related to depression than social anxiety, the Contingent version was similarly related to depression and social anxiety, and the Other version was more strongly related to social anxiety than depression. Scores on all three versions of the CBQ reduced from pre- to post-treatment and this change predicted treatment outcome. LIMITATIONS This is the first validation study of the CBQ. CONCLUSIONS This study provides initial support for the reliability and validity of the CBQ.

A review of scales to measure social anxiety disorder in clinical and epidemiological studies

To advance research into social anxiety disorder (SAD) and provide efficacious treatments for individuals with SAD, researchers and clinicians must have effective assessment instruments for identifying the disorder in terms of its diagnostic criteria, symptoms, and the presence of specific maintaining factors. This review highlights the main lines of existing adult and youth research on scales that form part of diagnostic instruments that assess SAD, scales that measure social anxiety symptoms, and scales that measure theory-based psychological maintaining factors associated with SAD. The review also highlights methodological issues that impact on the use of the aforementioned scales. The continued refinement and comparative evaluation of measures for SAD, culminating in the ascertainment of optimal measures, will improve the assessment and identification of the disorder. Improved identification of the disorder will contribute to the advancement of SAD research and treatment.

Relationships between probability estimates, cost estimates, and social anxiety during CBT for social anxiety disorder

The present study examined the reciprocal relationships between probability estimates, cost estimates, and social anxiety during a 12-week course of cognitive-behaviour therapy (CBT) for social anxiety disorder (SAD). One hundred and sixty-three individuals with a principal diagnosis of SAD completed a weekly tracking measure that included questions about probability and cost estimates for negative consequences and current levels of social anxiety relating to a hypothetical speech task. Paired-samples t tests revealed that these variables changed from pre-to-post treatment. Cross-lagged path analyses revealed that cost estimates predicted subsequent changes in social anxiety levels early in treatment, over and above previous anxiety ratings, while probability estimates predicted subsequent levels of social anxiety at the final stages of treatment, over and above previous anxiety ratings. Overall, the results indicated that (1) cost bias early in treatment predicts subsequent social anxiety levels, and (2) both probability and cost estimates seem to play important, but seemingly independent, roles as mechanisms of change in CBT for SAD.

Anticipatory Processing, Maladaptive Attentional Focus, and Postevent Processing for Interactional and Performance Situations: Treatment Response and Relationships With Symptom Change for Individuals With Social Anxiety Disorder ☆

Anticipatory processing, maladaptive attentional focus, and postevent processing are key cognitive constructs implicated in the maintenance of social anxiety disorder (SAD). The current study examined how treatment for SAD concurrently affects these three cognitive maintaining processes and how these processes are associated with each other as well as with symptom change from pre- to posttreatment. The sample consisted of 116 participants with SAD receiving group cognitive behavioral therapy. All three cognitive maintaining processes were measured relative to a speech task and again relative to a conversation task. Across both tasks, the three cognitive process variables demonstrated decreases from pre- to posttreatment. Within the same task, a slower rate of decrease in a specific cognitive process variable from pre- to posttreatment was predicted from higher pretreatment levels of either one or both of the other cognitive process variables. Additionally, higher levels of pretreatment conversation-related anticipatory processing and maladaptive attentional focus predicted a slower rate of decrease in social anxiety symptoms from pre- to posttreatment. Results are consistent with cognitive models of SAD and have important implications for enhancing existing treatments.

Maladaptive Self-Beliefs During Cognitive Behavioural Therapy for Social Anxiety Disorder: A Test of Temporal Precedence

Given the putative importance of maladaptive self-beliefs in cognitive models of social anxiety, there is growing interest in the construct’s influence on social anxiety reduction in treatment. The present study sought to examine whether maladaptive self-beliefs reduce over a 12-week course of cognitive behavioural therapy (CBT) for social anxiety disorder (SAD), and whether change in self-beliefs is an indicator of later change in social anxiety symptom severity within treatment. Participants were 77 individuals with SAD who completed measures of maladaptive self-beliefs every 2 weeks of the treatment protocol and measures of social anxiety each week. Using a dynamic bivariate latent difference score framework, results indicated that maladaptive self-beliefs reduced during CBT for SAD, and that change in maladaptive self-beliefs was a significant predictor of later change in social anxiety symptom severity. Reductions in social anxiety was not a significant predictor of later change in self-beliefs. Findings underscore the importance of maladaptive self-beliefs in the maintenance of social anxiety and in treatment for SAD. Moreover, they permit inferences about the temporal sequence of change processes in therapy and are consistent with CBT therapeutic models suggesting that cognitive change precedes symptom change.

An empirical analysis of Moscovitch’s reconceptualised model of social anxiety: How is it different from fear of negative evaluation?

Cognitive-behavioural models propose that excessive fear of negative evaluation is central to social anxiety. Moscovitch (2009) instead proposes that perceived deficiencies in three self attributes: fears of showing signs of anxiety, deficits in physical appearance, or deficits in social competence are at the core of social anxiety. However, these attributes are likely to overlap with fear of negative evaluation. Responses to an online survey of 286 participants with a range of social anxiety severity were analysed using hierarchical multiple regression to identify the overall unique predictive value of Moscovitchs model. Altogether, Moscovitchs model provided improvements in the prediction of safety behaviours, types of fears and cognitions; however only the fear of showing anxiety subscale provided unique information. This research supports further investigations into the utility of this revised model, particularly related to utility of explicitly assessing and addressing fears of showing anxiety.