Faith A. Brozovich

A Cognitive behavioral model of social anxiety disorder : update and extension

Publisher Summary This chapter focuses on the original 1997 cognitive behavioral model for social anxiety disorder (SAD), which delineates the processes by which SAIs are affected by their fear of negative evaluation in potentially social-evaluative situations. The original model has provided a solid framework for understanding the factors that comprise and maintain SAD. Since the publication of Rapee and Heimberg (1997), updates are provided in the form of reviews of the literature that support various aspects of the model, applied the model to a case study of a person with SAD, and conducted a comparison between the model and the very influential and productive model proposed by Clark and Wells. Given that there has been over a decade of intervening research, however, there are areas in the model that warrant expansion, as well as additional factors that necessitate inclusion in the model. The chapter presents a revised cognitive behavioral model of SAD and the research supporting these modifications. The chapters primary focus are five areas: the important role of imagery (and imagery perspective), PEP, the combined cognitive biases hypothesis, fear of positive evaluation (FPE), and the potential role of difficulties in the regulation of emotional responses, including but not limited to anxiety.

An analysis of post-event processing in social anxiety disorder.

Research has demonstrated that self-focused thoughts and negative affect have a reciprocal relationship [Mor, N., Winquist, J. (2002). Self-focused attention and negative affect: A meta-analysis. Psychological Bulletin, 128, 638-662]. In the anxiety disorder literature, post-event processing has emerged as a specific construction of repetitive self-focused thoughts that pertain to social anxiety disorder. Post-event processing can be defined as an individuals repeated consideration and potential reconstruction of his performance following a social situation. Post-event processing can also occur when an individual anticipates a social or performance event and begins to brood about other, past social experiences. The present review examined the post-event processing literature in an attempt to organize and highlight the significant results. The methodologies employed to study post-event processing have included self-report measures, daily diaries, social or performance situations created in the laboratory, and experimental manipulations of post-event processing or anticipation of an upcoming event. Directions for future research on post-event processing are discussed.

Remembering the Good, Forgetting the Bad: Intentional Forgetting of Emotional Material in Depression

The authors examined intentional forgetting of negative material in depression. Participants were instructed to not think about emotional nouns that they had learned to associate with a neutral cue word. The authors provided participants with multiple occasions to suppress the unwanted words. Overall, depressed participants successfully forgot negative words. Moreover, the authors obtained a clear practice effect. However, forgetting came at a cost: Compared with the nondepressed participants and with the depressed participants who were instructed to forget positive words, depressed participants who were instructed to forget negative words showed significantly worse recall of the baseline words. These results indicate that training depressed individuals in intentional forgetting could prove to be an effective strategy to counteract automatic ruminative tendencies and mood-congruent biases.

Biases in Interpretation and Memory in Generalized Social Phobia

Two experiments examined the link between interpretation and memory in individuals diagnosed with Generalized Social Phobia (GSP). In Experiment 1, GSP and control participants generated continuations for nonsocial and ambiguous social scenarios. GSP participants produced more socially anxious and negative continuations for the social scenarios than did the controls. On the subsequent test of recalling the social scenarios, intrusion errors that shared meaning with the original continuations were made more frequently by the GSP group, producing false recall with emotionally negative features. To examine whether nonanxious individuals would also produce such errors if given emotional interpretations, in Experiment 2 the authors asked university students to read the scenarios plus endings produced by GSP participants in Experiment 1. The students either constructed vivid mental images of themselves as the main characters or thought about whether the endings provided closure. Low-anxious students in the closure condition produced fewer ending-based intrusions in recalling the social scenarios than did students in the other 3 conditions. Results illustrate the importance of examining the nature of source-monitoring errors in investigations of memory biases in social anxiety.

A Cognitive-Behavioral Model of Social Anxiety Disorder

Social anxiety disorder (SAD) is one of the most common and impairing psychological disorders. To advance our understanding of SAD, several researchers have put forth explanatory models over the years, including one which we originally published almost two decades ago (Rapee & Heimberg, 1997), which delineated the processes by which socially anxious individuals are affected by their fear of evaluation in social situations. Our model, as revised in the 2010 edition of this text, is summarized and further updated based on recent research on the multiple processes involved in the maintenance of SAD.

Cognitive Habits and Memory Distortions in Anxiety and Depression

When anxious or depressed people try to recall emotionally ambiguous events, they produce errors that reflect their habits of interpreting ambiguity in negative ways. These distortions are revealed by experiments that evaluate performance on memory tasks after taking interpretation biases into account—an alternative to the standard memory-bias procedure that examines the accuracy of memory for clearly emotional material. To help establish the causal role of interpretation bias in generating memory bias, these distortions have been simulated by training interpretation biases in nondisordered groups. The practical implications of these findings for therapeutic intervention are discussed; future directions are described.

Group CBT versus MBSR for social anxiety disorder: A randomized controlled trial.

OBJECTIVE The goal of this study was to investigate treatment outcome and mediators of cognitive-behavioral group therapy (CBGT) versus mindfulness-based stress reduction (MBSR) versus waitlist (WL) in patients with generalized social anxiety disorder (SAD). METHOD One hundred eight unmedicated patients (55.6% female; mean age = 32.7 years, SD = 8.0; 43.5% Caucasian, 39% Asian, 9.3% Hispanic, 8.3% other) were randomized to CBGT versus MBSR versus WL and completed assessments at baseline, posttreatment/WL, and at 1-year follow-up, including the Liebowitz Social Anxiety Scale-Self-Report (primary outcome; Liebowitz, 1987) as well as measures of treatment-related processes. RESULTS Linear mixed model analysis showed that CBGT and MBSR both produced greater improvements on most measures compared with WL. Both treatments yielded similar improvements in social anxiety symptoms, cognitive reappraisal frequency and self-efficacy, cognitive distortions, mindfulness skills, attention focusing, and rumination. There were greater decreases in subtle avoidance behaviors following CBGT than MBSR. Mediation analyses revealed that increases in reappraisal frequency, mindfulness skills, attention focusing, and attention shifting, and decreases in subtle avoidance behaviors and cognitive distortions, mediated the impact of both CBGT and MBSR on social anxiety symptoms. However, increases in reappraisal self-efficacy and decreases in avoidance behaviors mediated the impact of CBGT (vs. MBSR) on social anxiety symptoms. CONCLUSIONS CBGT and MBSR both appear to be efficacious for SAD. However, their effects may be a result of both shared and unique changes in underlying psychological processes.

Anxiety trajectories in response to a speech task in social anxiety disorder: Evidence from a randomized controlled trial of CBT ☆

The subjective experience of anxiety plays a central role in cognitive behavioral models of social anxiety disorder (SAD). However, much remains to be learned about the temporal dynamics of anxiety elicited by feared social situations. The aims of the current study were: (1) to compare anxiety trajectories during a speech task in individuals with SAD (n=135) versus healthy controls (HCs; n=47), and (2) to compare the effects of CBT on anxiety trajectories with a waitlist control condition. SAD was associated with higher levels of anxiety and greater increases in anticipatory anxiety compared to HCs, but not differential change in anxiety from pre- to post-speech. CBT was associated with decreases in anxiety from pre- to post-speech but not with changes in absolute levels of anticipatory anxiety or rates of change in anxiety during anticipation. The findings suggest that anticipatory experiences should be further incorporated into exposures.

Attentional blink impairment in social anxiety disorder: Depression comorbidity matters

BACKGROUND AND OBJECTIVES Difficulties with attentional control have long been thought to play a key role in anxiety and depressive disorders. However, the nature and extent of attentional control difficulties in social anxiety disorder (SAD) are not yet well understood. The current study was designed to assess whether attentional control for non-emotional information is impaired in SAD when taking comorbid depression into account.. METHODS Individuals with SAD and healthy controls (HCs) were administered an attentional blink (AB) task in which they identified number targets in a rapid serial visual presentation stream of letters. RESULTS Individuals with SAD and current comorbid depression exhibited reduced accuracy to identify a target that fell within the AB window after the presentation of a first target compared to individuals with SAD without current comorbid depression, as well as to HCs. The latter two groups did not differ from each other, and the three groups did not differ in accuracy for the second target when it was presented after the AB window. LIMITATIONS Although we included two clinical groups and the sample size for the non-comorbid SAD group was large, the comorbid SAD group was relatively small. CONCLUSIONS These results suggest that impaired attentional control among individuals with SAD may be limited to those suffering from current comorbid depression..