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Specificity of cognitive biases in social phobia and their role in recovery
Abstract
Cognitive theorists propose that each anxiety disorder is associated with a specific tendency to overestimate the danger inherent in particular situations or internal states. Studies comparing anxious patients with non-patient controls have shown that several anxiety disorders are associated with elevated subjective estimates of the likelihood (probability) and cost of negative events. The present study focuses on social phobia and extends previous findings by: a) including a control group of equally anxious patients with another anxiety disorder and b) investigating the effects of successful cognitive and drug treatments on patients' probability and cost estimates. In line with cognitive theory, the results indicate that social phobia is associated with a specific elevation in subjective estimates of both the probability and cost of potentially negative social events. Reductions in overestimation occurred in successful cognitive and drug treatment and were closely related to the degree of symptomatic improvement in both treatments. Contrary to previous findings, there was no evidence that reductions in cost were more important than reductions in probability.
... At least one longitudinal cohort study has also found a variation on the SCQ to be predictive of increased social anxiety as studied outside of treatment (Chiu et al., 2021). Also relevant for social anxiety, the Social Probability and Cost Questionnaire (SPCQ) probes the perceived probability and cost of adverse social outcomes, indicative of dysfunctional assumptions that can be targeted in therapy (Foa et al., 1996;Hoffart et al., 2009;Hoffart et al., 2016;McManus et al., 2000). Although the most widespread version of the SPCQ has 33 items (McManus et al., 2000), an 8-item version has also been used (Hoffart et al., 2009;Santoft et al., 2019b). ...
... Also relevant for social anxiety, the Social Probability and Cost Questionnaire (SPCQ) probes the perceived probability and cost of adverse social outcomes, indicative of dysfunctional assumptions that can be targeted in therapy (Foa et al., 1996;Hoffart et al., 2009;Hoffart et al., 2016;McManus et al., 2000). Although the most widespread version of the SPCQ has 33 items (McManus et al., 2000), an 8-item version has also been used (Hoffart et al., 2009;Santoft et al., 2019b). Probability and cost biases have been found to respond to CBT for social anxiety disorder (Benbow and Anderson, 2018), and at least one study has been indicative of a reciprocal relationship between the SPCQ and social anxiety over the course of CBT (Santoft et al., 2019b). ...
... , we also administered eight items from the Social Probability and Cost Questionnaire (SPCQ) which concerns the perceived probability and valence of adverse social outcomes (Foa et al., 1996;Hoffart et al., 2016;McManus et al., 2000). The Social Behavior Questionnaire (SBQ) is usually found to have two subfactors: Avoidance (SBQ-A) and Impression Management (SBQ-IM) (Gray et al., 2019). ...
Background
The measurement of process variables derived from cognitive behavioural theory can aid treatment development and support the clinician in following treatment progress. Self-report process measures are ideally brief, which reduces the burden on patients and facilitates the implementation of repeated measurements.
Aims
To develop 13 brief versions (3–6 items) of existing cognitive behavioural process scales for three common mental disorders: major depression, panic disorder, and social anxiety disorder.
Method
Using data from a real-world teaching clinic offering internet-delivered cognitive behavior therapy ( n =370), we drafted brief process scales and then validated these scales in later cohorts ( n =293).
Results
In the validation data, change in the brief process scales significantly mediated change in the corresponding domain outcomes, with standardized coefficient point estimates in the range of –0.53 to –0.21. Correlations with the original process scales were substantial ( r =.83–.96), internal consistency was mostly adequate (α=0.65–0.86), and change scores were moderate to large (| d| =0.51–1.18). For depression, the brief Behavioral Activation for Depression Scale-Activation subscale was especially promising. For panic disorder, the brief Agoraphobic Cognitions Questionnaire-Physical Consequences subscale was especially promising. For social anxiety disorder, the Social Cognitions Questionnaire, the Social Probability and Cost Questionnaire, and the Social Behavior Questionnaire-Avoidance and Impression Management subscales were all promising.
Conclusions
Several brief process scales showed promise as measures of treatment processes in cognitive behaviour therapy. There is a need for replication and further evaluation using experimental designs, in other clinical settings, and preferably in larger samples.
... The expected negative consequences of social behaviour, namely the social costs, might also play an important role in maintaining SAD, as suggested by Foa and Kozak [15]. More specifically, individuals with SAD tend to overestimate the costs of negative social incidents [16]. Changes in estimated social costs during treatment have been positively associated with treatment outcome in cognitive therapy [16], cognitive behavioural therapy [17][18][19], drug treatment [16], and exposure therapy [20]. ...
... More specifically, individuals with SAD tend to overestimate the costs of negative social incidents [16]. Changes in estimated social costs during treatment have been positively associated with treatment outcome in cognitive therapy [16], cognitive behavioural therapy [17][18][19], drug treatment [16], and exposure therapy [20]. However, current literature is inconclusive regarding the role of estimated social costs as a predictor of treatment outcome in SAD. ...
... More specifically, individuals with SAD tend to overestimate the costs of negative social incidents [16]. Changes in estimated social costs during treatment have been positively associated with treatment outcome in cognitive therapy [16], cognitive behavioural therapy [17][18][19], drug treatment [16], and exposure therapy [20]. However, current literature is inconclusive regarding the role of estimated social costs as a predictor of treatment outcome in SAD. ...
Background
Cognitions play an important role in the development and maintenance of social anxiety disorder (SAD).
Methods
To investigate whether changes in cognitions during the first six sessions of exposure therapy are associated with treatment outcome, we assessed reported self-focused attention, self-efficacy in social situations, and estimated social costs in 60 participants (Mage = 36.9 years) diagnosed with SAD who received in vivo or virtual reality exposure therapy.
Results
Patients demonstrating a greater decrease in estimated social costs during treatment reported greater improvement of their social anxiety symptoms following both forms of exposure therapy. While changes in self-focused attention and social self-efficacy during treatment were significantly associated with treatment outcome when examined individually, these changes did not significantly predict symptom improvement beyond social costs.
Conclusions
Changes in estimated social costs during treatment are associated with improvement of social anxiety symptoms after exposure therapy. Future research needs to further investigate estimated social costs as a predictor in relation to other cognitive variables.
Trial registration
NCT01746667; www.clinicaltrials.gov, November 2012, retrospectively registered.
... Empirical research shows that compared to non-anxious controls, people with social anxiety disorder report that negative outcomes following social events are more likely and more costly (Foa et al. 1996;McManus et al. 2000;Uren et al. 2004). Several studies show that cognitive-behavioral therapy (CBT) for social anxiety disorder is associated with significant reductions in probability and/or cost biases immediately following treatment (Boden et al. 2012;Lucock and Salkovskis 1988;Poulton and Andrews 1996). ...
... Studies using wait-list control groups found that various forms of CBT lead to significantly greater reductions in probability and/or cost biases, including cognitive behavioral group therapy (Hofmann 2004;Taylor and Alden 2008), exposure group therapy (Calamaras et al. 2015;Hofmann 2004), and virtual reality exposure therapy (Calamaras et al. 2015). McManus et al. (2000) used an active control (placebo medication) and found that cognitive therapy and fluoxetine produced significant reductions in probability and cost biases. Finally, two studies compared active treatments to each other. ...
... Hoffart et al. (2009) found that cognitive therapy and interpersonal therapy were associated with reductions in probability and cost biases, and Rapee et al. (2009) found that relative to stress management and standard CBT, CBT that was intentionally modified to target cognitive processes (enhanced CBT) produced greater changes in cost biases, but not probability biases. In summary, the small body of research designed to test whether standard CBT causes changes in cognitive biases tends to suggest this is the case, as all studies show that CBT produces reductions in probability and/or cost biases (Calamaras et al. 2015;Hoffart et al. 2009;Hofmann 2004;McManus et al. 2000;Taylor and Alden 2008), with one exception (Rapee et al. 2009). ...
This study examines whether improvements in probability and cost biases following cognitive behavioral therapy for social anxiety disorder endure over the long-term. Participants (N=65) diagnosed with social anxiety disorder were randomly assigned and completed eight sessions of either exposure group therapy or virtual reality exposure therapy delivered according to a treatment manual. Twenty-four participants completed standardized self-report measures of probability and cost biases at pre-treatment, post-treatment, and 5 ½ years, on average, after completing active treatment (range 2.5 – 6.5 years). Analyses of variance show that, relative to wait list, participants who completed an active treatment reported greater decline in probability and cost biases at post-treatment. Further, relative to pre-treatment, all treated participants reported significant improvements in probability and cost biases at post-treatment and at long-term follow-up. Cognitive-behavioral therapy may lead to long-lasting reductions in cognitive biases.
... Expectancy biases are common in phobia. For instance, social phobics appear to overestimate the negative consequences of negative social events (Foa, Franklin, Perry, & Herbert, 1996;McManus, Clark, & Hackmann, 2000). Related effects have been observed in fears that are unrelated to social events. ...
... Consistent off-line encounter expectancy biases have been reported for social phobia. Specifically, social phobics have been observed to overestimate the likelihood of being personally confronted with negative social events (Foa et al., 1996;Gilboa-Schechtman, Franklin, & Foa, 2000;Lucock & Salkovskis, 1988; possibly restricted to situations regarding personal performance: McManus et al., 2000), while underestimating the likelihood of being confronted with positive social events (Gilboa-Schechtman et al., 2000;Lucock & Salkovskis, 1988). Offline encounter expectancy biases have also been observed in agoraphobia (McNally & Foa, 1987) and acrophobia (Menzies & Clarke, 1995). ...
... Notably, both types of expectancy bias diminished or even extinguished after effective treatment of social phobia (e.g., Foa et al., 1996;Lucock & Salkovskis, 1988;McManus et al., 2000). Patients in the Foa et al. (1996) study, for instance, underwent comprehensive cognitive-behavioral therapy for generalized social phobia. ...
Healthy individuals often exhibit prioritized processing of aversive information, as manifested in enhanced orientation of attention to threatening stimuli compared with neutral items. In contrast to this adaptive behavior, anxious, fearful, and phobic individuals show exaggerated attention biases to threat. In addition, they overestimate the likelihood of encountering their feared stimulus and the severity of the consequences; both are examples of expectancy biases. The co-occurrence of attention and expectancy biases in fear and anxiety raises the question about causal influences. Herein, we summarize findings related to expectancy biases in fear and anxiety, and their association with attention biases. We suggest that evidence calls for more comprehensive research strategies in the investigation of mutual influences between expectancy and attention biases, as well as their combined effects on fear and anxiety. Moreover, both types of bias need to be related to other types of distorted information processing commonly observed in fear and anxiety (e.g., memory and interpretation biases). Finally, we propose new research directions that may be worth considering in developing more effective treatments for anxiety disorders.
... ДУШАН Ј. РАНЂЕЛОВИЋ Ре:укција EрисMрасносMи Eроцене исхо:а :о;ађаја сMаMисMички значајно корелира са снижењем социјалне анксиозносMи (Foa et al., 1996) и симEMома социјалне фоKије (Hormann, 2004;Wilson & Rapee, 2005). Дру;е сMу:ије (нEр., McManus et al., 2000;Smits, Rosenfield, McDonald & Telch, 2006a) Eоказују :а Eромене у Eри-сMрасносMи Eроцене вероваMноће Eојаве неEожељних :о;ађаја Kоље Eре:виђају ре:укцију социјалне анксиозносMи не;о Eромене у EрисMрсносMи Eроцене Eосле:ица :о којих они мо;у :овесMи. Реформулисана Теорија осеMљивосMи на EоMкреEљење (rRST; Gray & McNaughton, 2003) EреMEосMавља :а су ин:иви:уалне разлике у сисMему Kихејвиоралне инхиKиције (BIS -behavioral inhibition system), сисMему Kихејвиоралне акMивације (BASbehavioral approach system) и БорKа/Бежање/Блокирање сисMему (BBBS ili Fight/Flight/Freezing System -FFFS), о:;оворне за мно;е ин:иви:уалне разлике у личносMи, EсихоEаMоло;ији и осеMљи-восMи на EоMкреEљење. ...
... Такође, EосMоји EозиMивна EовезаносM између, анксиозносMи, сMраха о: не;аMивне евалуације (која лежи у основи социјалне анскиозносMи) и ко;ниMивних EрисMрасносMи, Mј. EрисMрасносMи расуђивања (McManus, Clark & Hackmann, 2000). ...
... Имајући у ви:у значајносM консMрукMа EрисMрасносMи расуђивања за исMраживачку и клиничку Eраксу и не:осMаMак инсMру-менаMа који оEерационализује исMи ко: нас, основна сврха ово; ра:а је Eровера меMријских каракMерисMика срEске верзије је:но; о: најчечешће сEомињаних и коришћених уEиMника који је намењен Eроцени ово; консMрукMа. Реч је о УEиMнику социјалне вероваMноће и EоMенцијалних Eосле:ица (Social Probability Cost Questionnaire; SPCQ; McManus, Clark & Hackmann, 2000). СMо;а Eос-Mављени су сле:ећи циљеви: 1) ИсEиMаMи Eоуз:аносM уEиMника на узорку исEиMаника из СрKије; 2) ИсEиMаMи лаMенMну сMрукMуру уEиMника и 3) ИсEиMаMи консMрукM вали:носM уEиMника Eровером корелација са :ру;им релеванMним консMрукMима (осоKине личносMи, анксиозносM као црMа и сMрах о: не;аMивне евалуације). ...
Prejudice in judgment has an important role in cognitive models of psychopathology. Every selective processing of emotionally relevant stimuli is called cognitive prejudice. One of the cognitive prejudices that is considered a key factor of socially - anxious disorder is prejudice in judgment. It is defined as a disposition to overestimate the probability of occurrence of negative social events in the near future, as well as potential consequences (agitation) that might follow them. The perception of danger is essentially determined by a joined effect of subjective assessment of probability and agitation created by certain events. The researches have shown that socially-anxious individuals have a more expressive prejudice in judgment and that it can be reduced by applying certain psychotherapeutic and pharmacological treatments, which proves its relevance for the socially-anxious disorder. Considering the significance of the prejudice in judgment construct for the research and clinical practice and the lack of instruments that is operational in our country, the basic purpose of this paper is to check metric characteristics of the Serbian version of one of the most often mentioned and used questionnaires aimed at the assessment of this construct. It is the Questionnaire of social probability and potential consequences, which has two subscales: 1) to examine the reliability of the questionnaire on the sample of examinees from Serbia; 2) to examine the latent structure of the questionnaire and 3) to examine the construct of validity of the questionnaire by checking the correlations with other relevant constructs (personality traits, anxiety as a trait and fear of negative evaluation).The was adapted for Serbian language from English. The sample consists of 166 examinees, aged from 19 to 29 (AS = 21,73; SD = 1,43). The questionnaire for sensitivity to confirmation assessment was used to estimate personality traits, Anxiety as a trait was estimated by the Scale of anxiety as a trait, which is a part of the anxiety as a trait and condition Inventory, and fear of negative evaluation was estimated by the Scale of fear of negative evaluation - short form. The results show that the instrument for evaluation of prejudice in judgment is highly reliable (α=.96; α=.96), and that its items can be considered representative (KMO = .93; KMO = .93) and homogeneous (h1 = .47; h1 =.44). In the purpose of the assessment of the latent structure of the questionnaire an explorational factor analysis was conducted (the methods of the main components), and the results suggested that the questionnaire is the kind with two one-dimension subscales (the percentage of the explained variance is 49.21% i 45.80%). In favor of the construct of validity are the results of correlation analysis, that describe important relations of both components of prejudice in judgment with personality traits, anxiety and fear of negative evaluation, and they do so in the expected direction. In accordance with all this, the Serbian version of the questionnaire can be recommended for measuring prejudice in judgment.
... Apart from the biased interpretation of social information, socially anxious individuals also overestimate the likelihood and costs of negative social events (judgmental bias). Experimental studies showed that a decrease in judgmental bias mediates the reduction of social anxiety symptoms (e.g., Foa, Franklin, Perry, & Herbert, 1996;Hofmann, 2004;McManus, Clark, & Hackmann, 2000). Voncken, B€ ogels, and de Vries (2003) assessed both interpretation and judgmental bias and found evidence for biased interpretation and judgment of social events irrespective of the valence of the situation, including positive and neutral events. ...
... Trainings that induced benign or positive interpretation biases resulted in reduced trait anxiety (Mathews, Ridgeway, Cook, & Yiend, 2007;Salemink, van den Hout, & Kindt, 2009). As an additional hint to the relevance of cognitive biases in SAD, several studies showed that interpretation and judgment biases could be reduced through cognitive-behavior therapy and were associated with symptom change (Hofmann, 2004;McManus et al., 2000). Although CBT protocols do not specifically target interpretation and judgmental bias, cognitive restructuring techniques address all forms of 'negative thinking', including those forms relevant in ambiguous social situations. ...
... Compared to conventional CBT interventions delivered face-toface, our program yielded smaller decreases of anxiety symptoms (d ¼ 0.7e1.4) and smaller cognitive bias reductions (d ¼ 0.9e1.5) (Foa et al., 1996;Hofmann, 2004;McManus et al., 2000;Voncken & B€ ogels, 2006). Also, Internet-based CBT interventions show higher effect sizes for social anxiety symptoms than the current program (d ¼ 0.3e1.6) ...
... Several studies on change processes in CBT for SAD support the cognitive maintenance model. For example, pre-to-post reductions in probability estimates (McManus, Clark, & Hackmann, 2000), cost estimates (Foa, Franklin, Perry, & Herbert, 1996), post-event processing (McEvoy, Mahoney, Perini, & Kingsep, 2009), and use of safety behaviors (Goldin et al., 2016) have been found associated with pre-to-post improvements in social anxiety. However, a limitation in previous research is that a vast majority of process and mediational studies have not been designed to investigate temporal precedence, that is, whether change in processes occurred before change in outcome. ...
... Estimated probability and cost of negative social events were measured by the Social Probability and Cost Questionnaire (SPCQ; Foa et al., 1996;McManus et al., 2000). Each item (e.g., "Someone will think I'm odd") was rated on a scale from 0 to 100 regarding both estimated probability and estimated cost, and a mean score (0-100) was used for each subscale. ...
Although cognitive behavior therapy (CBT) is an effective treatment for social anxiety disorder, little is known about the processes during treatment that bring about change. The aim of this study was to investigate whether the proposed processes of change according to the cognitive model of social anxiety disorder predicted subsequent symptom reduction in CBT delivered as therapist-guided bibliotherapy. We analyzed data from patients with social anxiety disorder (N = 61) who participated in an effectiveness trial of CBT in primary care. Seven putative processes and outcome (i.e., social anxiety) were assessed on a weekly basis throughout treatment. We used linear mixed models to analyze within-person relations between processes and outcome. The results showed a unidirectional effect of reduced avoidance on subsequent decrease in social anxiety. Further, we found support for reciprocal influences between four of the proposed processes (i.e., estimated probability and cost of adverse outcome, self-focused attention, and safety behaviors) and social anxiety. The remaining two processes, (i.e., anticipatory and post-event processing) did not predict subsequent social anxiety, but were predicted by prior symptom reduction. The findings support that several of the change processes according to the cognitive model of social anxiety disorder are involved in symptom improvement.
... Foa and Kozak (1985) originally theorized that inflated cost estimates are the primary variable mediating change in SAD because, whereas other anxiety disorders are characterized by overestimates of the probability of objectively catastrophic outcomes (e.g., heart attack, death of a loved one), the feared outcomes in SAD (e.g., appearing foolish, being embarrassed) are not objectively dangerous. Empirical research with clinical samples has, however, yielded mixed findings: two studies found cost bias to be more important (Foa et al., 1996;Rapee et al., 2009), two studies found probability bias to be more important (McManus, Clark, & Hackmann, 2000;Smits et al., 2006), and two studies found each to be significant predictors and did not make inferences about their relative importance (Hoffart et al., 2009;Taylor & Alden, 2008). Based on Foa and Kozak's original theory, we hypothesize that reductions in cost will be a stronger predictor of treatment outcome than reductions in probability when modeled simultaneously. ...
... Our finding that cost bias at midtreatment was not a significant predictor of treatment outcome is consistent with two of the six previous empirical investigations that examined both cost and probability biases as predictors or mediators of treatment outcome (McManus et al., 2000;Smits et al., 2006). The consistency with the Smits et al. (2006) findings is especially noteworthy, given that the authors used similarly robust mediation analyses and different measures of anxiety and judgmental biases. ...
Reductions in judgmental biases concerning the cost and probability of negative social events are presumed to be mechanisms of treatment for SAD. Methodological limitations of extant studies, however, leave open the possibility that, instead of causing symptom relief, reductions in judgmental biases are correlates or consequences of it. The present study evaluated changes in judgmental biases as mechanisms explaining the efficacy of CBT for SAD. Participants were 86 individuals who met DSM-IV-TR criteria for a primary diagnosis of SAD, participated in one of two treatment outcome studies of CBT for SAD, and completed measures of judgmental (i.e., cost and probability) biases and social anxiety at pre-, mid-, and posttreatment. Treated participants had significantly greater reductions in judgmental biases than not-treated participants; pre-to-post changes in cost and probability biases statistically mediated treatment outcome; and probability bias at midtreatment was a significant predictor of treatment outcome, even when modeled with a plausible rival mediator, working alliance. Contrary to hypotheses, cost bias at midtreatment was not a significant predictor of treatment outcome. Results suggest that reduction in probability bias is a mechanism by which CBT for SAD exerts its effects.
Copyright © 2015 Elsevier Ltd. All rights reserved.
... We assessed anxious cognitions using 11 questions from the Anxious Questionnaire, ATQ. Seven items from the ATQ relating to agoraphobia (ATQ-AP) (Chambless et al., 1984;Hoffart, 1995) and four items from the social anxiety ATQ (ATQ-SA) (Hoffart et al., 2009;McManus et al., 2000) were used. More details are available in our previous publication (Knapstad & Smith, 2021). ...
Background
In this exploratory study, we investigated a comprehensive set of potential moderators of response to the primary care service Prompt Mental Health Care (PMHC).
Methods
Data from an RCT of PMHC (n = 463) versus treatment as usual (TAU, n = 215) were used. At baseline mean age was 34.8, 66.7% were women, and 91% scored above caseness for depression (PHQ-9) and 87% for anxiety (GAD-7). Outcomes: change in symptoms of depression and anxiety and change in remission status from baseline to six- and 12- months follow-up. Potential moderators: sociodemographic, lifestyle, social, and cognitive variables, variables related to (mental) health problem and care. Each moderator was examined in generalized linear mixed models with robust maximum likelihood estimation.
Results
Effect modification was only identified for anxiolytic medication for change in symptoms of depression and anxiety; clients using anxiolytic medication showed less effect of PMHC relative to TAU (all p < 0.001), although this result should be interpreted with caution due to the low number of anxiolytic users in the sample. For remission status, none of the included variables moderated the effect of treatment.
Conclusion
As a treatment for depression and/or anxiety, PMHC mostly seems to work equally well as compared to TAU across a comprehensive set of potential moderators.
... Anxiety disorders are common and debilitating disorders characterized by excessive worry and fear that often increases in late childhood/early adolescence, particularly among girls (Essau et al., 2018;Hartung & Lefler, 2019). Compared to non-anxious individuals, individuals with anxiety expect future experiences to be more negative (e.g., McManus et al., 2000;Spielberg et al., 2015). ...
Objective:
Anxiety symptoms often increase in late childhood/early adolescence, particularly among girls. However, few studies examine anxiety-relevant gender differences during anticipation and avoidance of naturalistic experiences during adolescence. The current study uses ecological momentary assessment (EMA) to examine associations among clinical anxiety, gender, anticipation, and attempted avoidance of person-specific anxiety-provoking experiences in youth ages 8-18.
Method:
124 youth (73 girls) completed 7 consecutive days of EMA. Seventy participants (42 girls) met criteria for one or more anxiety disorders, while the remaining 54 were healthy controls (31 girls). Participants reported the experience that they were "most worried about happening that day" and completed ratings about that event including whether they attempted to avoid that experience. Multilevel models examined whether diagnostic group (anxious, healthy), gender (boys, girls), or their interaction predicted anticipatory ratings or avoidance of these experiences.
Results:
Analyses revealed significant diagnostic group by gender interactions for anticipatory ratings. Specifically, anxious girls reported greater worry and predicted more negative outcomes related to future experiences. However, only a main effect of diagnostic group emerged for attempted avoidance. Finally, anticipatory worry predicted higher rates of attempted avoidance, but this association did not vary by diagnostic group, gender, or their interaction.
Conclusion:
These findings extend the literature on the interplay of anticipation and avoidance to person-specific naturalistic experiences in pediatric anxiety. They reveal that anxious girls report more anticipatory anxiety and worry, while avoidance of real-world anxiety-provoking scenarios is a key concern for anxious youth independent of gender. By using EMA to examine person-specific anxiety-inducing experiences we can begin to understand how these processes and experiences unfold in the real world.
... Four items from the Social Probability and Cost Questionnaire (SPCQ) were used to measure cognitions (Table I) (McManus et al., 2000). These four items have been used for this purpose before (Hoffart et al., 2016;Johnson et al., 2018;Santoft et al., 2019), and were initially selected because these were found to have the highest Cronbach's alpha in a study conducted with social phobia patients at Modum Bad (Hoffart et al., 2009). ...
Objectives
In cognitive behavioral therapy (CBT) for social anxiety disorder (SAD), avoidance behavior (AB) and cognitions (COG) are two important targets of intervention, but so far no studies have directly examined their relative importance. By means of cross-lagged panel models (CLPM), we examined their temporal associations and impacts on outcome in clients with symptoms of SAD while addressing typical methodological challenges.
Method
We used data from the first six therapy sessions in a sample of 428 primary care clients (mean [SD] age = 34.6 [12.2], 34.3% men), participating in the Prompt Mental Health Care trial. Session-by-session data was collected on AB, COG, depression and general anxiety. Competing multiple indicator CLPMs were tested.
Results
The Random Intercept-CLPM provided best fit, and indicated that AB predicted COG at subsequent time points (.39 ≤ β ≤ .42 for T2–T5, p < .05), but not vice versa. In addition, AB, but not COG, predicted clients’ general anxiety score at subsequent time points. Results were both robust to the inclusion of depressive symptoms as a within-level covariate, and sensitivity tests for stationarity and missing data assumptions.
Conclusion
Targeting avoidance behavior for primary care clients with symptoms of SAD may be more vital for the optimal effect of CBT than targeting cognitions. Methodological considerations and limitations of the study are discussed.
Trial registration: ClinicalTrials.gov identifier: NCT03238872.
... These social anxieties are typically accompanied by avoidance of social situations (Clark, 1995;Hoffman, 2007). Although individuals with high social anxiety often feel that by avoiding social interaction they can reduce and control their anxiety, studies have suggested that avoidance contributes to anxiety maintenance as it prevents disconfirmation of negative beliefs (Aderka et al., 2013;Hoffmann, 2004;McManus et al., 2000McManus et al., , 2008Turk et al., 2001), and increases risk of comorbid depression (Moitra et al., 2008). Accordingly, cognitive-behavioral therapy (CBT) deliberately encourages systematic exposure to social situations to allow patients to experience a natural reduction in anxiety through habituation and learning (Clark, 1995;Turk et al., 2008). ...
Background
The COVID-19 pandemic has led to extensive social distancing measures. For those suffering from social anxiety, social distancing coincides with a tendency to avoid social interactions. We used this natural experiment imposed by a COVID-19 lockdown to examine how mandated low social exposure influenced socially anxious university students, and compared their anxiety to that of socially anxious students in preceding academic years with no social distancing.Methods
Ninety-nine socially anxious students were assessed for social anxiety symptoms at the beginning of the fall and spring semesters. Students from the 2019–2020 academic year (which included a lockdown followed by social distancing measures at the end of the fall semester) were compared to students from preceding years (2016–2019) on social anxiety levels.ResultsWhereas social anxiety decreased in socially anxious students from the fall to the spring semester in the years preceding the pandemic, during the 2019–2020 academic year social anxiety levels remained high and unchanged. These results held when controlling for depressive symptoms and when analyzing social anxiety items that cannot be confounded with COVID-19-related anxiety.Conclusions
The current results suggest that reduced exposure to social situations may play a role in the maintenance of social anxiety. Alternative explanations are discussed.
... Considering interpretation biases, prior studies have mainly focused on their assessment in single disorders, e.g., depression (e.g., Hindash and Amir 2012;Wisco and Nolen-Hoeksema 2010), social anxiety disorder (SAD; e.g., BeVonard and Amir 2009;Hirsch and Clark 2004;Huppert et al. 2003;Voncken et al. 2003), generalized anxiety disorder (GAD; e.g., Hazlett-Stevens and Borkovec 2004), and eating disorders (e.g., Rosser et al. 2010). Conversely, few studies have systematically compared interpretation bias patterns (e.g., Buhlmann et al. 2002;McManus et al. 2000;Voncken et al. 2007). Exemplarily, Buhlmann et al. (2002) showed that individuals with body dysmorphic disorder (BDD) favored more threatening and less non-threatenineg interpretations for appearance-related (e.g., "While talking to some colleagues, you notice that some people take special notice of you.") and social scenarios (e.g., "You are having a conversation with some friends. ...
Background
Interpretation biases are suggested to be transdiagnostic phenomena, but have rarely been compared across different disorders and current concerns.
Methods
We investigated explicit, decision-based, and more implicit, reaction time-based interpretation bias in individuals with body dysmorphic disorder (BDD; N = 29), social anxiety disorder (SAD; N = 36), generalized anxiety disorder (GAD; N = 22), and non-clinical controls (NC; N = 32), using an adapted Word Sentence Association Paradigm (WSAP).
Results
Results indicated that interpretation bias occurred transdiagnostically, while content-specific bias patterns varied meaningfully across groups. BDD and SAD shared explicit and, more inconsistently, implicit interpretation biases for appearance-related and social situations. The GAD group exhibited an explicit and implicit negative interpretation bias for general situations, and an additional implicit lack of positive bias. Mechanistic Wiener diffusion model analyses revealed that interpretation bias patterns were mainly driven by speeded information uptake, potentially mirroring disorder-specific associative memory organization.
Conclusions
These findings have important implications for understanding interpretation biases as both etiological and treatment factors.
... SAD individuals, relative to controls, estimated social events as more probable and more costly, than non-social events. In addition, SAD individuals, as compared to individuals with other anxiety disorders, estimated the probability and cost of negative social events to be much higher (McManus, Clark, & Hackmann, 2000). Further, Hofmann suggested that changes in estimated social cost mediated treatment changes in cognitive behaviour therapy (CBT) for SAD (Hofmann, 2004). ...
... That is, individuals with SAD assume that other people are critical and will evaluate them negatively (Heimberg et al., 2010). Consistent with these theories, studies showed that socially anxious individuals estimate a higher probability of being judged negatively by others and perceive the outcomes of these negative judgments as more catastrophic than controls do (Foa, Franklin, Perry, & Herbert, 1996;McManus, Clark, & Hackmann, 2000;Uren, Szab� o, & Lovibond, 2004;Voncken, B€ ogels, & de Vries, 2003). Importantly, reducing the believability of negative cognitions in the course of treatment is associated with the overall effect of the treatment outcome (Foa, Franklin, Perry, & Herbert, 1996;Gregory, Peters, Abbott, Gaston, & Rapee, 2015;Hofmann, 2004;Lucock & Salkovskis, 1988;Poulton & Andrews, 1994). ...
Background and objectives
Negative beliefs about other's judgments play an important role in the development and maintenance of social anxiety disorder. The present experiment examined the effects of role-playing followed by role reversal compared to role-playing twice on altering these negative cognitions.
Methods
Thirty-six adult social anxiety patients were randomized into two conditions: a role-playing condition in which 18 participants role-played an anxiety-provoking social situation twice, or a role reversal condition in which 18 participants role-played an anxiety-provoking social situation followed by enacting the same situation using role reversal. Before the start of the experiment, patients were asked to report their negative cognitions about the other's judgments. Next, they were asked to rate the believability of these negative cognitions, as well as the probability and cost estimates of negative judgments by the other person, at three time-points: before the first block of role-playing, after the first block of role-playing, and after the second block of the experiment.
Results
Results demonstrated that role-playing followed by role reversal had a stronger effect on the most negative cognitions than role-playing twice.
Limitations
The most important limitation of the present study is that there was no control group to assess the effects of role-playing alone. Moreover, the second block of the experiment was repetitive in role-playing, however, it was a new task in role reversal.
Conclusions
The results support the hypothesis that role reversal is an effective technique that can be used to correct negative cognitions about other's judgments in SAD.
... As previously mentioned, social anxiety also appears to be related with PIU because it develops and is maintained through cognitive distortions. In social anxiety, distorted cognition involves the overvaluation of the possibility and/or costs of different negative social settings (McManus, Clark & Hackmann, 2000). In addition, socially anxious people tend to be less successful at employing cognitive reappraisal (Goldin, Manber-Ball, Werner, Heimberg & Gross, 2009). ...
This research investigated direct and indirect relationships that occur between interpersonal cognitive distortions, loneliness, social anxiety and problematic Internet use (PIU) when the effect of social desirability was controlled. The study was based on a cognitive-behavioural model of generalized PIU. Data were collected from 260 university students ranging from 18 to 26-year-olds (M=21.29, SD=1.78). The participants answered the Interpersonal Cognitive Distortions Scale (ICDS), UCLA-R Loneliness Scale, The Liebowitz Social Anxiety Scale Self-Report Version (LSAS-SR), Compulsive Internet Use Scale (CIUS) and Marlowe-Crowne Social Desirability Scale (MCSDS). Structural equation modelling (SEM) was used to examine a model in which interpersonal cognitive distortions predicted PIU via loneliness and social anxiety. The results showed that of the two intervening variables, only loneliness had a mediator role between interpersonal cognitive distortions and PIU when social desirability was controlled. The findings were discussed in terms of the literature and the implications for practice were considered.
... As previously mentioned, social anxiety also appears to be related with PIU because it develops and is maintained through cognitive distortions. In social anxiety, distorted cognition involves the overvaluation of the possibility and/or costs of different negative social settings (McManus, Clark & Hackmann, 2000). In addition, socially anxious people tend to be less successful at employing cognitive reappraisal (Goldin, Manber-Ball, Werner, Heimberg & Gross, 2009). ...
This research investigated direct and indirect relationships that occur between interpersonal cognitive distortions, loneliness, social anxiety and problematic Internet use (PIU) when the effect of social desirability was controlled. The study was based on a cognitive-behavioural model of generalized PIU. Data were collected from 260 university students ranging from 18 to 26-year-olds (M=21.29, SD=1.78). The participants answered the Interpersonal Cognitive Distortions Scale (ICDS), UCLA-R Loneliness Scale, The Liebowitz Social Anxiety Scale Self-Report Version (LSAS-SR), Compulsive Internet Use Scale (CIUS) and Marlowe-Crowne Social Desirability Scale (MCSDS). Structural equation modelling (SEM) was used to examine a model in which interpersonal cognitive distortions predicted PIU via loneliness and social anxiety. The results showed that of the two intervening variables, only loneliness had a mediator role between interpersonal cognitive distortions and PIU when social desirability was controlled. The findings were discussed in terms of the literature and the implications for practice were considered.
... Together with the finding that high socially anxious individuals endorsed significantly more threat interpretations in comparison to low socially anxious individuals, these results lend support to Clark and Wells' (1995) cognitive model of Social Anxiety Disorder, which proposes that negative interpretation bias is a key factor that contributes to the maintenance of the disorder. In addition, a number of studies have demonstrated that high socially anxious individuals estimate higher probability and cost of social events when compared to low socially anxious individuals (McManus, Clark, & Hackmann, 2000;Vassilopoulos, 2006;Voncken, Bogels, & de Vries, 2003). Furthermore, some researchers have argued that the interpretation process itself involves estimation of the probability and cost of negative events, that is, the perceived negative impact of the social events on the individual (Mobini, Reynolds, & Mackintosh, 2013). ...
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.
... α = .97) in a study by McManus et al. (2000). Given that the SPCQ had not thus far been applied to the Serbian population, a validation study was conducted, which showed that the measure had satisfactory validity, reliability, representativeness, and homogeneity (Ranđelović & Ranđelović, 2014). ...
The purpose of this study was to examine the effects of dispositional and situational factors on cognitive biases. The theoretical background was based on Kimbrel's Mediated Model of Social Anxiety and the revised reinforcement sensitivity theory by Gray and McNaughton. Two experiments were conducted. Study 1 (78 participants [85.9% females, aged 19-21 years]) included the induction of potential social threat, while in Study 2 (121 participants [85.1% females, aged 19-23 years]) real threat was used. The Reinforcement Sensitivity Questionnaire was employed as a measure of personality traits (Behavioral Inhibition System [BIS], Behavioral Approach System [BAS], Fight, Flight, and Freeze). Cognitive biases were assessed with the Dot Probe Task (attentional bias), Incidental Free Recall Task (memory bias), and Social Probability Cost Questionnaire (judgmental bias). The probability of occurrence of negative events was higher in the experimental group. BIS contributed positively to the prediction of probability of occurrence of negative events; and Freeze was positively related to attention bias toward pleasant stimuli. The results of the second study showed that experimentally induced circumstances of social threats did not affect cognitive biases. BIS and Freeze contributed positively to prediction of probability and distress in social context, while BIS was positively related with probability of occurrence of negative social events.
... A substantial body of research has identified both of these biases in socially anxious individuals (Foa et al., 1996;Lucock & Salkovskis, 1988;McManus, Clark, & Hackmann, 2000). Previous studies have also identified probability and general cost overestimation as strong predictors of behavioral and experiential avoidance (Abramowitz, 2013;Smith & Bryant, 2000). ...
The present study investigated the role of social cost bias, probability bias, and self-efficacy as correlates of behavioral action in a nonclinical sample of 197 individuals, using a series of vignettes and self-report measures. The findings indicated that, as hypothesized, social cost bias, probability bias, and self-efficacy were associated with social anxiety. While social anxiety was associated with behavioral action, the three cognitive factors were associated with behavioral action above and beyond the contribution of social anxiety. However, contrary to the hypothesis, self-efficacy was the only cognitive factor directly associated with behavioral action when all variables were in the model. This information has implications for potential methods and target mechanisms for increasing client engagement with exposures and behavioral experiments in treatments for social anxiety.
... Several cognitive processes have been identified as potential mechanisms of CBT-related reductions in social anxiety symptoms in adults with SAD. These include CBT-related changes in probability bias for negative social events (Hoffart, Borge, Sexton, & Clark, 2009;McManus, Clark, & Hackmann, 2000;Smits, Rosenfield, McDonald, & Telch, 2006), self-focus, perceived acceptance by others, safety behaviors (Hoffart et al., 2009), anticipated aversive social outcomes (Hofmann, 2004), interpersonal judgments, and degree of interpersonal feedback on self-evaluations (Taylor & Alden, 2008). ...
... A specific questionnaire was developed to assess catastrophic belief across diagnosis called the Anxious Thought Questionnaire-23 (ATQ-23; Johnson & Hoffart, 2013). ATQ is composed of items taken from social probability and cost questionnaire (SPCQ; McManus, Clark, & Hackmann, 2000), posttraumatic cognitions inventory (PTCI; Foa, Tolin, Ehlers, Clark, & Orsillo, 1999), and agoraphobic cognitions questionnaire (ACQ; Chambless, Caputo, Bright, & Gallagher, 1984). The four item's from SPCQ where those that together had the highest Cronbach's alpha in a study conducted with social phobia patients at Modum Bad (Hoffart, Borge, Sexton, & Clark, 2009). ...
Psychotherapists have long questioned what mediating processes are linked to outcome of psychotherapy. Few studies examining this question have assessed within-person changes in the process outcome relationship over time. The present study examined changes in cognition and metacognition over the course of therapy using a dataset from a randomized controlled trial comparing Metacognitive therapy (MCT) and Cognitive–behavioral therapy (CBT). The sample included 74 patients measured on process and symptom instruments weekly throughout therapy. Multilevel longitudinal models (sessions nested within patients) were used to examine the relationship between metacognition, cognition, and anxiety. Main effects of metacognition and cognition on anxiety and the interaction with treatment, as well as the reciprocal relationships, were investigated. The results indicate a main effect of both cognitions and metacognitions on predicting anxiety. However, there was no interaction with treatment condition. The reciprocal relationship of anxiety on metacognitions was larger in MCT compared with CBT. This is the first study documenting within-person effects of both cognitions and metacognitions on anxiety over the course of therapy. Implications for therapy are discussed.
... Clark and Wells (1995) propose that individuals with SAD falsely assume that it is likely they will behave in an unacceptable way and that this behaviour will have disastrous consequences in terms of their social status. Threat appraisals, which consist of this overestimation of probability and consequences of a feared social outcome, play a significant role in the maintenance of SAD (see Nelson, Lickel, Sy, Dixon, & Deacon, 2010 for a review) and appear to mediate treatment outcome (McManus, Clark, & Hackmann, 2000). While most studies that consider the predictors of negative rumination in social anxiety do not include measures of threat appraisals, rather focusing on performance appraisals, threat appraisals have also been reported to predict increased levels of negative rumination following a speech task in a select few studies. ...
Social anxiety disorder (SAD) is characterised by an intense fear of social situations in which the individual believes they may be negatively evaluated (American Psychiatric Association, 2013). A number of cognitive models (Clark & Wells, 1995; Hofmann, 2007; Rapee & Heimberg, 1997) have been proposed that provide frameworks for understanding the key cognitive processes involved in SAD. Negative rumination, which can be divided into pre- and post-event rumination, appears to be a key maintaining factor in the cycle of social anxiety. However, there are mixed findings regarding the cognitive predictors of post-event rumination and a lack of research regarding the consequences and predictors of pre-event rumination. Furthermore, there has been little empirical research investigating the effects of targeting negative rumination and state anxiety in social anxiety treatment. If the cognitive predictors of negative rumination can be determined then they can be targeted when designing interventions that aim to break the vicious cycle of social anxiety. The state of research investigating the cognitive determinants of state anxiety and negative rumination is reviewed and suggestions are made for continuing research.
... "jeg vil blive ydmyget for mine fejl") (McManus, Clark, & Hackmann, 2000). At traene brugen af kognitiv revurdering i psykoterapi kan derfor vaere fordelagtigt. ...
Emotioner er kommet i fokus inden for en række videnskaber de sidste årtier, hvor man er begyndt at tale om affektive videnskaber, der bl.a. omfatter psykologi, neurovidenskab, medicin og sociologi. I denne artikel hævder vi, at emotioner er en funktionel størrelse, og at uhensigtsmæssig regulering af emotioner spiller en vigtig rolle ved psykisk lidelse. Vi fremhæver herefter nogle centrale emotionsreguleringsstrategier ved angstlidelser og depression og præsenterer på denne baggrund emotionsreguleringsterapi som et bud på en psykologisk behandling, der direkte retter sig mod emotionsregulering i angst og depression. Anxiety and depression: Emotion regulation in psychotherapy. There has been an increasing interest in emotions during the past couple of decades, reflected in a rapid growth of the affective sciences. In this article we argue that emotions serve important functions in human life and that adaptive emotion regulation is crucial for mental health. We review some of the central emotion regulation strategies in anxiety disorders and depression and describe how Emotion Regulation Therapy is aimed at targeting emotion dysfunction in so-called distress disorders.
... The primacy of cost over probability could not be tested in their study because the latter was not examined. However, in a follow-up study, McManus, Clark, and Hackmann (2000) included both mild and severe negative social events and found that both probability and cost were related to severity of social anxiety and to treatment outcome. Voncken, Bogels, and de Vries (2003) also found that both probability and cost equally contributed to severity of social anxiety. ...
... The primacy of cost over probability could not be tested in their study because the latter was not examined. However, in a follow-up study, McManus, Clark, and Hackmann (2000) included both mild and severe negative social events and found that both probability and cost were related to severity of social anxiety and to treatment outcome. Voncken, Bogels, and de Vries (2003) also found that both probability and cost equally contributed to severity of social anxiety. ...
We feel honoured to contribute this chapter to a volume that is devoted to recognizing the unique place that Andrew Mathews has had in the study of anxiety and the anxiety disorders. From the beginning of his career, he set the course for research on anxiety, including psychophysiology, treatment and, most recently, cognitive mechanisms. This chapter will relate predominantly to Mathews' contribution to the cognitive psychopathology of anxiety (see Chapter 1 in this book), attempting to integrate Mathews and Mackintosh's (1998) concepts of anxiety with Foa and Kozak's (1985, 1986; see also Foa & McNally, 1996; Foa & Cahill, 2001) emotional processing theory to further our understanding of social anxiety disorder and its treatment. Emotional processing theory Emotional processing theory utilizes information processing concepts to explain the psychopathology and treatment of anxiety disorders. A basic concept in emotional processing theory is the presence of fear structures that serve as blueprints for responding to danger (Foa & Kozak, 1986; Lang, 1977). The theory proposes that three kinds of representations are contained in these structures: Information about the stimuli, Information about verbal, physiological and behavioural responses, andThe interpretive meaning of these stimuli and responses. Thus, a fear structure is comprised of an intricate network of associations of the different elements. A normal fear structure contains associations that generally reflect reality accurately (e.g. a car veering towards me → fear (heart rate acceleration, scanning the road, veering my car off the road) → cars coming towards me are dangerous). © Cambridge University Press 2004 and Cambridge University Press, 2009.
... "I will probably make a mistake"). The costlikelihood evaluation bias is a tendency to rate ambiguous social events as being very likely to result in a very negative outcome (Foa, Franklin, Perry and Herbert, 1996;Hofmann, 2004;McManus, Clark and Hackmann, 2000;Smits, Rosenfield, McDonald and Telch, 2006). The cost-likelihood evaluation bias shifts the individual's attention towards negative self-imagery and anxiety symptoms . ...
Background:
Clark and Wells' (1995) cognitive model of social anxiety (CWM) explains the maintenance of social anxiety and has been used as a guide for treatment of Social Anxiety Disorder (SAD). Few studies have examined the components of the model together across different samples.
Aims:
This study had two distinct aims: to test the components of CWM and to examine how the variables of CWM may differ between clinical and non-clinical samples with varying levels of social anxiety.
Method:
Hypothesized relationships between three groups (i.e. a clinical sample of individuals diagnosed with SAD (ClinS), n = 40; socially anxious students (HSA), n = 40; and, non-anxious students (LSA), n = 40) were investigated.
Results:
Four out of five CWM variables tested were able to distinguish between highly socially anxious and non-anxious groups after controlling for age and depression.
Conclusions:
CWM variables are able to distinguish between high and low levels of social anxiety and are uniquely related to social anxiety over depression.
... has identified multiple factors in explaining the underlying processes and maintenance of social phobias. These include distorted perceptions and cognitive processes , biased attention to social threat (Mogg & Bradley, 2002;Mogg, Philippot, & Bradley, 2004), excessive attention to internal physiological cues (Bogels & Mansell, 2004), negative interpretations of ambiguous social events (Amir, Foa, & Coles, 1998;Moscovitch & Hoffman, 2006), negative self-images (Hackmann, Clark, & McManus, 2000), underestimation of social performance and overestimation of the visibility of anxiety (Wallace & Alden, 1997), fear of negative evaluation (Rapee & Heimberg, 1997), which further results in post-event rumination (Mellings & Alden, 2000) or avoidance and safety behaviors (Wells, Clark, Salkovskis, Ludgate, Hackmann, & Gelder, 1995). ...
Cognitive models of social anxiety propose that overestimation of the probability and cost of negative evaluation plays a central role in maintaining the disorder. However, there are currently no self-report state-based measures of probability and cost appraisals. The current paper examines the psychometric properties of the Probability and Consequences Questionnaire for social anxiety (PCQ-SA), which measures probability and consequence appraisals both in anticipation of, and in response to, an impromptu speech task. A total of 532 participants were recruited for the present study, consisting of 409 participants with a principal diagnosis of Social Anxiety Disorder (SAD), and 123 non-clinical controls. Results of exploratory and confirmatory factor analyses supported a two-factor solution for the PCQ-SA. The PCQ-SA demonstrated excellent internal consistency, excellent test-retest reliability, good convergent validity at both time points (i.e., pre and post speech task), and sensitivity to treatment. Finally, using Receiver Operating Characteristic Curve Analysis, clinical cut-off scores were calculated for probability and consequences at both time points, with the PCQ-SA scales showing good sensitivity, specificity, and positive and negative predictive values. Overall, the results provide evidence that the PCQ-SA possesses excellent psychometric properties. The PCQ-SA is suitable for use in clinical and research settings to assess key cognitive maintaining factors for SAD.
Many individuals with intellectual and developmental disabilities (IDD) or a diagnosis on the autism spectrum will experience anxiety. Research examining anxiety in these populations has provided understanding of how it presents and how it can be measured more accurately in these individuals. Less is known, however, about the impact that anxiety can have on cognitive tasks or issues. Within neurotypical individuals, anxiety has been shown to impact decision making, both by increasing the likelihood of a “jump-to-conclusion” style of reasoning and also by influencing perceptions of relative risk. The impact of anxiety on the decision making of individuals with IDD or those on the autism spectrum is less well understood. In this chapter we describe the limited research in this area. We then use this to hypothesise about the potential impact it may have across the decision-making process. Given the high prevalence of anxiety (and other mental health challenges) in those with IDD and/or autism, there is a clear need for more work in this area. With this additional knowledge we will be better placed to understand whether anxiety has a positive, negative or neutral effect on decision making in these populations. This knowledge can then be used to support decision making and also reduce any possible negative effects of anxiety on this process.
Background
Prompt Mental Health Care (PMHC, Norwegian adaption of Improving Access to Psychological Therapies) has shown effects on symptoms of anxiety and depression compared to treatment as usual (TAU). In this secondary analysis, we examine the effectiveness of PMHC among clients presenting with symptoms of social anxiety disorder (SAD) and/or agoraphobia on core symptoms at 6‐ and 12‐month follow‐up.
Methods
Randomized controlled trial in two PMHC sites (70:30 ratio PMHC:TAU). Of participants, 61.3% (n = 472) scored at caseness for SAD and 47.7% (n = 367) for agoraphobia (40% both). Effects on SAD avoidance and physiological discomfort (SPIN‐9), SAD cognitions (ATQ‐SA), agoraphobic avoidance (MIA‐8), and agoraphobic cognitions (ATQ‐AP) were examined in piecewise growth models.
Results
The PMHC group showed substantially greater symptom reduction than the TAU group for all outcomes: At 6‐month follow‐up, the between‐group effect sizes were d −0.60 (95% CI: −0.94 to −0.26) for SPIN‐9, −0.45 (95% CI: −0.70 to −0.20) for ATQ‐SA, −0.50 (95% CI: −0.87 to −0.13) for MIA‐8, and −0.61 (95% CI: −0.92 to −0.31) for ATQ‐AP. All effects were sustained at similar level at a 12‐month follow‐up.
Conclusion
PMHC effectively alleviated SAD and agoraphobia symptoms, and individuals struggling with such symptoms constituted a large proportion of clients. Although results should be interpreted with caution due to risk of attrition bias, they lend further support for a scale‐up of PMHC and similar initiatives. Individuals struggling with SAD and/or agoraphobia stood out as relatively high burdened, whereas only one of five had sought help the last 12 months, underscoring the need for the PMHC service.
People high in negative affect tend to think negative events are more likely than positive events (‘probability bias’). Studies have found that weak attentional control exaggerates another negative affect-related cognitive bias – attentional bias – but it is not clear why this might be. We therefore wanted to know whether weak attentional control would be related to probability bias too. Four studies, with predominantly female student samples (N = 857), revealed correlations of around -.38 between attentional control and probability bias. This remained significant when trait anxiety and depression were controlled; there were no interactions between attentional control and negative affect. Studies 3 and 4 found that attentional control’s relationship with probability bias was partly mediated by emotion regulation ability. These results suggest attentional control is important for regulating affect-related cognitive biases, and for emotion regulation in general. Furthermore, because cognitive biases are thought to be important for maintaining emotional disorders, these results are also consistent with weak attentional control being a risk factor for these disorders.
Social anxiety is a highly debilitating disorder maintained by a number of cognitive and behavioral factors. Understanding the core tenets of contemporary empirically supported models of social anxiety disorder (SAD) is crucial for clinicians, because it provides a framework for conceptualizing the factors contributing to an individual's social anxiety and their response to treatment. Cognitive behavioral therapy (CBT) is considered the psychological treatment of choice for SAD and has a great deal of empirical support for its efficacy. Psychoeducation serves to teach the patient how social anxiety is maintained through avoidance behaviors and maladaptive beliefs related to social situations, and how confronting feared situations will help overcome anxiety experienced in social settings. Modern forms of CBT begin with an introduction to the CBT model of social anxiety so that patients can identify their own thoughts and behaviors that maintain their social anxiety, and the manner and reasons for modifying them.
"Vumile" was a patient in a cognitive therapy group that was designed for socially phobic African students and based on a therapy model developed by Clark and Wells. The case narrative shows how Vumile constructed a personal model of the factors maintaining his social phobia, and within the group and through homework challenged negative beliefs, reduced self-consciousness and engaged in a range of previously avoided behaviors. A significant maintaining factor, spontaneous images of women looking at him with pity or mockery, was only identified in the last session. However, Vumile was able to use the skills he had learned to investigate this further and to correct these processes, which were distorting his experience of social interactions with women. Significant gains were made after the end of the formal treatment program and these are reflected in scores at follow-up on several self-report scales measuring anxiety, depression and various aspects of social phobic behavior and cognition.
Process-outcome research in psychotherapy has mainly focused on between-person data (e.g., how differences in psychological process among patients are related to differences in outcome among the patients). However, this level of analysis is in danger of missing its target because psychotherapy models and therapists focus primarily on within-person relationships (e.g., whether change in a patient's cognitive process during the course of therapy may lead to a reduction of symptoms in that client). The study of within-person processes requires collection of repeated data and a disaggregation of the between-and within-person components of time-varying process predictors. The purpose of this study was to examine whether the results of a previously published longitudinal process-outcome study of cognitive and interpersonal therapy for social anxiety disorder (SAD) (Hoffart, Borge, Sexton, & Clark, 2009) were maintained when the process predictors were disaggregated. Eighty social phobic patients were randomized to 10-week residential cognitive or interpersonal psychotherapy. In the present reanalysis, time-varying predictors were disaggregated by use of person-mean centering. For the cognitive process predictors (self-focus, estimated probability and estimated cost of negative social events, safety behaviors), the within-person relationships between predictors and subsequent social anxiety remained significant when disaggregating the predictors. On the other hand, the previously significant within-person relationship between the interpersonal variable of perceived acceptance by others and subsequent social anxiety disappeared with disaggregation. Disaggregated social anxiety also predicted fluctuations in self-focus, estimated probability and estimated cost of negative social events, but not in safety behaviors and perceived acceptance.
Can prior expectancies shape attention to threat? To answer this question, we manipulated the expectancies of spider phobics and nonfearful controls regarding the appearance of spider and bird targets in a visual search task. We observed robust evidence for expectancy influences on attention to birds, reflected in error rates, reaction times, pupil diameter, and heart rate (HR). We found no solid effect, however, of the same expectancies on attention to spiders; only HR revealed a weak and transient impact of prior expectancies on the orientation of attention to threat. Moreover, these asymmetric effects for spiders versus birds were observed in both phobics and controls. Our results are thus consistent with the notion of a threat detection mechanism that is only partially permeable to current expectancies, thereby increasing chances of survival in situations that are mistakenly perceived as safe.
Group-based Transdiagnostic Cognitive Behavioral Therapy (TCBT) for anxiety disorders aims to target common factors to produce beneficial effects on multiple anxiety disorders at once. While there is growing evidence that various anxiety disorders can be effectively treated by this approach, the common factors contributing to these treatment effects are not well delineated. In a sample of 48 Veterans who completed Group-based TCBT, the current study examined change in threat perception and change in experiential avoidance pre to post-treatment and as potential mediators of changes in negative affect and personalized fear ratings. Results indicated that both threat perception and experiential avoidance were significantly reduced during treatment. Additionally, reductions in both threat perception and experiential avoidance significantly predicted reductions in negative affect and fear ratings. When change in threat perception and change in experiential avoidance were examined simultaneously, both remained significant predictors of changes in negative affect though only experiential avoidance predicted changes in fear ratings. Thus, both reductions in threat perception and experiential avoidance may mediate the broad treatment effects observed in group-based TCBT. Directions for future research are discussed.
Social anxiety disorder (SAD) is a chronic and persistent disorder, with pharmacotherapy and traditional cognitive interventions only demonstrating minimal efficacy. While cognitive behavioral therapy (CBT) and exposure-based therapy are the most empirically supported treatment for individuals with SAD, many patients do not achieve full symptom remission and others do not respond to treatment at all. SAD is a heterogeneous disorder with diverse symptom presentations, and as such, the maintenance factors may not be relevant for all patients with SAD. However, the modern disorder-specific cognitive behavioral model provides guidelines for successful treatment of SAD by explicating the maintenance factors that are likely to also be important mediators of treatment outcome. The efficacy of CBT can be improved by targeting cognitive factors that are intricately involved in maintaining the symptoms of SAD.
Aim: This thesis describes the development and initial validation of a questionnaire to
measure Hayes, Strosahl and Wilson’s (1999) constructs of cognitive fusion and cognitive
defusion. Within the literature there is currently no specific measure of these constructs.
Design and Method: Principal Component Analysis was conducted on two independent
samples (Study One n = 425 and Study Two n = 167). Reliability analyses were conducted
for both Study One and Study Two and validation analyses were conducted in Study Two.
All participants in both studies completed the Cognitive Fusion Questionnaire (CFQ).
Participants in Study Two completed additional measures related to their satisfaction with
life, their beliefs about worry, mindful responding to unpleasant thoughts and images and
levels of experiential avoidance. Results: The final solution revealed a two component fifteen item questionnaire accounting
for 54% of the variance. Based on item content, the components were labelled fusion and
defusion. The items within the questionnaire reflected Hayes et al. (1999) constructs of
cognitive fusion and cognitive defusion. Internal consistencies as measured by Cronbach’s
alpha were .91 (fusion), .71 (defusion) and .88 (total scale). The measure correlated
moderately to highly and in the expected directions with questionnaires measuring individual
beliefs about worry, mindful responding to unpleasant thoughts and images and levels of
experiential avoidance. Similarly, there was a significant negative correlation between the
current questionnaire and a measure related to satisfaction with life. Conclusions: The findings of the above research provide initial support for the CFQ. The
results show support for the validity of the scale including content and convergent validity of
the CFQ.
Concepts related to the self are an integral feature of contemporary models of social anxiety disorder (SAD). Here, we provide a brief overview of major topics related to the self and SAD. Four issues are addressed: self-schema content, self-referent processing, self-related motives and behavioral strategies, and finally, self-schema characteristics such as structure and clarity. This review document highlights the breadth and complexity of empirical findings regarding the self and self-related cognitive processes in SAD and points to future directions for research.
Social anxiety disorder is a common and debilitating disorder, often leading to complications such as depression, substance abuse and increased suicide risk. During the past two decades, research on the cognitive, behavioral, interpersonal and physiological aspects of social anxiety and subsequent theoretical models have greatly increased our understanding of the nature and maintaining factors for social anxiety disorder. Well-validated assessment procedures including self-report, interview and behavioral measures, are now available. Therapeutic exposure, typically combined with cognitive interventions, is the most established evidence-based treatment. Comparisons of psychosocial treatment to pharmacotherapy and some promising innovative treatment approaches are discussed as well. Emerging work on mechanisms of change suggest that changes in judgments about the probability and costs of negative outcomes are key to clinical change. Competencies for clinicians include expertise with basic cognitive and behavioral therapies, therapeutic exposure and adaptations for the unique characteristics of social anxiety disorder. Especially important is the impact of socially anxious individuals’ fears in interpersonal relationships on the therapeutic relationship. Expert competencies include treatment of more severe cases, overcoming extreme social isolation, complex presentations and social anxiety disorder that presents within the context of serious mental illness. Working in a multicultural context, particularly with language differences and sexual minorities are also discussed. Transition to expert competency relies on traditional educational venues, written material and utilizing expert consultation that is available on electronic venues.
In a study designed to clarify and extend previous research on social blunders in social anxiety, 32 participants with social anxiety disorder (SAD), 25 anxious control (AC) participants with anxiety disorders other than SAD, and 25 healthy control (HC) participants with no history of anxiety problems estimated the costs of hypothetical blunders committed by either themselves or by others. Participants with SAD rated the costs of their own imagined blunders as highly inflated relative to both AC and HC participants. In contrast, for blunders participants imagined others committing, only SAD and healthy control participants' cost estimates differed from one another. Moreover, concerns about revealing self-flaws - and, in particular, about appearing socially incompetent - accounted for significant, unique variance in SAD participants' exaggerated cost estimates of self blunders, over and above symptoms of social anxiety and depression. These results enhance our understanding of how and why socially anxious individuals negatively appraise social blunders and help to clarify the potential function and role of social mishap exposures in the treatment of SAD.
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Despite significant advances in the understanding and treatment of social anxiety disorder (SAD) over the past two decades, there remains much room for improvement. Most individuals with SAD do not receive an evidence-based treatment, and even the best-established treatments leave most patients with residual symptoms and suboptimal functioning. Moreover, treatment mechanisms of action are poorly understood. There has recently been considerable growth in CBT models that de-emphasize direct cognitive change efforts, and instead focus on cultivating mindfulness and psychological acceptance of distressing experiences in the service of behavior change. These intervention models have begun to be applied to understanding and treating SAD. The results of initial research are promising, both in terms of treatment outcomes and theoretical treatment processes. Mindfulness and acceptance-based CBT models for SAD are likely to play an increasingly important role in future treatment development, research, and dissemination efforts.
This chapter focuses on mechanisms that are thought to be common to a range of cognitive-behavior therapies (CBTs) and anxiety disorders. It also concentrates on theoretically derived cognitive, behavioral, and affective change processes thought to alter anxiety. The chapter discusses characteristics of the therapy process and client–therapist relationship that may mediate change in CBT. Numerous cognitive factors have been proposed as potential mediators of CBT for anxiety disorders. These include explicit cognitions related to threat, danger, and personal vulnerability that reflect relatively more controllable and deliberate processing, and implicit measures of associations. There is strong evidence that behavior changes over the course of CBT for anxiety in both children and adults, but less is known about whether and how behavior change mediates treatment effects. Avoidance is a diagnostic criterion for many anxiety disorders, and reducing avoidance behaviors is a clear goal in multiple forms of CBT.
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.
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