The impact of cognitive restructuring and mindfulness strategies on postevent processing and affect in social anxiety disorder

https://doi.org/10.1016/j.janxdis.2014.05.012Get rights and content

Highlights

  • Postevent processing (PEP) is a key maintenance factor of social anxiety disorder.

  • Cognitive restructuring and mindfulness strategies decreased PEP and improved affect.

  • There were no significant differences between these conditions.

  • Cognitive restructuring, but not mindfulness, decreased probability and cost biases.

  • Decreases in cost biases and maladaptive beliefs predicted reductions in PEP.

Abstract

Postevent processing (PEP; reviewing a past social event in detail) is a key maintenance factor of social anxiety disorder (SAD). The current study examined the efficacy of a single session cognitive restructuring or mindfulness strategy on decreasing PEP and its associated effects, and investigated the cognitive processes involved. Fifty-six individuals with SAD completed a speech task to elicit PEP and were taught a cognitive restructuring, mindfulness, or control strategy to manage their negative thoughts. Participants in the cognitive restructuring and mindfulness conditions reported significantly reduced PEP and improved affect as compared to the control condition. There were no significant differences between the cognitive restructuring and mindfulness conditions. Participants in the cognitive restructuring condition reported decreased probability and cost biases. Regardless of study condition, decreases in cost biases and maladaptive beliefs significantly predicted reductions in PEP. Cognitive restructuring and mindfulness appear to be promising strategies to decrease PEP and improve affect.

Introduction

Social anxiety disorder (SAD) is characterized by a marked fear of potential negative evaluation in social situations in which an individual is exposed to possible scrutiny by others (American Psychiatric Association, 2013). Prominent models of SAD (Clark and Wells, 1995, Heimberg et al., 2010, Rapee and Heimberg, 1997) postulate that postevent processing (PEP), which is defined as the process of engaging in a detailed review of one's performance after a social situation (typically in a negative way), serves as a key maintenance factor of SAD. For the purposes of this paper, the term PEP will refer to a negative review of one's performance. During PEP, socially anxious individuals tend to recall past instances of social situations that they perceive to have been failures. This process then leads individuals to view the recent social situation as more negative than it objectively was, and further strengthens their beliefs regarding their inability to meet social expectations. Clark and Wells (1995) state that treatment for SAD should include a discussion of the role of PEP in the maintenance of the disorder, and that PEP should then be “banned”. However, no recommendations were provided with regard to specific strategies to use to decrease or eliminate PEP. As such, further research is necessary in order to establish effective ways to help clients reduce or prevent PEP.

There is ample literature demonstrating that socially anxious individuals, both clinical and nonclinical samples, engage in PEP more frequently and intensely than those lower in social anxiety (e.g., Abbott and Rapee, 2004, Dannahy and Stopa, 2007). As well, a number of studies have experimentally manipulated PEP, typically comparing the effects of PEP to distraction. The majority of studies have found that, as compared to distraction, PEP can lead to more (or at least maintain) negative thoughts and memories, negative affect including anxiety, and maladaptive beliefs (e.g., Kocovski et al., 2011, Wong and Moulds, 2009); although two recent studies found results that challenge the findings of positive effects of distraction as compared to PEP (Makkar and Grisham, 2012, Rowa et al., 2014).

Cognitive restructuring and mindfulness techniques appear to be promising methods to decrease PEP and its associated negative effects. Meta-analyses of CBT for SAD have consistently shown moderate to large effect sizes in symptom reduction at posttreatment, as compared to waitlist control groups; as well as moderate to large effect sizes from pre to posttreatment. Proposed mechanisms of CBT include decreases in probability overestimation and cost biases (e.g., Foa et al., 1996, McManus et al., 2000, Smits et al., 2006), reduced dysfunctional thinking and increased willingness to engage in activities despite unpleasant thoughts or emotions (Forman et al., 2012), cognitive reappraisal (Gross & John, 2003), acceptance, and decentering (Kocovski, Fleming, Hawley, Huta, & Antony, 2013). Decentering is the ability to observe one's thoughts and feelings as transient, objective events in the mind, as compared to true reflections of oneself (Safran & Segal, 1990). As well, interventions with a mindfulness component have recently been applied to the treatment of SAD, with research supporting its efficacy and effectiveness (see Vøllestad, Nielsen, & Nielsen, 2012, for a review). Mindfulness is defined as “paying attention in a particular way – on purpose, in the present moment and nonjudgmentally” (Kabat-Zinn, 1994, p. 4). Proposed mechanisms of mindfulness-based interventions include acceptance, decreasing experiential avoidance, acting with awareness (Forman, Herbert, Moitra, Yeomans, & Geller, 2007), decentering (e.g., Teasdale et al., 2001), and decreased rumination (e.g., Alleva et al., 2012, Kocovski et al., 2013).

There is considerable overlap in the proposed mechanisms of CBT and mindfulness-based interventions. However, the theoretical goals of the treatment modalities appear to be different, with the goal of CBT to reduce anxiety by targeting cognitions and behaviors, and mindfulness to have clients accept their anxiety and behave in accordance with their values, without the explicit goal of anxiety reduction. CBT encourages clients to identify and change the content of their thoughts to be more realistic and evidence-based, while mindfulness-based treatments encourage clients to change their relationship to their thoughts by noticing and accepting their thoughts without judgment, rather than changing the actual content. Some theorists and researchers state that CBT and mindfulness-based treatments are very distinct (e.g., Eifert and Forsyth, 2005, Hayes et al., 2011), while others believe that these treatments are more similar than they are dissimilar (e.g., Arch and Craske, 2008, Hofmann and Asmundson, 2008). It may be that the mechanisms of these two approaches are similar, while the treatment rationales and strategies are different.

Preliminary research indicates that mindfulness-based interventions are as effective as the more established CBT interventions for SAD (Kocovski et al., 2013, Koszycki et al., 2007). For example, Kocovski and colleagues (2013) conducted a randomized controlled trial and found that both Mindfulness and Acceptance-based Group Therapy (MAGT) and group CBT for SAD were more effective at social anxiety symptom reduction as compared to the waitlist control group, and that the two treatment conditions were equally effective. However, few studies have examined the immediate effects of the specific strategies used in CBT and mindfulness-based interventions on PEP and affect, or the cognitive processes involved.

One study demonstrated that engaging in brief cognitive restructuring or reappraisal has beneficial effects on mood related to thinking about a past social situation. Rodebaugh and colleagues (2009) divided students who were high in social interaction anxiety into those who tended to purposefully engage with unpleasant thoughts and be open to different perspectives (high purposeful engagers) and those who tended not to actively engage with unpleasant thoughts or consider alternative views (low purposeful engagers). Participants were asked to think of a recent negative social situation and were randomly assigned to a 25-min unstructured writing condition about the social situation, or to a 25-min structured writing condition that involved cognitive restructuring prompts. It was found that low purposeful engagers who did not receive cognitive restructuring prompts reported worsened mood at the end of the study, whereas low purposeful engagers who received the prompts and high purposeful engagers in both conditions did not report as much deterioration in mood. The researchers proposed that cognitive restructuring may be efficacious for socially anxious individuals who are low purposeful engagers, specifically after completing exposures or when they start to engage in PEP.

Another study found that a brief mindfulness strategy may be useful in decreasing the distress associated with PEP and improving affect. Cassin and Rector (2011) provided individuals with SAD with 10 min of mindfulness training, 10 min of distraction training, or no training. They were asked to recall a recent negative social situation for 5 min (PEP induction), and were then told to apply the strategy in which they were trained. Results indicated that, in comparison to the no training group, participants in the mindfulness condition reported significantly less distress, more positive affect, and less negative affect over the PEP period. The distraction and no training groups performed similarly to each other, and both conditions did not lead to reductions in distress or change in affect over the PEP period.

As well, preliminary research has supported the beneficial effects of engaging in experiential self-focused attention, defined as focusing on the direct experience of one's feelings and experiences (similar to mindfulness without the emphasis on acceptance), as compared to analytical self-focused attention, defined as thinking analytically about the meanings, causes, and consequences of one's feelings and experiences (i.e., the type of self-focus used when ruminating). Specifically, these beneficial effects included improved anxiety, amount of positive and negative thoughts, and self-judgments (e.g., Vassilopoulos, 2008, Vassilopoulos and Watkins, 2009). However, one recent study (Wong & Moulds, 2012) found that experiential self-focus may lead to more maladaptive unconditional beliefs; thus, more research is necessary to clarify this discrepancy in findings.

Given the role of PEP as an important maintenance factor in SAD, its associated negative effects, and the limited research on strategies to decrease PEP, the goal of the present study was to compare the efficacy of cognitive restructuring, mindfulness, and control strategies on PEP in SAD. This study also sought to examine the cognitive processes (e.g., probability and cost biases, degree of mindfulness) involved in these strategies. As previous studies of PEP have typically relied only on self-report questionnaires, skin conductance level (SCL) was included as a dependent variable, as it is a common physiological index of anxiety. A major strength of the current study was its aim to extend the original work of Clark and Wells (1995) by examining the efficacy of two promising strategies for decreasing PEP, with the overall goal of improving treatment outcomes of CBT for SAD.

Based on the existing literature and cognitive models of social anxiety, the hypotheses of the current study were as follows:

  • (1)

    Participants in the cognitive restructuring condition (compared to the control condition) would report or exhibit from pre to poststrategy: (a) less PEP (degree and associated distress), (b) improved state affect, and (c) greater decrease in SCL.

  • (2)

    Participants in the mindfulness condition (compared to the control condition) would report or exhibit from pre to poststrategy: (a) less PEP (associated distress), (b) improved state affect, and (c) greater decrease in SCL.

  • (3)

    Participants in the cognitive restructuring condition would experience the greatest decrease in PEP (as it theoretically targets both degree and distress associated with PEP), followed by participants in the mindfulness condition (as it theoretically targets only the distress associated with PEP), followed by participants in the control condition.

  • (4)

    Participants in the cognitive restructuring condition would experience decreases in probability and cost biases, and decreases in maladaptive beliefs; while participants in the mindfulness condition would experience increases in mindfulness and decentering. Participants in the cognitive restructuring condition may also experience increases in decentering, albeit to a lesser extent than those in the mindfulness condition, based on previous research (e.g., Kocovski et al., 2013).

  • (5)

    Participants who experienced greater changes in the cognitive processes (i.e., probability and cost biases, maladaptive beliefs, mindfulness, and decentering), as compared to those who experienced fewer changes, would report less PEP at 1-day follow-up.

No hypothesis was put forth as to which cognitive process would be the strongest predictor of reduced PEP.

Section snippets

Participants

Individuals from the Greater Toronto Area were recruited for study participation through advertisements posted around the community and on websites that allowed for free postings. Interested community members were invited to complete an online version of the Social Phobia Inventory (SPIN; Connor et al., 2000) and the Personal Report of Confidence as a Speaker (PRCS; Paul, 1966). Individuals who scored 19 or above on the SPIN and 16 or above on the PRCS were invited to participate in the study,

Results

Means and standard deviations of scores on the SPIN, PRCS, and DASS-21 (depression subscale), separated by study condition, are presented in Table 1.

A one-way analysis of variance (ANOVA) indicated that there were no significant differences between study conditions on the SPIN, PRCS, and DASS-21, and were therefore not used as covariates in the subsequent analyses (Tabachnick & Fidell, 2007). To ensure that the speech task was successful at inducing PEP, the data were examined to determine

Discussion

In line with our hypotheses, cognitive restructuring and mindfulness strategies led to reduced PEP and improved state affect (including reduced self-reported anxiety) from pre to poststrategy, as compared to the control condition. These findings are consistent with previous research that examined the efficacy of single session strategies on the negative effects associated with PEP (Cassin and Rector, 2011, Rodebaugh et al., 2009). However, this study is novel as it assessed both cognitive

Acknowledgements

This study was supported by a Canadian Psychological Association Foundation student research grant award and a Social Sciences and Humanities Research Council Joseph-Armand Bombardier Canada doctoral graduate scholarship awarded to the first author.

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      Citation Excerpt :

      Second, we sought to extend prior work by testing whether participants in the BMT condition would report less state anxiety during a social anxiety induction task following training compared to participants in the control condition. Third, we sought to replicate the only other test of mindfulness’s impact on PEP (Shikatani et al., 2014) and extend this finding by testing whether participants in the BMT condition would report less state PEP than individuals in the control condition poststrategy use following laboratory induction of state social anxiety. Fourth, we aimed to extend prior work (Cassin & Rector, 2011; Shikatani et al., 2014) by testing whether individuals in the BMT (but not control) condition would report continued decreases in state PEP and state anxiety throughout a 2-week follow-up period in which they were encouraged to engage in daily practice of their strategy following PEP induction.

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