- Email: [email protected]
Social phobic interoception: effects of bodily information on anxiety, beliefs and self-processing
Behaviour Research and Therapy 39 (2001) 1–11 www.elsevier.com/locate/brat
Social phobic interoception: effects of bodily information on anxiety, beliefs and self-processing Adrian Wells a
a,*
, Costas Papageorgiou
b
Department of Clinical Psychology, University of Manchester, Rawnsley Building, MRI, Oxford Road, Manchester M13 9WL, UK b University of Manchester and North Manchester NHS Trust, Manchester, UK Received 23 May 1999; received in revised form 23 July 1999
Abstract It has been suggested that body-state information influences self-perception and negative thinking in social phobia [Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment and treatment (pp. 69–93). New York: Guilford Press.]. This study explored the effects of body-state information on anxiety and cognition in patients with generalised social phobia during a feared social interaction. It was hypothesised that information concerning an increase in pulse rate would lead to increments in anxiety, negative beliefs and self-processing whilst information concerning a decrease in pulse rate would have the opposite effect. The results of this study were generally consistent with the hypotheses. These findings are important as they may help to account for fluctuations in anxiety, negative beliefs and self-processing in social situations that do not present objective social threat. In particular, social anxiety appears to be modulated by body-state information. The implications of the present findings for cognitive therapy of social phobia are briefly discussed. 2000 Elsevier Science Ltd. All rights reserved. Keywords: Social phobia; Bodily information; Anxiety; Beliefs; Self-focused attention; Perspective taking
* Corresponding author. Tel.: +44-161-276-5399; fax: +44-161-273-2135. E-mail address: [email protected] (A. Wells).
0005-7967/00/$ - see front matter 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 9 9 ) 0 0 1 4 6 - 1
2
A. Wells, C. Papageorgiou / Behaviour Research and Therapy 39 (2001) 1–11
1. Introduction
Processing of body-state information has been conceptualised as a key factor in the maintenance of social phobia (e.g.,Clark & Wells, 1995). At a surface level, many individuals with social phobia fear showing signs of anxiety, such as trembling, sweating or blushing. Therefore, it is conceivable that these individuals will show increased sensitivity to bodily cues that signal the occurrence of such responses, and will be prone to appraise these responses in a socially catastrophic fashion. Clark and Wells have presented a cognitive model in which individuals with social phobia use interoceptive information to construct a distorted impression of themselves, which they assume reflects what other people observe. This negative impression occurs from an ‘observer’ perspective in which individuals with social phobia see themselves from another person’s vantage point (Wells & Papageorgiou, 1999; Wells, Clark & Ahmad, 1998), and is often in the form of a spontaneous image (Hackmann, Suraway & Clark, 1998) or a felt sense. This impression is likely to strengthen negative appraisals and beliefs in social phobia. Several studies report results consistent with the idea that social phobics’ estimates of the dangerousness of social situations are partly based on the perception of their own emotional reaction (e.g.,Arntz, Rauner & van den Hout, 1995; Bruch, Gorsky, Collins & Berger, 1989; McEwan & Devins, 1983). However, so far, there has not been a direct test of Clark and Wells’ (1995) assertion that social phobics’ in-situation anxiety and negative beliefs are influenced by interoceptive information. The present study served as a preliminary test of this hypothesis. We aimed to evaluate the effects of body-state information on anxiety, negative beliefs and self-processing during an anxiety-provoking social interaction. We hypothesised that the provision of bodily information should affect levels of anxiety and negative beliefs in a social interaction task in patients with social phobia. More specifically, information about an increase in bodily activity should increase anxiety and negative beliefs, whilst information about a decrease in such activity should produce the opposite effect. We also explored the effects of body-state information on the direction of attention and perspective taking in imagery. We predicted that information about body-state increments would increase self-focus and the observer perspective in self-imagery, whilst information about decrements would lead to decreases in these variables. Because self-reports of anxiety may be prone to demand effects, we included an observer rating of how publicly noticeable the patients’ anxiety was during the interaction task. Differences in observer ratings of anxiety would rule against an interpretation of the results solely in terms of demand. In order to test our hypotheses, it is important not to confound the provision of bodily information with inadvertent direct effects on self-image and negative beliefs. The use of physiological monitoring and recording equipment is likely to render the individual self-conscious and conspicuous. The provision of information on bodily events that are conspicuous or a focus of existing anxiety confounds body-state information with self-presentational concerns. An effective method of determining the influence of body-state information that avoids such confounds must provide information on bodily fluctuations that are not observable to other members of the social situation, and are not the bodily events that represent individuals’ normal focus of attention. In this study, we evaluated the effects of simple informational manipulations about fluctuations in pulse rate. This method satisfies our criteria as outlined above.
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2. Method 2.1. Participants Eight male patients consecutively referred for psychological treatment of social phobia participated in the study. A summary of patient characteristics including age, duration and severity of social phobia, and negative beliefs, is presented in Table 1. All of the patients met DSM-IV (American Psychiatric Association, 1994) criteria for generalised social phobia, and diagnoses were made following the administration of the Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition (SCID-I/P;First, Spitzer, Gibbon & Williams, 1997). None of the patients met criteria for another Axis I disorder. Two of the patients were stabilised on Fluoxetine, but none of the other patients were taking psychotropic medication, and none had received any previous psychological treatment. Patients were excluded from the study if they reported little or no anxiety in making conversation with a stranger. None of the patients were excluded on the basis of this criterion. 2.2. Measures 2.2.1. Descriptive measures In order to describe the sample fully, all patients completed a battery of standardised and widely used measures of anxiety, depression and social phobia. These measures included the following: Beck Anxiety (BAI;Beck, Epstein, Brown & Steer, 1988) and Depression (BDI; Beck, Ward, Mendelson, Mock & Erbaugh, 1961) Inventories; Fear of Negative Evaluation (FNE) and Social Avoidance and Distress (SAD) scales (Watson & Friend, 1969); Social Phobia (SPS) and Social Interaction Anxiety (SIAS) Scales (Heimberg, Mueller, Holt, Hope & Liebowitz, 1992; Mattick & Clarke, 1989). 2.2.2. Dependent measures 2.2.2.1. Anxiety Two measures of anxiety were used: a self-report rating of anxiety and an observer rating of anxious appearance (i.e., nervousness). Self-report ratings of anxiety were measured on an 11-point rating scale ranging from 0 (‘not at all anxious’) to 100 (‘the most anxious I have ever been’). This scale was administered at 1, 3 and 5 min during a social interaction task. Observer ratings of anxious appearance were based on an item derived from a behavioural checklist. This checklist requires raters to indicate how publicly noticeable a range of positive and negative behaviours are during social interaction. Responses are made on a 7-point rating scale ranging from 1 (‘not noticeable’) to 7 (‘very noticeable’). 2.2.2.2. Belief Idiosyncratic negative belief was measured on an 11-point rating scale ranging from 0 (‘do not believe the thought at all’) to 100 (‘completely convinced the thought is true’). This scale was administered at 1, 3 and 5 min during the social interaction task. 2.2.2.3. Self-focused attention To assess the degree of external versus self-focused attention during the interaction task, we used a 7-point bipolar rating scale ranging from ⫺3 (‘entirely
Age
27 29 34 44 22 18 25 43
Patient
(1) (2) (3) (4) (5) (6) (7) (8)
5 7 11 27 2 4 8 24
Duration (in years) 5 5 4 5 4 4 5 5
SCID-P severity
I’ll shake constantly and people will think that I’m an alcoholic I’ll look anxious and people will think that I’m stupid I’ll babble a lot and everyone will think that I’m nervous I’ll blush and people will think that I’m anxious I’ll look very tense and people around will stare at me I’ll sweat heavily and everyone will think that I’m nervous I’ll go red and people will think that I’m anxious I’ll tremble uncontrollably and people will think that I have Parkinson’s disease
Idiosyncratic negative belief
Table 1 Patient characteristics. For SCID-P severity: 4=about half the time (50%); 5=a significant majority of the time (70–80%)
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A. Wells, C. Papageorgiou / Behaviour Research and Therapy 39 (2001) 1–11
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externally focused’) to +3 (‘entirely self-focused’). This scale was administered following completion of each manipulation. 2.2.2.4. Perspective taking Individual perspectives in imagery of the social interaction were assessed using a 7-point bipolar rating scale ranging from a ‘field’ to an ‘observer’ perspective: ⫺3 (‘entirely looking out through my eyes’) to +3 (‘entirely observing myself from an external point of view’). This measure was administered following completion of each manipulation. 2.2.3. Manipulation check measure The credibility of the informational manipulations were verified by two 11-point belief rating scales in which patients were asked to indicate how much they believed each pulse rate manipulation: ‘When I told you that your pulse rate had increased/decreased, how much did you believe that?’ These scales ranged from 0 (‘I did not believe it at all’) to 100 (‘I was completely convinced it was true’). The manipulation check measures were administered upon completion of the experiment. 2.2.4. Procedure Following initial diagnostic screening, patients were asked if they would be willing to take part in a project investigating the effects of conversation on pulse rate, and consisting of holding a series of conversations with a colleague. All patients were suitable for the study and agreed to participate. Initially, idiosyncratic beliefs were elicited by asking patients to think about the worst possible thing that could happen to them during the conversation with the colleague. The negative belief associated with the highest conviction and anxiety rating was selected as the dependent variable. The patients’ idiosyncratic negative beliefs are given in Table 1. Prior to presenting the experimental instructions, patients were given practise in rating anxiety and beliefs using the appropriate scales. They were then informed that it was necessary to obtain these ratings in a discrete way at three particular intervals during the interaction and that this would be accomplished by asking them for an ‘A’ (anxiety) and ‘B’ (belief) rating. In order to explore the effects of pulse rate information, within-subject comparisons were made. All patients engaged in a conversation task with a confederate under three experimental conditions: an initial behaviour test, and two different informational manipulations. The behaviour test was conducted prior to the first ‘information’ condition and the order of subsequent ‘information’ conditions was counterbalanced across the eight patients. For purposes of the behaviour test, patients were asked to “go into the situation for 5 min and behave in the way you are accustomed to behaving”. Following the behaviour test, half of the patients received information concerning an increased pulse rate followed by decreased pulse rate information. For the other half of the patients, this sequence was reversed. Because two patients were stabilised on Fluoxetine, and we know little about the impact of such medication on brief exposure to feared situations, one of them received increase information first whilst the other received decrease information first. Each patient was provided with the following experimental instructions: I would like you to hold a brief conversation with a colleague. You may talk about whatever you like, but please do not talk about your anxiety problems. Please make conversation about
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the kinds of things that you normally would in social situations. It is important that you start the conversation and try to keep it going. Each patient was then allowed 1 min to contemplate the forthcoming social interaction and then the experimenter felt for a pulse in the patient’s wrist. The experimenter pretended to covertly count the pulse rate whilst watching his wristwatch for 1 min. Immediately after this, each patient was provided with verbal pulse rate information to produce the relevant experimental manipulation. Instructions for the behaviour test and the pulse rate conditions were as follows: for the behaviour test, patients were told “I’ve got a good count of your pulse rate. My colleague will be with us shortly”; for the increased pulse rate condition, they were told “I’ve got a good count of your pulse rate. Your pulse rate has increased. It is higher than before. My colleague will be with us shortly”; and for the decreased pulse rate condition, they were informed “I’ve got a good count of your pulse rate. Your pulse rate has decreased. It is lower than before. My colleague will be with us shortly”. One min after the relevant instruction was given, the confederate entered the room and the conversation task commenced and lasted for 5 min. The confederate was a 25-year-old female colleague who had not previously met any of the patients and was unaware of the patients’ problem and the nature of the experiment. She was instructed to behave in a “reserved but friendly and responsive manner towards the patients” and “to avoid initiating or maintaining the conversation unless there are long pauses of more than 30 s”. She was provided with standard neutral questions that could be used in the event of a 30-s pause. The confederate was also closely monitored by the experimenter throughout each interaction task to ensure that the above criteria were met. Following each conversation, patients completed retrospective ratings of the degree of selffocused attention and perspective taking. After leaving the room, the confederate completed the retrospective behavioural checklist that included a rating of patients’ anxious appearance (i.e., nervousness) during the interaction task. This item was used as the objective measure of anxiety (the full checklist of behaviours was intended for use in subsequent therapy only and it is not relevant to the present hypotheses). Upon completion of the experiment, patients were asked to rate the credibility of the pulse rate conditions and appropriately debriefed. 3. Results Descriptive statistics for anxiety, depression and social phobia measures are shown in Table 2. Patients in this study demonstrated levels of anxious and social phobic symptoms that are compaTable 2 Means and standard deviations (S.D.) for preexperimental variables. BAI=Beck Anxiety Inventory; BDI=Beck Depression Inventory; FNE=Fear of Negative Evaluation scale; SAD=Social Avoidance and Distress scale; SPS=Social Phobia Scale; SIAS=Social Interaction Anxiety Scale Variable
Mean
S.D.
Variable
Mean
S.D.
BAI BDI FNE
21.3 16.0 24.8
7.6 8.3 3.5
SAD SPS SIAS
20.6 40.6 47.4
4.8 9.9 7.8
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rable with previous studies of social phobia (e.g., Heimberg et al., 1992; Holt, Heimberg & Hope, 1992). The measures of credibility showed that the provision of increase and decrease pulse rate information was seen as highly credible by patients. Mean credibility ratings for the increased and decreased conditions were 91.3 (S.D.=11.3) and 92.5 (S.D.=8.6), respectively. There was no significant difference between conditions (z=⫺0.45, p=0.65). The effects of pulse rate information on self-report ratings were analysed using the Wilcoxon statistic. For these analyses, change scores were computed between the behaviour test and the first manipulation, and between the first manipulation and the second manipulation. For half of the patients, the first manipulation consisted of increased pulse rate information whilst for the other half it was decreased pulse rate information. Thus, change scores for the increase condition consisted of combining the difference between the behaviour test and the increase manipulation for half of the patients (who received increase information first), with the difference between the decrease and increase manipulations for the patients who received the increase information second (following decrease information). Changes associated with the decrease condition were computed in a similar way. Median change scores in anxiety, negative beliefs, self-focused attention and perspective taking are presented in Figs. 1 and 2 (means and standard deviations for these variables are presented in the text for purposes of comparison with other studies). The effect of the manipulations on observer ratings of anxiety were also based on analyses of change scores.
Fig. 1.
Median changes in anxiety and belief for the increase and decrease pulse rate conditions.
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Fig. 2.
A. Wells, C. Papageorgiou / Behaviour Research and Therapy 39 (2001) 1–11
Median changes in self-focused attention and observer perspective for the increase and decrease pulse rate conditions.
Fig. 1 shows median changes in self-report anxiety and negative belief ratings associated with the increase and decrease conditions. Note that a negative change score denotes an increase in anxiety/ belief, whilst a positive score denotes a decrease in these variables. It is clear from these data that information about an increase in pulse rate was associated with increments in anxiety and negative beliefs, whilst decrease information led to decrements in these variables. The mean change in anxiety associated with the increase manipulation was ⫺7.1 (S.D.=7.9), and that associated with decrease manipulation was 19.6 (S.D.=5.8). A Wilcoxon T-test showed that this difference was significant (z=⫺2.52, p⬍0.01). Following the increase manipulation, the mean belief change was ⫺7.0 (S.D.=6.3) and following the decrease manipulation it was 18.3 (S.D.=6.4). This difference in change scores was also significant (z=⫺2.53, p⬍0.01). The mean changes in observer ratings of anxiety for the increase and decrease conditions were 0.4 (S.D.=1.1) and 2.0 (S.D.=1.6), respectively. This difference was significant (z=⫺2.23, p⬍0.03). These data show that the confederate rated patients in the decrease condition as less anxious than in the increase condition. The observer ratings of anxiety contribute to the validity of the self-report ratings suggesting that the results cannot be attributed to demand. Fig. 2 shows the changes in self-focused attention and perspective taking associated with the increase and decrease manipulations. Note again that a negative change score denotes an increase in self-focus/observer perspective, whilst a positive score denotes a decrease in these variables.
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The decrease manipulation was associated with a reduction in self-focus (mean change=1.3, S.D.=0.46), whilst the increase manipulation heightened self-focus (mean change=⫺0.5, S.D.=0.53). The difference between the manipulations was significant (z=⫺2.56, p⬍0.01). The mean changes in perspective taking for the increase and decrease conditions were 0.38 ( S.D.=1.41) and 1.2 (S.D.=0.46), respectively. Although both conditions were associated with a reduction in observer perspectives, and the decrease manipulation led to a larger decrement, the difference between manipulations was not significant. 4. Discussion This study set out to test a prediction of Clark and Wells’ (1995) cognitive model of social phobia. The model predicts that interoceptive information is an important source of data influencing anxiety and cognition in social situations. Consistent with our hypotheses, the results of this study demonstrated that manipulations of pulse rate information were associated with increments or decrements in anxiety and negative beliefs during a threatening social encounter. Information about an increase in pulse rate led to greater anxiety, negative beliefs and self-focused attention. However, information about a decrease in pulse rate led to decreases in these variables. We failed to find support for our prediction that body-state information would differentially affect perspective taking in imagery. Both types of information were associated with a decrease in the observer perspective, and although this was greater in the decreased pulse rate condition, the difference was not significant. It is possible that a difference may emerge with larger samples, and this remains to be explored in future investigations. Alternatively, the pulse rate manipulation may affect aspects of self-processing associated more directly with private rather than public selfawareness, or the content of self-image other than perspective taking. The finding that each type of information was associated with a different directional shift in attention may suggest that bodily information effects on anxiety and beliefs may be attributable to attentional mechanisms. Wells and Papageorgiou (1998) demonstrated that instructions that reduce self-focus by increasing external attention in feared social situations led to reductions in anxiety and negative beliefs in patients with social phobia. Additional studies are required to investigate the relative contributions of attention and body-state information to anxiety and negative beliefs. The present results seem relevant to understanding the maintenance of social phobia in two ways. First, they could help to account for the success or failure of exposure to modify anxiety and negative beliefs. Exposure may be most effective when the constellation of bodily sensations and associated negative self-image is activated, and the individual is able to process information that disconfirms the negative self-image (e.g., by redirecting attention away from the self and onto the external social environment). Second, it may explain a phenomenon that we frequently observe in patients with social phobia. Some of our patients state that they can ‘sense’ when they are likely to have a ‘bad day’ characterised by greater social anxiety, despite the fact that this ‘day’ is objectively little different from any other. It is possible that this ‘sense’ is influenced by the presence of body-state information. An important question for future research concerns the developmental and personality factors that may contribute to the tendency to use interoceptive information as a basis for self-confidence.
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Since we did not monitor actual heart rate activity in this study, we cannot rule out the possibility that pulse rate information actually affected heart rate responses, which in turn may have influenced anxiety. However, in a study involving the provision of heart rate information in socially anxious individuals during a threatening social interaction task (Papageorgiou & Wells, 1997) we found that such information did not affect actual heart rate. In conclusion, the results of this study suggest that provision of pulse rate information can have a positive or negative effect on anxiety and cognition in social phobia. The present data also suggest that caution should be exercised when discussing bodily events in social phobia treatment. If handled inappropriately, dwelling on social phobic symptoms during treatment and the provision of certain types of body-state feedback could enhance social anxiety and strengthen negative beliefs. Treatment should focus on modifying the discrepancy that exists between the patients’ overall negative self-perception and the way patients actually appear socially, which is usually more positive than depicted in self-images.
References American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders. (4th ed.). Washington, DC: American Psychiatric Association. Arntz, A., Rauner, M., & van den Hout, M. (1995). If I feel anxious, there must be danger: ex-consequentia reasoning in inferring danger in anxiety disorders. Behaviour Research and Therapy, 33, 917–925. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E., & Erbaugh, J. K. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. Bruch, M. A., Gorsky, J. M., Collins, T. M., & Berger, P. A. (1989). Shyness and sociability reexamined: a multicomponent analysis. Journal of Personality and Social Psychology, 57, 904–915. Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier, Social phobia: diagnosis, assessment and treatment (pp. 69–93). New York: Guilford Press. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1997). Structured Clinical Interview for DSM-IV Axis I Disorders — Patient Edition (SCID-I/P, Version 2.0, 4/97 revision). , New York: Biometrics Research Department, New York State Psychiatric Institute. Hackmann, A., Suraway, C., & Clark, D. M. (1998). Seeing yourself through others eyes: a study of spontaneously occurring images in social phobia. Behavioural and Cognitive Psychotherapy, 26, 3–12. Heimberg, R. G., Mueller, G., Holt, C. S., Hope, D. A., & Liebowitz, M. R. (1992). Assessment of anxiety in social interaction and being observed by others: the Social Interaction Anxiety Scale and the Social Phobia Scale. Behavior Therapy, 23, 53–73. Holt, C. S., Heimberg, R. G., & Hope, D. A. (1992). Avoidant personality disorder and the generalized subtype of social phobia. Journal of Abnormal Psychology, 101, 177–189. Mattick, R. P. & Clarke, J. C. (1989). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Unpublished manuscript. McEwan, K. L., & Devins, G. M. (1983). Is increased arousal in social anxiety noticed by others? Journal of Abnormal Psychology, 92, 417–421. Papageorgiou, C., & Wells, A. (1997). Social self-perception: effects of false heart rate feedback in socially anxious subjects. Paper presented at the Annual Conference of the British Association for Behavioural and Cognitive Psychotherapies, Canterbury, England. Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and Clinical Psychology, 33, 448–457.
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Wells, A., & Papageorgiou, C. (1998). Social phobia: effects of external attention on anxiety, negative beliefs and perspective taking. Behavior Therapy, 29, 357–370. Wells, A., & Papageorgiou, C. (1999). The observer perspective: biased imagery in social phobia, agoraphobia and blood/injury phobia. Behaviour Research and Therapy, 37, 653–658. Wells, A., Clark, D. M., & Ahmad, S. (1998). How do I look with my mind’s eye: perspective taking in social phobic imagery. Behaviour Research and Therapy, 36, 631–634.
Social phobic interoception: effects of bodily information on anxiety, beliefs and self-processing Adrian Wells a
a,*
, Costas Papageorgiou
b
Department of Clinical Psychology, University of Manchester, Rawnsley Building, MRI, Oxford Road, Manchester M13 9WL, UK b University of Manchester and North Manchester NHS Trust, Manchester, UK Received 23 May 1999; received in revised form 23 July 1999
Abstract It has been suggested that body-state information influences self-perception and negative thinking in social phobia [Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment and treatment (pp. 69–93). New York: Guilford Press.]. This study explored the effects of body-state information on anxiety and cognition in patients with generalised social phobia during a feared social interaction. It was hypothesised that information concerning an increase in pulse rate would lead to increments in anxiety, negative beliefs and self-processing whilst information concerning a decrease in pulse rate would have the opposite effect. The results of this study were generally consistent with the hypotheses. These findings are important as they may help to account for fluctuations in anxiety, negative beliefs and self-processing in social situations that do not present objective social threat. In particular, social anxiety appears to be modulated by body-state information. The implications of the present findings for cognitive therapy of social phobia are briefly discussed. 2000 Elsevier Science Ltd. All rights reserved. Keywords: Social phobia; Bodily information; Anxiety; Beliefs; Self-focused attention; Perspective taking
* Corresponding author. Tel.: +44-161-276-5399; fax: +44-161-273-2135. E-mail address: [email protected] (A. Wells).
0005-7967/00/$ - see front matter 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 9 9 ) 0 0 1 4 6 - 1
2
A. Wells, C. Papageorgiou / Behaviour Research and Therapy 39 (2001) 1–11
1. Introduction
Processing of body-state information has been conceptualised as a key factor in the maintenance of social phobia (e.g.,Clark & Wells, 1995). At a surface level, many individuals with social phobia fear showing signs of anxiety, such as trembling, sweating or blushing. Therefore, it is conceivable that these individuals will show increased sensitivity to bodily cues that signal the occurrence of such responses, and will be prone to appraise these responses in a socially catastrophic fashion. Clark and Wells have presented a cognitive model in which individuals with social phobia use interoceptive information to construct a distorted impression of themselves, which they assume reflects what other people observe. This negative impression occurs from an ‘observer’ perspective in which individuals with social phobia see themselves from another person’s vantage point (Wells & Papageorgiou, 1999; Wells, Clark & Ahmad, 1998), and is often in the form of a spontaneous image (Hackmann, Suraway & Clark, 1998) or a felt sense. This impression is likely to strengthen negative appraisals and beliefs in social phobia. Several studies report results consistent with the idea that social phobics’ estimates of the dangerousness of social situations are partly based on the perception of their own emotional reaction (e.g.,Arntz, Rauner & van den Hout, 1995; Bruch, Gorsky, Collins & Berger, 1989; McEwan & Devins, 1983). However, so far, there has not been a direct test of Clark and Wells’ (1995) assertion that social phobics’ in-situation anxiety and negative beliefs are influenced by interoceptive information. The present study served as a preliminary test of this hypothesis. We aimed to evaluate the effects of body-state information on anxiety, negative beliefs and self-processing during an anxiety-provoking social interaction. We hypothesised that the provision of bodily information should affect levels of anxiety and negative beliefs in a social interaction task in patients with social phobia. More specifically, information about an increase in bodily activity should increase anxiety and negative beliefs, whilst information about a decrease in such activity should produce the opposite effect. We also explored the effects of body-state information on the direction of attention and perspective taking in imagery. We predicted that information about body-state increments would increase self-focus and the observer perspective in self-imagery, whilst information about decrements would lead to decreases in these variables. Because self-reports of anxiety may be prone to demand effects, we included an observer rating of how publicly noticeable the patients’ anxiety was during the interaction task. Differences in observer ratings of anxiety would rule against an interpretation of the results solely in terms of demand. In order to test our hypotheses, it is important not to confound the provision of bodily information with inadvertent direct effects on self-image and negative beliefs. The use of physiological monitoring and recording equipment is likely to render the individual self-conscious and conspicuous. The provision of information on bodily events that are conspicuous or a focus of existing anxiety confounds body-state information with self-presentational concerns. An effective method of determining the influence of body-state information that avoids such confounds must provide information on bodily fluctuations that are not observable to other members of the social situation, and are not the bodily events that represent individuals’ normal focus of attention. In this study, we evaluated the effects of simple informational manipulations about fluctuations in pulse rate. This method satisfies our criteria as outlined above.
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2. Method 2.1. Participants Eight male patients consecutively referred for psychological treatment of social phobia participated in the study. A summary of patient characteristics including age, duration and severity of social phobia, and negative beliefs, is presented in Table 1. All of the patients met DSM-IV (American Psychiatric Association, 1994) criteria for generalised social phobia, and diagnoses were made following the administration of the Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition (SCID-I/P;First, Spitzer, Gibbon & Williams, 1997). None of the patients met criteria for another Axis I disorder. Two of the patients were stabilised on Fluoxetine, but none of the other patients were taking psychotropic medication, and none had received any previous psychological treatment. Patients were excluded from the study if they reported little or no anxiety in making conversation with a stranger. None of the patients were excluded on the basis of this criterion. 2.2. Measures 2.2.1. Descriptive measures In order to describe the sample fully, all patients completed a battery of standardised and widely used measures of anxiety, depression and social phobia. These measures included the following: Beck Anxiety (BAI;Beck, Epstein, Brown & Steer, 1988) and Depression (BDI; Beck, Ward, Mendelson, Mock & Erbaugh, 1961) Inventories; Fear of Negative Evaluation (FNE) and Social Avoidance and Distress (SAD) scales (Watson & Friend, 1969); Social Phobia (SPS) and Social Interaction Anxiety (SIAS) Scales (Heimberg, Mueller, Holt, Hope & Liebowitz, 1992; Mattick & Clarke, 1989). 2.2.2. Dependent measures 2.2.2.1. Anxiety Two measures of anxiety were used: a self-report rating of anxiety and an observer rating of anxious appearance (i.e., nervousness). Self-report ratings of anxiety were measured on an 11-point rating scale ranging from 0 (‘not at all anxious’) to 100 (‘the most anxious I have ever been’). This scale was administered at 1, 3 and 5 min during a social interaction task. Observer ratings of anxious appearance were based on an item derived from a behavioural checklist. This checklist requires raters to indicate how publicly noticeable a range of positive and negative behaviours are during social interaction. Responses are made on a 7-point rating scale ranging from 1 (‘not noticeable’) to 7 (‘very noticeable’). 2.2.2.2. Belief Idiosyncratic negative belief was measured on an 11-point rating scale ranging from 0 (‘do not believe the thought at all’) to 100 (‘completely convinced the thought is true’). This scale was administered at 1, 3 and 5 min during the social interaction task. 2.2.2.3. Self-focused attention To assess the degree of external versus self-focused attention during the interaction task, we used a 7-point bipolar rating scale ranging from ⫺3 (‘entirely
Age
27 29 34 44 22 18 25 43
Patient
(1) (2) (3) (4) (5) (6) (7) (8)
5 7 11 27 2 4 8 24
Duration (in years) 5 5 4 5 4 4 5 5
SCID-P severity
I’ll shake constantly and people will think that I’m an alcoholic I’ll look anxious and people will think that I’m stupid I’ll babble a lot and everyone will think that I’m nervous I’ll blush and people will think that I’m anxious I’ll look very tense and people around will stare at me I’ll sweat heavily and everyone will think that I’m nervous I’ll go red and people will think that I’m anxious I’ll tremble uncontrollably and people will think that I have Parkinson’s disease
Idiosyncratic negative belief
Table 1 Patient characteristics. For SCID-P severity: 4=about half the time (50%); 5=a significant majority of the time (70–80%)
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externally focused’) to +3 (‘entirely self-focused’). This scale was administered following completion of each manipulation. 2.2.2.4. Perspective taking Individual perspectives in imagery of the social interaction were assessed using a 7-point bipolar rating scale ranging from a ‘field’ to an ‘observer’ perspective: ⫺3 (‘entirely looking out through my eyes’) to +3 (‘entirely observing myself from an external point of view’). This measure was administered following completion of each manipulation. 2.2.3. Manipulation check measure The credibility of the informational manipulations were verified by two 11-point belief rating scales in which patients were asked to indicate how much they believed each pulse rate manipulation: ‘When I told you that your pulse rate had increased/decreased, how much did you believe that?’ These scales ranged from 0 (‘I did not believe it at all’) to 100 (‘I was completely convinced it was true’). The manipulation check measures were administered upon completion of the experiment. 2.2.4. Procedure Following initial diagnostic screening, patients were asked if they would be willing to take part in a project investigating the effects of conversation on pulse rate, and consisting of holding a series of conversations with a colleague. All patients were suitable for the study and agreed to participate. Initially, idiosyncratic beliefs were elicited by asking patients to think about the worst possible thing that could happen to them during the conversation with the colleague. The negative belief associated with the highest conviction and anxiety rating was selected as the dependent variable. The patients’ idiosyncratic negative beliefs are given in Table 1. Prior to presenting the experimental instructions, patients were given practise in rating anxiety and beliefs using the appropriate scales. They were then informed that it was necessary to obtain these ratings in a discrete way at three particular intervals during the interaction and that this would be accomplished by asking them for an ‘A’ (anxiety) and ‘B’ (belief) rating. In order to explore the effects of pulse rate information, within-subject comparisons were made. All patients engaged in a conversation task with a confederate under three experimental conditions: an initial behaviour test, and two different informational manipulations. The behaviour test was conducted prior to the first ‘information’ condition and the order of subsequent ‘information’ conditions was counterbalanced across the eight patients. For purposes of the behaviour test, patients were asked to “go into the situation for 5 min and behave in the way you are accustomed to behaving”. Following the behaviour test, half of the patients received information concerning an increased pulse rate followed by decreased pulse rate information. For the other half of the patients, this sequence was reversed. Because two patients were stabilised on Fluoxetine, and we know little about the impact of such medication on brief exposure to feared situations, one of them received increase information first whilst the other received decrease information first. Each patient was provided with the following experimental instructions: I would like you to hold a brief conversation with a colleague. You may talk about whatever you like, but please do not talk about your anxiety problems. Please make conversation about
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the kinds of things that you normally would in social situations. It is important that you start the conversation and try to keep it going. Each patient was then allowed 1 min to contemplate the forthcoming social interaction and then the experimenter felt for a pulse in the patient’s wrist. The experimenter pretended to covertly count the pulse rate whilst watching his wristwatch for 1 min. Immediately after this, each patient was provided with verbal pulse rate information to produce the relevant experimental manipulation. Instructions for the behaviour test and the pulse rate conditions were as follows: for the behaviour test, patients were told “I’ve got a good count of your pulse rate. My colleague will be with us shortly”; for the increased pulse rate condition, they were told “I’ve got a good count of your pulse rate. Your pulse rate has increased. It is higher than before. My colleague will be with us shortly”; and for the decreased pulse rate condition, they were informed “I’ve got a good count of your pulse rate. Your pulse rate has decreased. It is lower than before. My colleague will be with us shortly”. One min after the relevant instruction was given, the confederate entered the room and the conversation task commenced and lasted for 5 min. The confederate was a 25-year-old female colleague who had not previously met any of the patients and was unaware of the patients’ problem and the nature of the experiment. She was instructed to behave in a “reserved but friendly and responsive manner towards the patients” and “to avoid initiating or maintaining the conversation unless there are long pauses of more than 30 s”. She was provided with standard neutral questions that could be used in the event of a 30-s pause. The confederate was also closely monitored by the experimenter throughout each interaction task to ensure that the above criteria were met. Following each conversation, patients completed retrospective ratings of the degree of selffocused attention and perspective taking. After leaving the room, the confederate completed the retrospective behavioural checklist that included a rating of patients’ anxious appearance (i.e., nervousness) during the interaction task. This item was used as the objective measure of anxiety (the full checklist of behaviours was intended for use in subsequent therapy only and it is not relevant to the present hypotheses). Upon completion of the experiment, patients were asked to rate the credibility of the pulse rate conditions and appropriately debriefed. 3. Results Descriptive statistics for anxiety, depression and social phobia measures are shown in Table 2. Patients in this study demonstrated levels of anxious and social phobic symptoms that are compaTable 2 Means and standard deviations (S.D.) for preexperimental variables. BAI=Beck Anxiety Inventory; BDI=Beck Depression Inventory; FNE=Fear of Negative Evaluation scale; SAD=Social Avoidance and Distress scale; SPS=Social Phobia Scale; SIAS=Social Interaction Anxiety Scale Variable
Mean
S.D.
Variable
Mean
S.D.
BAI BDI FNE
21.3 16.0 24.8
7.6 8.3 3.5
SAD SPS SIAS
20.6 40.6 47.4
4.8 9.9 7.8
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rable with previous studies of social phobia (e.g., Heimberg et al., 1992; Holt, Heimberg & Hope, 1992). The measures of credibility showed that the provision of increase and decrease pulse rate information was seen as highly credible by patients. Mean credibility ratings for the increased and decreased conditions were 91.3 (S.D.=11.3) and 92.5 (S.D.=8.6), respectively. There was no significant difference between conditions (z=⫺0.45, p=0.65). The effects of pulse rate information on self-report ratings were analysed using the Wilcoxon statistic. For these analyses, change scores were computed between the behaviour test and the first manipulation, and between the first manipulation and the second manipulation. For half of the patients, the first manipulation consisted of increased pulse rate information whilst for the other half it was decreased pulse rate information. Thus, change scores for the increase condition consisted of combining the difference between the behaviour test and the increase manipulation for half of the patients (who received increase information first), with the difference between the decrease and increase manipulations for the patients who received the increase information second (following decrease information). Changes associated with the decrease condition were computed in a similar way. Median change scores in anxiety, negative beliefs, self-focused attention and perspective taking are presented in Figs. 1 and 2 (means and standard deviations for these variables are presented in the text for purposes of comparison with other studies). The effect of the manipulations on observer ratings of anxiety were also based on analyses of change scores.
Fig. 1.
Median changes in anxiety and belief for the increase and decrease pulse rate conditions.
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Fig. 2.
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Median changes in self-focused attention and observer perspective for the increase and decrease pulse rate conditions.
Fig. 1 shows median changes in self-report anxiety and negative belief ratings associated with the increase and decrease conditions. Note that a negative change score denotes an increase in anxiety/ belief, whilst a positive score denotes a decrease in these variables. It is clear from these data that information about an increase in pulse rate was associated with increments in anxiety and negative beliefs, whilst decrease information led to decrements in these variables. The mean change in anxiety associated with the increase manipulation was ⫺7.1 (S.D.=7.9), and that associated with decrease manipulation was 19.6 (S.D.=5.8). A Wilcoxon T-test showed that this difference was significant (z=⫺2.52, p⬍0.01). Following the increase manipulation, the mean belief change was ⫺7.0 (S.D.=6.3) and following the decrease manipulation it was 18.3 (S.D.=6.4). This difference in change scores was also significant (z=⫺2.53, p⬍0.01). The mean changes in observer ratings of anxiety for the increase and decrease conditions were 0.4 (S.D.=1.1) and 2.0 (S.D.=1.6), respectively. This difference was significant (z=⫺2.23, p⬍0.03). These data show that the confederate rated patients in the decrease condition as less anxious than in the increase condition. The observer ratings of anxiety contribute to the validity of the self-report ratings suggesting that the results cannot be attributed to demand. Fig. 2 shows the changes in self-focused attention and perspective taking associated with the increase and decrease manipulations. Note again that a negative change score denotes an increase in self-focus/observer perspective, whilst a positive score denotes a decrease in these variables.
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The decrease manipulation was associated with a reduction in self-focus (mean change=1.3, S.D.=0.46), whilst the increase manipulation heightened self-focus (mean change=⫺0.5, S.D.=0.53). The difference between the manipulations was significant (z=⫺2.56, p⬍0.01). The mean changes in perspective taking for the increase and decrease conditions were 0.38 ( S.D.=1.41) and 1.2 (S.D.=0.46), respectively. Although both conditions were associated with a reduction in observer perspectives, and the decrease manipulation led to a larger decrement, the difference between manipulations was not significant. 4. Discussion This study set out to test a prediction of Clark and Wells’ (1995) cognitive model of social phobia. The model predicts that interoceptive information is an important source of data influencing anxiety and cognition in social situations. Consistent with our hypotheses, the results of this study demonstrated that manipulations of pulse rate information were associated with increments or decrements in anxiety and negative beliefs during a threatening social encounter. Information about an increase in pulse rate led to greater anxiety, negative beliefs and self-focused attention. However, information about a decrease in pulse rate led to decreases in these variables. We failed to find support for our prediction that body-state information would differentially affect perspective taking in imagery. Both types of information were associated with a decrease in the observer perspective, and although this was greater in the decreased pulse rate condition, the difference was not significant. It is possible that a difference may emerge with larger samples, and this remains to be explored in future investigations. Alternatively, the pulse rate manipulation may affect aspects of self-processing associated more directly with private rather than public selfawareness, or the content of self-image other than perspective taking. The finding that each type of information was associated with a different directional shift in attention may suggest that bodily information effects on anxiety and beliefs may be attributable to attentional mechanisms. Wells and Papageorgiou (1998) demonstrated that instructions that reduce self-focus by increasing external attention in feared social situations led to reductions in anxiety and negative beliefs in patients with social phobia. Additional studies are required to investigate the relative contributions of attention and body-state information to anxiety and negative beliefs. The present results seem relevant to understanding the maintenance of social phobia in two ways. First, they could help to account for the success or failure of exposure to modify anxiety and negative beliefs. Exposure may be most effective when the constellation of bodily sensations and associated negative self-image is activated, and the individual is able to process information that disconfirms the negative self-image (e.g., by redirecting attention away from the self and onto the external social environment). Second, it may explain a phenomenon that we frequently observe in patients with social phobia. Some of our patients state that they can ‘sense’ when they are likely to have a ‘bad day’ characterised by greater social anxiety, despite the fact that this ‘day’ is objectively little different from any other. It is possible that this ‘sense’ is influenced by the presence of body-state information. An important question for future research concerns the developmental and personality factors that may contribute to the tendency to use interoceptive information as a basis for self-confidence.
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Since we did not monitor actual heart rate activity in this study, we cannot rule out the possibility that pulse rate information actually affected heart rate responses, which in turn may have influenced anxiety. However, in a study involving the provision of heart rate information in socially anxious individuals during a threatening social interaction task (Papageorgiou & Wells, 1997) we found that such information did not affect actual heart rate. In conclusion, the results of this study suggest that provision of pulse rate information can have a positive or negative effect on anxiety and cognition in social phobia. The present data also suggest that caution should be exercised when discussing bodily events in social phobia treatment. If handled inappropriately, dwelling on social phobic symptoms during treatment and the provision of certain types of body-state feedback could enhance social anxiety and strengthen negative beliefs. Treatment should focus on modifying the discrepancy that exists between the patients’ overall negative self-perception and the way patients actually appear socially, which is usually more positive than depicted in self-images.
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Wells, A., & Papageorgiou, C. (1998). Social phobia: effects of external attention on anxiety, negative beliefs and perspective taking. Behavior Therapy, 29, 357–370. Wells, A., & Papageorgiou, C. (1999). The observer perspective: biased imagery in social phobia, agoraphobia and blood/injury phobia. Behaviour Research and Therapy, 37, 653–658. Wells, A., Clark, D. M., & Ahmad, S. (1998). How do I look with my mind’s eye: perspective taking in social phobic imagery. Behaviour Research and Therapy, 36, 631–634.