The interpretation of negative social events in social phobia: changes during treatment and relationship to outcome

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Behaviour Research and Therapy 43 (2005) 373–389 www.elsevier.com/locate/brt

The interpretation of negative social events in social phobia: changes during treatment and relationship to outcome Judith K. Wilson, Ronald M. Rapee Department of Psychology, Macquarie University, Sydney NSW 2109, Australia Received 16 September 2003; received in revised form 5 February 2004; accepted 18 February 2004

Abstract Catastrophic interpretations of negative social events are considered to be an important factor underlying social phobia. This study investigated the extent to which these interpretative biases change during cognitive-behavioural treatment for social phobia, and examined whether within-treatment changes in different types of interpretations predict longer-term treatment outcome. Results showed that treatment was associated with decreases in various types of maladaptive interpretations of negative social events, but that social phobia symptoms 3 months after treatment were independently predicted only by withintreatment reductions in the degree to which individuals personally believed that negative social events were indicative of unfavourable self-characteristics. These findings are discussed in relation to cognitive models of the maintenance of social anxiety, and implications for treatment are considered. r 2004 Elsevier Ltd. All rights reserved. Keywords: Social phobia; Cognitive bias; Treatment; Outcome; Predictors

1. Introduction Cognitive theories of social phobia emphasise the importance of maladaptive beliefs and thought processes in the development and maintenance of the disorder (e.g. Beck, Emery, & Greenberg, 1985; Clark & Wells, 1995; Rapee & Heimberg, 1997). Such theories are supported by Corresponding author. +61-2-9850-8032; fax: 61-2-9850-8062.

E-mail address: [email protected] (R.M. Rapee). 0005-7967/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2004.02.006

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a wealth of research evidence indicating that people with dispositionally high levels of social anxiety show a variety of cognitive biases in social situations compared to non-anxious individuals, including increased attentional focus on the self and on cues related to social threat (e.g. Asmundson & Stein, 1994; Lundh & O¨st, 1996; Mattia, Heimberg, & Hope, 1993; Melchior & Cheek, 1990; Veljaca & Rapee, 1998; Woody & Rodriguez, 2000), a higher frequency of negative self-evaluative thoughts (e.g. Beidel, Turner, & Dancu, 1985; Stopa & Clark, 1993), more negative interpretations of ambiguous social information (e.g. Amir, Foa, & Coles, 1998; Constans, Penn, Ihen, & Hope, 1999; Stopa & Clark, 2000), and inflated estimates of the probability and cost of negative social occurrences (Foa, Franklin, Perry, & Herbert, 1996; Gilboa-Schechtman, Franklin, & Foa, 2000; Lucock & Salkovskis, 1988; McManus, Clark, & Hackmann, 2000; Poulton & Andrews, 1994, 1996). A primary implication of cognitive theory and research regarding social phobia is that the effectiveness of treatment interventions will be based largely on the extent to which they are successful in modifying dysfunctional thinking patterns (e.g. Chambless & Gillis, 1993; Heimberg, 1994). Indeed, there are a number of studies that have shown that treatment-induced improvements in social phobia symptomatology are associated with changes in cognitions during social situations, including reductions in the frequency of negative thoughts (Chambless, Tran, & Glass, 1997; Scholing & Emmelkamp, 1999), decreases in self-focus (Woody, Chambless, & Glass, 1997), reductions in attention to social threat (Mattia et al., 1993), and lowered estimates of the probability and cost of negative social events (McManus et al., 2000). Nevertheless, as Chambless et al. (1997) assert, these observed associations provide no evidence with regard to causality, in terms of whether cognitive change may lead to reductions in anxiety, whether symptom improvement results in cognitive change, or whether the two constructs are simply correlates of each other. There are relatively few investigations that have provided evidence pertaining to the issue of whether the types of cognitive changes outlined above represent important mechanisms by which treatment for social phobia exerts its effects. To date, such studies suggest that a number of cognitive variables may potentially be important in producing treatment-related improvements in symptomatology. Foa et al. (1996), for example, examined the effect of cognitive-behavioural therapy on judgements regarding the probability and cost of negative social events among people with social phobia, and used hierarchical regression analyses to determine whether such cognitive changes predicted post-treatment anxiety after controlling for pre-treatment symptom severity and post-treatment depression. They found that treatment-related reductions in cost estimates were more important than reductions in probability estimates in explaining variance in posttreatment social anxiety, consistent with the notion that changes in judgements regarding the cost of negative social events mediated treatment outcome. Slightly different results, however, were obtained in a similar study by McManus et al. (2000), in which participants received medication, placebo or cognitive therapy for social phobia. These researchers found that treatment-related reductions in both the perceived probability and cost of negative social events predicted posttreatment symptomatology after controlling for pre-treatment social anxiety when each variable was considered separately, although only changes in probability estimates remained significant after controlling for variance common to both variables on two out of three outcome measures. Several further studies have examined the question of whether cognitive variables predict longer-term functioning following cognitive-behavioural treatment for social phobia. Such studies

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have examined pre- to post-treatment cognitive changes, or post-treatment measures of cognitive variables, in terms of their ability to predict functioning up to 18 months following treatment. These investigations have yielded variable results depending on the cognitive construct being examined, suggesting that specific cognitive changes may account for longer-term treatment effects. Chambless et al. (1997), for instance, found a non-significant relationship between posttreatment frequency of negative self-statements during social situations and changes in social phobia symptoms from post-treatment to 6-month follow-up, thus providing no support for the hypothesis that a higher frequency of negative thoughts following treatment may predict subsequent relapse among individuals who were treated for social phobia. A replication of this study by Scholing and Emmelkamp (1999) using a longer follow-up period (18 months) yielded the same non-significant result with regard to the relationship between post-treatment cognitions and symptom changes between post-treatment and follow-up, and also failed to show a relationship between pre- to post-treatment changes in frequency of negative cognitions during social situations and social anxiety symptoms 18 months following treatment. These non-significant results obtained in studies examining the frequency of negative selfstatements, however, contrast with those obtained in research employing fear of negative evaluation as the cognitive variable. In two studies by Mattick and colleagues (Mattick & Peters, 1988; Mattick, Peters, & Clarke, 1989), changes in fear of negative evaluation during cognitive, exposure, or combined therapy were examined with regard to the prediction of longer-term functioning among individuals with social phobia. In these studies, reduction in the fear of negative evaluation by others from pre- to post-treatment was found to be a significant predictor of both overall functioning and degree of improvement in social phobia symptoms 3 months following treatment. Within-treatment changes on measures of irrational beliefs and locus of control were found to explain little further variance in the severity of social phobia at follow-up. In summary, therefore, there is evidence to suggest that overestimations of the probability and cost of negative social events, and excessive concern with regard to negative evaluation by other people may be of particular importance in the maintenance of social phobia. Research regarding the role of changes in the perceived costs or consequences of negative social events in treatment outcome, however, has examined this variable in a nonspecific manner, by asking participants to indicate on a numerical scale ‘‘how bad or distressing’’ hypothetical negative social occurrences would be if they occurred (Foa et al., 1996; McManus et al., 2000). Thus, these studies provide no information with regard to why such events are considered to be so aversive, or the specific types of ‘‘catastrophic’’ interpretations of negative social events that may be important in maintaining social phobia. In addition, the evidence obtained in the two studies by Mattick and colleagues in support of the notion that fear of negative evaluation by others may play a key role in social phobia both employed the Fear of Negative Evaluation Scale (FNES; Watson & Friend, 1969), which may not be an optimal measure to examine the specific types of cognitions associated with the disorder. Inspection of the content of the FNES, for instance, reveals several items that may potentially be answered by respondents according to whether they believe that negative evaluation is likely or deserved, rather than the extent to which they fear being negatively judged by others per se (e.g. ‘‘If someone is evaluating me, I tend to expect the worst’’).1

1

We thank the helpful comments of an anonymous reviewer for this suggestion.

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Previous evidence suggests that biases in the interpretation of negative social outcomes among individuals with social phobia relate not only to the way they are perceived by others, but also to evaluations of the self and beliefs about the long-term repercussions of such events. Researchers have shown, for instance, that people with social phobia are more likely than those without the disorder to: (1) believe that unfavourable social events will result in other people evaluating them in a negative manner; (2) interpret negative social events to mean that they possess undesirable personal characteristics according to their self-evaluations; and (3) to believe that such events will have adverse consequences in the long-term future upon factors such as interpersonal relationships and achievement opportunities (Stopa & Clark, 2000; Wilson & Rapee, 2004). While the aforementioned results of Mattick and colleagues support the view that negative evaluation by others represents a central underlying concern in social phobia, questions as to whether the negative impact of unfavourable social events on personal beliefs regarding the self and the future may also be important in maintaining the disorder have not been addressed. The primary aim of the present study was to investigate these questions by examining the relationship between modifications in specific types of interpretations of negative social events and improvements in symptomatology following treatment for social phobia. In particular, the present study sought to determine whether longer-term treatment outcome in social phobia was predicted by within-treatment changes in the degree to which individuals believed that negative social events: (1) would result in negative evaluation by other people; (2) were indicative of negative self-characteristics according to their personal evaluations; and/or (3) would lead to adverse consequences in the long-term future in terms of factors such as their interpersonal relationships and career outlook. The selection of these specific types of interpretations was based on the previously mentioned evidence indicating that social phobia is associated with biases in these beliefs (Stopa & Clark, 2000; Wilson & Rapee, 2004). It was hypothesised that greater within-treatment reductions in the extent to which individuals believed all three types of interpretations would predict better long-term functioning among individuals with social phobia. The question of whether changes in one type of interpretation may be more important than changes in others in predicting improvements in social phobia symptomatology was of particular interest, given the lack of previous evidence in relation to this issue. 2. Method 2.1. Participants Participants consisted of 36 individuals (18 male, 18 female) who underwent cognitivebehavioural treatment for social phobia as part of a controlled treatment outcome trial at the Macquarie University Anxiety Research Unit in Sydney, Australia. Prior to treatment, all participants met criteria of the Diagnostic and Statistical Manual for Mental Disorders—Fourth Edition (DSM-IV; American Psychiatric Association, 1994) for a principal diagnosis of generalised social phobia.2 Diagnoses were established by means of the Anxiety Disorders 2

The DSM-IV states that a diagnosis of generalised social phobia is given when fears encompass ‘‘most’’ social situations. The criterion for determining what constituted ‘‘most’’ social situations was not formally defined in the present research, such that decisions regarding subtype relied on the judgement of the assessing clinicians.

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Interview Schedule for DSM-IV (ADIS-IV; DiNardo, Brown, & Barlow, 1994), a semi-structured interview that evaluates DSM-IV criteria for anxiety, mood, somatoform and substance use disorders, and screens for additional disorders such as psychosis. Recent evidence has indicated that the ADIS-IV is generally associated with good inter-rater reliability for current diagnoses (Brown, DiNardo, Lehman, & Campbell, 2001), and data from the Macquarie University Anxiety Research Unit supports this finding, with a kappa of 0.92 for a principal diagnosis of social phobia (Abbott & Rapee, 2002). All diagnostic interviews were conducted either by clinical psychologists, or by graduate psychology students trained in the use of the ADIS-IV. In terms of demographic characteristics, the mean age of participants at pre-treatment assessment was 36.0 years (s.d.=11.9). Twenty-four (66.7%) had never been married, 8 (22.2%) were currently married or in a defacto relationship, and 4 (11.1%) were separated or divorced. With regard to the highest educational qualification that participants had obtained, 2 (5.6%) had not completed high school, 8 (22.2%) had completed high school, 8 (22.2%) had completed a technical certificate or diploma, 15 (41.7%) had completed an undergraduate degree, and 3 (8.3%) had completed a post-graduate degree. 2.2. Measures Social interaction anxiety scale and social phobia scale (SIAS and SPS; Mattick & Clarke, 1998): The SIAS3 and SPS comprise self-report measures of social interaction anxiety, and performance/ scrutiny fears, respectively. Designed as companion measures in the assessment of social phobia, scores on each scale range from 0 to 80, with higher totals reflecting greater anxiety. Psychometric evaluation suggests that the SIAS and SPS represent reliable and valid measures of social phobia, with both scales demonstrating high internal consistency and test–retest reliability, as well as good discriminant and construct validity (e.g. Brown et al., 1997; Heimberg, Mueller, Holt, Hope, & Liebowitz, 1992; Mattick & Clarke, 1998). Depression Anxiety Stress Scales-21 item version (DASS-21; Lovibond & Lovibond, 1995; Lovibond & Lovibond, 1995): The DASS-21 is a self-report measure that yields scores on three separate scales, indicating individuals’ levels of depression, anxiety and stress/tension, respectively. Factor analyses indicate that the DASS-21 discriminates relatively well between these three negative affective states, and further psychometric data have shown that the DASS-21 has good internal consistency, and acceptable concurrent validity as assessed by correlations with established measures of depression and anxiety (Antony, Bieling, Cox, Enns, & Swinson, 1998). For each scale, scores range from 0 to 42, with higher totals reflecting greater symptomatology. The current study employed the trait version of the questionnaire, which assesses individuals’ characteristic levels of each negative emotional state. ADIS-IV clinical severity ratings (DiNardo et al., 1994): As part of ADIS-IV assessments, clinicians assign severity ratings to disorders on a 0–8 scale to indicate the associated degree of distress and life interference, with ratings above 4 required for a clinical diagnosis. The ADIS-IV is generally associated with good inter-rater reliability for clinical severity ratings (Brown et al., 2001), and preliminary data from the Macquarie University Anxiety Research Unit has shown 3

The SIAS has been revised to include only 19 items, although the original 20-item version was used in the current study.

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acceptable inter-rater agreement for social phobia severity scores (Pearson’s r ¼ 0:73; Abbott & Rapee, 2002). Clinician-rated severity of social phobia was therefore examined as an additional outcome measure in the present study, to supplement self-report measures of social anxiety. Consequences of negative social events questionnaire (CONSE-Q; Wilson & Rapee, 2004): The CONSE-Q was designed to examine the way in which people interpret negative interpersonal events, and was based upon measures used in previous studies of the perceived probability and/or cost of negative social situations in social phobia (e.g. Foa et al., 1996; Lucock & Salkovskis, 1988; Stopa & Clark, 2000). The questionnaire requests individuals to imagine themselves in hypothetical negative social situations, and to indicate the extent to which they would believe various interpretations of each event. Empirical development of the CONSE-Q (see Wilson & Rapee, 2004) yielded a final version that included descriptions of 16 negative social situations, and asked people to rate their degree of belief in three distinct interpretations of each event: (1) that the event would result in other people evaluating them in a negative manner (others’ evaluations); (2) that the event would be indicative that they possessed negative personal characteristics (self-evaluations); and (3) that the event would have adverse long-term consequences upon factors such as interpersonal relationships and career opportunities (perceived long-term consequences). Belief ratings for each interpretation are made on 9-point (0–8) Likert-type scales, where 0=strongly disbelieve, 4=unsure, and 8=strongly believe. A sample item is as follows: Someone you have been on several dates with tells you they do not want to see you any more. If this happened, I would believe that: He/she thinks I am undesirable (negative evaluation by others) I am an undesirable person (negative self-evaluation) I will always be lonely (negative long-term consequences) Preliminary psychometric data suggest that each of the CONSE-Q scales are characterised by high internal consistency, and are factor analytically distinct from each other, despite showing high intercorrelations (Wilson & Rapee, 2004, Study 1). Furthermore, a previous investigation using this measure (which included data from all participants in the current sample) has shown that prior to treatment, individuals with social phobia score significantly higher than do non-clinical controls on each of the subscales comprising the CONSE-Q (Wilson & Rapee, 2004, Study 2). 2.3. Procedure Questionnaires were posted to all participants following an initial telephone screening for social anxiety, and were returned by participants when they attended their pre-treatment assessment interview. Questionnaires and assessment interviews were re-administered to all participants immediately following a 12-week cognitive-behavioural treatment programme for social phobia, as well as 3 months after treatment had ended. Treatment was delivered in one of the following two formats as part of a larger randomised treatment outcome study (Rapee, Abbott, & Gaston, 2001): (1) a ten-session group treatment programme (see Gaston & Rapee, 2000; Rapee & Sanderson, 1998) (n ¼ 25); or (2) a combination of bibliotherapy (see Rapee, 1998) and a fivesession group treatment programme (n ¼ 11). Regardless of the delivery format, the content of treatment was the same for all individuals, and consisted of cognitive restructuring, graded

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exposure, and attentional training.4 Comparisons between the two different treatment groups at each assessment point revealed that they did not differ significantly on any of the CONSE-Q subscales or symptom measures at pre-treatment, post-treatment, or at the 3-month follow-up. Furthermore, the main regression analyses reported below were repeated with the interaction between groups and CONSE-Q measures included as predictor variables. These interaction terms were all non-significant, indicating that the relationship between cognitive changes and outcome measures did not vary between the two treatment groups. Thus, analyses investigating the relationship between within-treatment changes in the interpretation of negative social events and long-term outcome combined data from all 36 participants, irrespective of treatment delivery format.

3. Results 3.1. Changes in CONSE-Q scales and symptom measures following treatment Pre- and post-treatment means and standard deviations for each CONSE-Q interpretative category are presented in Table 1. Paired t-tests indicated that pre- to post-treatment reductions in belief ratings for each interpretative category were significant [belief that others would perceive one unfavourably tð35Þ ¼ 7:65, po0:001; belief in negative self-characteristics tð35Þ ¼ 5:59, po0:001; belief in adverse long-term consequences tð35Þ ¼ 6:58; po0:001]. Table 1 also presents means and standard deviations of symptom measures at pre- and posttreatment, and at 3-month follow up. One-way repeated measures Analyses of Variance (ANOVAs) indicated that there were significant differences at the different time points for each social phobia outcome measure [SIAS: Fð2; 70Þ ¼ 55:16, po0:001; SPS: F ð2; 70Þ ¼ 61:82, po0:001; Clinician-Rated Severity: Fð2; 70Þ ¼ 101:93; po0:001]. Comparisons between scores on social phobia symptom measures at each assessment occasion were conducted by means of paired t-tests, using a Bonferroni-adjusted alpha level of 0.017 (0.05/3) to avoid inflation of the Type I error rate. These comparisons revealed that scores on each social phobia measure were significantly higher at pre-treatment than at post-treatment [SIAS: tð35Þ ¼ 8:40, po0:001; SPS: tð35Þ ¼ 8:05; po0:001; Clinician-Rated Severity: tð35Þ ¼ 12:08, po0:001] or at the 3-month follow-up [SIAS: tð35Þ ¼ 8:08, po0:001; SPS: tð35Þ ¼ 8:89, po0:001; Clinician-Rated Severity: tð35Þ ¼ 11:07, po0:001]. There were no significant differences between post-treatment and 3month follow-up on any of the social phobia measures [SIAS: tð35Þ ¼ 2:07, p40:017; SPS: tð35Þ ¼ 2:32, p40:017; Clinician-Rated Severity: tð35Þ ¼ 2:32, p40:017], indicating that although participants maintained treatment gains in the longer-term, they did not, on average, continue to improve significantly after treatment had ended. Interestingly, as Table 1 also indicates, treatment for social phobia was associated with decreases in scores on each of the DASS-subscales. One-way repeated measures ANOVAs 4

The majority of treating clinicians were blind to the hypotheses of the present study, with the exception of one of the authors (J.W.), who was a co-therapist in the treatment of a small number of participants (o10). All therapists followed a detailed treatment manual that did not specifically target the cognitions being investigated in the present study, although data concerning treatment fidelity are not available at the present time.

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Table 1 Means and standard deviations (in parentheses) for interpretative categories of the CONSE-Q and symptom measures by assessment occasion Measure

Occasion Pre-treatment

Post-treatment

5.85a (1.11) 3.85a (1.74) 3.89a (1.74)

4.13b (1.33) 2.25b (1.62) 2.11b (1.60)

Social phobia symptom measures Social interaction anxiety scale Social phobia scale ADIS-IV clinician-rated severity

56.06a (11.45) 38.88a (14.37) 6.47a (0.92)

39.86b (12.94) 21.66b (11.59) 4.21b (1.17)

36.75b (12.58) 18.51b (10.48) 3.82b (1.49)

DASS-21 subscales Depression General anxiety Stress

21.00a (12.26) 16.87a (6.84) 22.33a(7.54)

13.28b (7.77) 10.95b (6.12) 17.19b (6.96)

10.32c (6.83) 8.33c (5.27) 15.61c (6.72)

CONSE-Q scales Belief that others would perceive one in negative manner Belief that event was an indication of negative self-characteristics Belief that event would have adverse long-term consequences

3-month f/u — — —

Note: Means with different superscripts differ at po0:017.

showed that the differences in each of the DASS-subscale scores across time were significant [DASS-Anxiety: F ð2; 70Þ ¼ 43:14, po0:001; DASS-Depression: F ð2; 70Þ ¼ 24:58, po0:001; and DASS-Stress: F ð2; 70Þ ¼ 23:81, po0:001]. Follow-up pairwise comparisons, again using a Bonferroni-adjusted alpha level of 0.017, showed that for all three DASS subscales, pre-treatment scores were significantly higher than post-treatment scores [DASS-Anxiety pre vs. post: tð35Þ ¼ 5:80, po0:001; DASS-Depression pre vs. post: tð35Þ ¼ 4:70, po0:001; DASS-Stress pre vs. post: tð35Þ ¼ 4:77, po0:001], which were in turn, higher than 3-month follow-up scores [DASS-Anxiety post vs. 3m: tð35Þ ¼ 4:13, po0:001; DASS-Depression post vs. 3m: tð35Þ ¼ 2:99, po0:017; DASS-Stress post vs. 3m: tð35Þ ¼ 2:60, po0:017]. Thus, symptoms of general anxiety, depression and stress appeared to improve during treatment, and also showed further improvements after treatment had ended. 3.2. Relationship between treatment-related interpretative changes and symptom reduction In order to determine whether changes in the different interpretations of negative social events were associated with treatment-related changes in symptomatology, simple correlations were computed between pre–post residualised gain scores for each interpretative category and pre–post residualised gain scores for each of the symptom measures (see Table 2). Residualised gain scores represent a measure of improvement during treatment that controls for initial symptom severity and for measurement error associated with repeated assessment, and thus have advantages over other measures of change (see Steketee & Chambless, 1992). All correlations between residualised gain scores for CONSE-Q scales and self-report measures of social phobia were significant, suggesting that improvements in social anxiety observed during treatment were associated with reductions in the degree to which individuals believed that negative social events meant that other

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Table 2 Correlations between pre–post treatment residualised gain scores for CONSE-Q scales and symptom measures CONSE-Q scale (Pre–post residualised gain Symptom measure (Pre–post residualised gain score) score) Social phobia DASS-21 scale

Belief that others would perceive one in negative manner Belief that event was an indication of negative self-characteristics Belief that event would have adverse longterm consequences

SIAS

SPS

Clinician-rated severity

Depression

Anxiety

Stress

0.34*

0.43**

0.30

0.11

0.19

0.38*

0.48**

0.48**

0.20

0.32

0.36*

0.52**

0.49**

0.39*

0.22

0.24

0.26

0.40*

*po0:05. **po0:01.

people evaluated them in a negative manner, were an indication of negative self-characteristics, and would have adverse consequences in the long-term future. Nevertheless, the evidence was not entirely consistent, as the correlations between within-treatment interpretative changes and reductions in clinician-rated severity failed to reach significance. In addition, several significant correlations were observed between pre–post residualised gain scores for the DASS-scales and those for the CONSE-Q interpretative categories (see Table 2). Specifically, the results indicated that treatment-related changes in each type of interpretation assessed by the CONSE-Q were also associated with improvements in symptoms of stress, and that changes in the degree to which individuals believed that negative social events were indicative of unfavourable self-characteristics were also associated with reductions in general anxiety. 3.3. Prediction of social phobia symptoms at 3-month follow-up A further question of interest in the present study was whether reductions in negative interpretations of unpleasant social events were associated with the maintenance of treatmentrelated improvements in the longer-term. In order to examine this issue, a series of hierarchical, multiple regression analyses were conducted to determine whether changes in the various types of unfavourable interpretations of negative social events from pre- to post-treatment predicted social phobia symptoms 3 months after treatment had finished. Separate analyses were conducted for each outcome measure (SIAS, SPS, and ADIS-IV clinician-rated severity), with 3-month followup scores being entered as the dependent variables.5 For each outcome measure, separate regression analyses were conducted for each type of interpretation on the CONSE-Q, with pre- to post-treatment residualised gain scores for belief ratings in each interpretative category being entered as predictor variables. In line with previous investigations regarding the potential role of 5

Although a multivariate approach involving structural equation modeling would be the optimal method of analysing the data, this approach was unfortunately not possible due to an insufficient sample size.

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cognitive changes in producing treatment-related improvements in symptomatology (Foa et al., 1996; McManus et al., 2000), pre-treatment scores on the relevant social phobia measure (SIAS, SPS, and ADIS-IV clinician-rated severity) were also included as predictors in each of the regression analyses. Pre-treatment scores were entered into the equations first, and residualised gain scores for belief in interpretations second, such that the ability of treatment-related changes in interpretations of negative social events to predict social phobia symptoms 3 months following treatment was assessed independently of initial symptom severity. The analyses revealed that pre- to post-treatment changes in the degree to which individuals believed that negative social events would result in other people perceiving them in an unfavourable way did not account for a significant amount of variance in 3-month follow-up scores on any of the social phobia outcome measures, after controlling for pre-treatment severity [SIAS: change in R2 ¼ 0:08, Fð1; 33Þ ¼ 3:04, p40:05; SPS: change in R2 ¼ 0:07, Fð1; 33Þ ¼ 2:89, p40:05; ADIS-IV severity: change in R2 ¼ 0:07, F ð1; 33Þ ¼ 3:06, p40:05]. Pre- to post-treatment changes in the belief that negative social events would have adverse consequences in the long-term upon factors such as relationships and career did not account for a significant amount of additional variance when entered after pre-treatment scores for either the SPS [change in R2 ¼ 0:06, F ð1; 33Þ ¼ 2:81, p40:05] or ADIS-IV clinical severity ratings [change in R2 ¼ 0:09, F ð1; 33Þ ¼ 4:01, p40:05], but did reach significance for the SIAS [change in R2 ¼ 0:12, F ð1; 33Þ ¼ 5:11, po0:05]. In contrast, within-treatment changes in the degree to which individuals believed that negative social events were an indication of undesirable personal characteristics accounted for a significant amount of the variance in three-month follow-up scores independently of pre-treatment symptom scores on all three outcome measures [SIAS: change in R2 ¼ 0:24, F ð1; 33Þ ¼ 12:04, po0:01; SPS: change in R2 ¼ 0:12, F ð1; 33Þ ¼ 5:37, po0:05; ADIS-IV clinicianrated severity: change in R2 ¼ 0:14, Fð1; 33Þ ¼ 6:36, po0:05].6 Given that 3-month scores on the SIAS were predicted by treatment-related changes in negative interpretations regarding the self as well as those concerning the long-term future, additional hierarchical regression analyses were conducted in order to determine whether significant results on this measure reflected unique variance explained by changes in the different interpretative categories. Three-month follow-up scores on the SIAS were again entered as the dependent variable, while the independent variables were pre-treatment SIAS scores, and residualised gain scores for all three interpretative categories. These analyses indicated that within-treatment change in the belief that negative social events meant that one possessed negative personal characteristics remained a significant predictor of outcome at follow-up when entered into the equation after pre-treatment scores on the SIAS and after changes in the other two interpretative categories [change in R2 ¼ 0:16, F ð1; 31Þ ¼ 7:88, po0:01]. In contrast, changes in the belief that negative social events would have adverse long-term consequences no longer accounted for a significant proportion of variance in 3-month SIAS scores after variance due to pre-treatment scores and within-treatment changes in the other two interpretative categories had been partialled out [change in R2 ¼ 0:01, Fð1; 31Þ ¼ 0:68, p40:05]. Thus, these results suggest that longer-term treatment-related improvements in social phobia symptoms may be partially determined by the 6

The results of these regression analyses remained the same when difference scores between CONSE-Q variables at pre- and post-treatment were substituted for residualised gain scores, thus indicating that they were robust to different measures of change.

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extent to which treatment can change beliefs regarding negative social events being an indication of undesirable traits that one possesses, rather than beliefs about how one will be perceived by others, or beliefs about long-term negative effects in terms of one’s future relationships or career outlook. 3.4. Prediction of depression, general anxiety and stress at 3-month follow-up Given that treatment-related improvements were observed not only for social phobia symptoms, but also for depression, general anxiety and stress, it is possible that treatmentrelated changes in the interpretation of negative social events may be important in predicting longer-term improvement in more general psychopathology. In order to address this issue, a final series of regression analyses was conducted in which pre- to post-treatment residualised gain scores for the different CONSE-Q scales were assessed separately in terms of their ability to predict each of the DASS-21 scale scores at follow-up, after controlling for pre-treatment scores on the relevant DASS-21 measure. These regression analyses indicated that within-treatment interpretative changes did not significantly predict follow-up scores on either the DASSDepression or DASS Anxiety scales after controlling for initial symptom severity [residualised gain scores for beliefs regarding negative evaluation by others: change in R2 ¼ 0:00, F ð1; 33Þ ¼ 0:13, p40:05 for DASS-Depression; change in R2 ¼ 0:02, Fð1; 33Þ ¼ 0:62, p40:05 for DASS-Anxiety; residualised gain scores for negative self-evaluations: change in R2 ¼ 0:07, F ð1; 33Þ ¼ 3:04, p40:05 for DASS-Depression; change in R2 ¼ 0:08, F ð1; 33Þ ¼ 3:76, p40:05 for DASS-Anxiety; residualised gain scores for belief in negative long-term consequences: change in R2 ¼ 0:05, F ð1; 33Þ ¼ 2:20, p40:05 for DASS-Depression; change in R2 ¼ 0:06, F ð1; 33Þ ¼ 2:60, p40:05 for DASS-Anxiety]. These results therefore suggest that within-treatment changes in the interpretative categories assessed by the CONSE-Q did not account for longer-term improvements in depression or general anxiety. In contrast, however, the individual regression analyses assessing the relationship between preto post-treatment interpretative changes and DASS-Stress scores at follow-up all yielded significant results [residualised gain scores for beliefs regarding negative evaluation by others: change in R2 ¼ 0:10, F ð1; 33Þ ¼ 4:46, po0:05; residualised gain scores for negative selfevaluations: change in R2 ¼ 0:20, Fð1; 33Þ ¼ 10:90, po0:01; residualised gain scores for belief in negative long-term consequences: change in R2 ¼ 0:12, F ð1; 33Þ ¼ 5:97, po0:05]. Nevertheless, when residualised gain scores for all three interpretative categories were included as predictors in the regression equation in addition to pre-treatment DASS-Stress scores, the results indicated that none of the specific types of interpretative changes made a unique contribution to the prediction of DASS-Stress scores at follow-up [residualised gain scores for beliefs regarding negative evaluation by others: change in R2 ¼ 0:00, F ð1; 31Þ ¼ 0:16, p40:05; residualised gain scores for negative self-evaluations: change in R2 ¼ 0:07, F ð1; 31Þ ¼ 3:81, p40:05; residualised gain scores for belief in negative long-term consequences: change in R2 ¼ 0:00, F ð1; 31Þ ¼ 0:12, p40:05]. The failure of the different types of interpretative changes to explain significant variance in symptoms of stress at follow-up independently of pretreatment scores and changes in the other two interpretative categories thus provides little evidence that changes in specific types of unfavourable interpretations are more important than others in contributing to the alleviation of symptoms of stress in the longer-term.

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4. Discussion The results of the present study support cognitive theory and research suggesting that judgements concerning the cost, or ‘‘catastrophic interpretations’’ of negative social events may be a key factor in maintaining social phobia (e.g. Clark & McManus, 2002; Foa et al., 1996). Furthermore, the current results extend previous findings by suggesting that within-treatment changes in specific types of interpretations of negative social events may be important determinants of social phobia symptom improvement in the longer-term. Consistent with previous studies suggesting that cognitive-behavioural treatment is associated with reductions in cognitive biases in social phobia (e.g. Foa et al., 1996), the present study found significant pre- to post-treatment decreases in the degree to which individuals with the disorder believed negative interpretations of unpleasant social events. Thus, following treatment, participants were less likely than they were prior to treatment to believe that negative social events would result in negative evaluation of the self by other people, to personally believe that such events were indicative of negative self-characteristics, or to believe that these events would have adverse consequences in the long-term future for their relationships and careers. Moreover, the results showed that treatment-related reductions in the degree to which participants believed each of these interpretations were associated with improvements in self-reported social phobia symptomatology, in accordance with other research showing correlations between cognitive change during treatment and decreases in social anxiety (e.g. Chambless et al., 1997; McManus et al., 2000). The question of primary interest, however, was whether treatment-related reductions in unfavourable interpretations of negative social events may be important in producing longer-term improvements in social phobia symptoms. In this respect, the present study examined the question of whether changes in different types of interpretations of negative social events during treatment predicted social phobia symptomatology 3 months following treatment termination, independently of pre-treatment symptom severity. Consistent with hypotheses, the results supported the view that changes in interpretations of negative social events predict better longer-term treatment outcome among individuals with social phobia. Reductions in the belief that negative social events were indicative of negative self-characteristics were found to predict longer-term treatment outcome on all three outcome measures employed. Furthermore, the results of a regression analysis including within-treatment changes in all three interpretative categories as predictors indicated that decreases in negative self-evaluations predicted longer-term improvement on a measure of social anxiety even after variance attributable to changes in other types of interpretations was partialled out of the equation. In contrast, changes in the belief that negative social events would have adverse long-term consequences upon factors such as interpersonal relationships and achievement opportunities did not make a unique contribution to the prediction of symptom scores 3 months following treatment. Interestingly, the results also showed no significant relationship between social phobia symptoms at the 3-month follow-up and withintreatment changes in negative beliefs regarding the effect of unfavourable social events on others’ perceptions of the self. Thus, it appears that decreases during treatment in the personal belief that negative social events are indicative of negative self-characteristics may be more important than changes in other types of interpretations in terms of producing a more positive longer-term outcome among individuals with social phobia.

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Initially, these results may appear to be at odds with theoretical conceptualisations of social phobia that emphasise fear of negative evaluation by other people as being a key factor in social phobia, as well as research findings indicating that decreases in fear of negative evaluation predict long-term treatment outcome for individuals with the disorder (Mattick & Peters, 1988; Mattick et al., 1989). It may be argued, however, that this is not necessarily the case. The current study assessed the degree to which individuals with social phobia believed that negative social events would result in unfavourable evaluations of themselves by others, rather than the importance that they attached to such negative evaluations. In other words, it was found that within-treatment changes in the perceived probability of negative evaluation following negative social events did not predict long-term treatment outcome. The degree to which individuals fear negative evaluation, however, may reflect the subjective meaning that they attach to negative evaluation by others when it does occur. Indeed, a critical assumption of cognitive models of social anxiety is that a high estimation of the likelihood of negative evaluation by others will only produce anxiety in social encounters to the extent that it is accompanied by a strong motivation to convey more favourable impressions to other people (Schlenker & Leary, 1982), or overestimations of the adverse consequences of negative evaluation (Rapee & Heimberg, 1997). Thus, while two individuals may show equivalent levels of belief that a particular event will result in negative evaluation by others, the degree of distress that this causes may differ between the two individuals depending on the meaning they attach to such negative evaluation. Although speculative, it may be the case that people with social phobia are more likely than individuals without the disorder to interpret unfavourable evaluations of the self by other people as being an accurate indication of the characteristics they possess (see Clark & Wells, 1995), such that perceived negative evaluation by others may mediate the relationship between negative social events and unfavourable self-evaluations. In other words, it may be that individuals with social phobia do not fear negative evaluation by others per se, but rather, may fear it because of what they believe it means about themselves. Interestingly, there is evidence to suggest that individuals with social phobia tend to attribute control over events less to internal resources, and more to ‘‘powerful others’’ than do non-anxious individuals (Cloitre, Heimberg, Liebowitz, & Gitow, 1992; Leung & Heimberg, 1996). If this tendency in social phobia to overestimate the power of other people also manifests in attaching greater importance to others’ opinions, it is evident that perceived negative evaluation by others may be interpreted as being a ‘‘true’’ or ‘‘correct’’ assessment of the self, such that adverse information is incorporated into the self-concept (see Wilson & Rapee, 2004). Future research is needed in order to determine whether the types of interpretations that individuals with social phobia make about themselves are a direct response to negative social events, or are mediated by the assumed impact of the event on others’ evaluations of the self. With regard to the issue of specificity of cognitive biases in social phobia, previous research suggests that negative interpretations of unfavourable social occurrences are independently associated not only with social anxiety, but also with depression (e.g. Wilson & Rapee, 2004). In the current study, several significant correlations were observed between within-treatment decreases in unfavourable interpretations of negative social events and pre- to post-treatment reductions in anxiety and stress, although not with reductions in depression. This raises the possibility that such biases may be important not only in the maintenance of social phobia, but may also be important in maintaining psychopathology in general. To address this issue, analyses

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were conducted which examined the ability of within-treatment changes in each type of interpretation of negative social events to predict longer-term improvements in symptoms of depression, general anxiety and stress. The analyses for anxiety and depression yielded nonsignificant results, suggesting that changes in the interpretation of negative social events may not play a primary role in the longer-term alleviation of these symptoms. In contrast, the analyses for stress indicated that within-treatment changes in each type of interpretation were significantly associated with longer-term symptom improvement when entered into regression equations separately, although none of the interpretative changes made a unique contribution to the prediction of stress scores at follow-up when all three were included in the equation. This finding is consistent with the view that decreases in negative interpretations of unfavourable social events in a general sense may contribute to the alleviation of stress symptoms in the longer-term, although decreases in one specific type of interpretation may not be more important than others. Overall, therefore, the present results support the view that negative beliefs about unpleasant social events in terms of what they mean about the self may be specifically important in maintaining social anxiety, rather than other forms of psychopathology. It is important to note, however, that the present results are largely preliminary, such that further research is required before more definite conclusions can be made with regard to the potential causal or maintaining role that specific types of interpretative biases may play in symptoms of social anxiety. For instance, an alternate interpretation of the present results is that treatment that successfully reduces symptoms of social anxiety provides individuals with a learning experience that changes the extent to which they believe that unfavorable social outcomes are indicative of undesirable personality traits. Future research is required which examines the effect of experimentally manipulating specific types of interpretations of potentially negative social outcomes on symptoms of social anxiety. To date, there is some evidence to suggest that increasing the likelihood that individuals will blame potential failures in social situations on external factors, rather than personal deficiencies, may lead to reductions in symptoms of social anxiety (e.g. Brodt & Zimbardo, 1981; Leary, 1986; Olson, 1988). Unfortunately, however, this research failed to determine whether the alleviation of symptoms was primarily due to reductions in individuals’ personal beliefs that they were to blame for potential failures, or reductions in their belief that they would be blamed by other people (see Leary, 1986). In addition, future research could employ alternate data analytic strategies in order to determine whether particular types of interpretative changes are important in producing treatment effects. The statistical analyses employed in the present study were based on those used by previous researchers investigating the question of whether cognitive changes may account for improvements in social phobia symptoms following treatment (e.g. Foa et al., 1996; Mattick et al., 1989; McManus et al., 2000). A more structured mediational test as outlined by Baron and Kenny (1986) would have been optimal (i.e. an analysis showing that the effects of treatment vs. no treatment on symptom improvement were eliminated or reduced after controlling for cognitive change). Unfortunately, however, this was not possible in the present study due to the absence of data from a no-treatment control group. Furthermore, it is not clear from the present results to what extent the negatively biased inferences that individuals with social phobia draw about their personal characteristics following negative social events merely reflect pre-existing negative views that they hold in relation to themselves, given that previous research suggests that their general self-evaluations are

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characteristically less positive than those of non-anxious people (e.g. Leary, 2001). The factors that underlie the types of interpretations that people with social phobia make in relation to negative social events are a topic requiring further investigation. In summary, while previous research has shown that people with social phobia are more likely than other individuals to attach a variety of negative interpretations to adverse social occurrences, the results of the present study are consistent with the view that it is ultimately the negative inferences they draw with regard to the self that may be important in maintaining the disorder. Such potential threats to the way in which individuals view themselves may operate to increase the perceived danger within social situations, thus contributing to anxiety in such situations. These results suggest that the modification of negative beliefs regarding what unfavorable social events mean about one’s personal attributes may be an important aim of treatment programmes for social phobia. Nevertheless, further investigation is required before these conclusions may be considered substantive.

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