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research-article2013
Empirical Article
1
Department of Psychology, Stanford University, Stanford, California; 2Department of Psychiatry, Stanford Medical School, Stanford,
California; and 3Department of Psychology, Temple University, Philadelphia, Pennsylvania
Abstract
Social anxiety disorder is thought to be characterized by maladaptive self-views. This study investigated whether (a) patients
with social anxiety disorder (n = 75) differ at baseline from healthy controls (n = 43) in negative and positive self-views,
(b) cognitive-behavioral therapy (CBT) for social anxiety disorder versus wait-list control produces statistically and clinically
significant changes in negative and positive self-views, (c) changes in self-views mediate the effect of CBT on social anxiety
symptoms, and (d) changes in self-views during CBT related to social anxiety symptoms at 1-year post-CBT. As expected,
patients endorsed more negative and fewer positive self-views than healthy controls at baseline. Compared to wait-list control,
CBT yielded statistically and clinically significant changes, specifically, fewer negative and more positive self-views. Mediational
analysis indicated that increased positive (but not reduced negative) self-views mediated the effect of CBT on social anxiety
reduction. Correlational analyses determined that increased positive self-views were associated with social anxiety symptom
reduction at 1-year post-CBT.
Keywords
social anxiety, self-view, self-referential, cognitive-behavioral therapy, meditation
Received 10/12/12; Revision accepted 1/8/13
Social anxiety disorder (SAD) is highly prevalent (with a lifetime prevalence of 12.1%; Kessler et al., 2005), has an early
onset (Otto et al., 2001), and has a high rate of persistence that
is well predicted by symptom severity and comorbid mood
disorders (Blanco et al., 2011). Individuals with SAD experience distressing levels of social fear, humiliation, and embarrassment (Stein & Stein, 2008), which can lead to significant
impairment in social, educational, and occupational functioning (Schneier et al., 1994; Stein & Kean, 2000) and thus create a substantial personal as well as a societal burden (Acarturk
et al., 2009; Patel, Knapp, Henderson, & Baldwin, 2002).
Cognitive-behavioral models of social anxiety (Clark &
Wells, 1995; Heimberg, Brozovich, & Rapee, 2010) highlight
the important role played by maladaptive self-views, exaggerated self-focus, and distorted interpretations in generating
and maintaining heightened social anxiety. Individuals with
SAD tend to view themselves as socially awkward, inadequate, or flawed. These negative self-views are thought to
trigger exaggerated self-focused attention that can lead to
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Goldin et al.
change in negative and positive self-views compared to normative HC data. We expected that increases in positive and
reductions in negative self-views during CBT would mediate
the effect of CBT versus WL on social anxiety symptoms. We
further expected that increases in positive and reductions in
negative self-views would be related to social anxiety symptom reduction at 1-year post-CBT.
Method
Participants
Patients were seeking treatment for SAD and met criteria per
the Diagnostic and Statistical Manual of Mental Disorders,
fourth edition (American Psychiatric Association, 1994), for
a principal diagnosis of generalized SAD based on the
Anxiety Disorders Interview Schedule for the DSM-IV
Lifetime version (ADIS-IV-L; DiNardo, Brown, & Barlow,
1994). In the context of an RCT and of the 436 individuals
assessed for eligibility (see Consolidated Standards of
Reporting Trials diagram in Goldin et al., 2012), 110 were
administered the ADIS-IV-L in person to determine whether
they met diagnostic inclusion and exclusion criteria. After 35
patients were excluded owing to not meeting diagnostic criteria (n = 26) or incomplete baseline assessments (n = 9), the
remaining 75 patients were randomly assigned to either
immediate CBT for SAD (n = 38) or a WL group (n = 37),
who were offered CBT after the waiting period. After accounting for dropout from CBT (n = 6, 16%) and WL (n = 5, 14%),
as well as incomplete data at post-CBT (n = 5) and post-WL
(n = 6), we assessed 43 HC participants for comparison to
patients with SAD. Participants in this study are the same participants as reported in Goldin et al. (2012) and Boden et al.
(2012).
Because participants were part of a larger functional magnetic resonance imaging study, they had to pass a magnetic
resonance safety screen and be right-handed as assessed by
the Edinburgh Handedness Inventory (Oldfield, 1971), and
they were excluded for current pharmacotherapy or psychotherapy, past CBT, history of neurological or cardiovascular
disorders, and current psychiatric disorders other than SAD,
generalized anxiety disorder, agoraphobia without a history
of panic attacks, or specific phobia. HCs had to have no history of Axis I psychiatric disorders as assessed by the
ADIS-IV-L.
Procedure
HCs were recruited via electronic bulletin boards and assessed
only once. Patients were recruited for an RCT of CBT for
SAD through clinician referrals and Web-based community
listings. After they passed a telephone screening, they completed the ADIS-IV-L during a face-to-face interview. After
completing all baseline assessments, patients were randomly
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Measures
To measure severity of social anxiety symptoms, we used
the 24-item Liebowitz Social Anxiety ScaleSelf-Report
(LSAS-SR; Fresco et al., 2001; Liebowitz, 1987), which consists of questions that assess social interaction situations (11
items) and performance situations (13 items). A 4-point
Likert-type scale is used for ratings of fear and avoidance for
situations during the past week (0 = none and never; 3 =
severe and usually, respectively). Ratings are summed for a
total LSAS-SR score (range = 0144). The LSAS-SR has
good reliability and construct validity (Rytwinski et al.,
2009), and its internal consistency (Cronbachs alpha) was
excellent in this study (SAD patients = .91, HCs = .93).
To measure the potential confound of social desirability,
we administered the 10-item Marlowe-Crowne Social
Desirability Scale (Crowne & Marlowe, 1960). The instrument consists of true-false items with four reverse-coded
items, with higher scores reflecting a greater tendency to give
a socially desirable response. It has shown adequate internal
consistency and reliability (Crino, Svoboda, Rubenfeld, &
White, 1983).
Statistical analyses
For the baseline comparison, we conducted between-group t
tests on positive and negative self-endorsement on the SRET.
For the RCT, we conducted a 2 2 repeated-measures analysis of variance (ANOVA)Group (CBT, WL) Time (pretreatment, posttreatment)of positive and negative
self-endorsement to determine the effect of CBT on selfviews. We report effect sizes as Cohens d (Cohen, 1988) and
as partial eta squared (p2; Pierce, Block, & Aguinis, 2004).
For the RCT, we also report effect sizes as success rate difference (SRD), defined as the difference between the probabilities that a randomly chosen patient from CBT will have a
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Goldin et al.
Results
Preliminary analyses
Patients with SAD and HCs did not differ significantly (all
ps > .18) in gender, age, education, ethnicity, and marital status (Table 1). Patients in the CBT and WL groups also did not
differ in gender, age, education, ethnicity, marital status, current or past Axis I comorbidity, and past psychotherapy or
pharmacotherapy (all ps > .05). The two groups also reported
similar age at symptom onset (M SD: CBT = 13.2 7.9, WL
= 13.0 6.1 years; t = 0.16) and years since symptom onset
(CBT = 20.4 11.1, WL = 20.3 12.9 years; t = .02).
To rule out baseline differences in self-views, betweengroup t tests of patients with SAD who were randomly
assigned to (but had yet to begin) CBT or WL revealed no
between-group differences on self-endorsement of positive
self-views (p > .18) or negative self-views (p > .37). To rule
out the possibility of a social desirability response bias on
self-report measures, we examined the relationship of the
Marlowe-Crowne Social Desirability Scale and endorsement
of self-views. In the CBT group, we found no significant relationships between the scale and baseline SRET negative selfendorsement (r = .15, p > .37) and positive (r = .01, p >.97).
Similarly, in the WL group, we found no significant relationships between the scale and baseline SRET negative selfendorsement (r = .28, p > .13) and positive (r = .34, p > .07).
SAD
Men
Age, yearsa
Education, yearsa
White
Marital status
Single, never married
Married/with partner
Divorced, separated, widowed
HC
39 (52.0)
33.5 8.9
16.8 2.3
43 (57.3)
23 (53.4)
33.8 9.8
17.4 2.0
25 (58.1)
46 (63.0)
24 (32.9)
3 (4.1)
21 (48.8)
21 (48.8)
1 (2.3)
Test
2
= 0.07
t = 0.21
t = 1.34
2 = 0.41
2 = 0.78
Note: SAD = patients with social anxiety disorder (n = 75); HC = healthy controls (n =
43). All comparisons were nonsignificant (p > .05).
a
Mean standard deviation.
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CBT
WL
100
90
Self-Endorsement%
80
70
60
50
40
30
20
10
0
Pre-Positive
Post-Positive
Pre-Negative
Post-Negative
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Goldin et al.
SE
67.01
1.55
0.30
0.41
3.95
7.89
0.14
0.27
.035
.31
.25
.85
.03
.14
Linear (CBT)
WL
Linear (WL)
120
100
80
y = 0.09x + 68
R = 0.01
60
40
y = 0.50x + 66
R = 0.22
20
0
30
20
10
10
20
30
40
50
60
70
80
90
100
307
Discussion
This study found that CBT reduced negative and increased
positive self-views and that increased positive (but not
reduced negative) self-views mediated the effect of CBT on
social anxiety symptom reduction, as well as predicted social
anxiety symptom reduction at immediate CBT and 1-year
post-CBT.
As expected, compared to HC, patients with SAD at baseline showed a maladaptive profile of self-views, characterized by few positive and many negative self-endorsements.
This pattern converges with prior reports of maladaptive selfviews in SAD (Goldin et al., 2009; Hofmann et al., 2004) and
more generally with self-critical cognitive styles that reflect a
fundamental cognitive diathesis in anxiety and mood disorders (Moscovitch, Hofmann, Suvak, & In-Albon, 2005).
Importantly, the effect size for differential positive (p2 = .53)
and negative (p2 = .52) self-views in patients with SAD versus nonanxious HCs showed an equivalent degree of distortion. This means that individuals with SAD have fewer
positive and more negative self-views than do nonclinical
individuals.
Compared to WL, CBT resulted in significant enhancement of positive and reduction of negative self-views (pre- to
post-CBT change in self-endorsement: positive = 27% and
negative = 25%). This indicates that CBT affects not only
negative but also positive self-concepts. However, when
viewed through the lens of clinically significant change, CBT
was more effective in moving positive self-views (48%) than
negative self-views (31%) into the normative range.
Prior RCTs of clinical treatments have examined negative,
but not positive, self-referential thoughts and self-views
(Hofmann et al., 2004). The present findings add to our understanding of the effects of CBT for SAD, suggesting that cognitive restructuring and exposure to feared social situations
modifies at least two aspects of self-processing (positive and
negative self-views) but that the impact on positive self-views
may be more clinically meaningful than previously considered. Moscovitch and colleagues (2009) found that positive
self-views (based on ratings of 13 self-attribute dimensions)
were related to higher levels of certainty and importance in
HCs. It may be the case that as patients with SAD shift after
CBT into the normative range for positive self-views, they,
like HCs, regard these positive self-views as more definitive
and relevant to their well-being (than the changes in negative
self-views). If so, this suggests that changes in positive selfviews may be even more meaningful and effective than
changes in negative self-views.
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Goldin et al.
Funding
This research was supported by a National Institute of Mental Health
grant (R01 MH076074) awarded to James J. Gross. Richard G.
Heimberg is the author of the commercially available cognitivebehavioral therapy protocol utilized in this study. None of the
authors have any biomedical financial interests or potential conflicts
of interest. Philippe R. Goldin, who is independent of any commercial funder, had full access to all data in the study and takes responsibility for their integrity and the accuracy of their analysis.
Note
ClinicalTrials.gov identifier: NCT00380731.
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