Jan-Erik Nilsson

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Experimental studies of components in the treatment for social anxiety disorder

SOCIAL ANXIETY DISORDER (social phobia) is a debilitating and common anxiety disorder, with a lifetime prevalence ranging from 6 % to 12 %. The condition has its onset in childhood and early adolescence, affects females more often than males, and if untreated is associated with high risk of developing comorbid anxiety and mood disorders, as well as substance abuse. The increasingly growing body of research during the last decades has helped to understand the mechanisms of social anxiety disorder, and has made possible the development of efficacious cognitive behavioural treatment (CBT) methods for the disorder. However, all clients do not improve as much as desired, and there is room for improvement. To explore the relative effectiveness of separate treatment interventions in isolation, or in interaction, may be critical in attempting to enhance the efficacy of current treatment methods. The present thesis is based on three studies investigating the effects of relatively novel contributions to the treatment repertoire for social anxiety disorder: audio-feedback, imagery rescripting, and experiential self-focused attention. Study I concerned an analogue experimental study showing that cognitive preparation (CP) enhanced the beneficial effects of audio feedback (A-F) in modifying participants` negative self-evaluation. The effects generalised to a second social task and the changes were associated with concomitant reductions on social anxiety measured by explicit self-reports and by an implicit method. Study II was designed to experimentally investigate the effects of imagery rescripting (IR) of early adverse memories in social anxiety disorder. Results indicated that IR reduced the distress associated with memory and recurrent catastrophe images in clients with social anxiety disorder. Also, the intervention led to significant improvements on fear of negative evaluation and fear of social interaction. The content of client’s negative self-judgements was radically improved as reflected in increased positivity, empowerment and attraction. Furthermore, in contrast to previous research, results were obtained without the use of a preceding cognitive restructuring. Study III was an attempt to experimentally explore the effects of two distinct attentional modes on post-event processing: the analytical and the experiential self-focus modes. Using a cross-over design with a sample of socially phobic clients it was demonstrated that the two self-focus modes affected cognitions differently: the experiential mode led to a decreased proportion of negative thoughts and the analytical mode to a reduction on neutral thoughts. Also, negative self-evaluation following an initial performance situation strongly predicted the degree of subsequent negative thinking but only if participants had been subject to an analytical self-focus induction. Supporting previous findings, results showed that an experiential self-focus may have beneficial effects on rumination in social anxiety disorder. Of special interest in this thesis is the emphasis on imagery in the cognitive behavioural treatment for social anxiety disorder. It is suggested that imagery, as opposed to verbal interventions, plays a key role in the access of emotion and promotion of emotional change. The treatment techniques presented here, do all to some extent involve imagery as important elements of the treatment procedures. Clearly, audio feedback with cognitive preparation, and in particular imagery rescripting, relies heavily on imagery to access fear structures and to provide corrective information for the purpose of emotional processing. Similarly, in the experiential ‘mindful’ self-focused attention, images provide an important link to the immediate experience in the moment-to-moment of the social situation. Thus, it is concluded that in the attempts to elaborate current treatment methods, the role of imagery should be given special consideration.