The treatments for social anxiety disorder (SAD) appear to work through different mechanisms, i.e. mediational processes. Mediators of treatment help to identify how or why there are differences between treatment 1 and treatment 2 by describing the events or changes that occur during treatment but before the outcome of the treatment is determined (Kraemer, 2014).
A key contributor to the development of treatments for SAD, David Clark, highlights four key mediating factors:
1) increase in self-focused attention, which reduces processing of external factors, such as other people and their reactions;
2) extensive use of safety seeking behaviours, which are intended to prevent feared catastrophes, but have the consequence of maintaining negative beliefs and can negatively impact social interaction;
3) use of misleading information (automatic thoughts, feelings, images) to make excessively negative interpretations about how one appears to others;
4) negatively biased anticipatory and post-event processing
(Clark et al., 2006; Mörtberg, Hoffart, Boecking, & Clark, 2013; Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003).
Self-focused attention refers to the tendency to monitor internal processes and conduct self-focused observation (Hedman et al., 2013). Individuals with social anxiety use internal cues, such as feeling anxious, to infer external perceptions, such as looking anxious (Clark, 2001). Evidence suggests that internal and external focuses become competing domains (Bögels & Mansell, 2004; Schultz & Heimberg, 2008), and increasing self-focus reduces the ability to observe what is really happening in the situation. This process is what Clark (2001) refers to as a closed system, where evidence of fears are self-created and disconfirming evidence, what is really happening, is no longer accessible.
Another mediator of SAD is safety behaviours, defined as acts intended to prevent or minimise a feared catastrophe and so increase an individual’s sense of safety (Clark, 2001; Plasencia, Alden, & Taylor, 2011). One form of safety behaviour is the avoidance of anxiety provoking situations, a frequent aspect of SAD (Bunnell, Beidel, & Mesa, 2013; Veale, 2003). Other forms of safety behaviours can create the symptoms of anxiety, such as trying to hide underarm sweat by wearing a jacket that then produces more sweating.
These common behaviours are considered necessary therapy targets, as they prevent the contradiction of inaccurate negative beliefs and may increase the possibility of feared outcomes occurring (Clark & Wells, 1995; Rapee & Heimberg, 1997). And while these behaviours prevent effective processing of the situation, it has also been proposed that avoidance and other safety behaviours may increase self-focus (Bögels & Mansell, 2004; Clark & Wells, 1995; Rapee & Heimberg, 1997).
The use of misleading information to make negative interpretations of one’s self is the third key mediating factor. Studies have shown that individuals with social anxiety have an excessively negative self-perception, whereby they underestimate their ability to perform in social situations and they overestimate the ability of others to see their symptoms (Clark & McManus, 2002; Rapee & Lim, 1992; Stopa & Clark, 1993). This pattern of behaviour of negative self-perception in the socially anxious is cyclical, starting from the prospect of meeting a stranger triggering anticipatory thoughts focused on negative self-evaluation, to anxious thoughts leading to thoughts of avoidance, to maladaptive behaviour because of the negative thoughts, to further anxiety and more negative thoughts about the self (Stopa & Clark, 1993).
It has been suggested that this cyclical pattern of behaviour impacts on interpersonal relationships where the socially anxious individual appears less warm and friendly, and other people may then be less friendly in return (Clark & McManus, 2002). Interrupting this cyclical pattern of thinking and behaviour requires attentional training (Wells & Papageorgiou, 2004), such as mindfulness instruction, which has also been shown to decrease the symptoms of anxiety and depression across clinical and non-clinical populations (Piet, Hougaard, Hecksher, & Rosenberg, 2010). Piet et al. (2010) suggest that mindfulness training assists clients to gain attentional control and develop an increased tolerance of negative effects, and so assist in managing worry, rumination and the negative aspects of self-focused attention.
Individuals suffering from social anxiety, in anticipation of a social event, will review in detail what they think will happen at the upcoming event with a focus on the prediction of negative outcomes (Clark, 2001). This anticipatory processing may result in the socially anxious individual avoiding the event completely. Or if they do attend, they may already be so self-focused and expecting failure that they are unable to absorb any signs of acceptance from others (Clark, 2001). After social events, the rumination continues, with the event being reviewed in detail. This post-event processing will frequently focus on negative thoughts and images, and any behaviours that could also be negatively interpreted (Clark & Wells, 1995; Rapee & Heimberg, 1997). Clark (2001) also indicates that as part of the post-mortem process previous failures are retrieved and used as evidence of current failure.
Research on the impact of individual mediators is growing (McManus et al., 2009; Mörtberg et al., 2013), with some experimental studies looking at the relationship between mediators, such as the causal role of self-focus and post-event processing (Gaydukevych & Kocovski, 2012; Nilsson, Lundh, & Viborg, 2012). There appears to be differences in the effectiveness of mediators depending on the treatment process, with the Hedman et al. (2013) study finding that improvement in CBIT was mainly mediatated by reductions in the avoidance and self-focused attention mediators, and CBGT was impacted by the self-focused attention, and the anticipatory and post-event processing mediators.
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