Negative self-imagery blocks inferences

Self-image and self-focused attention in a social interaction situation: what is relevant for social anxiety?

BACKGROUND

According to Clark and Wells' cognitive model (Clark and Wells, 1995), social anxiety is maintained by both a negative self-image and self-focused attention (SFA). Although these maintaining factors were investigated extensively in previous studies, the direction of this relationship remains unclear, and so far, few studies have investigated self-image and SFA together within a current social interaction situation.

AIMS

The aim of this experiment is to investigate the influence of a negative versus positive self-image on social anxiety and on SFA during a social interaction.

METHOD

High (n = 27) and low (n = 36) socially anxious participants, holding a manipulated negative versus positive self-image in mind, had a real-time video conversation with a confederate. Social anxiety, SFA and state anxiety before and during the conversation were measured with questionnaires.

RESULTS

An interaction between negative self-image and social anxiety showed that high socially anxious individuals with a negative self-image in mind were more anxious than those with a positive self-image in mind during the conversation. They were also more anxious compared with low socially anxious individuals. Furthermore, high socially anxious individuals reported higher SFA; however, SFA was not affected by negative or positive self-image.

CONCLUSION

The present results confirm once again the strong influence of self-image and SFA on social anxiety, highlighting that a negative self-image has more impact on socially anxious individuals. Moreover, the present results suggest that SFA is not necessarily affected by a negative self-image, indicating that therapies should focus on both.

Prevalence and features of spontaneous recurrent images in social anxiety disorder: findings from a Korean community sample

BACKGROUND

Previous studies have indicated that people with social anxiety disorder (SAD) often experience spontaneous, recurrent images (SRI). It was assumed that Koreans with interdependent self-views may contain more features related to social contexts in their self-images than those reported in Western cultures.

AIMS

In the present study, we aimed to explore the prevalence and content of SRIs in individuals with SAD in Korea. Furthermore, we investigated the relationship between features of SRIs and variables of SAD.

METHOD

Sixty-four individuals with SAD (27.00 ± 7.42 years, 64.1% female), diagnosed with SAD, completed self-report questionnaires related to social anxiety. Afterwards, a semi-structured interview was used to assess features and content of the individuals' SRI.

RESULTS

Thirty (47%) of the participants reported experiencing SRIs in social situations. The content of the SRIs were classified under three themes: negative self-images, negative images of others, and abstract images. The distress level of SRIs was positively associated with social phobia scales (r = .385, p < .05) and physical anxiety symptoms (r = .478, p < .05). Frequency of SRIs was positively associated with avoidance scores (r = .402, p < .05).

CONCLUSIONS

The results demonstrated differences in the prevalence and content of the SRIs between Western and non-Western cultures. Fewer individuals with SAD in Korea reported having SRIs, and the content of these SRIs involved people other than the self. Some features of SRIs were associated with variables of SAD.

Using event-related potential and behavioural evidence to understand interpretation bias in relation to worry

The tendency to interpret ambiguous information in a consistent (e.g., negative) manner (interpretation bias) may maintain worry. This study explored whether high and low worriers generate different interpretations and examined at which stages of information processing these interpretations can occur. Participants completed interpretation assessment tasks yielding behavioural and N400 event-related potential indices, which index whether a given interpretation was generated. High worriers lacked the benign interpretation bias found in low worriers. This was evident for early "online" interpretations (reflected in reaction times to relatedness judgments and lexical decisions, as well as at a neurophysiological level, N400, for lexical decisions only), to later "offline" interpretations (observed at a behavioural level on the scenario task and recognition task) when participants had time for reflection. Results suggest that a benign interpretation bias may be a protective factor for low worriers, and that these interpretations remain active across online and offline stages of processing.

Effects of Self-Image on Anxiety, Judgement Bias and Emotion Regulation in Social Anxiety Disorder

BACKGROUND

Research to date has focused on the detrimental effects of negative self-images for individuals with social anxiety disorder (SAD), but the benefits of positive self-images have been neglected.

AIMS

The present study examined the effect of holding a positive versus negative self-image in mind on anxiety, judgement bias and emotion regulation (ER) in individuals with SAD.

METHOD

Forty-two individuals who met the diagnostic criteria for SAD were randomly assigned to either a positive or a negative self-image group. Participants were assessed twice with a week's interval in between using the Reactivity and Regulation Situation Task, which measures social anxiety, discomfort, judgement bias and ER, prior to and after the inducement of a positive or negative self-image.

RESULTS

Individuals in the positive self-image group reported less social anxiety, discomfort and distress from social cost when compared with their pre-induction state. They also used more adaptive ER strategies and experienced less anxiety and discomfort after using ER. In contrast, individuals in the negative self-image group showed no significant differences in anxiety, judgement bias or ER strategies before and after the induction.

CONCLUSIONS

This study highlights the beneficial effects of positive self-images on social anxiety and ER.

Physiological and psychological effects of imagery techniques on health anxiety

Previous research has shown that intrusions are part of the psychopathology of mental disorders. Imagery techniques seem to be an effective treatment of negative intrusions. Since negative mental imagery is part of health anxiety, the present study investigated the impact of imagery techniques on health anxiety. A total of 159 students with elevated scores in a health anxiety questionnaire watched an aversive film concerning a cancer patient and were randomly allocated to one of three interventions (positive imagery, imagery reexperiencing, imagery rescripting) or the control group. The intervention lasted 9 min. Physiological data (heart rate and cortisol) as well as psychological measures, such as mood ratings, health anxiety scores, and intrusions, were assessed during the appointment, while psychological measures were assessed over a period of 1 week after the intervention. Cortisol levels changed over time depending on the intervention. Heart rate changed during the 9-min interventions as well, with the fastest decrease during imagery rescripting. Moreover, negative mood and distress decreased after the intervention, while intrusions were reduced 1 week after the intervention in all groups equally. The results suggest that imagery rescripting is a promising technique that seems to activate a process of deep elaboration. Therefore, it might be an adequate way to target health anxiety symptoms such as anxiety, intrusions, and avoidance or safety-seeking behavior. Further studies should focus on imagery rescripting in clinical samples with health anxiety and target individual intrusive images to increase effectiveness. Nevertheless, the development of a long-term explanatory model of rescripting is needed.

Changes in the self during cognitive behavioural therapy for social anxiety disorder: A systematic review

A consistent feature across cognitive-behavioural models of social anxiety disorder (SAD) is the central role of the self in the emergence and maintenance of the disorder. The strong emphasis placed on the self in these models and related empirical research has also been reflected in evidence-based treatments for the disorder. This systematic review provides an overview of the empirical literature investigating the role of self-related constructs (e.g., self-beliefs, self-images, self-focused attention) proposed in cognitive models of SAD, before examining how these constructs are modified during and following CBT for SAD. Forty-one studies met the inclusion criteria. Guided by Stopa's (2009a, b) model of self, most studies examined change in self-related content, followed by change in self-related processing. No study examined change in self-structure. Pre- to post-treatment reductions were observed in self-related thoughts and beliefs, self-esteem, self-schema, self-focused attention, and self-evaluation. Change in self-related constructs predicted and/or mediated social anxiety reduction, however relatively few studies examined this. Papers were limited by small sample sizes, failure to control for depression symptoms, lack of waitlist, and some measurement concerns. Future research directions are discussed.

Emotional Mental Imagery as Simulation of Reality: Fear and Beyond-A Tribute to Peter Lang

This article pays tribute to the seminal paper by Peter J. Lang (1977; this journal), "Imagery in Therapy: Information Processing Analysis of Fear." We review research and clinical practice developments in the past five decades with reference to key insights from Lang's theory and experimental work on emotional mental imagery. First, we summarize and recontextualize Lang's bio-informational theory of emotional mental imagery (1977, 1979) within contemporary theoretical developments on the function of mental imagery. Second, Lang's proposal that mental imagery can evoke emotional responses is evaluated by reviewing empirical evidence that mental imagery has a powerful impact on negative as well as positive emotions at neurophysiological and subjective levels. Third, we review contemporary cognitive and behavioral therapeutic practices that use mental imagery, and consider points of extension and departure from Lang's original investigation of mental imagery in fear-extinction behavior change. Fourth, Lang's experimental work on emotional imagery is revisited in light of contemporary research on emotional psychopathology-linked individual differences in mental imagery. Finally, key insights from Lang's experiments on training emotional response during imagery are discussed in relation to how specific techniques may be harnessed to enhance adaptive emotional mental imagery training in future research.

How can we enhance cognitive bias modification techniques? The effects of prospective cognition

BACKGROUND AND OBJECTIVES

Cognitive bias modification for interpretation, a computerized program which manipulates biased interpretations, has shown therapeutic promise, including evidence that negatively biased interpretations can be reduced, leading to corresponding improvements in symptoms. Cognitive bias modification for cognitive errors (CBM-errors) is a second generation CBM-I procedure which manipulates seven types of cognitive error and is especially relevant to depressive cognition. The aim of this study was to investigate whether the effects of the CBM-errors manipulation would be enhanced by adding a component facilitating prospective cognition to help embed and extend newly acquired interpretations.

METHODS

A sample of 80 volunteers completed a single session experiment. With a pretraining-posttraining design, we compared the effects of enhanced CBM-errors (targeting cognitive errors plus prospective cognition) with standard CBM-errors (targeting cognitive errors without prospective cognition), on interpretations of new material and mood.

RESULTS

Significant differences between enhanced and standard CBM-errors revealed that enhanced positive training was more effective at decreasing negative interpretations compared to the standard procedure.

LIMITATIONS

Extending the current investigation to a sample dysphoria or depression is needed for an appropriate next step.

CONCLUSION

The findings serve as 'a proof of principle' for the potential of prospective cognition to enhance the effects of CBM-errors and other similar CBM procedures. Further work to enhance the effectiveness of CBM procedures is needed.

The effect of self-imagery on symptoms and processes in social anxiety: a systematic review

BACKGROUND

Cognitive models of Social Anxiety Disorder suggest that negative self-images maintain social fears despite repeated exposure to benign social situations. An accumulating body of evidence supports this notion, and preliminary data indicate that modifying self-imagery can potentially reduce fears of negative evaluation in socially anxious individuals. This systematic review aims to evaluate the existing research on the effect of self-imagery on symptoms and processes in social anxiety.

METHODS

The following databases were searched: PsycInfo, Medline, PubMed, and Cochrane Central Register of Controlled Trials. Articles were limited to adult samples and English language papers that examined the effect of self-imagery on at least one measure related to social anxiety. Risk of bias and study results were reviewed for each study.

RESULTS

In the 17 studies that were identified, negative self-imagery had a consistently adverse effect on anxiety, self and observer-rated performance appraisals, and negative thoughts for both socially anxious and non-clinical participants. Effects of negative self-imagery were generally not significantly greater for socially anxious participants.

CONCLUSIONS

Further research is warranted to determine the precise role of different types of self-imagery for both clinical and non-clinical individuals.

The Impact of Self-Imagery on Affective, Cognitive, and Attentional Processes in Social Phobia: A Comprehensive Literature Review of the Theoretical and Empirical Literature

Social Phobia (SP) is a psychological disorder characterised by an excessive and persistent fear of negative evaluation in social or performance situations that interferes with daily functioning. Cognitive models of SP (Clark & Wells, 1995; Hofmann, 2007; Rapee & Heimberg, 1997) emphasise the role of negative images of the self as an important factor in the maintenance of SP. While empirical research has demonstrated the link between negative self-imagery and social anxiety, many aspects of this cognitive factor are yet to be understood. Currently, there is limited research investigating the impact of different types of self-imagery and their effects on social anxiety and performance. Further research assessing the relationships between self-imagery and other maintaining processes proposed in cognitive models is also warranted. This review assesses the literature focusing on self-imagery in social anxiety, including qualitative, empirical, and preliminary treatment studies to date. Recommendations for future research and the use of imagery-based rescripting methods in the treatment of SP are also discussed.

Looking on the bright side in social anxiety: the potential benefit of promoting positive mental imagery

Current cognitive models of social phobia converge on the view that negative imagery is a key factor in the development and maintenance of the disorder. Research to date has predominantly focussed on the detrimental impact of negative imagery on cognitive bias and anxiety symptoms, while the potential benefit of promoting positive imagery has been relatively unexplored. Emerging evidence suggests however that positive imagery could have multiple benefits such as improving positive affect, self-esteem and positive interpretation bias, and enhancing social performance. The present article defends the view that combining bias induction with a repeated practice in generating positive imagery in a cognitive bias modification procedure could represent a promising area for future research and clinical innovation in social anxiety disorder.

Social anxiety and social anxiety disorder

Research on social anxiety and social anxiety disorder has proliferated over the years since the explication of the disorder through cognitive-behavioral models. This review highlights a recently updated model from our group and details recent research stemming from the (a) information processing perspective, including attention bias, interpretation bias, implicit associations, imagery and visual memories, and (b) emotion regulation perspective, including positive emotionality and anger. In addition, we review recent studies exploring the roles of self-focused attention, safety behaviors, and post-event processing in the maintenance of social anxiety. Within each area, we detail the ways in which these topics have implications for the treatment of social anxiety and for future research. Finally, we conclude with a discussion of how several of the areas reviewed contribute to our model of social anxiety disorder.

Images of the self and self-esteem: do positive self-images improve self-esteem in social anxiety?

Negative self-images play an important role in maintaining social anxiety disorder. We propose that these images represent the working self in a Self-Memory System that regulates retrieval of self-relevant information in particular situations. Self-esteem, one aspect of the working self, comprises explicit (conscious) and implicit (automatic) components. Implicit self-esteem reflects an automatic evaluative bias towards the self that is normally positive, but is reduced in socially anxious individuals. Forty-four high and 44 low socially anxious participants generated either a positive or a negative self-image and then completed measures of implicit and explicit self-esteem. Participants who held a negative self-image in mind reported lower implicit and explicit positive self-esteem, and higher explicit negative self-esteem than participants holding a positive image in mind, irrespective of social anxiety group. We then tested whether positive self-images protected high and low socially anxious individuals equally well against the threat to explicit self-esteem posed by social exclusion in a virtual ball toss game (Cyberball). We failed to find a predicted interaction between social anxiety and image condition. Instead, all participants holding positive self-images reported higher levels of explicit self-esteem after Cyberball than those holding negative self-images. Deliberate retrieval of positive self-images appears to facilitate access to a healthy positive implicit bias, as well as improving explicit self-esteem, whereas deliberate retrieval of negative self-images does the opposite. This is consistent with the idea that negative self-images may have a causal, as well as a maintaining, role in social anxiety disorder.

Interpretation of ambiguous social scenarios in social phobia and depression: evidence from event-related brain potentials

In the current study, event-related potentials (ERPs) and behavioral responses were measured in individuals meeting diagnostic criteria for social phobia, depression, their combination, or neither in order to examine the unique and combined effects of social phobia and depression on the interpretation of ambiguous social scenarios. ERPs revealed a lack of positive interpretation bias and some suggestion of a negative bias in the semantic expectancy N4 component across all clinical groups. Furthermore, socially phobic and comorbid individuals showed reductions in baseline attention allocation to the task, as indexed by P6 amplitude. RT and accuracy likewise revealed a lack of positive interpretation bias across disordered groups. When considered on a continuum across all samples, social phobia and depression symptoms were related to the N4 interpretation bias effect whereas P6 amplitude reduction and RT interpretation bias appeared uniquely associated with social phobia.

Imagery Rescripting of Early Traumatic Memories in Social Phobia

Negative self-images appear to play a role in the maintenance of social phobia and research suggests they are often linked to earlier memories of socially traumatic events. Imagery rescripting is a clinical intervention that aims to update such unpleasant or traumatic memories, and is increasingly being incorporated in cognitive behavioral therapy programs. In previous research, we have found that imagery rescripting was superior to a control condition in terms of its beneficial effects on negative beliefs, image and memory distress, fear of negative evaluation, and anxiety in social situations. In this article, we describe our imagery rescripting procedure. We consider the importance of updating negative imagery in social phobia, the theoretical basis for imagery rescripting, directions for future research, and how to conduct imagery rescripting, including potential problems and their solutions.

Imagery rescripting for psychological disorder following cancer: a case study

OBJECTIVES

Intrusive memories have been identified in cancer patients and associated with psychological distress and maladaptive adjustment. Imagery rescripting is a psychological therapy that has proved successful for reducing the impact and distress associated with intrusive memories in various populations (e.g. depression). This paper describes the first application of this technique for a cancer patient reporting intrusive memories.

DESIGN

A single-case design was used to assess the stand-alone therapy.

RESULTS

Imagery rescripting was associated with significant reductions in the adverse impact of intrusive memories and psychological distress and these effects remained at 3- and 6-month follow-up.

CONCLUSIONS

Imagery rescripting shows promise for utility in medical patients experiencing intrusive memories.

Implicit but Stable

This study investigates the malleability of explicit and implicit anxiety through mental imagery. Sixty adults imagined themselves in an anxious, calm, or neutral situation. Thereafter, explicit state and trait anxiety were assessed with self-reports, and implicit anxiety was assessed with a variant of the Implicit Association Test. The results indicate that imagery manipulation changed state anxiety in the expected direction. Explicit trait anxiety and implicit anxiety, however, were found to be stable. These findings suggest that the implicit self-concept of anxiety has trait-like characteristics and is as stable against a short-term voluntary mental control strategy as an established explicit measure of trait anxiety.

Coping strategies and anticipatory processing in high and low socially anxious individuals

The purpose of this study was to investigate coping responses associated with anticipatory social anxiety. Participants were presented with vignettes that involved anticipating a stressful social situation and were instructed to record their thoughts and recalled memories to allow for the examination of the content of anticipatory processing. Anticipatory coping and distraction were assessed via self-report. Results indicated that participants high in social anxiety were more likely to engage in mental preparation for stressful events compared to those low in social anxiety. Further, high socially anxious participants reported more planning thoughts about concealing their state of anxiety or avoiding the stressful situation and less planning thoughts about improving their in-situation performance compared to those low in social anxiety. Finally, individuals high in social anxiety produced less positive autobiographical memories and more negative self-evaluative thoughts. No group differences on distraction coping emerged. The theoretical and clinical implications of the results are discussed.

Inducing an interpretation bias changes self-imagery: A preliminary investigation

Prior work suggests that variations in self-imagery can influence the emotional interpretations people make about social situations. The current experiment investigated the converse possibility: that inducing an inferential bias can change the content of self-related images. The effects of repeated practice in accessing either negative or positive social outcomes was tested by having participants report on self-images generated during subsequent experience with ambiguous social situations. Participants and independent judges rated the content of participants' self-images as being more negative after prior practice in accessing negative rather than positive social outcomes. Furthermore, participants who practiced accessing negative outcomes rated their anticipated anxiety in an imagined stressful social situation as being greater, and their expected social performance as poorer than participants in the positive outcome group. Groups did not differ in state anxiety levels when making their ratings, so it is unlikely that any observed differences between groups can be attributed to mood effects. We suggest that this finding is consistent with the hypothesis that inferential biases and content of self-images can interact with each other and may together serve to maintain social anxiety.

Imagery and interpretations in social phobia: support for the combined cognitive biases hypothesis

Cognitive-behavioral models of clinical problems typically postulate a role for the combined effects of different cognitive biases in the maintenance of a given disorder. It is striking therefore that research has tended to examine cognitive biases in isolation rather than assessing how they work together to maintain psychological dysfunction. The combined cognitive biases hypothesis presented here suggests that cognitive biases influence each another and can interact to maintain a given disorder. Furthermore, it is proposed that the combined effects of cognitive biases may have a greater impact on sustaining a given disorder than if the biases operated in isolation. The combined cognitive biases hypothesis is examined in relation to imagery and interpretation in social phobia. Individuals with social phobia experience negative images of themselves performing poorly in social situations, and they also interpret external social information in a less positive way than those without social anxiety. Evidence of a reciprocal relationship between imagery and interpretations is presented, and the mechanisms underlying the combined effects are discussed. Clinical implications and the potential utility of examining the combined influence of other cognitive biases are highlighted.

Cognitive Vulnerability to Emotional Disorders

A review of recent research on cognitive processing indicates that biases in attention, memory, and interpretation, as well as repetitive negative thoughts, are common across emotional disorders, although they vary in form according to type of disorder. Current cognitive models emphasize specific forms of biased processing, such as variations in the focus of attention or habitual interpretative styles that contribute to the risk of developing particular disorders. As well as predicting risk of emotional disorders, new studies have provided evidence of a causal relationship between processing bias and vulnerability. Beyond merely demonstrating the existence of biased processing, research is thus beginning to explore the cognitive causes of emotional vulnerability, and their modification.

Information-processing bias in social phobia

Social phobia is a persistent disorder that is unlikely to be maintained by avoidance alone. One reason for the enduring nature of social phobia may be the way individuals with the disorder process social information. It is important for those involved in social phobia to have an understanding of information-processing biases, because it has the potential to guide psychological interventions. In this review of social phobia, probability and cost estimates of social situations are examined, interpretive biases are evaluated and findings relating to memory and negative imagery are also reviewed. The clinical implications of social-phobia-related information-processing biases are discussed and possible avenues for future research are outlined.

On the malleability of emotional encoding

The encoding of emotional events has sometimes been regarded as automatic, because the processing involved can occur outside awareness. However, this does not mean that emotional encoding cannot be controlled, although it may often be the case that people are unaware of how to do so, or even that such control is possible. Evidence is presented to show that the neural activation associated with fear-related stimuli can be modified by top-down control, and that related instructions can modify emotional vulnerability to stressful events. However, it is further argued that such effortful control is resource limited, and that more robust control might be achieved via repeated practice in accessing positive representations that inhibit competing negative meanings. Studies of attentional and interpretative encoding biases induced by practice show that they have causal effects on emotional vulnerability, by influencing how threatening events are encoded. Experimental investigations are beginning to reveal the critical processes underlying these changes in emotional vulnerability, and it is argued that the same approach is likely to be helpful in addressing questions relevant to therapeutic change.