Background
Social anxiety disorder (SAD) refers to the fear of one or more social situations in which one can behave embarrassingly or be scrutinized by others [
1]. Cognitive models of SAD assume that an individual’s negative beliefs related to social situations as well as the fear of behaving inappropriately and the subsequent consequences play an important role in the development and maintenance of the disorder [
2]. Although exposure therapy, a psychological intervention that focusses on fear-related overt behaviour, does not directly address maladaptive cognitions, research suggests that this effective treatment produces similar changes in cognitions as cognitive therapy or cognitive behavioural therapy (see [
3‐
5]). This suggests that although exposure therapy does not explicitly target cognitions during treatment, changes in cognitions can occur. However, it is unclear whether changes in SAD-related cognitions are associated with treatment outcome of pure exposure therapy. In this article, we examine the role of three cognitive variables in predicting treatment outcome in exposure therapy: self-focused attention, self-efficacy in social situations, and estimated social costs.
Self-focused attention in social situations, where an individual shows increased vigilance for internal stimuli (e.g., cognitions, emotions, physiological reactions), has been suggested to play an important role in the maintenance of SAD [
2,
6]. Research indicates that self-focused attention is associated with higher social anxiety levels and biased self- and performance judgements in SAD [
7]. Moreover, in cognitive behavioural therapy, higher levels of maladaptive attentional focus predicted slower symptom improvement [
8] and a decrease in self-focused attention predicted and mediated reductions in social anxiety (see [
9], for a review). Hofmann [
10] showed that exposure therapy, although it does not explicitly target cognitions, can lead to reduced self-focused attention in patients with SAD after treatment. However, it remains unclear whether changes in self-focused attention are associated with treatment outcome in pure exposure therapy.
Additionally, social anxiety has been found to be associated with low levels of self-efficacy in social situations, which refers to one’s belief in his or her own ability to achieve certain goals while interacting with other individuals. A lack of self-efficacy might facilitate the use of dysfunctional coping strategies when experiencing anxiety in social situations [
11]. Research on cognitive behavioural therapy indicates that in-treatment changes in self-efficacy in social situations [
12,
13] and in therapy context [
14] are associated with treatment outcome. Yet, there is a lack of research as to whether changes in self-efficacy during exposure treatment that does not explicitly targets cognitions, are associated with treatment outcome.
The expected negative consequences of social behaviour, namely the social costs, might also play an important role in maintaining SAD, as suggested by Foa and Kozak [
15]. More specifically, individuals with SAD tend to overestimate the costs of negative social incidents [
16]. Changes in estimated social costs during treatment have been positively associated with treatment outcome in cognitive therapy [
16], cognitive behavioural therapy [
17‐
19], drug treatment [
16], and exposure therapy [
20]. However, current literature is inconclusive regarding the role of estimated social costs as a predictor of treatment outcome in SAD. While some studies found that decreased estimated social cost mediated improvement during cognitive behavioural therapy [
18,
19,
21] and exposure therapy [
19], others found contradicting results. More specifically, Calamaras and colleagues [
17] concluded from their study, that although change in cost bias mediated treatment outcome of cognitive behavioural therapy, cost bias at midtreatment did not significantly predict treatment outcome. Additionally, decreases in estimated costs did not precede decreases in anxiety levels during exposure therapy [
20]. The association between estimated social costs and social anxiety levels might also depend on a temporal component, as suggested by Gregory and colleagues [
22] who found cost bias to predict social anxiety levels in early but not in final stages of treatment. Yet, the results from studies on social cost bias in exposure therapy were limited to exposure therapy administered in a group format [
19] and public speaking anxiety only, and hence neglected other social situations that are relevant for SAD patients with heterogeneous fears [
20]. However, research suggests that working mechanisms can vary across treatment formats. A study by Hedman et al. [
23] indicates that although symptom improvement during cognitive therapy was mediated by decreases in self-focused attention in both group and individually administered treatment, decreases in avoidance mediated effects of individual cognitive therapy only, and decreases in anticipatory and post-event processing mediated effects of group therapy only. Therefore, research that addresses various social fears is needed to investigate the role of social cost bias in exposure treatment for SAD and to investigate whether changes in estimated social costs during individual exposure therapy are associated with treatment outcome.
The aim of the current study was to examine the association between change in SAD-related cognitions and treatment outcome in individually administered exposure therapy (without any cognitive components) for SAD. The association between change in self-focused attention, self-efficacy in social situations, and estimated social costs and change in social anxiety symptoms was evaluated across both in vivo exposure therapy (iVET) and virtual reality exposure therapy (VRET) for SAD. We expected that decreases in self-focused attention and estimated social costs, and an increase in self-efficacy during treatment would be associated with treatment outcome across both exposure treatments. If changes in these cognitions are associated with treatment outcome, these findings might form the base for further research on working mechanisms of exposure therapy. Eventually, this research can help to improve the efficacy of exposure treatments by informing us on which cognitions we need to focus on during therapy and which related changes we need to facilitate.
Discussion
The present study aimed at investigating a possible association between cognitions and treatment outcome in exposure therapy for SAD patients with heterogeneous social fears. For this purpose, we examined whether change during the first six sessions regarding self-focused attention, self-efficacy in social situations, and estimated social costs were associated with symptom change in individuals with SAD receiving exposure therapy. The results revealed that, when social costs, self-focused attention, and self-efficacy were separately examined, patients who showed a decrease in estimated social costs during the first six sessions reported a greater decrease of social anxiety symptoms after treatment and decreases in self-focused attention and self-efficacy during treatment were significantly associated with symptom improvement. When treatment condition (VRET and iVET) was part of the separate models, neither of the three predictors was significantly associated with treatment outcome. However, when social costs, self-focused attention, and self-efficacy were combined in one model, social costs were significantly associated with treatment outcome.
These findings are in line with earlier research that found decreases in social costs to be positively associated with treatment outcome in exposure therapy [
19,
20]. However, while treatment in Smits et al. [
20] focused on public speaking anxiety and treatment in Hofmann [
19] was administered in a group format, our findings go further by showing that changes in expected social costs are associated with treatment outcome of individually administered exposure therapy in patients with SAD and heterogeneous social fears. Moreover, our results suggest that the effects of expected social costs as a predictor of treatment outcome might be consistent across different treatment modalities in exposure-based interventions. More specifically, in both in vivo and virtual reality exposure, declined estimated social costs seem to predict decrease of SAD symptoms.
Changes in self-focused attention and self-efficacy in social situations were significantly associated with treatment outcome when examined individually. Focussing less on oneself in social situations and gaining greater self-efficacy seem to foster improvement during exposure treatment. This was in accordance with research on cognitive behavioural therapy, showing that decreases in self-focused attention predict social anxiety reductions (see [
9], for a review) and increases in self-efficacy are associated with treatment outcome of cognitive behavioural therapy [
12,
13]. However, both variables were no longer significant predictors when they were part of the final model, indicating that neither one of them significantly contributed to the prediction of treatment outcome beyond social costs and treatment modality. Note, the inspection of the intercorrelations of the predictor variables suggests that social costs and self-efficacy might be partly overlapping concepts (
r = −.66), but this applied less for social costs and self-focused attention (
r = −.36).
The cognitive model of SAD [
2] suggests that an individual who manages to focus less on himself/herself during exposure therapy, and therefore has less attention for anxiety symptoms, might report less SAD symptoms after treatment. Likewise, an individual who gains self-efficacy during treatment might feel less afraid of social situations after treatment and expect to better cope with social situations. However, if an individual learns during treatment to be less afraid of the negative consequences that his/her behaviour in social situations might have, he/she might report less fear and avoidance of social situations after treatment regardless of levels of self-focused attention and self-efficacy. In this situation, even if an individual cannot focus on the situation and does not think that he/she can handle the situation very well, he/she might be less afraid of the negative consequences that might follow. Learning that exposure to social situations is not followed by disastrous consequences and/or that individuals can cope with the (negative) consequences of their behaviour might help to decrease both anticipatory anxiety as well as anxiety during the actual social interaction. Yet, further research is needed to better understand the mechanism by which a reduction in expected social costs benefits a reduction of social anxiety symptoms. Moreover, one important question regarding clinical implications of these results is whether a stronger focus on expected social costs during exposure treatment can help to maximize treatment efficacy.
A limitation of the present study is the temporal overlap between the assessment of the predictor variables and the outcome measure given that we controlled for pre-treatment social anxiety in the analyses. While Hofmann [
19] and Smits et al. [
20] used mediation analyses, we investigated associations between the change in cognitions and treatment outcome rather than causal relationships. This was a first step in order to gather information on possible variables that could function as working mechanisms of exposure therapy. As suggested by Cole and Maxwell [
41], for mediation analyses, multiple assessment points throughout treatment are necessary to investigate temporal precedence, which was not feasible within this study. Therefore, as a next step, future research should assess the session-to-session change in self-focused attention, self-efficacy, social costs and social anxiety levels within the framework of mediation analyses, to investigate changes in cognitions as a possible working mechanism of exposure therapy. Furthermore, not all predictor variables were assessed at the same time points. Whereas the self-efficacy and social costs measures referred to social situations in general and therefore could be assessed before the first exposure session, the self-focused attention measure referred to the social situations during the exposure exercises. Consequently, the first assessment of self-focused attention took place after the first exposure session, which was Session 3. However, the time between the assessment points was limited to one week because treatment was administered twice a week. Another limitation is that in addition to social cost bias, probability bias, the overestimation of the estimated probability that a negative social event occurs, was not assessed. A decrease of social cost bias might have resulted from a reduction of probability bias as suggested by Smits et al. [
20]. Given the equivocal results on the predominance of social cost and probability bias in the literature, future research is needed that simultaneously examines social cost and probability bias as predictors of treatment outcome after exposure therapy for SAD. Finally, we can only tentatively conclude that the effects of the investigated predictors on treatment outcome do not differ between in vivo and virtual reality exposure therapy, since we cannot rule out that insufficient power is responsible for the lack of differential effects.