SCANDINAVIAN JOURNAL OF BEHAVIOUR THERAPY VOL 30, NO 1, PAGES 4–16, 2001
Attentional Bias, Self-consciousness and Perfectionism in Social Phobia Before and After Cognitive-Behaviour Therapy Lars-Gunnar Lundh and Lars-Go¨ran O¨st Department of Psychology, Stockholm University, Stockholm, Sweden Attentional bias for threat words (as measured by the emotional Stroop task), selfconsciousness and perfectionism was studied in 24 patients with social phobia before and after cognitive-behaviour treatment. A total of 18 (75%) of the patients were classified as treatment responders on the basis of reduced scores for social anxiety. The treatment responders showed a significant reduction in attentional bias for social threat words, in public self-consciousness and in perfectionism. The non-responders showed an equal reduction in perfectionism; as they had a much higher level of perfectionism before treatment, however, their change only amounted to a lowering of their level of perfectionism to the level that characterized the treatment responders before treatment. The treatment responders, on the other hand, reduced their level of perfectionism to that of non-clinical samples. Key words: Social phobia; perfectionism; self-consciousness; attentional bias; cognitive-behaviour therapy. Correspondence address: Lars-Gunnar Lundh, Department of Psychology, Stockholm University, SE-106 91 Stockholm, Sweden. Fax: ‡46 8 16 62 36. E-mail:
[email protected]
Social phobia is a common anxiety disorder, characterized by a marked and persistent fear of acting in a humiliating or embarrassing way in social situations where the individual is confronted with unfamiliar people or to possible scrutiny by others (DSM-IV; American Psychiatric Association, 1994). In an American study, Kessler et al., (1994) found that more than 13% of the population meet diagnostic criteria for social phobia at some point in their lives and in a Swedish study Furmark, et al. (1999) found a point prevalence of 15.6%. From being a neglected anxiety disorder (Liebowitz, Gorman, Fyer, & Klein, 1985), social phobia has become the focus of steadily increasing research efforts during the last decade. Cognitive-behavioural models for the understanding of social phobia have been formulated by several writers, for example, Clark and Wells (1995) and Rapee and Heimberg (1997). According to these models and the empirical research that has been carried out so far, social phobia is associated with a number of cognitive characteristics, including: (1) an attentional bias for negative social information (critical comments, angry faces, signs of nervousness in the person’s own behaviour, etc.); (2) high “public self-consciousness” (i.e. being excessively focused on how one appears to others); and (3) a high degree of perfectionism (e.g. unrealistically high personal standards for social performance, and beliefs that other people have perfectionistic demands on one’s social performance). The purpose of the present study was to investigate to what extent these 3 characteristics change after cognitive-behavioura l treatment.
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Attentional bias During the last decade, research on cognitive bias has become an important area within cognitivebehavioural research on anxiety disorders and other psychiatric problems. “Cognitive bias” is a systematic tendency to attend to some kinds of information more than others (attentional bias), to remember some kinds of information better than others (memory bias), or to interpret ambiguous situations in one way rather than another (interpretive bias). Cognitive bias in itself need not, however, be associated with psychopathology. An attentional bias to threat-related information, for example, is clearly adaptive in situations of real threat, since it will increase the individual’s chances of detecting real dangers and responding to these before it is too late. Under certain circumstances the same mechanisms may become maladaptive, however. For example, if the individual has developed beliefs, or “schemata”, that define relatively harmless situations as highly threatening, he or she will respond with fear and attentional biases in a less adaptive way (e.g. Beck, 1997). Research indicates that patients with social phobia have an attentional bias for socially threatening information, i.e. their attention is automatically drawn to stimuli that convey threats of being negatively evaluated by others. The most common measure of attentional bias is the emotional Stroop task, which requires the individual to colour-name different kinds of words as fast as possible. A general finding in this research is that words that are associated with an individual’s emotional concerns tend to automatically capture that individual’s attention to such an extent that it disturbs his or her colour-naming performance. In the case of social phobia, a main emotional concern is the fear of being negatively evaluated by others. In accordance with this, a number of studies have demonstrated an emotional Stroop effect for social threat words in patients with social phobia, in the sense that these individuals are slower to colour-name social threat words than neutral words (Amir et al., 1996; Holle, Neely, & Heimberg, 1997; Hope, ¨ st, 1996; Maidenberg, Chen, Craske, Bohn, & Rapee, Heimberg, & Dombeck, 1990; Lundh & O Bystritsky, 1996; Mattia, Heimberg, & Hope, 1993; McNeil et al., 1995). What happens to this bias as a result of treatment? Mattia et al. (1993) tested this by administering the emotional Stroop task both before and after treatment (which was either cognitive-behavioura l or pharmacological), and by comparing treatment responders and treatment non-responders both before and after treatment. They found that the emotional Stroop interference effect disappeared after treatment in the treatment responders, but remained at the same level in the treatment non-responders. One purpose of the present study was to determine whether this finding could be replicated in the context of a treatment study with cognitive-behaviour therapy (CBT).
Public self-consciousness From a social psychological perspective, it has been argued (e.g. Argyle & Williams, 1969) that a well-functioning social interaction requires the individual to be aware of both him/herself and the other person. Sarason (1975) suggested that for socially anxious individuals, this balance is disrupted by a pattern of excessive negative self-referent thinking, or anxious self-preoccupation. Hope, Gansler and Heimberg (1989) suggested that an excessive self-focused attention may have be functionally involved in social phobia in several ways: for example: (1) given an already low expectancy for success, the social phobic’s self-focus will interfere with his/her performance in a way that may lead to negative feedback from his/her interaction partner; (2) even if no negative feedback is given, the self-focused attention may lead to an overperception of the self as target, and may thereby cause the social phobic to make internal attributions for neutral or ambiguous feedback; (3) throughout the encounter, the increased self-focus heightens the social phobic’s perception of the aversiveness of the situation, and thereby his/her emotional reaction and the probability that he/she will avoid similar situations in the future. Fenigstein, Scheier, and Buss (1975) introduced a distinction between “private self-
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consciousness” and “public self-consciousness”, and developed an instrument for measuring these different forms of dispositional self-consciousness, the Self-Consciousness Scale (SCS). “Private self-consciousness” refers to a dispositional tendency to attend to private events such as one’s own thoughts, feelings, moods and attitudes, whereas “public self-consciousness” refers to a dispositional tendency to think about outwardly observable (“public”) aspects of oneself, such as physical appearance and overt behaviour, i.e. how one appears to others. Social anxiety and social phobia has been found to be consistently associated with elevated degrees of public selfconsciousness (Bo¨gels, Alberts, & de Jong, 1996; Fenigstein, Scheier, & Buss, 1975; Hope & ¨ st, 1996; Monfries & Kafer, 1993; Heimberg, 1988; Jostes, Pook, & Florin, 1999; Lundh & O ¨ Saboonchi & Lundh, 1997; Saboonchi, Lundh, & Ost, 1999; Smari, Clausen, Hardarson, & Arnarsen, 1995). Hope and Heimberg (1988) found that socially phobic individuals who were also high in public self-consciousness demonstrated less social skill in social situations, reported more anxiety and more frequent negative thoughts. The results with regard to private selfconsciousness, however, are less consistent: whereas some studies have found an association between social anxiety and elevated degrees of private self-consciousness (Fenigstein et al., 1975; Jostes et al., 1999; Monfries & Kafer, 1993; Saboonchi & Lundh, 1997), other studies have failed to find a significant association (Bo¨gels et al., 1996; Hope & Heimberg, 1988; Saboonchi et al., 1999; Smari et al., 1995). One purpose of the present study was to investigate whether CBT leads to changes in public (and possibly also private) self-consciousness. Other studies have reported that psychological treatments are associated with changes in the patients’ degree of self-focus when confronted with social situations, as assessed by a Focus of Attention Questionnaire (Woody, Chambless, & Glass, 1997) and by thought-listing methods (Hofmann, 2000), but no study has so far reported changes on Fenigstein et al.’s (1975) Public Self-Consciousness scale as a result of CBT.
Perfectionism Perfectionistic beliefs have been assumed to be important for the development and maintenance of social phobia by a number of writers (e.g. Clark & Wells, 1995; Heimberg, Juster, Hope, & Mattia, 1995; Schlenker & Leary, 1982). According to Heimberg et al. (1995), for example, persons with social phobia often believe that meeting a very high standard of social performance is the only way to prevent humiliation in social situations. There is some question, however, as to whether social phobics suffer primarily from excessively high personal standards for their own performance, or whether they suffer more from a belief that other people set excessively high standards for their performance (e.g. Bieling & Alden, 1997). The development in the early 1990s of 2 multidimensional instruments for the measurement of perfectionism (Frost, Marten, Lahart, & Rosenblate, 1990; Hewitt & Flett, 1991) has made it possible to study the importance of various aspects of perfectionism in different anxiety disorders. Hewitt and Flett (1991) Multidimensional Perfectionism Scale (MPS-H) identifies 3 dimensions of perfectionism: Self-Oriented Perfectionism (setting high standards for oneself and judging oneself on the basis of these harsh dictates), Other-Oriented Perfectionism (setting exacting standards for others and subjecting them to stringent evaluation) and Socially Prescribed Perfectionism (feeling that others place unreasonable standards on one’s behaviour). With regard to these dimensions of perfectionism, Alden, Bieling and Wallace (1994) found that social anxiety in university students was associated with socially prescribed perfectionism, but not with selforiented perfectionism. Similarly, Bieling and Alden (1997) found that patients with social phobia scored higher than controls on socially prescribed perfectionism, but not on self-oriented perfectionism. As these authors conclude, this would imply that social phobics believe they need to be perfect to meet others’ expectations, but that they do not require perfectionism of themselves. The present study made use of Frost et al.’s (1990) Multidimensional Perfectionism Scale
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(MPS-F), which identifies 6 dimensions of perfectionism: Personal Standards; Concern Over Mistakes; Doubts About Action; Organization; Parental Expectations; and Parental Criticism. Research with the MPS-F indicates that social anxiety and social phobia is associated primarily with elevated scores on the dimensions Concern Over Mistakes, Doubts About Action and Parental Criticism on the MPS-F (Antony, Purdon, Huta, & Swinson, 1998; Juster, Heimberg, ¨ st, 1996; Saboonchi & Lundh, 1997; Frost, Holt, Mattia, & Faccenda, 1996; Lundh & O ¨ Saboonchi, Lundh, & Ost, 1999). Interestingly, patients with social phobia have been found to score higher than patients with panic disorder on both Concern over Mistakes and Doubts about Action (Antony et al., 1998; Saboonchi et al., 1999), and higher than patients with obsessivecompulsive disorder on Concern over Mistakes and Parental Criticism (Antony et al., 1998). No study so far, however, has compared perfectionism scores among social phobics before and after cognitive-behaviour treatment. A further purpose of the present study, therefore, was to do this. If perfectionism is centrally involved in social phobia, successful treatment should lead to a reduced degree of perfectionism. To summarize, the purpose of the present study was to compare patients with social phobia before and after treatment on the above-mentioned measures. It was expected that successful treatment of the social phobia would be associated with a reduced attentional bias for social threat words and a reduction on public self-consciousness and perfectionism (especially Concern over Mistakes and Doubts about Action).
Method Participants The subjects were 24 patients who met DMS-III-R (American Psychiatric Association, 1987) criteria for social phobia, and who were part of a treatment study with CBT. As part of the ¨ st, unpublished data), the patients were randomized to 3 different treatment treatment study (O conditions: (1) 12 sessions of individual CBT; (2) 12 sessions of CBT in group; and (3) use of a self-treatment manual over a period of 3 months. Of the patients in the present study, 9 received individual CBT, 10 group CBT and 5 used the self-treatment manual. The participants were interviewed with the revised version of the Anxiety Disorders Interview Schedule (ADIS-R; DiNardo & Barlow, 1988) before treatment. They were rated on the 0–8 Severity Rating Scale, included in the ADIS-R, and only Ss who received a rating of 4 (moderate impairment) or greater were included in the treatment study. Potential Ss were excluded if they received a diagnosis of primary depression, bipolar disorder, psychotic disorder or active drug or alcohol dependence. The mean age of the participants was 35.0 (SD = 9.2) years. There were 22 females and 2 males. A total of 21 of the patients had a diagnosis of generalized social phobia, whereas 3 had a diagnosis of non-generalized social phobia. A total of 13 participants had college education, whereas 11 had not. The degree of severity of their phobia was rated by the clinical interviewer as 5.63 (SD = 1.10) on the Severity Rating Scale in the ADIS-R. The post-treatment testing was carried out 8.0 (SD = 4.9; range 4–25) months after the pre-treatment testing. The present sample of patients is a subsample of a group of 42 patients who were tested before ¨ st (1996). The original plan was to re-test all these 42 treatment as part of a study by Lundh and O patients after treatment; unfortunate circumstances, however, made this impossible.
Materials and procedure All tests were carried out by the first author. Each patient was tested individually and the tests were given in the same order at both test occasions for all participants: first the Stroop task, then the Self-Consciousness Scale and, finally, the Multidimensional Perfectionism Scale.
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Table 1. Threatening words and control words used in the Stroop task. Social threat words
Social control words
Physical threat words
Physical control words
Lo¨jlig [“foolish”] Va¨rdelo¨s [“worthless”] TraÊkig [“dull”] Ynklig [“piteous”] Dum [“stupid”]
Borgen [“bail”] Storstad [“city”] Moster [“aunt”] Kuliss [“side-scene”] Lax [“salmon”]
Sma¨ rta [“pain”] Do¨dlig [“lethal”] Cancer [“cancer”] Galen [“crazy”] Kista [“cof n”]
Seklet [“century”] Dubbar [“studs”] Fisken [“ sh”] Lakan [“sheet”] Limpa [“loaf”]
Stroop task
The Stroop procedure used a Swedish translation of the computerized “Colour naming task for social phobics and panickers”, as developed by Hope (1990). This version of the Stroop task involves 2 categories of threat words (social threat words and physical threat words), 2 corresponding categories of control words, a category of colour words and groups of 5 Xs. The categories of socially threatening and physically threatening words were matched with the 2 corresponding groups of neutral words (Table 1) for number of syllables, number of letters and frequency of usage in the Swedish language (Alle´n, 1970). That is, each set of threatening words was matched to a separate set of neutral words and not to each other, which means that it is not appropriate to make direct comparisons between the colour-naming latencies for social and physical threat words. Colour names were matched with groups of 5 Xs. Each category of stimuli was presented on a separate stimulus screen on a PC monitor, 5 mm high, double-spaced, 9 per line for 11 lines. The 11 lines constituted a “screen” with all words being of the same type. The 6 stimulus type screens were randomly ordered by the computer for each subject. The participants were seated in front of the monitor and asked to name quickly and accurately the colours in which words or letters were shown on the screen. Time was kept manually by the experimenter, who pressed the space bar when the Ss said the first colour name on each stimulus screen and pressed it again when they said the last.
Self-Consciousness Scale (SCS) This instrument, which was developed by Fenigstein et al. (1975), includes a subscale for Private Self-Consciousness (i.e. the disposition to attend to one’s own thoughts, feelings, moods and attitudes), a subscale for Public Self-Consciousness (i.e. the disposition to think about outwardly observable aspects of the self, such as physical appearance and overt behaviour) and a subscale for Social Anxiety. The items are in the form of statements with a Likert-type 5-point response format. The present study used a Swedish translation (Nystedt & Smari, 1989) of the SCS, which has shown good reliability and validity.
Multidimensional Perfectionism Scale (MPS) This instrument, which was developed by Frost et al. (1990), contains 35 items in the form of statements with a Likert type 5-points response format from “strongly disagree” to “strongly agree”. The MPS generates an overall perfectionism score as well as scores for 6 subscales that reflect specific domains of perfectionism: Concern over Mistakes (e.g. “If I fail at work/school, I am a failure as a person”); Doubts about Actions (e.g. “I usually have doubts about the simple everyday things I do”); Personal Standards (e.g. “I set higher goals than most people”); Parental Expectations (e.g. “My parents set very high standards for me”); Parental Criticism (e.g. “As a child, I was punished for doing things less than perfectly”); and Organization (e.g. “Organization is very important for me”). The total perfectionism score is the sum of all the subscales except
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Table 2. Stroop latencies (SL) and Stroop interference (SI) in seconds in social phobics (n = 24) before and after CBT. Comparison by paired t-test.
SL Social threat words SL Social control words SI Social threat words SL Physical threat words SL Physical control words SI Physical threat words SL Colour words SL XXXXX SI Colour words
Pre-test M (SD)
Post-test M (SD)
72.83 67.74 5.10 70.69 65.32 5.26 84.92 56.01 28.92
68.35 67.11 1.24 65.72 64.09 1.63 80.73 54.98 25.75
(13.94) (13.85) (10.75) (14.29) (10.26) (7.12) (15.32) (9.74) (9.87)
(14.58) (13.52) (5.41) (11.70) (12.35) (5.07) (17.45) (11.79) (10.70)
t(23)
p
1.63
0.117
2.57
0.018
2.11
0.046
Organization, which tends not to correlate highly with the other subscales or with total perfectionism (Frost et al., 1990). The Swedish version of the MPS shows good reliability and validity (Saboonchi, 2000).
Results The time from pre-test to post-test varied a lot between the participants: from 4 to 25 months, which means that some patients were tested directly after treatment, whereas others were tested 1– 2 years after treatment. For this reason, the Social Anxiety subscale from the SCS was used to measure improvement in social anxiety from pre-test to post-test, since this was the only measure of social anxiety that was administered at the same time as the other tests. A total of 18 (75%) of the patients showed a reduction in their scores on the SCS subscale Social Anxiety from pretesting to post-testing. These patients were defined as treatment responders in the following analyses. The results with regard to the changes on these measures are analysed first with regard to the whole sample and then separately for the treatment responders in order to test the 3 hypotheses. There was no significant difference between the treatment responders and non-responders in terms of time from pre- to post-testing (mean time interval 8.59 vs 6.33 months) and there was no correlation between time from pre- to post-testing and degree of reduction on social anxiety (r = 0.02).
Changes on Stroop measures The degree to which the colour naming latencies (Stroop latencies) were inflated on threat word trials relative to non-threat words trials and on colour words relative to Xs, was calculated separately for each subject. This was done by subtracting the colour naming latency shown on non-threat word trials from the colour naming latency shown on threat word trials and by subtracting the colour naming latency shown on Xs from that shown on colour words. The mean Stroop latencies (SL) for each category of stimuli and the resultant indexes of Stroop interference (SI) of social threat words, physical threat words and colour names are shown in Table 2. SI of colour words before and after treatment showed a strong correlation, r = 0.77, p < 0.0001. There were no significant correlations, however, between SI of social threat words before and after treatment (r = 0.18), or SI of physical threat words before and after treatment (r = 0.15).
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Table 3. Stroop latencies (SL) and Stroop interference (SI) in seconds in treatment responders (n = 18) and nonresponders (n = 6) before and after CBT. Treatment responders
SL Social threat words SL Social control words SI Social threat words SL Physical threat words SL Physical control words SI Physical threat words SL Colour words SL XXXXX SI Colour words
Non-responders
Pre-test M (SD)
Post-test M (SD)
Pre-test M (SD)
Post-test M (SD)
74.86 68.43 6.43 71.16 66.92 5.53 85.74 56.43 29.31
69.15 68.11 1.05 65.68 65.03 0.65 81.97 55.55 26.47
66.74 65.64 1.10 69.28 61.06 8.22 82.48 54.75 27.74
65.92 64.10 1.83 65.84 61.28 4.56 77.21 53.36 23.96
(14.23) (15.23) (10.33) (15.43) (10.82) (8.00) (17.47) (10.43) (10.70)
(16.18) (15.11) (5.49) (12.72) (13.49) (5.23) (20.05) (12.76) (11.38)
(12.05) (9.28) (11.97) (11.27) (7.82) (3.83) (5.70) (8.03) (7.56)
(8.86) (7.10) (5.65) (8.89) (8.38) (3.41) (5.80) (8.99) (10.23)
All patients As seen in Table 2, paired t-tests showed that the social phobics had significantly less Stroop interference of colour words at post-testing and that they also showed significantly less Stroop interference of physical threat words after treatment. There was, however, no significant reduction on Stroop interference of social threat words. Of the 24 patients, 15 individuals (62.5%) showed reduced Stroop interference for social threat words, whereas 18 (75%) showed reduced Stroop interference for physical threat words and 17 (70.8%) showed reduced Stroop interference for colour words.
Treatment responders and non-responders The mean scores on the Stroop task in the treatment responders and non-responders are shown in Table 3. The hypothesis that the treatment responders would show reduced Stroop interference for social threat words after treatment was supported. Paired t-test showed that the treatment responders had significantly less Stroop interference of social threat words at post-testing (mean reduction 5.38 seconds, t(17) = 1.86, p < 0.05, one-tailed), whereas the non-treatment responders showed no such effect (mean increase 0.73 seconds). In order to interpret this finding correctly, however, it must be taken into account that the non-responders, in fact, showed virtually no Stroop interference of social threat words before treatment (mean interference score 1.10 s). The treatment responders showed a clear interference effect before treatment (mean interference score 6.43 s), which was rendered virtually non-existent after treatment (mean interference score 1.05 s). The treatment responders showed a reduced interference of physical threat words (mean reduction 4.80 seconds, t(17) = 2.07, p < 0.05, but the non-treatment responders showed a similar effect (mean reduction 3.66, t(5) = 1.90). Neither the treatment responders nor the non-responders showed any significant effect on colour words (mean reductions 2.91 and 3.78 seconds, respectively, both p > 0.10). Of the 6 non-responders, 3 (50%) were faster to respond to the social threat words than the control words at pre-testing, i.e. they showed Stroop facilitation for social threat words before treatment, whereas none (0%) showed Stroop facilitation for physical threat words before treatment. Of the 18 treatment responders, 4 (22%) showed Stroop facilitation for social threat words before treatment and 5 (27%) showed Stroop facilitation for physical threat words.
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Table 4. Scores on the Self-Consciousness Scale (SCS) and the Multidimensional Perfectionism Scale (MPS) in social phobics (n = 24) before and after CBT. Comparison by paired t-test, two-tailed.
SCS Private Self-Consciousness SCS Public Self-Consciousness MPS Concern over Mistakes MPS Personal Standards MPS Doubts about Action MPS Organization MPS Parental Expectations MPS Parental Criticism MPS total score
Pre-test M (SD)
Post-test M (SD)
t(23)
p
26.0 23.1 27.1 23.2 9.8 21.0 12.8 10.8 84.2
22.8 21.3 21.2 20.9 8.1 20.9 11.3 8.7 70.2
2.29 3.10 4.17 3.07 3.64 0.24 2.85 3.02 5.17
0.0318 0.0050 0.0004 0.0054 0.0014 ns 0.0092 0.0062 0.0001
(8.0) (4.2) (8.3) (6.7) (3.6) (4.3) (6.2) (5.6) (24.4)
(7.5) (5.3) (7.8) (6.2) (3.2) (4.3) (5.4) (5.2) (22.4)
Changes in self-consciousness and perfectionism All patients The mean scores on the self-consciousness scales are shown in Table 4. Because comparisons were made on 8 subscales, the alpha level was adjusted to 0.05/8 = 0.0064. Paired t-tests showed that the social phobics scored significantly lower after treatment on public self-consciousness and on 4 of the 6 perfectionism scales: Concern over Mistakes, Doubts about Action, Personal Standards and Parental Criticism. Of the 24 patients, 14 (58%) showed reduced scores on Public Self-Consciousness after treatment, whereas 20 (83%) showed reduced MPS total scores after treatment. All 4 patients who showed no reduction in their perfectionism scores belonged to the treatment responders and, of these, 2 had very low MPS scores already before treatment (35 and 41, respectively, which is considerably lower than the means found in non-clinical samples; for example, 58.5 in the study ¨ st, 1996). by Lundh & O The patients’ scores on Public Self-Consciousness before and after treatment showed a strong correlation, r = 0.87 and the corresponding correlations for Private Self-Consciousness and Social Anxiety were r = 0.67 and r = 0.68, respectively. The patients’ MPS scores before and after treatment showed a strong correlation, r = 0.84. The corresponding correlations for the MPS subscales were: Concern over Mistakes r = 0.60; Personal Standards r = 0.78; Doubts about Action r = 0.84; Organization r = 0.80; Parental Criticism r = 0.82; and Parental Expectations r = 0.89.
Treatment responders and non-responders The mean scores on the self-consciousness and perfectionism scales in the treatment responders and non-responders are shown in Table 5. The hypotheses that the treatment responders would show reduced scores on Public Self-Consciousness and on Perfectionism after treatment were supported. Paired t-test showed that the treatment responders had significantly lower scores on Public Self-Consciousness at post-testing (mean reduction 2.22, t(17) = 3.69, p < 0.002), whereas the non-treatment responders showed no effect (mean reduction 0). Both the treatment responders and the non-treatment responders showed reductions of similar size on total MPS scores (mean reductions 13.11 and 16.50). But since the non-responders started from a much higher level (96.2 vs 80.2 among the treatment responders), this only means that their MPS scores were reduced to the same level (79.7) as the treatment responders had before treatment. The treatment responders, on the other hand, showed a reduction in their scores to a
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Table 5. Scores on the Self-Consciousness Scale (SCS) and the Multidimensional Perfectionism Scale (MPS) in treatment responders (n = 16) and non-responders (n = 8) before and after CBT. Treatment responders
SCS Social Anxiety SCS Private Self-Consciousness SCS Public Self-Consciousness MPS Concern over Mistakes MPS Personal Standards MPS Doubts about Action MPS Organization MPS Parental Expectations MPS Parental Criticism MPS total score
Non-responders
Pre-test M (SD)
Post-test M (SD)
Pre-test M (SD)
Post-test M (SD)
17.2 25.7 22.4 26.3 22.2 9.4 20.9 11.8 10.4 80.2
11.9 (3.6) 22.5 (7.2) 20.2 (5.6) 20.9 (8.1) 19.8 (5.3) 7.8 (3.1) 20.2 (4.6) 10.4 (4.9) 8.1 (5.0) 67.1 (21.9)
19.7 26.2 24.3 30.5 27.7 9.8 21.5 16.5 11.7 96.2
20.7 23.8 24.3 22.2 24.0 8.8 22.8 14.0 10.7 79.7
(6.2) (7.9) (4.5) (8.5) (5.8) (3.3) (4.1) (5.6) (5.7) (22.5)
(4.8) (9.3) (3.0) (8.0) (7.7) (4.1) (5.4) (7.5) (6.3) (28.0)
(3.6) (8.8) (2.9) (7.6) (8.3) (3.8) (2.7) (6.5) (5.9) (23.3)
level (67.1) that is more nearly typical of non-clinical samples (64.9 in a non-clinical sample of 113 individuals from Stockholm, Sweden; Saboonchi et al., 1999) As can be seen in Table 5, the non-responders’ higher MPS scores, as compared with the treatment responders, before treatment was due primarily to the MPS subscales Personal Standards (mean difference 5.5) and on Parental Expectations (mean difference 4.7) – i.e. 2 MPS scales on which social phobics generally do not seem to score higher than non-clinical samples. It may also be noted that the treatment non-responders still scored higher after treatment than the treatment responders did before treatment on these 2 MPS scales.
Discussion As expected, the treatment responders in the present study showed significant reductions in Stroop interference for social threat words and in public self-consciousness and perfectionism. The nonresponders did not show any reduction in Stroop interference of social threat words or in public self-consciousness, but showed a reduction in perfectionism that was of equal size to that of the treatment responders. Since the non-responders started from a much higher level of perfectionism before treatment, however, their change only amounted to lowering their level of perfectionism to the level that characterized the treatment responders before treatment. The treatment responders, on the other hand, reduced their level of perfectionism to that of normal controls.
Changes in attentional bias With regard to Stroop interference, the present results represent a partial replication of the results obtained by Mattia et al. (1993). That is, the treatment responders showed a significant reduction in Stroop interference of social threat words. The interpretation of the Stroop results, however, is complicated by 2 other aspects of the results: (1) all participants showed a reduced Stroop interference of physical threat words; and (2) although the non-responders showed no reduction in interference of social threat words after treatment, this must be seen against the background that they did not show any Stroop interference of social threat words before treatment. It is therefore possible that the lack of change on social threat words among the non-responders is due to a “floor effect”.
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How to explain the reduced effects of physical threat words? One possibility is that treatment of one anxiety disorder may also produce effects on the attentional bias for other kinds of threatening information that is not associated with the anxiety disorder being treated. Another possibility is that there are two kinds of effects involved here: one that occurs as the result of CBT and one that occurs as the result of some other kind of process, e.g. practice with the Stroop task. This possibility is underscored even more by the reductions among all patients that were obtained with regard to Stroop interference also for conflicting colour words (e.g. the word “blue” written in red letters). Stroop effects on colour words can hardly be assumed to be the result of an attentional bias for threatening information, but must rest on some other kind of process. In this context it is interesting to note that the effect on colour words was not significant among the treatment responders. In fact, both treatment responders and non-responders showed similar reductions on Stroop interference for colour words, which suggests that this effect is unrelated to treatment. The fact that Stroop interference for colour words shows strong stability from pre- to post-testing (r = 0.77), whereas the SI indexes for social threat words and physical threat words showed no such stability, also testifies to different kinds of phenomena that seem to be involved in emotional Stroop interference and Stroop interference for colour words.
Changes in public self-consciousness and perfectionism
The reduced scores on public self-consciousness after treatment are consistent with those reported by Woody et al. (1997) and Hofmann (2000), with other measures of self-focused attention. The present study, however, adds to earlier research by showing reductions also in perfectionism. Both treatment responders and non-responders showed reductions in total perfectionism scores. However, as the non-responders started from a much higher level, the effect of this change was only that their MPS scores were reduced to the same level as the treatment responders had before treatment. The treatment responders, on the other hand, showed a reduction in their scores to a level that is nearly typical of non-clinical samples. It is interesting that the non-responders’ higher MPS scores before treatment was due primarily to the MPS subscales Personal Standards and Parental Expectations, i.e. 2 MPS scales on which social phobics generally do not score higher than non-clinical samples (Antony et al., 1998; Juster ¨ st, 1996; Saboonchi et al., 1999). This suggests that the non-responders et al., 1996; Lundh & O may have represented a subgroup of social phobics with somewhat different characteristics than the treatment responders – characteristics that may possibly have made their treatment more difficult and less likely to succeed. It may also be noted that after treatment the treatment nonresponders still scored higher than the treatment responders did before treatment on these 2 MPS scales. There are large individual variations in how a social phobia manifests itself and it seems reasonable to assume that perfectionism is more important in some cases than in others. The present results also suggest that different aspects of perfectionism may carry different weight in different cases of social phobia. Finally, it is also worth noticing that the patients showed reduced scores also on the MPS scale Parental Criticism after treatment. This seems to imply that the patients think differently about their parents after treatment. What before treatment was remembered as high criticism seems to have been reinterpreted as somewhat lower degrees of criticism after treatment. Since CBT does not focus on the patients’ images of their parents, this may imply that a generally reduced degree of perfectionistic thinking may also lead automatically to changes in how patients view their parents.
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Conclusion The present study indicates that reductions in attentional bias for threatening information, public self-consciousness and perfectionism occur after cognitive-behavioural treatment of social phobia. The results for perfectionism also suggest the possibility that certain aspects of perfectionism may make treatment more difficult and less likely to succeed. Because of the relatively small number of patients and the fact that only a self-assessment questionnaire was used to measure changes in social anxiety, however, these results should be interpreted with caution. It is important to recognize that the present study suffers from a number of weaknesses. Two major weaknesses are the small number of patients and the use of only a self-assessment measure of social anxiety to define treatment responders. Although the effects on the Stroop task were consistent with the hypothesis, there are also some aspects of these results (no pre-test Stroop effect of social threat words among the non-responders and effects on physical threat words among all participants) that make their interpretation less straightforward. The generalizability of the present findings is also limited by the fact that almost all patients (22 of 24) were female; and by the present sample being limited to social phobics of the generalized subtype (only 3 of the 24 patients had a diagnosis of non-generalized social phobia). Nevertheless, the present study indicates that it may be of interest to focus more research on these variables in future studies of social phobia.
Acknowledgements This research and the preparation of the manuscript were made possible by grants from the Faculty of Social Sciences at Stockholm University and the Magn. Bergwall Foundation to the first author and by grants from the L. J. Boethius Beneficiary Fund to the second author.
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