Can metacognition help explain social anxiety and related problems better than cognition and lead to innovation in treatment?

Abstract

Social anxiety disorder (SAD) is characterized by a marked or intense fear/anxiety of social situations in which the individual may be scrutinized by others. It is one of the most common mental health disorders with a life-time prevalence of 12 %. SAD often has an early onset and is considered a relatively chronic disorder if left untreated. Furthermore, SAD is also associated with the development of depressive symptoms and work-related problems. Currently, the treatment of choice for SAD is individual Cognitive-behavioural Therapy based on the Clark and Wells model (1995) which builds on Beck’s schema theory (Beck, 1976) and the Self-Regulatory Executive Function (S-REF) model of psychological disorder (Wells & Matthews, 1994). Central to the model is the view that individuals with SAD hold negative beliefs about the social self which cause them to engage in an information processing style characterized by self-attention and safety behaviors. This style is not capable of providing unambiguous disconfirmation of social fears and concerns during feared social situations. Hence, the Clark and Wells model accounts for the persistence of SAD with reference to a number of specific cognitive-behavioural mechanisms involving vicious circles that are responsible for maintaining the problem. A conceptual feature of the Clark and Wells model (1995) is that it draws on different theoretical frameworks in an integrative way that may create upper limits to what can be achieved in conceptualization and treatment of the disorder. For example, it places the content of cognition in center stage and argues that schemas or negative beliefs give rise to self-processing and social anxiety. However, the S-REF model (Wells & Matthews, 1994) that partially informed its development emphasizes failures to adaptively regulate processing such as worry and attention as the main features of psychological disorder. This effect is thought to emerge from metacognitive beliefs (i.e. beliefs about cognition) rather than from the content of negative self-beliefs. The aim of the current PhD project was therefore to explore the relative importance of metacognitive beliefs versus social phobic cognitive beliefs to social anxiety and to related problems such as depression symptoms and work status in socially anxious individuals. Furthermore, the thesis also includes a preliminary investigation of Metacognitive therapy (MCT; Wells, 2009) for SAD using single case methodology with the aim to investigate the feasibility of this treatment. Study 1 examined change in negative cognitive and metacognitive beliefs as independent correlates of symptom improvement in 46 SAD patients undergoing evidence based treatments. Both types of beliefs decreased during treatment. However, change in negative metacognitive beliefs was the only consistent independent predictor across all outcomes and change in cognitive beliefs did not significantly predict outcomes when change in self-consciousness was controlled. Study 2 aimed to test the relative contribution of metacognitive beliefs to depression symptoms in 102 SAD patients when also controlling social anxiety severity and factors postulated in cognitive models. In this study we found that negative metacognitive beliefs and low confidence in memory were the only factors explaining individual variance in depression symptoms when the overlap between the predictors were controlled. Study 3 aimed to test the relative contribution of metacognitive beliefs to work status (in- or out-of-work) in a sample of 204 high socially anxious individuals when also controlling social anxiety severity and factors postulated in cognitive models of SAD. Being out-of-work was associated with greater symptom severity and greater endorsement of maladaptive coping strategies and beliefs. However, only negative metacognitive beliefs significantly predicted work status when the overlap between predictors were controlled, suggesting that greater endorsements of negative metacognitive beliefs were associated with being out-of-work. Study 4 aimed to explore the effects of MCT for SAD using single case methodology across three patients with different presentations of SAD; performance type, generalized, and generalized with comorbid avoidant personality disorder, representing increasing SAD severity/complexity. All patients responded during treatment and achieved substantial symptom reductions which were largely maintained at 6 months’ follow-up, suggesting that MCT was a feasible treatment for these patients. In summary, the current thesis indicates that change in metacognitive- rather than cognitive beliefs is associated with symptom improvement in individuals undergoing treatment for SAD. Metacognitive- but not cognitive beliefs are statistical predictors of depression symptoms in patients with SAD, and of work status amongst high socially anxious individuals. These emerging data support the idea that moving beyond the content of cognition and towards a greater metacognitive-focused conceptualization and treatment of SAD may contribute positively to further developments. In line with this notion, MCT which aims to target metacognitive beliefs and strategies directly rather than the content of cognition appears to be a suitable treatment and was associated with positive outcomes for patients with different presentations of SAD. Hence, the metacognitive approach has the potential to advance our understanding and treatment of SAD, and the current thesis supports further research in this direction.