The effect of self-imagery on symptoms and processes in social anxiety: A systematic review
Introduction
Social Anxiety Disorder involves a marked and persistent fear of negative evaluation in social and/or performance situations (DSM-5; American Psychiatric Association, 2013). Individuals with Social Anxiety Disorder fear that they will act in a humiliating or embarrassing manner, hence, social and/or performance situations are avoided or endured with intense anxiety. This causes marked distress and impairment in social and occupational functioning. DSM-5 recognises a subtype of the disorder for performance situations only. This pertains to individuals for whom the fear is exclusive to speaking or performing in public and there is no fear or avoidance of non-performance social situations. Social Anxiety Disorder has a 12-month and a lifetime prevalence rate of 7.1% and 12.1% respectively, and is one of the most commonly diagnosed psychiatric disorders (Kessler, Chiu, Demler, & Walters, 2005).
Negatively valenced mental imagery of the perceived self is one of the key processes proposed by cognitive models to maintain Social Anxiety Disorder (e.g., Clark and Wells, 1995, Hofmann, 2007, Rapee and Heimberg, 1997). Negative self-imagery has been conceptualised as mental pictures of the self that represent an individual's feared outcomes (e.g., ‘looking foolish’; Hackmann, Surawy, & Clark, 1998). Such images tend to be idiosyncratic and themed around perceived catastrophes involving physical or psychosocial dangers specific to the individual's anxiety disorder (e.g., ‘being humiliated by others’; Hirsch, Clark, Mathews, & Williams, 2003). Findings from early qualitative studies (e.g., Hackmann et al., 2000, Hackmann et al., 1998) suggest that in social or performance situations, individuals with Social Anxiety Disorder frequently see themselves as though from the perspective of others, and that these self-images are typically negative, and distorted, such that visible symptoms of anxiety are exaggerated. For example, self-images resemble unflattering caricatures of the self that the individual believes are accurate representations of how they appear to others (Clark & Wells, 1995). In contrast, self-images of non-clinical controls are typically less frequent, less negative, and ‘viewed’ from one's own perspective (Hackmann et al., 1998). Preliminary studies have supported the link between negative self-imagery and social anxiety (Hirsch, Clark, Mathews and Williams, 2003, Hirsch et al., 2004). More recently, empirical research has investigated the effect of self-imagery on other processes related to social anxiety such as self-esteem (Hulme, Hirsch, & Stopa, 2012), and performance appraisal (e.g., Coles et al., 2001, Hirsch, Clark, Mathews and Williams, 2003, Hirsch et al., 2006, Hirsch et al., 2004, Spurr and Stopa, 2003, Vassilopoulos, 2005). Additionally, a number of studies have begun to examine the efficacy of ‘imagery rescripting’ as an intervention to modify negative self-imagery and improve symptoms of social anxiety (e.g., Nilsson et al., 2012, Wild et al., 2008). Imagery rescripting is a technique that exposes clients to memories of negative events experienced in childhood, and “introduces” a helpful adult into the memory to facilitate a more positive imagined outcome. More specifically, IR techniques attempt to alter the meaning associated with the memory and negative image to reflect a more empathic and appropriate self-perspective (Nilsson et al., 2012, Wild et al., 2007, Wild et al., 2008). Collectively, these studies have started to yield valuable insights into the role of self-imagery in social anxiety.
Cognitive models of social anxiety (e.g., Clark and Wells, 1995, Hofmann, 2007, Rapee and Heimberg, 1997) posit that negative self-imagery is a key maintaining factor of the disorder. Clark and Wells (1995) suggest that individuals with Social Anxiety Disorder hold an unflattering impression of themselves as a social object, and focus excessively on interoceptive cues of internal thoughts, feelings and physical sensations that confirm their impression. Whilst attending to these negative thoughts and sensations during a social event, the individual is less likely to notice signs of being accepted by others that could potentially disconfirm their beliefs and reduce levels of distorted self-images. In this way, negative self-imagery in conjunction with self-focussed attention on internal experiences, is hypothesised to reinforce individuals' negative assumptions about themselves, thereby maintaining the cycle of Social Anxiety Disorder.
Hofmann's (2007) model of Social Anxiety Disorder similarly argues that heightened self-focused attention leads to negative self-perception. This representation of the self (e.g., negative self-images) increases apprehension about social mishap, as the individual appraises their social skills as inadequate for the social task. Such beliefs motivate the use of safety behaviours, avoidance, as well as rumination after the social event, which further sustain social anxiety. Hofmann argues that the combination of these cognitive appraisals and attentional processes act to maintain anxiety, by perpetuating negative self-perceptions and high estimates of social cost, which lead to more negative rumination (Hofmann, 2007).
Likewise, Rapee and Heimberg (1997) recognise internally generated negative self-images as a significant component of the overall ‘mental representation of the self’, which comprises a central factor in their model of Social Anxiety Disorder. As in Hofmann's model, Rapee and Heimberg hypothesise that social anxiety stems from the discrepancy between the individual's self-representation and what they think the audience expects of them, and the belief that both the probability and cost of falling short of expected standards are high. Attentional resources are preferentially allocated to both external signs of negative evaluation that confirm distorted negative self-images, as well as internal cues including somatic and cognitive anxiety symptoms that are taken as evidence that the distorted view of oneself is accurate.
Whilst the main cognitive models of social anxiety essentially agree on the primary role of negative self-imagery in social anxiety, they say less about the relative impact of positive self-imagery, not only in terms of image frequency and intensity, but also whether positive self-images have either a helpful or deleterious impact on symptoms and processes. Additionally, the role and function of both positive and negative self-images in social anxiety may be context (i.e., situation) dependent, but this remains an empirical question with relatively little theoretical input to date.
When social situations trigger anxiety, individuals with Social Anxiety Disorder have been found to be more likely to experience spontaneously occurring, negative images, which they assume is how they appear to others (i.e., from an ‘observer-perspective’), in comparison to controls (Hackmann et al., 1998). Preliminary investigations suggest that these self-images appear to correspond with a particular memory of a traumatic social event, and are predominantly visual, but can include other modalities such as body sensations or perceptions (Hackmann et al., 2000). Empirical research employing a sample of clinically diagnosed Social Anxiety Disorder participants demonstrated that holding a negative self-image in mind during a social conversation adversely affects anxiety levels, and subjective and objective ratings of performance, when compared to holding a neutral self-image in mind (Hirsch, Clark, Mathews, & Williams, 2003). These findings have been replicated in an analogous sample of high socially anxious individuals (Hirsch et al., 2004). A similar pattern of results has been observed when exploring the effect of negative self-imagery on other social evaluative tasks, such as a brief speech (Makkar & Grisham, 2011). Further, in contrast to a control self-image, negative self-images have been linked to higher levels of rumination following social or performance events and self-focused attention (Makkar & Grisham, 2011), lower levels of self-esteem (Hulme et al., 2012), greater use of safety behaviours (Hirsch et al., 2004), and faster retrieval of negative memories and poorer predicted performance (Stopa & Jenkins, 2007).
More recently, empirical studies have begun to investigate how interventions based on self-imagery may alleviate symptoms of social anxiety. Stopa, Brown, and Hirsch (2012) tested the impact of imagery training techniques such as ‘imagery rescripting’ on anxiety, performance appraisal and self-concept, finding that positive self-imagery training produced better performance ratings in a conversation task. A small number of studies have begun to explore the effect of imagery rescripting on social anxiety. Preliminary findings suggest that imagery rescripting of early distressing memories may be a promising intervention in the treatment of Social Anxiety Disorder. All three preliminary treatment studies found a significant reduction in image vividness and anxiety following an imagery intervention (Nilsson et al., 2012, Wild et al., 2007, Wild et al., 2008). Effect sizes for reductions in anxiety ranged from 0.46 to 2.33 across these three treatment studies. More recently, Lee and Kwon (2013) conducted a randomised control trial investigating the efficacy of imagery rescripting as a brief intervention for Social Anxiety Disorder. Results showed improvements in self-reported anxiety symptoms that were maintained at three-month follow-up, suggesting that treatment targeting negative imagery in Social Anxiety Disorder is efficacious in alleviating distress and symptoms of the disorder (Lee & Kwon, 2013).
Studies in the area of self-imagery in social anxiety have differed in their methodologies, quality, and variables of interest. The degree to which self-imagery impacts symptoms and processes in social anxiety differs across studies, with some studies finding strong results in favour of the negative impact of self-imagery and others finding negative imagery to have a less substantial effect. Critically, some studies have included single group designs of clinical participants, whilst others have manipulated imagery conditions for a range of relevant participant groups. Evaluating the findings across such diverse methodologies will better inform the specific impact of a range of imagery valence conditions for socially anxious and control participants. Thus, a systematic review of the literature is warranted to determine the nature and extent of the effect of self-imagery on social anxiety, especially given the growing body of literature focussing on this topic.
This review aims to systematically evaluate the effect of imagery in social anxiety by assessing studies that have examined imagery in clinical and non-clinical participants as well as analogue samples of individuals with social anxiety. Such a review is timely, given the increasing number of studies assessing predictions of cognitive models as they relate to the maintaining role of emotional (positive and negative) self-imagery in social anxiety, and the increase in evaluations of imagery-based interventions. More fully understanding the impact of a range of imagery conditions within experimental paradigms should further inform imagery-based treatment interventions with converging evidence provided from research methods based in experimental and treatment paradigms. In this review we specifically sought to analyse identified experimental and treatment studies with a focus on seven key areas: participants, assessment, experimental design, imagery induction method, behavioural task, and both symptom and process outcomes. Risk of bias within and across these studies was assessed based on domains suggested by the Cochrane Handbook for Systematic Reviews (Higgins & Green, 2011). Risk of bias domains included: selection bias (random allocation, allocation concealment, inclusion of a control condition, assessment of clinical status), performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), attrition bias, and reporting bias. The present systematic review evaluates the quality of available research and reliability of current findings regarding the role of self-imagery in social anxiety for all relevant published literature.
Section snippets
Summary of search strategy
A comprehensive literature search was conducted amongst articles indexed in the following databases: PsycInfo, Medline, PubMed, and the Cochrane Central Register of Controlled Trials. The key words employed included: (‘Social Anxiety’ OR ‘Social Phobia’ OR ‘Social Anxiety Disorder’) AND (‘imagery’ OR ‘negative imagery’ OR ‘mental imagery’ OR ‘self-representation’). Articles were limited to English-language papers, and no limitations were made regarding publication date. Reference lists of
Clinical status, assessment measures and participant selection
Of the 17 studies, four studies reported a sample with clinically diagnosed Social Anxiety Disorder (DSM-IV-TR, 2000) and three of these studies used standardised interview schedules for assessment such as the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo, & Barlow, 2004) or the Structured Clinical Interview for DSM-IV (SCID-I; First, Spitzer, Gibbon, & Williams, 1996). Nine studies recruited and allocated participants to high and/or low social anxiety groups based on
Summary of findings
Cognitive models of Social Anxiety Disorder (e.g., Clark and Wells, 1995, Hofmann, 2007, Rapee and Heimberg, 1997) posit that negative self-imagery is a key predisposing and maintaining factor of the disorder, and a growing body of research has examined the effects of self-imagery on symptoms and processes in social anxiety. This review aimed to systematically evaluate the existing literature and examine the role of self-imagery on social anxiety by summarising and synthesising the current
Role of funding sources
We have no funding sources to declare.
Contributors
Named authors contributed at various stages of the research process including study design, selection and coding of manuscripts for review, data evaluation and analysis of relevant studies, drafting and writing of manuscript, and commenting on drafts of manuscript.
Conflict of interest
We can confirm that there are no conflicts of interest.
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