Carla Research Assignment FINAL

Running head: SOCIAL ANXIETY DISORDER: TREATMENTS COMPARED

Cognitive Restructuring and Exposure in the Group Treatment of

Generalised Social Anxiety Disorder: A Comparison of the Outcome of two

Programmes

CA Nortje

16954653

Research Assignment for partial fulfilment of the requirements of the degree Honours BA

(Psychology) at Stellenbosch University

Supervisor: Mr HR Steel, Department of Psychology

Stellenbosch University

12 October 2015

SOCIAL ANXIETY DISORDER: TREATMENTS COMPARED 1

Abstract

The aim of this study was to compare the efficacy of two active, group treatment

programmes, cognitive restructuring plus exposure (CBGT) versus exposure alone (EA), in

the treatment of generalised social anxiety disorder (GSAD) within a time-limited period (12

weekly sessions; 2-2.5 hours each). A basic quantitative, cross-sectional research design with

repeated measures was used. Participants (n = 44; 21-68 years old; diagnosed with GSAD

according to the DSM-IV-TR) were allocated to three treatment conditions namely, CBGT (n

= 15), EA (n = 15) and a control group (CTRL; n = 14). MANOVA results showed that,

compared to CTRL, both active treatment programmes showed significant treatment effects

on GSAD symptomatology (p < .01). The two programmes did not differ significantly from

one another with regards to the four dependent variables (i.e., depression; target phobia

avoidance; general social phobia symptomatology; and thought functionality). However,

CBGT was more effective in improving the cognitive variable. Future studies are required to

determine possible changes in the two treatment effects over time, and additionally, to

identify whether changes in the cognitive variable predicts changes in the other GSAD

variables.


According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.,

DSM-5; American Psychiatric Association [APA], 2013) social anxiety disorder (SAD), also

known as social phobia, is characterised by an irrational fear of potential humiliation and

embarrassment when performing in front of people (e.g., giving a speech), being in social

situations (e.g., interacting with others) and/or being observed (e.g., while eating). When the

fear is experienced in all or almost all situations it is classified as social anxiety disorder,

generalised type. SAD is a debilitating disorder that often has significant, detrimental effects

on the sufferer's social and occupational functioning and general health (APA, 2013).

SAD is one of the most common psychiatric disorders with an estimated prevalence

of between 4% and 6%, and a lifetime risk from 7% to 13% (Lochner et al., 2007). Williams

et al. (2007) suggest that mental disorders, including SAD, are one of the major contributors

to disease burden in South Africa. There is a variety of available treatments for people who

suffer from SAD, broadly categorised in somatic treatment (medication) and psychological

treatment (psychotherapy). Cognitive behaviour therapy (CBT) is a popular approach to the

psychotherapeutic treatment of SAD (Leichsenring et al., 2013), and it may be presented in

an individual or a group format. CBT within a group format will be the focus of the present

study.

CBT is a form of psychotherapy that developed from 1) the philosophical school of

behaviourism (Watson, 1930, cited in Schultz & Schultz, 1992), 2) behaviour therapy,

emphasising the centrality of overt, functional behaviour which originated simultaneously in

South Africa (cf Wolpe & Lazarus, 1966), England (cf Eysenck, 1960, cited in Hergenhahn,

1992) and the United States of America (cf Skinner, 1953, cited in Spiegler & Guevremont,

2003), and 3) cognitive therapy (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979). Today, the

cognitive model (which underlies CBT) advocates that dysfunctional and irrational thinking

(affecting mood and behaviour) is common to most psychological disturbances (Beck &


Beck, 2011; Clark & Beck, 2010). Although, according to the model, cognitive changes are

essential for improving emotional disturbances (including anxiety and depression), cognitive

restructuring is not the only available CBT technique to accomplish this (Beck & Beck,

2011). Behaviour focused techniques (e.g., repetitive and prolonged exposure to feared

objects and situations) are also regarded as powerful treatment methods for emotional

disorders by having an effect on cognitive changes (Marks, 1987; Mörtberg, 2014). Cognitive

change is viewed as one potential mechanism by which exposure affects positive outcomes in

anxiety disorder treatment; others are, for example, habituation, toughening-up, reciprocal

inhibition, counter-conditioning and emotional processing (Marcus, 1977).

Exposure based treatment was once described as the “gold standard” (Mersch, 1995,

p. 260) for the treatment of anxiety disorders. Although cognitive restructuring (e.g., by

correcting irrational thoughts), exposure (e.g., being made to repetitively present a speech in

front of people, in vivo or in fantasy) and an integrated combination of these two therapeutic

approaches, have proven to be effective treatments for SAD (Hope, Heimberg, & Bruch,

1995), it is not clear which is the best treatment strategy within a specific, limited time-frame

(e.g., in 10 to 15 treatment sessions). In dismantling studies, the relative strength of

components of an integrated cognitive restructuring plus exposure approach were

investigated (e.g., Hope et al., 1995). A different question, however, is the following: within a

limited time period, which of two CBT group treatment programmes (cognitive restructuring

plus exposure versus exposure alone) is the most efficient? Investigating this research

question will have theoretical relevance, for example, by providing answers to the question:

is it essential to involve cognitive restructuring in the treatment of SAD, or is exposure alone

sufficient? The social relevance of this study is related to which is the best treatment for SAD

and for providing the best relief for its debilitating effects. This description of the theoretical

and social relevance of the planned study forms the core of its rationale.


Literature Review

Classification and Diagnostic Features of Social Anxiety Disorder

SAD is defined as “the fear of being embarrassed or humiliated in front of others”

(Sadock, Sadock, & Ruiz, 2015, p. 293). The social fear occurs upon exposure to feared

social stimuli (social situations), creating a tendency to avoid or escape from the situation.

When escape or avoidance is not possible the individual becomes very anxious. When phobic

stimuli include all or most social situations, the disorder is classified as a generalised subtype

of SAD (referred to in this study as GSAD; APA, 2013).

The DSM-5 (APA, 2013) defines six presenting diagnostic features as criteria that

should be met to diagnose SAD. They include the following: fear in social situations, anxiety

when these situations cannot be avoided, insight that these fears are excessive, attempts to

avoid them, significant detrimental effects on the individual's functioning and duration of the

symptoms for at least six months.

To better conceptualise the clinical features of SAD and select an appropriate

therapeutic approach, psychologists have developed theoretical frameworks that are based on

selected criterion-related symptoms. One such framework is the Cognitive Model of Social

Phobia (CMSP; Clark & Beck, 2010), which focuses on cognitive variables (e.g.,

dysfunctional thinking patterns [Heimberg, Nyman, & O'Brien, 1987] as well as a fear of

negative evaluation [Watson & Friend, 1969]). The model will be discussed later in further

detail.

The Course, Prevalence and Effects of Social Anxiety Disorder

The onset of SAD may follow a traumatic or embarrassing experience (e.g., being

criticised, trembling and blushing during a speech), or it may develop slowly without the

individual being aware of it and persist over many years (APA, 2013; Sadock et al., 2015).


Social phobia has an early onset (40% of social phobias appear before the age of 10 and 90%

before the age of 20 years), has a chronic progression (with a 12-month prevalence of 7% and

a lifetime prevalence of 12%) and is one of the most prevalent mental disorders in the world

(Leichsenring et al., 2013) According to Williams et al. (2007), mental disorders, including

SAD, are one of the major contributors to disease burden in South Africa, which often result

in harsh psychosocial impairments. Sadock et al. (2015) state that the psychosocial

impairments include effects on a person’s functioning (e.g., academic success, social

development, job performance) as well as on the individual's informal, leisure activities (e.g.,

family gatherings, holidays and parties).

A Theoretical Model of Social Anxiety Disorder

My research will be based on Clark and Beck’s (2010) Cognitive Model of Anxiety

(CMA) and anxiety disorders, including social anxiety disorder (SAD), called the Cognitive

Model of Social Phobia (CMSP; Clark & Beck, 2010). This model originated from an earlier

cognitive theory of anxiety disorders (Beck, Emery, & Greenberg, 1985). The latter model

was at a later stage specifically adapted for SAD (Rapee & Heimberg, 1997) and more

recently revised as a cognitive model for SAD (Clark & Beck, 2010). The CMA provides an

account for why morbid (dysfunctional) anxiety develops in certain individuals and persists

in the absence of danger in these situations.

The central theme of the CMSP (Clark & Beck, 2010; Rapee & Heimberg, 1997;

Wells et al., 1995) is related to the role of cognitive variables, namely the effects of

dysfunctional thoughts (Heimberg et al., 1987) and the fear of negative evaluation by others

(Watson & Friend, 1969). The individual with SAD is concerned with the approval of other

people but is insecure about the impression they have made or will make (Wells et al., 1995).

This insecurity activates dysfunctional core beliefs (i.e., schemas; e.g., “I am vulnerable”, or


“People are unusually critical of others”), which, in turn, leads to dysfunctional intermediate

beliefs (including attitudes; e.g., “It’s terrible!”, rules; e.g., “I must make a good impression”,

“I should not show anxiety”, and conclusions/assumptions; e.g., “If I show anxiety, then I

will be looked upon as a failure!”).

These beliefs then give rise to negative automatic thoughts (NAT’s; e.g., “Oh no!

They can see I’m anxious”), replacing more positive thinking patterns. These cognitive

changes, in turn, lead to an increased state of self-awareness (self-processing of the self as a

social object from an onlookers perspective) and social phobic responses (i.e.,

symptomatology, including subjective feelings [feeling anxious], physiological reactions

[somatic symptoms; e.g., heart palpitations and blushing], behavioural characteristics

[including avoidance and escape; so-called safety behaviours], as well as cognitive symptoms

[e.g., reduction in concentration on the task and the social demand at hand]). These

symptoms, in turn, have a debilitating effect on the social phobic’s performance, and as such

form an important link in a vicious cycle. The model also distinguishes between three phases

of SAD: the anticipatory phase, the situational exposure phase, and the post-event processing

phase (Clark & Beck, 2010).

The first phase is characterised by potentially conscious, automatic thoughts about

pending social situations (i.e., expectations about a future experience, e.g., “Oh no! I will

have to make a speech at my brother’s wedding.”). The individual may experience as much

anxiety during this phase as they may during exposure to the actual situation.

The second phase involves both beliefs and automatic (potentially conscious)

thoughts during exposure to the feared social situation. The sequence of this maladaptive

cognitive process firstly involves the stimulation of maladaptive social schemas (e.g., core

beliefs about disapproval from others and personal weaknesses) that arise during social

exposure. This is followed by intermediate beliefs and automatic thoughts (ATs), which then


lead to an increased anxiety level and attempts to conceal the symptoms (by applying safety

behaviours) that, in turn, increase anxiety symptoms. Beliefs are less accessible consciously

than ATs.

The final phase involves post-event recollection and review by the individual of his or

her performance during the social situation. The biased, negative recollection of the event

plays a vital role in the maintenance of social anxiety as the individual is unable to escape the

anxiety process even after the social event has taken place (Beck, 1976; Beck et al., 1985;

Beck et al., 1979; Clark & Beck, 2010).

Cognitive Behaviour Group Treatment of Social Anxiety Disorder

Cognitive behaviour therapy (CBT) is a form of psychotherapy developed by Aaron

T. Beck (Beck et al., 1979, 1985; Clark & Beck, 2010). Beck developed CBT as a time-

restricted, structured approach that uses a cognitive (i.e., information-processing) model to

understand and treat disorders such as SAD. The therapist’s role is to assist SAD sufferers in

overcoming their fears by changing their thinking (e.g., “I am vulnerable”, “Everyone is

going to laugh at me”) and behaviour (e.g., automatic, safety responses such as avoidance).

Although medication can be effective, SAD can also be treated using

psychotherapeutic approaches such as CBT (Andersson & Carlbring, 2009). CBT has the

strongest experimental support among the psychotherapeutic approaches (e.g., compared to

psychodynamic treatment and interpersonal therapy; Acarturk, Cuijpers, van Straten, & de

Graaf, 2009; Andersson & Carlbring, 2009). CBT is an umbrella term that refers to several

treatment techniques (used in combination to treat psychopathological conditions such as

SAD), which include imagery rescripting, exposure, psychoeducation, cognitive

restructuring, social skills training and relaxation methods (Holmes, Arntz, & Smucker, 2007;

Hope, Burns, Hayes, Herbert, & Warner, 2010; Jørstad-Stein & Heimberg, 2009; Turner,


1994). The range of the current study is restricted to comparing the effects of two specific

treatment programmes, namely Cognitive Behaviour Group Therapy (CBGT; characterised

by cognitive restructuring plus exposure) and Exposure Alone (EA; characterised by only

exposure, without cognitive restructuring exercises) and the integration of the two techniques,

as described in a treatment manual by Heimberg (1991).

The goal of CBT is to change dysfunctional schemata (i.e., core cognitive structures)

that result in increased symptomatology (Hope et al., 2010). This is done through a major

component of CBGT known as cognitive restructuring. Cognitive restructuring, a verbal

questioning and disputation technique that targets ATs that occur when the client thinks about

or is exposed to the feared stimulus (and affect their underlying dysfunctional beliefs). It

involves four steps: 1) the identification of the problematic ATs, 2) the identification of the

irrational thought processes (cognitive errors) in the ATs, 3) rational discussion and

questioning of ATs through an explorative dialogue technique, and 4) development of

constructive alternative thoughts to replace these ATs. In CBGT, cognitive restructuring is

integrated with exposure therapy (Hope et al., 2010). Cognitive restructuring is used to

identify and confront thoughts that occur before, during and after exposure to the feared

stimulus.

Exposure therapy is used to treat negative emotional responses such as fear and

anxiety by exposing clients to the feared event or stimulus (Hofmann & Otto, 2008; Marcus,

1977). In order to avoid worsening the symptoms and for exposure to be therapeutic, the

therapist must decide on the duration and mode of exposure. It may be presented to the client

in a stepwise progression (gradually), as well as repetitively and over a prolonged period of

time. Exposure may also be presented to the client on an imaginary level (in fantasy) or in a

real life (in vivo) situation. Imaginary (in fantasy) scenarios involve the client imagining and

'experiencing' a frightening situation. In vivo exposure refers to confronting feared situations


in real life whereby the client is exposed to actual frightening situations (e.g., a person

suffering from SAD giving a speech to a group of strangers; Hofmann & Otto, 2008).

The Efficacy of Cognitive Behaviour Group Treatment on Social Anxiety Disorder

CBGT for SAD has been shown to be efficacious within research components and

effective within numerous clinical settings (McEvoy, Nathan, Rapee, & Campbell, 2012).

Below is a discussion of research that has been done on the various components of CBGT

and the efficaciousness of each.

For decades there have been viewpoints that cognitive restructuring is the best

treatment for changes in cognitive variables such as fear of negative evaluation and thought

dysfunctionality (Butler, 1989; Emmelkamp, 1982). It is an opinion still expressed in more

recent times (Beck & Beck, 2011; Clark & Beck, 2010).

Studies focused on cognitive restructuring without exposure attempted to determine if

cognitive restructuring alone is effective for SAD. According to cognitive theory of anxiety

disorders (e.g., Beck et al., 1985; Clark & Beck, 2010), cognitive change is essential for the

improvement of SAD, and there is a viewpoint from influential researchers in the field of

SAD (e.g., Beidel, Turner, & Dancu, 1985; Butler, 1985; Clark & Beck, 2010; Hammen,

Jacobs, Mayol, & Cochran, 1980; Heimberg, Dodge, Hope, Kennedy, & Zollo, 1990) that

change of dysfunctional cognitions is necessary for the successful treatment of SAD.

Several studies that focused on the efficacy of exposure alone have found that

exposure therapy has resulted in significantly greater improvement rates when being

compared to placebo groups (Blomhoff et al., 2001; Heimberg et al., 1990a) or control groups

(Mersh, 1995). In three studies (Alström, Nordlund, Persson, Harding, & Ljungqvist, 1984;

Hope et al., 1995; Wlazlo, Schroeder-Hartwig, Hand, Kaiser, & Munchau, 1990), published

more than two decades ago, EA was expressed as having the best outcome results.


Heimberg's treatment (1991) was only used in one of them namely, Hope et al. (1995).

Alström et al. (1984) compared EA with traditional relaxation therapy and found that

exposure therapy was superior in the treatment of SAD. An outcomes study done by Hope et

al. (1995) showed that EA was significantly superior to cognitive restructuring plus exposure

in a CBGT programme (see also an earlier study by Biran, Augusto, & Wilson, 1981). Lastly,

Wlazlo et al. (1990) found that EA had a significantly greater improvement than social skills

training in two groups of patients suffering from SAD.

Previous studies (e.g., Hindo & Gonzalez-Prendes, 2011; Mattick & Peters, 1988) that

compared the components of CBT, namely cognitive restructuring and exposure, as well as

theoretical arguments (Clark & Beck, 2010; Rodebaugh, Holaway, & Heimberg, 2004) argue

that the combination of the components would result in the best outcome. The expectation

that cognitive restructuring will improve the effects of exposure is emphasised in SAD

literature. Therefore, many theorists argue for the combined treatment. This argument is

based on a variety of opinions and research findings, some of which are given below.

Various meta-analytical studies (Norton & Price, 2007; Taylor, 1996; Wersebe,

Sijbrandij, & Cuijpers, 2013) demonstrate the facilitating effect that cognitive restructuring

has on exposure. Specific arguments are offered about potential ways in which cognitive

restructuring and exposure mutually facilitate one another (Hope et al., 1995) and there are

findings in SAD research outcome studies that cognitive restructuring sometimes facilitates

exposure (Butler, Cullington, Munby, Amies, & Gelder, 1984; Emmelkamp, Mersh, Vissia,

& Van der Helm, 1985; Shikatani, Anthony, Kuo, & Cassin, 2014). Mattick, Peters, and

Clarke (1989) showed a worsening of symptoms (a deterioration of initial therapeutic gains)

when EA was used but not when cognitive restructuring in combination with exposure was

used, and it was found that the improvement on cognitive measures seems bigger after

treatments where cognitive restructuring was included compared to EA based treatments


(Butler et al., 1984; Emmelkamp et al., 1985; Jerremalm, Jansson, & Öst, 1986; Kanter &

Goldfried, 1979). Finally, it seems as though cognitive restructuring treatments (that were

effective) also included exposure treatments (Jerremalm et al., 1986; Kanter & Goldfried,

1979; Shikatani et al., 2014).

Method

Archival data of a treatment outcomes study done in 2000 by Dr C Nortje and Dr T

Posthumus was used in this study. The original study compared two treatment procedures for

SAD with the CTRL group. The treated groups were namely 1) EA and 2) CBGT. The

participants that were diagnosed with GSAD were randomly allocated to groups as follows:

15 to the CBGT group, 15 to the EA group and 14 to the CTRL group.

Aims

The main aim of the study was to investigate and compare the effectiveness of CBGT

(i.e., cognitive restructuring plus exposure) and exposure alone (EA; also presented in group

format) in the treatment of generalised social anxiety disorder (GSAD). The specific aims of

this study were to investigate 1) the effectiveness of CBGT in the treatment of GSAD, 2) the

effectiveness of EA in the treatment of GSAD, 3) the difference between the two treatment

programs with regards to their effectiveness in treating GSAD.

Hypotheses

In the present study the data for certain selected dependent variables from the original

study were analysed to test the following hypotheses:

1. The two treatment condition groups (CBGT, EA) and the control group (CTRL) will

not differ significantly from one another with regards to the following variables at the

pre-treatment phase: target phobia as measured by the Fear Questionnaire-Target


Phobia (FQ-TP; Marks & Mathews, 1979), social phobia as measured by the Social

Phobia and Anxiety Inventory (SPAI; Turner, Beidel, Dancu, & Stanley, 1989), a

cognitive variable measured by the Thought-listing Technique (TLT; Heimberg et al.,

1987) and depression as measured by the Beck Depression Inventory II (BDI-II;

Beck, Steer, & Brown, 1996).

2. The treatment condition CBGT and CTRL will differ significantly at post-treatment

with regards to the above-mentioned dependent variables, with CBGT demonstrating

larger improvements of GSAD symptomatology compared to CTRL.

3. The treatment condition EA and CTRL will differ significantly at post-treatment with

regards to the above-mentioned dependent variables, with EA demonstrating larger

improvements of GSAD symptomatology compared to CTRL.

4. The treatment conditions, CBGT and EA, will differ significantly from one another at

post-treatment with regards to the above-mentioned dependent variables, with CBGT

demonstrating larger improvements of GSAD symptomatology compared to EA.

Research Design

A basic quantitative, cross-sectional research design with repeated measures was used

in the original study. Two groups each received different treatments, namely exposure plus

cognitive restructuring, or exposure alone.

Sampling Strategy and Participants

In the sampling of participants, the original researchers distributed about 300

pamphlets to general medical practitioners in the Stellenbosch area recruiting potential

participants who suffer from GSAD. Advertisements were also placed in local newspapers


and magazines. The original researchers' own clients and other clinical psychologists' clients

in the Western Cape were approached and invited to participate in the study.

The target population was determined to be middle-to-upper class individuals who

met the DSM-IV-TR (APA, 2000) diagnostic criteria for GSAD. Interviews were conducted

by two independent clinical psychologists (i.e., not involved in the treatment). The

participants were evaluated on a 5-axial diagnosis of SAD. Those who presented with GSAD

as their most serious problem were selected. Exclusion criteria were individuals younger than

18 years, individuals who suffered from another severe mental disorder, and individuals who

were recently (less than 3 weeks) prescribed medication for SAD.

The final sample consisted of 44 participants who met the DSM-IV-TR (APA, 2000)

criteria for GSAD. There were 30 females and 14 males, aged between 21 and 68 years old.

Participants were randomly assigned to one of the three treatment groups, namely 15 to

CBGT, 15 to EA and 14 to CTRL.

Procedure and Evaluation

The weekly group treatment sessions took place over 12 weeks and were two to two

and a half hours each. The dependent variables were measured at pre- and post-treatment

stage as well as at a 3-month follow-up (the latter data will not be analysed for the purpose of

the present study). The evaluation of the participants was done individually by one of the two

psychologists that were responsible for the initial selection process. A variety of different

scenes (scenarios), self-report questionnaires, a thought-listing technique and Likert-type

scales were used during the evaluation.


Measurements

A social target fear scene was created for each participant. Various measurements

were used in participant selection and for the measurement of idiosyncratic social fears, SAD

symptomatology, a SAD cognitive variable and depression. These measures are discussed

below.

Structured interview for selection of participants. The Anxiety Disorders Interview

Schedule Revised (ADIS-R; DiNardo & Barlow, 1988) was used as a structured interview for

participant selection. It was initially developed to assist the DSM-III-R diagnosis of SAD

(APA, 1980). The criteria, however, did not change in the DSM-IV-TR (APA, 2000) nor in

the DSM-5 (APA, 2013) diagnosis of SAD. It therefore remains relevant for and comparable

with more recent research. As stated previously, the participants were interviewed by two

independent psychologists. In the diagnosis of SAD, the ADIS-R had a strong inter-rater

reliability kappa-coefficient of = .77 (n = 80; Brown, DiNardo, Lehman, & Campbell,

2001).

Construction of idiosyncratic fear scenes. A unique and specific social target fear

scene was created for each participant (e.g., to make a speech, to meet someone of the

opposite sex.). The scene was assessed to be very relevant and anxiety provoking for the

individual. It was constructed as a written piece in two versions. A longer version, which

included an audio-recorded description of the scene, was developed for and used as part of a

thought-listening technique (Heimberg, Bruch, Hope, & Dombeck, 1990b; Heimberg et al.,

1987), and a shorter version has been developed and used as part of the FQ-TP (Marks &

Mathews, 1979).

Dependent variables and measuring scales.

Measurement of target phobia. The Fear Questionnaire-Target Phobia (FQ-TP), a

subscale of the Fear Questionnaire (FQ; Marks & Mathews, 1979), measured the level of


target phobia avoidance on a 0-to-8 point Likert type scale. The FQ-TP consisted of five

items referring to the idiosyncratic social fear identified in the ADIS-R interview. The

participants would rate their level of avoidance of their target phobia from 0 (e.g., “I will not

avoid it”) to 8 (e.g., “I will always avoid it”). The FQ was found to have good discriminatory

power and internal consistency (Cronbach alpha = .74; Cox, Swinson, & Shaw, 1991).

Measurement of generalised social anxiety disorder symptomatology. The Social

Phobia and Anxiety Inventory (SPAI; Turner et al., 1989) was used in the measurement of

GSAD symptomatology. It is a 45-item measure and comprises of two subscales namely, the

social phobia subscale (32 items) and the agoraphobia subscale (13 items). The former

measures somatic, behavioural and cognitive manifestations of SAD, and the latter measures

symptoms of agoraphobia. Turner et al. (1989) subtracted the score of the agoraphobia

subscale from the social phobia subscale to obtain a final total score as a measure of SAD

symptomatology. The reason for this was to accommodate and take into account the overlap

between agoraphobia and social phobia symptomatology. The study used a 7-point Likert

type scale ranging from 0 (never) to 7 (always) where the SPAI total score is calculated as the

difference between the subscales. The scale showed both high internal consistency (alpha =

.96) and test-retest reliability (r = .86) from a sample of 182 participants (Turner et al., 1989).

Measurement of a cognitive variable related to social anxiety disorder. The

Thought-listing Technique based on a State of Mind ratio (TLT-SOM; Heimberg et al.,

1990b; Heimberg et al., 1987) was used to determine and calculate the thought functionality

of ATs. The TLT-SOM was administered by using the typed, longer version of the

idiosyncratic target fear developed during the ADIS-R interview, whereby participants

reported in writing their spontaneous thoughts they recalled thinking while listening to an

audio-taped description of their idiosyncratic feared situation. Thereafter, two registered

clinical psychologists classified the self-reported thoughts into positive, neutral or negative


categories. These numbers were inserted onto a formula, called a State of Mind ratio (i.e., the

number of positive thoughts, divided by the number of positive thoughts plus negative

thoughts). It is important to emphasise that high TLT-SOM measures reflect thought

functionality and not thought dysfunctionality. On the other hand, low TLT-SOM scores may

be interpreted as reflecting thought dysfunctionality. In the study of Heinrichs and Hoffman

(2005) this measurement showed good convergent, divergent and construct validity, as well

as treatment sensitivity.

Measurement of depression. The Beck Depression Inventory-II (BDI-II; Beck et al.,

1996), a popular 21-item instrument, measured the depression symptoms intensity levels of

the 44 participants. The reason for adding this measure is related to the significant

comorbidity of social anxiety and depression (APA, 2000; APA, 2013). In Dozois, Dobson

and Ahnberg's (1998) study, the BDI-II demonstrated convergent validity, treatment

sensitivity and high internal consistency (Cronbach alpha = .91; see also Beck, Steer, &

Carbin, 1988).

Treatment

The two treatment condition programmes used in this study are the CBGT and the EA

programme. They are explained and discussed below.

Cognitive behaviour group therapy (CBGT) programme. The combined cognitive

restructuring plus exposure treatment that was used was based on a treatment manual of a

structured treatment programme developed by Heimberg (1991). According to Heimberg

(1989, 1991) the programme consisted of the following components: (a) Explanation of

treatment and the (SAD) cognitive model; (b) skills training of the patients through structured

exercises (i.e., identification, analysis and contention of maladaptive cognitions); (c)

simulated exposure exercises during group treatment; (d) teach patients to control


problematic cognitions through utilising cognitive restructuring methods before, during and

after exposure; (e) in vivo exposure homework assignments of already confronted exposure

exercises during treatment; and (f) the learning of the cognitive restructuring routine for use

before and after exposure assignments.

Exposure alone (EA) programme. The exposure alone condition is also described in the

treatment manual of Heimberg (1991). It is the same as the above mentioned treatment

programme except that it leaves out cognitive restructuring exercises. The rationale for the

treatment was based on the learning model of classical conditioning.

Data Analysis

The data were analysed by conducting between-groups and repeated-measures

multivariate analyses of variance (MANOVA’s) to determine the significance of differences

between- and within-groups. This was followed by post hoc analyses when the omnibus

multivariate test statistics were significant. Pairwise comparisons using the Bonferroni

correction for multiple comparisons were executed.

Ethical Considerations and Approval

This study used archival data. Therefore, the current study posed no risk to

participants and application for institutional permission was not necessary. The original study

in 2000 obtained ethical clearance before the research was conducted (Appendix A). At that

stage, the Department of Psychology made use of their own committee (the departmental

committee for ethical clearance) for ethical clearance of research proposals of master’s theses

and doctoral dissertations. The application for ethical clearance was submitted to the

Department of Psychology Research and Ethics Committee (DESC) and was approved before

data analysis commenced.


Results

Descriptive Statistics

The means and standard deviations for the four dependent measures (BDI-II, FQ-TP,

SPAI and TLT-SOM) with regards to the three treatment conditions (CBGT, EA and CTRL)

at the two assessment phases (pre- and post-treatment) appear in Table 1.

Table 1.

Means and Standard Deviations for the Different Treatment Groups at the Pre- and Post-

Treatment Phases

CBGT (n = 15) EA (n = 15) CTRL (n = 14)

Scales Pre-test Post-test Pre-test Post-test Pre-test Post-test

Depression

BDI-II

16.33

(9.04)

6.87

(5.34)

18.60

(14.69)

10.00

(7.36)

20.29

(12.56)

20.21

(13.91)

Target phobia

FQ-TP

6.93

(1.22)

2.87

(2.13)

6.80

(1.56)

2.73

(2.05)

7.00

(1.47)

6.93

(1.27)

Social phobia

SPAI

104.27

(22.75)

68.80

(21.90)

99.27

(31.59)

69.60

(28.15)

102.29

(23.68)

99.36

(30.76)

Cognitive

variable

TLT-SOM

.05

(.088)

.50

(.39)

.03

(.05)

.27

(.31)

.07

(.14)

.09

(.18)

Note. CBGT = Cognitive Restructuring plus Exposure; EA = Exposure Alone; CTRL =

Control Group; BDI-II = Beck Depression Inventory II; FQ-TP = Fear Questionnaire; SPAI =

Social Phobia Anxiety Inventory; TLT-SOM = Thought Listing Technique SOM-ratio.

Differences between Groups

In order to determine the significance of differences between the two active treatment

groups (EA, CBGT) and the control group (CTRL) at the pre- and post-treatment phase, a

between-groups multivariate analysis of variance (MANOVA) was performed. This was

executed in order to identify potentially significant differences with regards to the BDI-II,


FQ-TP, SPAI and TLT-SOM dependent variable measures between the three aforementioned

groups.

Pre-treatment differences between groups. The first hypothesis predicted that the

three treatment condition groups (CBGT, EA and CTRL) will not differ significantly from

one another on all four of the dependent variables (BDI-II, FQ-TP, SPAI and TLT-SOM) in

the pre-treatment phase. The omnibus statistic Wilks’ lambda (i.e., U statistic) is frequently

used for testing overall significance between groups with numerous dependent variables

(Hair, Black, Babin & Anderson, 2010). In the pre-treatment phase, the MANOVA indicated

that there were no significant differences between groups for the collective dependent

variables, with U = .92, F(8, 76) = .38, p = .926, partial 2 = .039. Therefore, the first

hypothesis was supported, suggesting that there were no significant differences between the

CBGT, EA and CTRL groups with regards to the dependent variables at the pre-treatment

phase.

Post-treatment differences between groups. A MANOVA was also executed at the

post-treatment phase. Wilks’ lambda was significant, with U = .39, F(8, 76) = 5.77, p = .000,

partial 2 = .38, indicating significant differences between the three treatment condition

groups (CBGT, EA and CTRL) with regards to the dependent variables. Between-groups

univariate ANOVA’s indicated significant differences between groups on all four dependent

variables (see Table 2).


Table 2.

Results of the Between-groups ANOVA’s at the Post-Treatment Phase

Source Dependent Variable SS df MS F p 2

Group Depression

BDI-II 1398.46 2 699.22 7.81 .001 .28

Target phobia

FQ-TP 162.84 2 81.42 23.25 .000 .53

Social phobia

SPAI 8685.95 2 4342.97 5.91 .006 .22

Cognitive variable

TLT-SOM 1.27 2 .64 6.86 .003 .25

Error Depression

BDI-II 3672.09 41 89.56

Target phobia

FQ-TP 143.59 41 3.50

Social phobia

SPAI 30109.21 41 734.37

Cognitive variable

TLT-SOM 3.81 41 .09

Note. BDI-II = Beck Depression Inventory II; FQ-TP = Fear Questionnaire; SPAI = Social

Phobia Anxiety Inventory; TLT-SOM = Thought Listing Technique SOM-ratio.

Active Treatments Compared to Control Group

The second and third hypothesis predicted that, in the post-treatment phase, CBGT

and EA would differ significantly from CTRL respectively. To test the hypotheses, pairwise

comparisons using the Bonferroni correction for multiple comparisons was conducted. The

results are shown in Table 3. Results showed that there were significant differences between


CBGT and CTRL, as well as between EA and CTRL. Therefore, the second and third

hypothesis were supported. These results are discussed in more detail below.

Cognitive restructuring plus exposure (CBGT) compared to control. The mean

scores on the BDI-II, FQ-TP and SPAI for CBGT were significantly lower than for CTRL (p

< .05). The mean score on the TLT-SOM was significantly higher for CBGT than for CTRL

(p = .002).

Exposure alone (EA) compared to control. As for CBGT, the mean scores on the

BDI-II, FQ-TP and SPAI for EA were also significantly lower than for CTRL (p < .05).

There was, however, no significant difference between EA and CTRL on the TLT-SOM (p =

.373).

Active Treatments Compared

The fourth and final hypothesis was that the treatment conditions, CBGT and EA, will

differ significantly from one another at post-treatment on the BDI-II, FQ-TP, SPAI and TLT-

SOM. However, analyses of the data showed that there were no significant differences

between CBGT and EA on the dependent variables (p > .05). Therefore, the last hypothesis is

not supported. These results are shown in Table 3 and interpreted below.

Cognitive restructuring plus exposure (CBGT) compared to exposure alone

(EA). The mean scores on the BDI-II, FQ-TP and SPAI for CBGT were not significantly

different from those of EA (p = 1.000 on all three dependent variables). The mean score for

thought functionality (cognitive variable; TLT-SOM) was also not significant (p = .112) but

was, however, almost significant on the 10% level. This result will be discussed in the

following section as it may have implications for further research.


Table 3.

Results of the Post Hoc Pairwise Comparisons at the Post-Treatment Phase

Dependent Variable (I) Group (J) Group MD (I-J) SE p-value

Depression

BDI-II

CBGT EA -3.13 3.46 1.000

CTRL -13.35 3.52 .001

EA CTRL -10.21 3.52 .018

Target phobia

FQ-TP

CBGT EA .13 .68 1.000

CTRL -4.06 .69 .000

EA CTRL -4.19 .69 .000

Social phobia

SPAI

CBGT EA -.80 9.89 1.000

CTRL -30.56 10.07 .013

EA CTRL -29.76 10.07 .015

Cognitive variable

TLT-SOM

CBGT EA .24 .11 .112

CTRL .42 .11 .002

EA CTRL .18 .11 .373

Note. CBGT = Cognitive Restructuring plus Exposure; EA = Exposure Alone; CTRL =

Control Group; BDI-II = Beck Depression Inventory II; FQ-TP = Fear Questionnaire; SPAI =

Social Phobia Anxiety Inventory; TLT-SOM = Thought Listing Technique SOM-ratio.

Discussion

The main aim of the present study was to determine whether cognitive restructuring

plus exposure (CBGT) and exposure alone (EA), both presented in group format, were

efficacious in treating generalised social anxiety disorder (GSAD), and furthermore, to

determine whether the two active treatments (CBGT and EA) differed significantly from one

another in treating GSAD (CBGT hypothesised to be the superior treatment). Both active

treatment condition groups were compared to an untreated control group (CTRL).


It was hypothesised that CBGT and EA will both demonstrate significantly larger

improvement effects on GSAD symptomatology compared to the untreated control group.

The second hypothesis (i.e., that CBGT and CTRL will differ significantly at post-treatment

on all four variables) was supported for four out of four of the main effects; depression;

target phobia avoidance; general social phobia symptomatology; and thought functionality

all demonstrated statistical significance. Results thus indicate that the combined treatment

programme was efficacious for significantly improving all GSAD symptomatology.

Findings for the third hypothesis (i.e., that EA and CTRL will differ significantly at

post-treatment on all four variables) were not as compelling as those seen for CBGT. With

regards to EA, only three out of the four main effects (depression, target phobia avoidance,

and general social phobia symptomatology) showed significant differences, whereas effects

on thought functionality were non-significant.

Results suggest that exposure alone (i.e., without the cognitive restructuring

component) was insufficient in ensuing cognitive change (i.e., improving thought

functionality). The statistical non-significance of EA's effects on the cognitive variable is

supported by the results reported in other studies (Hope et al., 1995; Mattick et al., 1989).

Contrastingly, with regards to the combined treatment programme (CBGT), the statistical

significant effect on thought functionality suggests that the combination of exposure and

cognitive restructuring was not only effective but necessary in targeting and improving the

cognitive component of SAD symptomatology (i.e., bringing about cognitive change).

Subsequently, it was lastly hypothesised that CBGT would demonstrate significantly

larger improvements to GSAD when compared to EA. However, the results of this study

showed that there were no significant statistical differences between the two active treatments

regarding their effects on all four dependent variables. This finding is congruent with the


results of Scholing and Emmelkamp (1993) who found that the integrated treatment

programme (i.e., CBGT) and EA were equally effective in treating GSAD.

Results from the present study suggest that regardless of EA having a non-significant

effect on the cognitive variable, it is still an effective therapeutic treatment for GSAD (i.e.,

changes in thought functionality did not correspond with changes in other dimensions in

GSAD pathology and overall treatment effects). Despite theoretical assumptions that

cognitive change is central to successful treatment of GSAD (e.g., Beidel et al., 1985; Butler,

1985; Clark & Beck, 2010), the findings of this study suggest that, compared to EA, adding

the cognitive restructuring component (CBGT) demonstrated no improvement for GSAD.

This, in turn, raises questions about Beck's cognitive theory of anxiety disorders which

maintain that cognitive interventions and cognitive change are essential for successful

treatment of GSAD (Clark & Beck, 2010).

As mentioned previously, when compared to the CTRL condition, CBGT showed

significant effects on more dependent variables than EA (i.e., also for the cognitive variable

thought functionality). Compared to CTRL, the cognitive variable (i.e., thought functionality)

showed significant improvements with regards to the CBGT condition, whereas the EA

condition did not. Supportive findings include those reported by Heimberg et al. (1990)

where significant increases in the number of positive thoughts from pre- to post-treatment

were discovered. Hope et al. (1995) found that the EA condition failed to demonstrate

significant improvements in thought functionality, supporting this study’s finding.

Furthermore, the inclination of CBGT to be regarded as the superior treatment for

improving thought functionality is supported by a treatment related recommendation made by

Rodebaugh et al. (2004). They argued that GSAD clients’ distorted expectations and

cognitions are limited to very specific (idiosyncratic) feared social situations, rather than

general (common) social situations. Therefore, Rodebaugh et al. (2004) proposed that clients,


through exposure to the feared social situation, experience a genuine feared response.

Cognitive restructuring may now assist the client in making situation specific cognitive

changes. Based on this view, both exposure and cognitive restructuring may be considered as

crucial strategies for treating the cognitive component of GSAD.

Limitations and Recommendations

I have identified two primary limitations to this study. Firstly, in terms of

methodological issues, the sample size was fairly small. Each treatment condition had a

maximum of 15 participants per treatment group. Therefore, the non-significant differences

between the CBGT and EA groups may be accredited to poor statistical power. This, in turn,

may have concealed potentially significant treatment differences. The differential efficacy of

the two active treatments (EA and CBGT) may be explored by future studies using bigger

samples.

Another factor which may have obscured potentially significant treatment differences

is the single post-treatment measurement of the variables. That is, even though the effects of

two active treatments did not differ significantly directly after treatment, they may differ

significantly over a longer follow-up time (i.e., the one may have increasingly larger long-

term effects). A question that may be asked is: as more time elapses after treatment, would

follow-up tests reveal a significant difference between the two active treatments and their

effects on the cognitive variable? I would, secondly, therefore recommend that future

research compare the effects of the two treatments (CBGT and EA) over different follow-up

periods.

As indicated by the post-treatment MANOVA, the best candidate for potentially

mediating such increasing improvements over time is the variable thought functionality (the

cognitive variable measured by the TLT-SOM). Therefore, a final recommendation for future


research would be to identify whether changes in the cognitive variable (i.e., thought

functionality indicated by the TLT-SOM) predicts changes in the GSAD symptomatology

(e.g., depression, target phobia and social phobia), as well as increasing effects during the

follow-up period. Future research should also concentrate on clinically significant effects,

rather than comparing only statistically significant changes.

Conclusion

The main aim of the study was to investigate and compare the efficacy of CBGT and

EA in the treatment of generalised social anxiety disorder (GSAD). A MANOVA was

executed to compare differences between treatment conditions. This was followed by post

hoc analyses, namely pairwise comparisons using the Bonferroni correction for multiple

comparisons. The results of the present study indicate that both active treatments (CBGT and

EA) were effective in reducing overall social phobic symptomatology (i.e., both had

significant effects on improving GSAD symptomatology). The two treatments did not differ

significantly from one another on any of the dependent variables (depression, target phobia,

social phobia, and the cognitive variable), therefore, suggesting that EA and CBGT are

equally efficacious in treating GSAD within a limited treatment time period.

However, unlike EA, CBGT had a significant effect on the cognitive variable when

compared to the CTRL group. Therefore, the present study’s results demonstrate a favourable

tendency for the combined treatment programme being the better treatment, which

corresponds with an outcome study by Heimberg et al. (1990a). It suggests that CBGT may

be the superior treatment in improving thought functionality (initiating positive cognitive

changes), theorised as necessary in reducing GSAD symptomatology (Heimberg et al.

1990b).


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Appendices

Please find the following Appendices attached to this research proposal:

A. Ethical Clearance Form

B. Measuring Instruments

C. Plagiarism declaration

D. Turn-it-in report


Appendix A

Ethical Clearance Form

(See next page)


Appendix B

Measuring Instruments:

1. General questionnaire

2. Fear Questionnaire

3. Thought Listing Technique

4. Social Phobia Anxiety Index

5. Becks Depression Inventory


1. General Questionnaire

Please fill in this questionnaire and post it to:

The Social Research Project (TEL.: 021-8084994)

Unit of Clinical Psychology (FAKS.: 021- )

University of Stellenbosch

Private Bag X1

MATIELAND

7602

Please omit those questions that you are uncertain of. These can be discussed during our first

interview. The questionnaire must reach us before the interview date.

NAME (e.g. Mrs. T.D. Cloete): ...............................

FIRST NAME (e.g. Trudie): ...................................

____________________________________________________________

FOR ADMINISTRATIVE PURPOSES ONLY:

Dates: First interview:............Interviewer:.............

Pretest:.............................................

Posttest:............................................

Follow up:...........................................

Group:............

Referred by:.................................Tel:...........

____________________________________________________________

ADDRESSES: Home:............................................

............................................

Postal:..........................................

Other (e.g. university residence):...............

TEL. (code and number please):

Home:..................................................

Work:..................................................

Other: (e.g. spouse, parents, during holidays; specify

please)................................. .......................................................

DATE OF BIRTH:.................. AGE:.........SEX:..........

MARITAL HISTORY (e.g. married, single, cohabiting, divorced, widowed; specify dates where

applicable):

....................................................................................................................................................................

................

............................................................

CHILDREN:

Still If not,

Age Sex Standard/ Occupation at home? When left?

... ... ................... ........ ..........

... ... ................... ........ ..........

... ... ................... ........ ..........

... ... ................... ........ ..........

... ... ................... ........ ..........

EDUCATIONAL AND OCCUPATIONAL HISTORY:

Date Specifications (e.g. highest standard, qualifications, previous and present occupation[s])

........ .............................................

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........ .............................................

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Spouse

........ .............................................

........ .............................................

........ .............................................

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RELIGIOUS DENOMINATION:.....................................

NAME OF GENERAL PRACTITIONER:...................TEL: .......

MEDICAL HISTORY:

Present:

Specify any physical illness and/or mental (emotional/ psychological) problems that you are currently

experiencing, when it started, and any times or periods of remission (when it didn't bother you or

when you were temporarily well):

....................................................................................................................................................................

........................................................................................................................................

Specify all prescribed medicines you are currently taking, the dose, the doctor who prescribed it and

the period you are taking it:

............................................................

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............................................................

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Specify any other form of treatment (e.g., psychotherapy) that you are receiving or received in the

past month:

....................................................................................................................................................................

................

Past:

Specify major physical and mental (emotional/ psychological) problems of the past, when it started,

how long it lasted, the medicine you took, how long you took it, and/or any other form of treatment

(e.g., psychotherapy) you received:

....................................................................................................................................................................

................

............................................................

............................................................

Past or present:

Have you experienced problems with medications such as side effects, withdrawel problems?

Yes ........ No..........

Specify: ...................................................

.......................................................

TOBACCO, CAFFEINE AND ALCOHOL USE:

Specify average intake per day:

Smoking: ..............................................

Coffee: ...............................................

Tea: ..................................................


Specify your approximate current average alcohol intake (type of drink and amount) during the week

and on weekends: .......................................................

............................................................

............................................................

EXERCISE, HOBBIES, RECREATION:

Specify your current activities and any changes in past year (e.g., went to Gym for two months but

stopped in November):

....................................................................................................................................................................

............................................................................

FAMILY HISTORY OF PSYCHOLOGICAL DISORDERS:

Has anybody in your family (mother, father, siblings, aunts, uncles, grandparents) ever been treated or

hospitalized for anxiety, depression, alcohol or drug abuse, or other such problems, or had any such

problems but did not seek treatment?

Yes ........ No..........

Relationship

....................................................................................................................................................................

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Dates

....................................................................................................................................................................

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Description of problem

....................................................................................................................................................................

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Treatment

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2. Fear Questionnaire – FQ-TP

Marks & Mathews

Name:........................Group:.......Date:.............

Choose a number from the scale below to show how much you would avoid each of the situations

listed below because of fear or other upleasant feelings. Then write the number you chose in the box

opposite each situation.

0 1 2 3 4 5 6 7 8

------------------------------------------------------------

Would Slightly Definitely Markedly Always

not avoid avoid avoid avoid

avoid it it it it

it

1. Main phobia you want treated (describe in

your own words)...................................

..................................................

.........................................................

2. Eating or drinking with other people.....................

3. Being watched or stared at...............................

4. Talking to people in authority...........................

5. Being criticised........................................

6. Speaking or acting to an audience.......................

How would you rate the present state of your phobic symptoms on the scale below?

0 1 2 3 4 5 6 7 8

------------------------------------------------------------

No Slightly Definitely Markedly Very

phobias disturbing/ disturbing/ disturbing/ severely

present not really disabling disabling disturbing/

disabling disabling

Please circle one number between 0 and 8


3. Thought Listing Technique – TLT-SOM

Name:........................ Group:............ Date:..................

In the boxes below, please write down as many thoughts as you can recall having while you were

involved (in your imagination) in the interaction or speaking situation just completed. Examples of

thoughts a person may have include:

"I'm not making a good impression"

"They probably won't like me"

"I know I'm going to panic"

"I'm all alone"

"There is no reason for me to be upset like this"

"I think they like me"

"I feel like . . ."

Remember, these are only examples. Please write whatever you were thinking. Please be completely

honest and remember that your responses will remain confidential. Don't spend too much time on any

one thought and don't worry about spelling or grammar. Write only one thought in each box. Please

try to remember as many thoughts as possible.

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4. Social Phobia Anxiety Index - SPAI

Developed by S. M. Turner. C. V. Dancu. and D. C. Beidel

Below is a list of behaviors that may or may not be relevant for you. Based on your personal

experience, please indicate how frequently you experience these feelings and thoughts in social

situations. A social situation is defined as a gathering of two or more people. For example: A

meeting; a lecture; a party; bar or restaurant; conversing with one other person or group of people,

etc. FEELING ANXIOUS IS A MEASURE OF HOW TENSE. NERVOUS OR

UNCOMFORTABLE YOU ARE DURING SOCIAL ENCOUNTERS. Please use the scale listed

below and circle the number which best reflects how frequently you experience these responses.

Never

Very

Infrequent Infrequent Sometimes Frequent

Very

Frequent Always

1 2 3 4 5 6 7 !

1. I feel anxious when entering social situations where there is a small group.............................

2. I feel anxious when entering social situations where there is a large group.......................................

3. I feel anxious when I am in a social situation and I become the center of

a t t e n t i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. I feel anxious when I am in a social situation and I am expected to engage in s o me a c t i v i t y

5. I feel anxious when making a speech in front of an audience.............................................

6. I fed anxious when speaking in a small informal meeting..........................................

7. I fed so anxious about attending social gatherings that I avoid these

s i t u a t i o n s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8. I fed so anxious in social situations that I leave the social gathering.....................................

9. I fed anxious when in a small lathering with:

s t r a n g e r s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

a u t h o r i t y f i gu r e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

o p p o s i t e s e x . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

people in genera l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11. I feel anxious when in a bar or restaurant with:

strangers ................................................................................................................ ............................... authority figures ............................................................... opposite sex ........................................................................................................................................... people in general ...............................................................................................................................

12. I feel anxious and I do not know what to do when in a new situation with: strangers ................................................................................................................................................ authority figures ...................................................................................................... ............................ opposite sex .............................................................................................................. ............................ people in general ..................................................................................................... ............................

13. I fed anxious and I do not know what to do when in a situation involving

confrontation with: strangers ..................................................................................................................... authority figures ........................................................................................................ opposite sex ...............................................................................................................

people in general .................................................................................................

14. I feel anxious and I do not know what to do when in an embarrassing

situation with:

strangers ...............................................................................................................

authority figures ............................................................................................... opposite sex ...........................................................................................................

people in general ..................................................................................................

15. I feel anxious when discussing intimate feelings with:


strangers .................................................................................................................

authority figures ....................................................................................................

opposite sex ...........................................................................................................

people in general ..................................................................................................

16. I feel anxious when stating an optional to:

strangers .................................................................................................................

authority figures ................................................................................................ opposite sex ............................................................................................................

people in general .................................................................................................. 17. I feel anxious when calking about business with:

strangers .................................................................................................................. authority figures .................................................................................................... opposite sex .......................................................................................................................... people in general .................................................................................................

18. I feel anxious when approaching and/or initiating a conversation with: strangers ................................................................................................................... authority figures ..................................................................................................... opposite sex ........................................................................................................................ .. people in general ................................................................................................. ..

19. I feel anxious when having to interact for longer than a few minutes with:

strangers ................................................................................................................ .. authority figures. opposite sex .......................................................................................................................... . people in general .................................................................................................. .

20. I fed anxious when drinking (any type of beverage) and/or eating in front

of: strangers .................................................................................................................. ... authority figures .........................................................................................................

opposite sex ...................................................................................................... people in general .....................................................................................................

21. I feel anxious when writing or typing in front of: strangers .....................................................................................................................

authority figures ................................................................................................

opposite sex ....................................................................................................... people in general .................................................................................................. ...

22. I fed anxious when speaking in front of: strangers .................................................................................................................. .

authority figures ........................................................................................ ..... opposite sex ......................................................................................................... people in general ....................................................................................................

23. I feel anxious when being criticized or rejected by: strangers ......................................................................... ........................................ authority figures ............................................................ ....................................... opposite sex ............................................................................ ...................................... people in general ........................................................ ......................................

24. I attempt to avoid social situations where there are: strangers ................................................................................................................ authority figures ............................................................ ....................................... opposite sex ............................................................................. ...................................... people in general .......................................................... ......................................

25. I leave social situations where there are: strangers ........................................................................... ...................................... authority figures ............................................................ ...................................... opposite sex ............................................................................. ...................................... people in general ......................................................... ......................................

26. Before entering a social situation I think about all the things that can go wrong. The types of

thoughts I experience are:


Will I be dressed properly? ................................................................................. I will probably make a mistake and look foolish ............................................ What will 1 do if no one speaks to me? ............................................................

If there is a lag in the conversation what can [ talk about? ........................ People will notice how anxious I am .................................................................

27. I feel anxious before entering a social situation ..................................... — 28. My voice leaves me or changes when I am talking in a social situation ------

29. I am not likely to speak to people until they speak to me .........................

.

30. I experience troublesome thoughts when I am in a social setting. For

example:

I wish I could leave and avoid the whole situation .....................................

If I mess up again I will really lose my confidence...................................

. What kind of impression am I making? ..................................................... Whatever I say it will probably sound stupid ...............................................

31. I experience the following prior to entering a social situation: sweating................................................................................................................. frequent urge to urinate...................................................................................... heart palpitations __ ..........................................................................................

32. I experience the following in a social situation:

sweating ...........................................................................................................

blushing ...........................................................................................................

shaking ............................................................................................................

frequent urge to urinate ..................................................................................

heart palpitations ............................................................................................

33. I feel anxious when I am home alone .............................................................

34. I feel anxious when I am in a strange place.....................................................

35. I fed anxious when I am on any form of public transportation (i.e., bus,

train, airplane).." ..............................................................................................

36. I fed anxious when crossing streets .................................................................

37. I fed anxious when I am in crowded public places (i.e., stores, church,

movies, restaurants, etc.) .................................................................................

38. Being in large open spaces makes me feel anxious ............................ ".;.- ----

39. I fed anxious when I am in enclosed places (elevators, tunnels, etc.) ..........

40. Being in high places makes me feel anxious (i.e., tall buildings) ...................

41. I fed anxious when waiting in a long line .....................................................

42. There are times when I feel like I have to hold on to things because I am

afraid I will fall ...............................................................................................

43. When I leave home and go to various public places, I go with a family

member or friend ..............................................................................................

44. ( fed anxious* when riding in a car .................................................................

45. There are certain places I do not go to because I may feel trapped .........


5. Beck’s Depression Inventory - BDI

Instructions: This questionnaire consists of 21 groups of statements. Please read each group of

statements carefully, and then pick out the one statement in each group that best describes the way

you have been feeling during the past two weeks, including today. Circle the number beside the

statement you have picked. If several statements in the group seem to apply equally well, circle the

highest number for that group. Be sure that you do not choose more than one statement for any group,

including Item 16 (Changes in sleeping pattern) or Item 18 (Changes in appetite).

1. Sadness

0 I do not feel sad.

1 I feel sad much of the time.

2 I am sad all the time.

3 I am so sad or unhappy that I can't stand it.

2. Pessimism

0 I am not discouraged about my future.

1 I feel more discouraged about my future than I used to be.

2 I do not expect things to work out for me.

3 I feel my future is hopeless and will only get worse.

3. Past failure

0 I do not feel like a failure.

1 I have failed more than I should have.

2 As I look back, I see a lot of failures.

3 I feel I am a total failure as a person.

4. Loss of pleasure

0 I get as much pleasure as I ever did from the things I enjoy.

1 I don't enjoy things as much as I used to.

2 I get very little pleasure from the things I used to enjoy.

3 I can't get any pleasure from the things I used to enjoy.

5. Guilty feelings

0 I don't feel particularly guilty.

1 I feel guilty over many things I have done or should have done.

2 I feel quite guilty most of the time.

3 I feel guilty all of the time.

6. Punishment feelings

0 I don't feel I am being punished.

1 I feel I may be punished.

2 I expect to be punished.

3 I feel I am being punished.

7. Self-dislike

0 I feel the same about myself as ever.

1 I have lost confidence in myself.

2 I am disappointed in myself.

3 I dislike myself.

8. Self-criticalness


0 I don't criticize or blame myself more than usual.

1 I am more critical of myself than I used to be.

2 I criticize myself for all of my faults.

3 I blame myself for everything bad that happens.

9. Suicidal thoughts or whishes

0 I don't have any thoughts of killing myself.

1 I have thoughts of killing myself, but I would not carry them out.

2 I would like to kill myself.

3 I would kill myself if I had the chance.

10. Crying

0 I don't cry anymore than I used to.

1 I cry more than I used to.

2 I cry over every little thing.

3 I feel like crying, but I can't.

11. Agitation

0 I am no more restless or wound up than usual.

1 I feel more restless or wound up than usual.

2 I am so restless or agitated that it's hard to stay still.

3 I am so restless or agitated that I have to keep moving or doing something.

12. Loss of interest

0 I have not lost interest in other people or activities.

1 I am less interested in other people or things than before.

2 I have lost most of my interest in other people or things.

3 It's hard to get interested in anything.

13. Indecisiveness

0 I make decisions about as well as ever.

1 I find it more difficult to make decisions than usual.

2 I have much greater difficulty in making decisions than I used to.

3 I have trouble making any decisions.

14. Worthlessness

0 I do not feel I am worthless.

1 I don't consider myself as worthwhile and useful as I used to.

2 I feel more worthless as compared to other people.

3 I feel utterly worthless.

15. Loss of energy

0 I have as much energy as ever.

1 I have less energy than I used to have.

2 I don't have enough energy to do very much.

3 I don't have enough energy to do anything.

16. Changes in sleeping pattern

0...I have not experienced any change in my sleeping pattern.

1a I sleep somewhat more than usual.

1b I sleep somewhat less than usual.

2a I sleep a lot more than usual.

2b I sleep a lot less than usual.

3a I sleep most of the day.

3b I wake up 1-2 hours early and can't get back to sleep.


3b I wake up 1-2 hours early and can't get back to sleep.

17. Irritability

0 I am no more irritable than usual.

1 I am more irritable than usual.

2 I am much more irritable than usual.

3 I am irritable all the time.

18. Changes in appetite

0..I have not experienced any change in my appetite.

1a My appetite is somewhat less than usual.

1b My appetite is somewhat greater than usual.

2a My appetite is much less than before.

2b My appetite is much greater than usual.

3a I have no appetite at all.

3b I crave food all the time.

19. Concentration difficulty

0 I can concentrate as well as ever.

1 I can't concentrate as well as usual.

2 It's hard to keep my mind on anything for very long.

3 I find I can't concentrate on anything.

20. Tiredness or fatigue

0 I am no more tired or fatigued than usual.

1 I get more tired or fatigued more easily than usual.

2 I am too tired or fatigued to do a lot of the things I used to do.

3 I am too tired or fatigued to do most of the things I used to do.

21. Loss of interest in sex

0 I have not noticed any recent change in my interest in sex.

1 I am less interested in sex than I used to be.

2 I am much less interested in sex now.

3 I have lost interest in sex completely.


Appendix C

Plagiarism Declaration

1 Plagiarism is the use of ideas, material and other intellectual property of another’s work

and to present is as my own.

2 I agree that plagiarism is a punishable offence because it constitutes theft.

3 I also understand that direct translations are plagiarism.

4 Accordingly all quotations and contributions from any source whatsoever (including

the internet) have been cited fully. I understand that the reproduction of text without

quotation marks (even when the source is cited) is plagiarism.

5 I declare that the work contained in this assignment is my original work and that I have

not previously (in its entirety or in part) submitted it for grading in this

module/assignment or another module/assignment.

Student number

Signature

Initials and surname

Date


Appendix D

Turn-it-in report

(See next page)

Carla Research Assignment FINAL

Documents

Transcript of Carla Research Assignment FINAL