Advances in Psychology Research: Volume 93 9781620814703, 9781620814710

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ADVANCES IN PSYCHOLOGY RESEARCH

ADVANCES IN PSYCHOLOGY RESEARCH VOLUME 93

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ADVANCES IN PSYCHOLOGY RESEARCH

ADVANCES IN PSYCHOLOGY RESEARCH VOLUME 93

ALEXANDRA M. COLUMBUS EDITOR

New York

Copyright © 2013 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book.

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ISSN: 1532-723x ISBN: 978-1-62081-471-0 (eBook)

Published by Nova Science Publishers, Inc. New York

CONTENTS Preface Chapter 1

Chapter 2

vii A Critical Review on the Empirical Status of Cognitive Models for Social Anxiety Paula Vagos and Anabela Pereira Critical Variables in Cognitive-Behavioral Therapy for Pediatric and Adult Obsessive-Compulsive Disorders Adam Reid, Joseph McNamara, Maria Constantinidou, Johanna Meyer, Yonnette Forde and Gary Geffken

Chapter 3

The Bandwagon May Drive Materialists’ Dietary Choices Michael W. Allen, Sik Hung Ng, Marc Wilson and Shaun Saunders

Chapter 4

Management of Trauma of War in COTE D’Ivoire: Building on the Past to Build the Future A. C. Bissouma, M. Anoumatacky, M. D. Té Bonlé, T.Gahié, D. Koné and R.C. J. Delafosse

Chapter 5

Chapter 6

Is it Truly just about the Money? The Impact of Overseas Working on Family Members Ma. Teresa G. Tuason, Jessica Rearick and C. Dominik Güss Treatment Trial and Long-Term Follow-Up Evaluation Among Co-morbid Youth with Major Depression and a Cannabis Use Disorder Jack R. Cornelius, Ihsan M. Salloum, Robert Ferrell, Antoine B. Douaihy, Jeanie Hayes, Levent Kirisci, Michelle Horner and Dennis C. Daley

1

29

53

73

93

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Contents

Chapter 7

Paradoxical Decrease in Striatal Activation on an fMRI Reward Task Following Treatment in Youth with Co-morbid Cannabis Dependence/Major Depression 123 Jack R. Cornelius, Howard J. Aizenstein, Tammy A. Chung, Antoine Douaihy, Jeanine Hayes, Dennis Daley and Ihsan M. Salloum

Chapter 8

Theoretical and Methodological Weaknesses of Current Psychiatric Models of Suicidal Behavior María Dolores Braquehais and Agustín Madoz-Gúrpide

131

Recognising Suicidality: General Practitioner Training and Education David Smith and Andrea Stewart

139

Chapter 9

Index

147

PREFACE This continuing series presents original research results on the leading edge of psychology. Each article has been carefully selected in an attempt to present substantial results across a broad spectrum. This book reviews research on the empirical status of cognitive models in social anxiety; critical variables in cognitive-behavioral therapy for pediatric and adult obsessive-compulsive disorders; management of trauma of war in Côte D’ivoire; the impact of overseas working on family members; and treatment trial and longterm follow-up evaluation among co-morbid youth major depression and a cannabis use disorder. Chapter 1 - Social anxiety refers to the discomfort felt in events involving social interaction or social performance, resulting from fear of negative evaluation from others. It is usually a persistent and stable fear, in spite of the social exposure that the individual necessarily faces. This may be accounted for by negative core beliefs and biased social information processing, that are active before, during, and after the individual faces the feared social event. Clark (2005) has put forward a cognitive model to account for this cognitive framework for social anxiety. Evidence has been found for this model, but focused mainly on the biased interpretation, attention and memory processes, and the negative imagery that is activated in social events. The authors intend to broaden these works, by providing a specific critical review on the topic. To do this, they performed online search on electronic databases using two combinations of keywords: “social anxiety” and “cognition”, and “social anxiety and “information processing”. Results were selected based on their title and abstracts’ pertinence to the theme. The references of these works were also scanned for additional important works. Fifty-one works were thus selected and subject to content analysis. Evidence was found for core negative cognitive structures specific to social anxiety, that pertain to representing the self as an incapable and inefficient social object and others as attentive critics. These cognitive structures may account for the biased social information processing, which consists of a tendency to judge others’ reactions and possible consequences of social events as more negative, to focus attention on personal negative symptoms or reactions, and to memorize and review this information. During exposure to the feared social event, cognitive symptoms are also activated, namely negative automatic thoughts and images, which reflect how the individual believes he is seen and judge by others. Because after the event all the individual remembers and ruminates on is negative, this is the experience he will build and re-activate when faced with a new social event, thus perpetuating the social anxiety cycle. Based on this review, the authos can conclude that cognitive models on social anxiety seem to be evidence-based, although topics like memory biases still lack

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consensus. Implications from these models on prevention and intervention strategies, particularly in less considered groups like children and adolescents, are discussed. Chapter 2 - Cognitive-Behavioral Therapy (CBT) has been empirically validated as an effective first-line treatment for both pediatric and adult Obsessive-Compulsive Disorder (OCD). However, OCD is a highly heterogeneous disorder, causing many treatment refractory cases that leave clinicians baffled. This chapter reviews the past ten years of research on several of the most challenging OCD presentations, including OCD with poor insight, high family accommodation, comorbid oppositional defiant disorder, scrupulosity, and post-partum onset. Each of these presentations are discussed in terms of identifying characteristics, treatment augmentation and case examples. Research supporting innovative assessment for these OCD presentations is outlined as well. CBT is a highly adaptable treatment approach. This chapter aims to summarize past findings and facilitate future research that will guide clinicians in adapting CBT for treatment refractory OCD, thus improving overall treatment outcome. Chapter 3 – The authors suggest that public self-consciousness affects whether one pursues a Bandwagon or Distinctiveness status-seeking strategy, where low public selfconsciousness leads to Distinctiveness, and high public self-consciousness leads to Bandwagon. Moreover, they propose that materialism involves high public self-consciousness and a high status-seeking drive, hence materialists pursue Bandwagon, not Distinctiveness. The authors investigated these possibilities by examining how materialism is expressed in food choice. Study 1 showed that materialism and status-seeking behavior differ according to one’s public self-consciousness and status-seeking drive, as speculated; that materialists prefer high-status foods and reject low-status ones; and that materialists do so for Bandwagon, not Distinctiveness. Study 2 found that increasing participants’ public selfconsciousness (using a mirror) decreased Distinctiveness and increased Bandwagon and materialism. The authors’ data suggest that materialism and status-seeking behavior depend heavily on public self-consciousness and status-seeking drive, and that materialists’ food choices may be shaped by their desire to achieve Bandwagon status. Chapter 4 - Armed conflicts and natural disasters cause serious suffering to the people, affecting them physically, psychologically and socially. The consequences of these emergencies can be dramatic in the short term, and could also affect the mental health and psychosocial well-being, and economic development of these populations over time. Chapter 5 - This study compared families of Filipino adult children from varied income levels that function with and without a family member working overseas. The focus of thier study draws a comparison in terms of their levels of anxiety, symptomatology, and how the family functions. Results indicate a significant interaction effect, overseas working status x income levels on participants’ anxiety and symptomatology. Families with the lowest and highest incomes have lower anxiety and symptomatology, while middle income families experience higher anxiety and symptomatology, when a family member works overseas. In terms of how well the family functions, conflict within the family was significantly higher when the mother was working overseas and expressiveness within the family was significantly higher with female participants. Chapter 6 - Objective: This study compared the acute phase (12-week) and the long-term (1 year) efficacy of fluoxetine versus placebo for the treatment of the depressive symptoms and the cannabis use of youth with comorbid major depressive disorder (MDD) and an cannabis use disorder (CUD)(cannabis dependence or cannabis abuse). We hypothesized that

Preface

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fluoxetine would demonstrate efficacy in the acute phase trial and at the 1-year follow-up evaluation. Data is also provided regarding the prevalence of risky sexual behaviors in their study sample. Methods: The authors recently completed the first double-blind placebocontrolled study of fluoxetine in adolescents and young adults with comorbid MDD/CUD. A total of 70 persons participated in the acute phase trial, and 68 of those persons (97%) also participated in the 1-year follow-up evaluation. Results of the acute phase study have already been presented, but the results of the 1 year follow-up assessment have not been published previously. All participants in both treatment groups also received manual-based cognitive behavioral therapy (CBT) and motivation enhancement therapy (MET) during the 12-week course of the study. The 1-year follow-up evaluation was conducted to assess whether the clinical improvements noted during the acute phase trial persisted long term. Results: During the acute phase trial, subjects in both the fluoxetine group and the placebo group showed significant within-group improvement in depressive symptoms and in cannabis-related symptoms. However, no significant difference was noted between the floxetine group and the placebo group on any treatment outcome variable during the acute phase trial. End of study levels of depressive symptoms were low in both the fluoxetine group and the placebo group. Most of the clinical improvements in depressive symptoms and for cannabis-related symptoms persisted at the 1-year follow-up evaluation. Conclusions: Fluoxetine did not demonstrate greater efficacy than placebo for treating either the depressive symptoms or the cannabis-related symptoms of our study sample during the acute phase study or at the 1-year follow-up assessment. The lack of a significant treatment effect for fluoxetine may at least in part reflect efficacy of the CBT/MET psychotherapy. A persistence of the efficacy of the acute phase treatment was noted at the 1-year follow-up evaluation, suggesting long-term effectiveness for the CBT/MET psychotherapy. Chapter 7 - Reward behavior, including reward behavior involving drugs, has been shown to be mediated by the ventral striatum and related structures of the reward system. The aim of this study was to assess reward-related activity as shown by fMRI before and after treatment among youth with comorbid cannabis dependence and major depression. The authors hypothesized that the reward task would elicit activation in the reward system, and that the level of activation in response to reward would increase from the beginning to the end of the 12-week treatment study as levels of depressive symptoms and cannabis use decreased. Six subjects were recruited from a larger treatment study in which all received Cognitive Behavioral Therapy/Motivational Enhancement Therapy (CBT/MET), and also were randomized to receive either fluoxetine or placebo. Each of the six subjects completed an fMRI card- guessing/reward task both before and after the 12-week treatment study. As hypothesized, the expected activation was noted for the reward task in the insula, prefrontal, and striatal areas, both before and after treatment. However, the participants showed lower reward-related activation after treatment relative to pre-treatment, which is opposite of what would be expected in depressed subjects who did not demonstrate a comorbid substance use disorder. These paradoxical findings suggest that the expected increase in activity for reward associated with treatment for depression was overshadowed by a decrease in reward-related activation associated with treatment of pathological cannabis use in these comorbid youth. These findings emphasize the importance of comorbid disorders in fMRI studies. Chapter 8 - Many studies on suicidal behavior identify several risk and protective factors associated with it. However, current psychiatric models that integrate those findings are not free from deep methodological and theoretical problems. In our opinion, their main

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weaknesses can be divided into: A. General limitations: 1) factors studied are not divided into the different ontological levels they belong to before including them into a theoretical model: 2) each level should be studied with its specific methodological approach and results at one level correlate (but do not merely cause) findings observed at other levels; 3) Statistics are useful when trying to “quantify” the “magnitude” of each factor but a “qualitative” analysis is needed for a richer comprehension of suicidal acts; 4) the content of each variable should be considered beyond its “statistical” significance (i.e. some factors could be reduced to and/or explained by more simple conditions); and, 5) current psychiatric models based on epidemiological and clinical findings are more descriptive than comprehensive in nature as they describe general patterns but fail to give an explanation of each individual suicidal behavior. B. Specific limitations: 1) there is neither a universally accepted definition of suicidal behavior nor of some of the constructs associated with if (e.g. impulsivity); 2) some invoked factors have low specificity as predictors of suicidal behavior; 3) some identified factors are confounding and/or intermediate variables while others play a primary role as triggers or protectors of suicidal behavior; 4) casual relations between factors are not linear but circular; and, 5) risk and protective factors change over time, each one with its own rhythm. Taking into account these weaknesses, a new, more precise model of suicidal behavior should be designed in order to combine general patterns of suicide risk with a comprehensive approach to the meaning of each individual suicidal behavior. Chapter 9 - The prevention of suicide is partially dependent on the ability to identify individuals and populations at high risk and to offer effective interventions. General practitioners (GPs) are in an ideal position to play a significant role in the detection of suicidality, and therefore to assist in the prevention of suicide. However, many suicidal individuals who attend GP practices remain undetected. Evaluations of the suicide awareness, education and training programs developed for GPs show that they are associated with improvements in the recognition of suicidal ideation, reduced suicide rates, and in the assessment and management of mental health more generally. Key factors for efficacious training programs have been identified. Training should also be extended to meet differential needs of minority populations at disproportionately high suicide risk (e.g., same-sex attracted). Sensitivity towards diversity and minority group stressors can gainfully inform and refine generalist models for training programs.

In: Advances in Psychology Research. Volume 93 Editor: Alexandra M. Columbus

ISBN: 978-1-62081-470-3 © 2013 Nova Science Publishers, Inc.

Chapter 1

A CRITICAL REVIEW ON THE EMPIRICAL STATUS OF COGNITIVE MODELS FOR SOCIAL ANXIETY Paula Vagos and Anabela Pereira Departament of Education, Universidade de Aveiro, Portugal

ABSTRACT Social anxiety refers to the discomfort felt in events involving social interaction or social performance, resulting from fear of negative evaluation from others. It is usually a persistent and stable fear, in spite of the social exposure that the individual necessarily faces. This may be accounted for by negative core beliefs and biased social information processing, that are active before, during, and after the individual faces the feared social event. Clark (2005) has put forward a cognitive model to account for this cognitive framework for social anxiety. Evidence has been found for this model, but focused mainly on the biased interpretation, attention and memory processes, and the negative imagery that is activated in social events. We intend to broaden these works, by providing a specific critical review on the topic. To do this, we performed online search on electronic databases using two combinations of keywords: “social anxiety” and “cognition”, and “social anxiety and “information processing”. Results were selected based on their title and abstracts’ pertinence to the theme. The references of these works were also scanned for additional important works. Fifty-one works were thus selected and subject to content analysis. Evidence was found for core negative cognitive structures specific to social anxiety, that pertain to representing the self as an incapable and inefficient social object and others as attentive critics. These cognitive structures may account for the biased social information processing, which consists of a tendency to judge others’ reactions and possible consequences of social events as more negative, to focus attention on personal negative symptoms or reactions, and to memorize and review this information. During exposure to the feared social event, cognitive symptoms are also activated, namely negative automatic thoughts and images, which reflect how the individual believes he is seen and judge by others. Because after the event all the individual remembers and ruminates on is negative, this is the experience he will build and re-activate when faced with a new social event, thus perpetuating the social anxiety cycle. Based on this review, we can conclude that cognitive models on social anxiety seem to be evidence-based, although topics like memory biases still lack consensus.

2

Paula Vagos and Anabela Pereira Implications from these models on prevention and intervention strategies, particularly in less considered groups like children and adolescents, are discussed.

INTRODUCTION Social anxiety refers to the activation of intense and persistent emotional and physiological symptoms, derived from fear of negative evaluation from others. These symptoms are activated before, during and after the exposure to events involving social interaction or social performance, where the individual believes he may be under scrutiny and evaluation by others. The individual fears he will behave in some inappropriate way that will lead to negative evaluation, and tries to avoid this by avoiding social events where he believes it may happen (American Psychiatricand Association, 1994). This fear is a gradual experience, varying in intensity (Kashdan and Herbert, 2001; Rapee and Spence, 2004). It is common when facing several daily events, like making an oral presentation or going on a first date. In this case, it leads to a motivational anxiety that activates resources to face the perceived social threat. Once they are activated, the anxiety and fear tend to diminish, and an adequate social response is given. In other occasions, this fear doesn’t subside so easily and the individual experiences emotional, behavioral and cognitive symptoms of social anxiety that interfere with performance in particular and restricted areas of his life (Turner, Beidel, and Larkin, 1986). There are many individuals admitting to intense social fears in one or more social events that do not fulfill criteria for social phobia, nor seek professional help for their difficulties (Furmark, 2002). At the extreme end of social fears we find individuals diagnosed with social phobia or social anxiety disturbance, which is the 3rd most common psychiatric disorder (Fresco and Heimberg, 2001), with an early onset at about 15 years old (Kashdan and Herbert, 2001). It is characterized by intense and persistent emotional responses of fear and anxiety in social events, and have significant interference in social and professional or academic performance (Elizabeth, King, and Ollendick, 2004; Rodebaugh, 2009). The persistence of these social fears, in spite of the social exposure that the individual necessarily faces, may be accounted for by a biased social information processing, which is grounded in negative core beliefs about the self and others, and activate negative automatic cognitive symptoms, anxiety emotional responses and behavioral avoidance or safety behaviors in social events. Clark (2005) has put forward a cognitive model to account for this cognitive framework for social anxiety, which he defined as a synthesis of previous works. This model considers what happens before, during and after the feared social event occurs. It proposes that individuals with social fears hold a set of interpersonal cognitive beliefs, whose content is based on their early developmental experiences. These cognitive beliefs may involve excessively high standards for social performance, conditional beliefs concerning the consequences of performing in a certain way (e.g. disagreeing, hands shaking, etc.), unconditional negative beliefs about the self as incompetent, unlikeable, different etc. Once entering a social event, these beliefs are activated and frame how the individual attends to, interprets and memorizes social clues. Attention will be focused on internal information used to build a distorted, negative impression of how one is seen by others, and this biased selected information will be used to make inferences on how others are judging the self. Therefore, the negative evaluation one expects and perceives to receive from others is actually based on

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internal and not external clues. If this negative information receives primary attention, it is this same information that will be primarily memorized. This memorization process is made even more evident by a process of detailed reviewing the event after it has ended, hence further confirming the failure and negative evaluation one perceives to have had. Every new social interaction or performance in thus added to the personal list of social failures that will be recalled when antecipating future social events, and serve to reinforce the negative expectations the socially anxious individuals have about how social events will develop. With this state of mind, preparing to face a first date or an oral presentation, so simple for some, becomes an extremely anxious event, which the socially anxious individual tries to avoid completely of faces with increased anxiety and associated cognitive symptoms, and trying to remain unnoticed, using a wide range of safety behaviors. We can decompose this model into three sequential groups of biased cognitive processes: 1. negative core beliefs and representations about the self; 2. social information processing, that is, how the individuals apprehend stimuli, namely by attending, interpreting and memorizing information, and 3. cognitive symptoms, namely negative automatic thoughts and images. Social anxiety is also reflected in emotional and behavioral symptoms, but those are not within the scope of this chapter. In order to empirically validate this model for social anxiety, the scientific literature should find evidence of these biased processes in socially anxious individuals and, preferably, not in non-socially anxious individuals. Indeed such evidence has been found, but “It is striking (…)that research has tended to examine cognitive biases in isolation rather than assessing how they work together to maintain psychological dysfunction” (Hirsch, Clark, and Mathews, 2006, p. 223). Proof of this is that revisions on works done on cognition in social anxiety have focused mainly on biased attention, interpretation and memory processes, neglecting other cognitive processes and especially how they may interact to maintain social anxiety. Some of these reviews will now be presented. Musa and Lepine (2000) reviewed evidence found for social information processing in social anxiety, according to the methods used to evaluate it. They present evidence for attention biases towards threating stimuli, but note that attention may also be drawn away from it, depending on the nature of the stimuli and time it is presented. For memory, they report more inconclusive findings, and consider the importance of encoding activities as determinant of memory bias in social anxiety. Attention and memory bias have been mainly evaluated using experimental procedures. As for interpretation, this review found evidence for a negative bias in the evaluation of self-performance, ambiguous social events and danger. This evidence was found mainly using tasks derived from socio-cognitive models. Heinrichs and Hofmann (2001) presented a critical review on information processing in social phobia, considering attention, interpretation/ judgment and memory. They conclude on an attentional bias towards socially threatening stimuli, if it is presented in words; when threatening faces are presented the bias seems to be away from the perceived social threat. Concerning interpretation/ judgment, there seems to be consensual evidence on a negative bias specific to social events. Socially anxious individuals tend to think negative social events and negative costs of social events as highly probable, and also to underestimate their social skills and the quality of their social performance. This bias is found even in positive or

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successful social events, which indicates that social clues are not completely or accurately encoded. As for memory processes, works reviewed by these authors were contradictory, whether explicit versus implicit memory or encoding versus retrieval processes were evaluated. The authors ascertain on the need for further investigation on memory biases on social anxiety, namely testing the hypothesis that the socially anxious individual starts by focusing and encoding social threating information, but then refrains from retaining and further retrieving such information in the future. Clark and McMannus (2002) also reviewed studies on social information processing in social phobia. They found that socially anxious individuals tend to focus attention on themselves, particularly on aspects of the self that may be negatively evaluated by others (e.g. shaking, blushing, breathing fast etc…), and this internal information is thought to coincide with the evaluations others are in fact making of the self. Socially anxious individuals also seem to be more alert to negative external social clues, if instructed to focus on the other person. Referring to interpretation/ judgment this work reported that socially anxious individuals tend to interpret ambiguous social events negatively, to predict negative social events to happen frequently, and to expect catastrophic outcomes from mildly negative social events. On memory recall tasks, the individual activates negative images of the self, as one believes was seen and will be seen by others. Bögels and Mansell (2004) focused on attention bias in social anxiety, and intended to ascertain if it could maintain or cause social anxiety, if it was specific to social anxiety, and if it should be a focus of treatment for social anxiety. These authors present initial evidence in favor of a vigilance-avoidance hypothesis in attentional bias in social anxiety, taken from investigations using less experimental and more naturalist methods. This hypothesis state that there is an initial tendency to attend to social threat clues (in on-line processing), which is later replaced by a tendency to avoid further processing such clues (in off-line processing), directing attention away from them. This work also ascertains that self-focused attention is a common feature of social anxiety associated with its increase, and particularly concerns aspects of the self as seen by others. It is proposed (but not confirmed by the literature reviewed) that initial vigilance attention may be self-focused, while avoidance processing may target external clues. Hirsch and Clark (2004) reviewed evidence on interpretation and memory processes in social anxiety. They also considered cognitive symptoms, in the form of images spontaneously activated in feared social events. They conclude that socially anxious individuals overestimate the probability of social risks and costs, but they question if this may not be an accurate perspective of their personal experience, living with social anxiety. These authors also state that there is evidence on a more negative and less positive interpretation bias in social anxiety for personal performance and expected outcomes in social events. Concerning memory, this review concluded that bias was only found when social threat was activated and perceived. This condition, which is usually present in anticipation of social events, leads to memorizing internal negative clues and neglecting external ones. Finally, this work reports that imagery is a common experience in social anxiety, usually taken from a negative and observer perspective. The meaning of this image is frequently associated with past aversive social experiences, which took place at about the same time as the onset of social fears. We can conclude from these reviews that there remains a surprising lack of investigation on the content of cognitive schemas underling social anxiety, and how they may influence

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social information processing (Wenzel, Brendle, Kerr, Purath, and Ferraro, 2007). At the same time, the content of negative automatic thoughts or images, although clearly evaluated in socially anxious individuals, hasn’t been placed in the cognitive cycle, but rather has been considered in isolation in cognitive assessment in social anxiety. For these reason, the present work intends to update and broadened those previous works, considering that “it is (…) important that (…) investigation of cognitive factors in social anxiety not be limited to cognitive products such as internal dialogue, but also consider the primary cognitive operations and schemata highlighted” (Glass and Furlong, 1990, p. 3637). Because this statement is still pertinent, we intend to provide a review on the empirical status of cognitive models on social anxiety considering the three sequential groups of biased cognition in social anxiety named above. We will consider the empirical evidence found for the existence of core beliefs or maladaptive schemas, of biased attention, interpretation and memory processes, and of negative automatic thoughts and images, distinctive of social anxiety.

METHOD Literature Search To gather research on cognition in social anxiety, computer online databases were used, namely Web of Science, PsycINFO and Dissertation Abstracts International, primarily using the keywords social anxiety, cognition and information processing. The search was restricted do the English language; no time frame was considered. A total of 589 papers were recovered, and their titles and abstracts were scanned for pertinence and fulfillment of the following criteria: 1) having defined as investigation objectives to characterize or explore cognitive processes in socially anxious clinical and non-clinical samples (papers on evaluation instruments and intervention strategies were excluded), 2) full text available for analysis, either by free download or made available by the authors. Forty seven papers were thus selected, and were subject to backward search (i.e., its references were scanned for pertinence). A total of fifty-one papers were then considered for the present review (Table 1). The works selected include a range of 26 years’ worth of investigation in the area of cognition in social anxiety, from 1985 to 2011. The majority of these works (about 70%) used an adult non-clinical sample. The mostly used methods for data gathering were evaluation of social interaction or social performance tasks (about 31%), followed by rating of ambiguous stories (about 19%). One the contrary, only two of these selected works (about 4%) used a clinical adolescent sample, and only about 6% of them used a semi-structure interview as method for gathering data. The widest range time of publication was found for cognitive symptoms. A total of 11 works were selected from 1986 to 2011, but a gap in time of publication should be noticed between 1985 and 86 and 1993. To analyze this category, adult clinical and non-clinical samples were mostly used (about 45%), and the mostly used method was evaluation of social interaction or social performance tasks (about 54%). The social processing information general category received the most attention in the literature, corresponding to a total of 32 selected works in this chapter, with publication years ranging from 1990 to 2011. To analyze

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this category, adult non-clinical samples were mostly used (about 71%) and the most used method for data gathering was the rating of ambiguous stories (about 29%). Table 1. Studies examining cognition in social anxiety Authors Alden and Wallace, 1995

Content a 2) interpretation

Alfano, Beidel, and Turner, 2006

3) automatic thoughts

Amin, Foa, and Coles, 1998 Amir, Beard, and Bower, 2005 Ashbaugh, Antony, McCabe, Schmidt, and Swinson, 2005 Baldwin and Main, 2001

2) interpretation

Beard and Amir, 2009 Beazley, Glass, Chambless, and Arnkoff, 2001 Beidel, Turner, and Dancu, 1985 Bogels and Zigterman, 2000 Brendle and Wenzel, 2004 Cho and Telch, 2005 Coles, Turk, and Heimberg, 2002 Constans, Penn, Ihen, and Hope, 1999 Creed and Funder, 1998 Garner, Mogg, and Bradley, 2006 George and Stopa, 2008 Hackmann, Clark, and McManus, 2000 Hackmann, Surawy, and Clark, 1998 Heinrichs and Hofmann, 2004 Hertel, Brozovich, Joormann, and Gotlib, 2008 Higa and Daleiden, 2008 Hirsch and Mathews, 2000 Hope, Rapee, Heimberg, and Dombeck, 1990

Design Social interaction task and performance rating Recall of thoughts present in social interaction and read-aloud task

2) interpretation

Participants Adult clinic and nonclinical Child and adolescent clinical and nonclinical Adult clinical and non-clinical Adult non-clinical

2) interpretation

Adult non-clinical

Speech task and rating of performance

1) core beliefs about the self and others 2) interpretation 3) automatic thoughts

Adult non-clinical

Cue activation experimental procedure Word SentenceAssociationParadigm Questionnaire

3) automatic thoughts

Adult clinical and non-clinical Child clinical and non-clinical Adult clinical and non-clinical Adult non-clinical Adult clinical and non-clinical Adult non-clinical

Social interaction and impromptu speech task Rating ambiguous stories

1) core beliefs about the self and others 2) interpretation

Adult non-clinical

Questionnaire

Adult non-clinical

2) attention

Adult clinical and non-clinical Adult clinical

Rating of happy, angry and neutral faces Social interaction task, with manipulation of focus of attention Semi-structured interview

2) interpretation 2) interpretation and memory 3) automatic thoughts 2) memory 2) interpretation

1) core beliefs about the self 3) images 3) images

Adult non-clinical Adult clinical

2) memory

Adult clinical and non-clinical Adult non-clinical

2) interpretation and memory

Adult clinical and non-clinical

2) attention and interpretation 2) interpretation

Child non-clinical

2) attention

Adult clinical and non-clinical Adult clinical

Rating ambiguous stories Social-evaluative videotape rating

Rating and recalling ambiguous stories Questionnaire Recall task Rating ambiguous stories

Semi-structured interview Release from proactive interference task Social scenarios continuation and recall task Ambiguous stories continuation, with manipulation of focus of attention Word or nonword lexical decision probes Revised Stroop color-naming task

A Critical Review on the Empirical Status of Cognitive Models for Social Anxiety Authors Huppert, Foa, Furr, Filip, and Mathews, 2003 Huppert, Pasupuleti, Foa, and Mathews, 2007 Ingram, Scott, Holle, and Chavira, 2003 Pinto-Gouveia, Castilho, Galhardo, and Cunha, 2006 Mansell and Clark, 1999 Mansell, Clark, Ehlers, and Chen, 1999 Mellings and Alden, 2000 Miers, Blote, Bogels, and Westenberg, 2008 Muris, Merckelbach, and Damsma, 2000 Rheingold, Herbert, and Franklin, 2003 Roth, Antony, and Swinson, 2001 Spence, Donovan, and Brechman-Toussaint, 1999 Spokas, Luterek, and Heimberg, 2009 Stopa and Clark, 1993

Content a 2) interpretation

Participants Adult non-clinical

Design Rating ambiguous stories

2) interpretation

Adult non-clinical

Sentencecompletiontask

2) attention and memory 1) core beliefs about the self and others

Adult non-clinical

Social interaction task, with experimental condition Questionnaire

2) interpretation and memory 2) attention

Adult non-clinical

Social interaction task

Adult non-clinical

2) attention and memory 2) interpretation

Adult non-clinical

Modified dot-probe task with face emotional expression as stimuli Social interaction task and questionnaire Questionnaire

2) interpretation 2) interpretation 2) interpretation 2) interpretation 3) automatic thoughts 1) core beliefs about the self and others 3) automatic thoughts

Stopa and Clark, 2000

2) interpretation

Tanner, Stopa, and De Houwer, 2006 Taylor and Alden, 2005

1) core beliefs about the self and others 1) core beliefs about the self and others 3) automatic thoughts

Turner et al., 1986 Tuschen-Caffier, Kuehl, and Bender, 2011 Voncken, Bogels, and de Vries, 2003

2) interpretation 3) automatic thoughts 2) interpretation

Wells, Clark, and Ahmad, 1998 Wenzel, 2004

3) images

Wenzel et al., 2007 Wenzel, Finstrom, Jordan, and Brendle, 2005 Wenzel and Holt, 2002 Wenzel and Holt, 2003

1) core beliefs about the self and others 1) core beliefs about the self and others 2) interpretation and memory 2) memory 1) core beliefs about the self and others

Adult clinical and non-clinical

Adolescent nonclinical Children non-clinical

Rating ambiguous stories

Adolescent clinical and non-clinical Adult clinical and non-clinical Child clinical and non-clinical

Questionnaire

Adult non-clinical

Questionnaire

Adult clinical and non-clinical Adult clinical and non-clinical Adult non-clinical

Social interaction task and questionnaire Rating ambiguous stories

Adult clinical and non-clinical Adult clinical and non-clinical Child clinical and non-clinical sample Adult non-clinical

Social interaction task and performance rating Social interaction task, impromptu speech task and questionnaire Social-evaluative role-play of performance tasks Rating positive, ambiguous, mildly negative and profoundly negativeinterpretations of scripts Semi-structured interview

Adult clinical and non-clinical Adult clinical and non-clinical Adult non-clinical

Questionnaire Social-evaluative task

Questionnaire

Semi-structured interview Semi-structured interview

Adult non-clinical

Recallof role-play

Adult clinical and non-clinical Adult non-clinical

Recalltask Script buildingmethodology

7

8

Paula Vagos and Anabela Pereira Table 1. (Continued) Authors Wenzel, Jackson, and Holt, 2002

a

Content a 1) core beliefs about the self and others

Participants Adult non-clinical

Design Autobiographicalmemorycueingprocedure

content analysis categories, specified bellow (cf Table 2).

The core beliefs about the self and others received the most recent attention in the literature, corresponding to 11 works selected for this chapter, published between 1998 and 2009. To analyze this category, again adult non-clinical samples were mostly used (about 63%) and self-reported questionnaire was the most frequently used method for gathering data (about 36%). No child or adolescent sample was used to access core beliefs about self and others. These texts were categorized into the pre-defined categories, according to their titles and abstracts (Table 2). According to our initial categorization, only four of the selected works set out to analyze more than one category of cognition in social anxiety.

Content Analysis Categories Cognition on social anxiety was organized into three super-ordinate categories (as mentioned above): 1. negative core beliefs and representations; 2. biased social information processing, and; 3. accompanying cognitive symptoms. These contents were taken directly from cognitive models on social anxiety, which, in turn, sprung from broader cognitive theories on anxiety (Beck, Emery, and Greenberg, 1985). Beck’s cognitive model for anxiety specifically differentiates between schemas or core beliefs, cognitive distortions manifested in the attention, interpretation and memory levels, and cognitive products that derivate from the social information processing. This super-ordinate categories were further divided into subcategories, according to the procedures of NUD*IST6, which allows for the building, organizing and analyzing of several categories in a tree like structure, in order to facilitate the interpretation of the data in meaningful order. The tree that resulted from this papers’ review may be seen in table 2. Analyzes of the method, results and discussion sections of each work selected allowed to include them in each of the above mentioned subcategories. Introduction was not analyzed because it consists, by definition, of reviewing previous work done on the subject in order to place the current investigation. Since our goal was to present evidence found for each component of cognition in social anxiety having Clarks’ model as a framework, we did not concern ourselves with literature reviews, but rather focused on the evidence presented by each individual work.

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Cognition in social anxiety

Table 2. Categories and subcategories for content analysis Core beliefs Perceptions about the self Perceptions about others Relational knowledge Social Information Processing Attention Interpretation/judgment Memory Cognitive symptoms Automatic thoughts Images

CONTENT ANALYSIS RESULTS Core Beliefs Based on early developmental experiences, individuals develop cognitive assumptions about themselves and the social world that may make them more vulnerable to feeling socially anxious. Overprotection, emotional abuse or neglect and limited social exposure are parental interactions that associate with social anxiety, because they convey to the child a message that he is incapable of functioning outside parental supervision, that he is unworthy of love and affection, or that he is unable to respond to highly demanding social interactions or performance (Taylor and Alden, 2005). Other than that, going through a traumatic social experience (of rejection or humiliation ) may be intensive enough so that negative beliefs about the self are built and kept against all contrary evidence that might be taken from other social experiences (Hackmann et al., 2000). Yet, no differences were found in autobiographical memories recollected by socially anxious and non-anxious individuals, either being of more frequent or more negative social failure (Wenzel et al., 2002). Therefore, experiencing social failure, humiliation or rejection doesn’t seem to be a necessary condition for the onset of social anxiety, and so we should consider that the child’s temperament and social context are also important contributes to making her vulnerable to experiencing social anxiety. When anticipating a new social event, if it resembles the social threat that the individual learnt to fear, these defensive negative core beliefs or interpersonal schemas are activated (Baldwin and Main, 2001; Wenzel and Holt, 2002). These interpersonal schemas contain not only negative beliefs about the self, but also about others and about how interactions should unfold (Ingram et al., 2003). These beliefs may underlie biases found in social information processing in social anxiety and keep the individual trapped in a vicious maladaptive interpersonal cycle of expecting and receiving negative evaluation from others (Creed and Funder, 1998).

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Perceptions about the Self In general, high socially anxious individuals endorse an implicit less positive view of themselves, denoting a lack of positive bias when making rapid and automatic evaluations of the self. When explicitly and deliberately talking about themselves on self-report measures however, they present an outward negative (and not slightly less positive) self-image (Tanner et al., 2006). Using such self-report questionnaires, Creed and Funder (1998) found that socially anxious individuals perceive themselves as uncomfortable facing the uncertainty, vulnerable, sensitive when facing criticism and concerned with personal adequacy. These individuals also admit to their lack of social skills and awkwardness in social events. Sadly, this impression was passed on to their interaction partner, eliciting the very negative reaction that was feared and tried to avoid. Other than that, and also using self-report questionnaires, social anxiety associates with believing one has some intrinsic fault that is motive for personal shame and that one should subjugate his needs and wishes to those of others. Fear of negative evaluation in particular associates with holding perfectionist standards to personal performance, which the individual believes will be incapable of fulfilling, due to his self-perceived general social inefficacy, incompetence and inadequacy (Pinto-Gouveia et al., 2006). Also, socially anxious individuals hold dysfunctional beliefs about emotional expression, namely that it is a sign of weakness and should therefore be kept under control; if not, social rejection will fallow. This beliefs about the need for emotional suppression associates with social anxiety, probably resulting in behavioral correlates (Spokas et al., 2009), such as avoidance or trying to go unnoticed in social events.

Perceptions about Others Social anxiety, and particularly fear of negative evaluation, associated with believing that others will be abusive, manipulative or mistreat and take advantage of the self, and are not to be trusted (Pinto-Gouveia et al., 2006). Others are seen has attentive and critical evaluators, ready and prompt to make negative evaluations of the self, and as having control over what happens in social events, meaning that the individual needs to condo with their wishes in order to be socially successful (Ingram et al., 2003; Roth et al., 2001).

Relational Knowledge Wenzel and Holt (2003) found that there seems to be no difference between socially anxious and non-anxious individuals in knowing what is supposed to happen in several social events (e.g. go to a party, go on a date, present a speech or an idea). That is to say that socially anxious individuals are equally able to predict the script that unfolds in social events. Yet, how they interpret and what they expect to happen to themselves in these same events seems to be stained by negative beliefs about relationships. To this respect, Wenzel (2004) found that social scripts built by socially anxious individuals are usually more negative, give less detail and include references to anxiety and danger (e.g. mention of physiological anxiety symptoms). Thus, even though they think of normative sequences of

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events in social experiences, they don’t emotionally and cognitively experience those events in a normative manner. Especially when they are asked to describe typical experiences in their lifes, their scripts denote more negative and less positive affect, indicating a subjective interference placed upon general factual relational knowledge (Wenzel et al., 2007). This subjective interference seems to be negative, associated with expecting that emotional needs will not be satisfied in relationships (Pinto-Gouveia et al., 2006). Socially-anxious individuals’ emotional and behavioral responses may be more dependent on this personally meaningful script of social events than on procedural knowledge of typical social events.

Social Information Processing Attention, interpretation and memory bias may result from the activation of interpersonal core beliefs or schemas. In the case of social anxiety, these schemas may direct and facilitate attending to social clues that are interpreted as negative, leading to a constant perception of being negatively evaluated by others (Constans et al., 1999; Ingram et al., 2003). Beard and Amir (2009) particularly put this assumption to the test by examining how priming a threat or benign activation associated with interpretation biases. They found that when threat interpretation is activated, socially anxious individuals find it much easier to make negative interpretations and difficult to make benign interpretations. This was evident only for social sentences, and not for non-social sentences.

Attention When in social events, the socially anxious individual focus on his own feelings, behaviors and thoughts associated with his anxiety (Ingram et al., 2003). This was also found in children (Higa and Daleiden, 2008). While for non-anxious controls self-awareness decreases as the interaction flows, for socially anxious individuals it does not (George and Stopa, 2008): they keep focusing on themselves as the social event occurs. Attention is thus self-focused and directed at negative aspects of personal performance and experience in social events. This negative self-perception is used to create an image of how one thinks he appears to others, and thus contributes to increased anxiety, because the individual thinks others can see how anxious he is and, he beliefs, how anxious he looks (Mellings and Alden, 2000; Wells et al., 1998). Public self-awareness (that is, awareness of the self as seen by others) is increased when socially-anxious individuals focus attention on themselves, and associates with increased anxiety and observer perspective taking in social interactions (George and Stopa, 2008). Limited attentional resources are directed at the other persons’ behavior (Stopa and Clark, 1993). In line with this, Mansell et al. (1999) used faces expressing neutral positive or negative emotions, and manipulated a threat condition. Using this method, they found that, under perceived threat, socially anxious individuals avoid attending to positive or negative emotional expression in faces. These finds may represent a self-protective strategy: when we don’t look at others’ faces we are less likely to be called to interact with them or be subject to their evaluation. When attentional resources are allocated to the context, there is a tendency to focus solely on contextual clues that may point to a negative evaluation (Spence et al., 1999).

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Results found by Hope et al. (1990) using a revised stroop color naming task are in line with this assumption, because socially anxious individuals took longer to name social threat words. The meaning of the word was being processed attentively, and so interfered and made it difficult to name its color. By focusing on negative clues, the socially anxious individual refrains from encoding external clues that may disconfirm or question the image he built of himself and that he believes he is transmitting to others (Stopa and Clark, 1993). George and Stopa (2008) complemented this findings, by ascertaining that being self-focused does not necessarily means neglecting social context. Their experimental manipulation lead to selffocus attention but did not at the same time lead to diminish surroundings awareness, indicating that the socially anxious individual continues to be aware and attentive to clues taken from the social surroundings. These authors propose that this attention is focused on scanning surroundings for negative clues. They also add that the vast attentional demands faced by socially anxious individuals contribute to their limited processing and poor response when in social events.

Interpretation Socially anxious individuals present interpretation bias in social events, concerning others and concerning himself. This bias is specific so social events pertinent to the self (Amin et al., 1998; Amir et al., 2005; Spence et al., 1999), which are, by definition, more ambiguous and uncertain (Heinrichs and Hofmann, 2001) than events when others are not present, either as interaction partners or as mere observers or evaluators. This specific bias is not found in other kinds of events (e.g. physical threat) nor is it found in normal controls (Voncken et al., 2003) or other psychopathologies (e.g. specific phobias, obsessivecompulsive disorder, depression; Cho and Telch, 2005; Stopa and Clark, 2000). This was also proposed for socially anxious adolescents (Miers et al., 2008). Concerning others, Ashbaugh et al. (2005) found no difference between socially anxious and non-anxious individuals on performance evaluation. On the contrary, Alden and Wallace (1995) found a positive bias, meaning that others’ performance is judge more favorably than it actually was. Because a speech rating task was used in the first study and an interaction rating task was used in the second, one may speculate that different evaluation criteria is used for evaluating others’ performance in diferent types of social events. Concerning himself, there seems to be a negative bias, meaning that the socially-anxious individual underestimates the quality of his social performance (Ashbaugh et al., 2005; Bogels and Zigterman, 2000; Brendle and Wenzel, 2004; George and Stopa, 2008), and overestimate how much his anxiety is noticeable (Mansell and Clark, 1999; Roth et al., 2001), whether in positive or negative social events. This means that this negative bias is present regardless of others’ reactions, the way the interaction develops, or actual personal performance (Alden and Wallace, 1995). It also persists even when the individual is given the option to choose a more positive interpretation, meaning that he represents social events more negatively, even when a more positive perspective is available (Amir et al., 2005; Stopa and Clark, 2000). This negative bias is not completely inaccurate, because observers also rate socially anxious’ performance as lower in competency and higher in anxiety demonstrated (Alden and Taylor, 2004; Ashbaugh et al., 2005; Creed and Funder, 1998). For children role-

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playing performance tasks, however, only poorer self-evaluations were found, which were not reflected in others’ evaluation of personal performance (Tuschen-Caffier et al., 2011). The negative interpretation bias also applies to perception of danger in social events. The socially anxious individual tends to ascertain that ambiguous social events are threating (Constans et al., 1999; Wenzel et al., 2002) and will result in rejection, humiliation, loss of social status or any other form of negative evaluation. Broadening this findings, Voncken et al. (2003) found that the negative interpretation bias can be seen in positive, ambiguous, mildly negative and profoundly negative social events. In addition to expecting higher social costs from unsuccessful social events (Amir et al., 2005), or even catastrophic long-term outcomes from mildly unsuccessful social events (Stopa and Clark, 2000), socially anxious individuals also expect these unsuccessful social events to occur more frequently and result from their personal and enduring inability (Amir et al., 2005; Rheingold et al., 2003; Stopa and Clark, 2000; Voncken et al., 2003). That is to say, they expect to frequently fail in their social performance or interaction and to be exaggeratedly punished by it, and they attribute social failure to themselves (George and Stopa, 2008). This bias is evident also when socially anxious individuals are asked to imagine an ending to an ambiguous social event, written in the first person: their endings are usually more negative (Hertel et al., 2008). In line with this, when presented with ambiguous stories, socially anxious children need fewer information for assigning a bad ending to it, denoting a threat interpretation bias (Higa and Daleiden, 2008; Muris et al., 2000), and socially anxious adolescents more frequently endorse negative meaning to hypothetical social situations (Miers et al., 2008). Concerning positive outcomes, socially anxious individuals think them to be less probable for themselves than for others, especially in self-referring events (Amir et al., 2005; Spence et al., 1999). Accordingly, socially-anxious children expect to perform worse than other children, and this trend is more pronounced in comparison with non-anxious children, who do not expect other children to perform significantly different from themselves (Tuschen-Caffier et al., 2011). Even though socially anxious individuals may enter a social task (in this case, rating of emotional expression in faces) with an even positive and negative interpretation style, while the task continues, they tend to become increasingly negative in their evaluations of social stimuli, associating negative outcomes to positive emotional expression, and lacking a protective positive on-line bias (Garner et al., 2006). Thus, this author points to the pertinence of considering not only the existence of a negative bias in social anxiety (which he did not found to be significant), but, more importantly, the absence of a positive protective bias when faced with positive stimuli relevant to the self. This was also stressed by Constans et al. (1999) and Hirsch and Mathews (2000), who propose that interpretation bias in social anxiety is related to the absence of a positive interpretation bias, rather than the presence of a negative one. They claim that socially anxious individuals tend to make positive interpretations of social vignettes, but that they are less positive then their non-anxious counterparts, who seem to favor benign interpretations. This was also found by Beard and Amir (2009). They state that a positive interpretation bias may be more evident in non-anxious control and be lacking in socially anxious, who endorse threat and benign interpretations in a similar proportion. Huppert et al. (2003) refer to the difference in positive and negative interpretation bias, ascertaining that negative bias seems to be specific of social anxiety and be active during social events, whilst positive bias seem to associate to negative affect in general and be active after the threating events has ended. Posterior work by the same authors (Huppert et al., 2007)

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validates this assumption, because socially anxious individuals presented a negative bias when generating and selecting options for ambiguous sentence completion. Social anxiety seemed to associate to negative attributions on self-referent events, whilst depression seemed to relate to a more non-specific negative attribution style. This later work nevertheless extends the previous one, by ascertaining that the lack of positive bias for the same task remained associated with social anxiety after controlling for depression, and so lacking positive bias may also be a specific feature of social anxiety. This was not, however, found for adolescents, who did not display lower frequency of attributing positive meaning to hypothetical social scenarios (Miers et al., 2008). Thus, the relative importance of positive and negative interpretation biases for social anxiety is under ongoing scrutiny, and seems to be dependent on the evaluation method used to gather data. This shift between negative and positive interpretation bias may also change throughout a lifetime of social anxiety. As the individual has no other choice but to be exposed to several social events, namely positive ones, he may gradually develop a less negative attribution style, that nevertheless remains less positive than the attribution style found for non-anxious individuals.

Memory Results found concerning memory processes are the most controversial. Some studies found a negative bias for memory processes in social anxiety, meaning that socially anxious individuals preferably memorize negatives perspectives on social events in which they are or could be involved (Hertel et al., 2008), based on their own feeling, behavior and thoughts on those same events, and neglecting external information and inferences that could be drawn based on it (Hirsch and Mathews, 2000; Mellings and Alden, 2000). On the contrary, Wenzel and Holt (2002) and Heinrichs and Hofmann (2004) established that socially anxious individuals recall fewer words associated with social threat compared with non-anxious controls, demonstrating avoidance of rumination on negative information, probably to selfprotect from greater anxiety once the social event is over. Other studies have ascertained that there seems to be no differences between socially anxious and non-anxious individuals in recall of detailed and precise information from previously presented passages. For example, Brendel and Wenzel (2004) presented socially anxious and non-anxious individuals with positive, neutral and negative passages and found that although their memory ability is intact in what precise facts are concerned, socially anxious individuals tend to impose a biased interpretation style upon the material. A negative bias in positive passages relevant to the self (written in the first person perspective) was found in an immediate recall task, and a less positive bias was particularly evident in the long term recall task (48 hours). This lacking of positive interpretation when faced with positive stimuli was also found in recall tasks by Garner et al. (2006), while the specificity of memory bias for self-pertinent vignettes was documented by Constans et al. (1999), and, finally, the accuracy of factual recollection but attribution of negative meaning to the information was validated by Hertel et al. (2008). While aiming to replicate Brendel and Wenzels’ work, Wenzel et al. (2005) found the same factual accurate recall of information presented in positive, neutral and negative vignettes, and the same rating of negative interpretations as being more likely, but not of positive interpretations as being less likely. The lack of a positive bias may be more specific to self-referent information, while negative information bias may be more general

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and thus become apparent in Wenzels’ et al. (2005) work, where other and self-referent information was not made distinguishable. The findings reviewed above indicate that there doesn’t seem to be a biased memory process in social anxiety, other than that imposed by attentional and interpretation biases. If information is attended to in a negative perspective, it seems only logical that it will be encoded and later recalled as negative experiences in social events (Hertel et al., 2008; Wells et al., 1998). Thus, memory bias may be only found for off-line and not on-line processing of social events (Hirsch and Mathews, 2000) and may be contingent upon activating social fears when evaluated under experimental conditions (Hertel et al., 2008). In fact, Mansell and Clark (1999) only found that socially anxious individuals recalled less positive public-referent words when anticipating giving a speech. This means that although they focus on a less positive view of themselves as seen by others, this information only seems to linger in memory if social fears are activated. We should also consider that different results were found using different recall stimuli. When faces or words were used, there seems to be a bias away from threat, whereas when social vignettes were used, negative interpretation bias was placed upon memory processes, especially in positive and self-relevant passages. Results may also differ when the tasks’ instructions predispose to intentionally learning, and the individual thus feels motivated to memorize all the material he is presented with, regardless of it being social or physical threat, or neutral (Heinrichs and Hofmann, 2004). Other than negative or positive meaning given to memories, Coles et al. (2002) evaluated perspective taking in memories of social interactions and social performance. They found that socially anxious individuals, in comparison with non-anxious controls, recall interactions from a more observer perspective, and this difference became more pronounced over a period time of 3 weeks. Because these observer perspectives are usually negative and focused on how the individual believes to be seen by others, they represent an inaccurate perception of reality, which is kept and becomes more salient over time, thus perpetuating a negative selfrepresentation that is activated when anticipating new social events.

Cognitive Symptoms Cognitive symptoms are the verbal or visual manifestations of information processing when facing social events, namely attention and interpretation. They should therefore closely reflect findings for negative biased attention and interpretation process in social anxiety.

Automatic Thoughts Socially anxious individuals present more negative and less positive thoughts, both in social performance and interaction events, but more so in this last kind of events (Beazley et al., 2001; Stopa and Clark, 1993). Turner et al. (1986) found that frequency of negative thoughts differed according to types of social events: they seem to be more frequent when interacting with the opposite sex and in performance tasks, in comparison with interaction with a same sex partner. Regarding this thoughts’ content, is was found to be stable across social events and focus on fear of negative evaluation pending on personal social

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incompetence, anticipating negative consequences, and pondering how to avoid the situation (Beazley et al., 2001; Beidel et al., 1985). This fear of negative evaluation and selfdepreciation of personal social competence and acceptability was found to be specific to social anxiety, in comparison with depression (Cho and Telch, 2005). The socially anxious individual thinks about himself in a negative perspective, underestimating the quality of his social performance and coping skills (Alden and Wallace, 1995; Stopa and Clark, 1993). This was found especially in less structure and more ambiguous situations, that demand more on a persons’social skills, which are debilitated in the case of social anxiety, by anxiety physiological symptoms, social information processing biases, and negative automatic thoughts (Alden and Wallace, 1995). These individuals also underestimate how interesting, intimate, agreeable, likable, or attractive they appear to others and overestimate how anxious they look (Alden and Wallace, 1995; Alfano et al., 2006). Moreover, they think these anxiety symptoms are clearly noticed by others and seen by them as a sign of psychiatric condition and not normal anxiety (Roth et al., 2001). For socially anxious children, thoughts on performance tasks were not only more negative than on interaction tasks but they were also more frequent, when compared to their non-anxious counterparts (Tuschen-Caffier et al., 2011). Socially anxious children perceive themselves to be more anxious in social performance and interaction tasks and expect to perform poorly and be evaluated by others as such (Alfano et al., 2006; Spence et al., 1999). The fear and anticipation of negative evaluation is exacerbated by the fact that socially anxious individuals believe others hold very high and perfectionist standards by which one must abbey to be positively evaluated (Ingram et al., 2003). In fact, when asked to evaluate their own performance after it occurred, socially anxious youths are still the most ferocious critics of themselves, judging their performance more poorly then others do (Alfano et al., 2006; Beidel et al., 1985; Spence et al., 1999). Regarding frequency of positive automatic thoughts, they are more frequent when in same-sex interaction, followed by opposite-sex interaction and, finally, giving a speech (Turner et al., 1986). Moreover, regarding positive thoughts’ content, when interacting with the opposite sex, it is non-specific; when interacting with someone from the same sex, it is focused on assessing control, trust, potential risk and potential positive outcomes; when in social performance events, it focus on assessing control, risk and self-confidence on personal ability to perform (Beazley et al., 2001). Socially anxious individuals also express less coping thoughts and attribute the discomfort in the event to themselves and not to the characteristics of the event (Beidel et al., 1985). Not only do these individuals express less coping and more avoidance thoughts, but they believe them more than their non-anxious counterparts (Stopa and Clark, 1993). Positive thoughts on rational coping, self-efficacy and positive anticipation seem to be specific of social anxiety, in comparison with depression (Cho and Telch, 2005).

Images Socially anxious individuals tend to see themselves how they imagine others see them, but only use information from their own experience to generate such an image. Internal information is used to sustain inferences on how others see and evaluate the self (Wells et al., 1998). This self-image is, consequently, distorted, negative and using an observer perspective, but nevertheless the individual, when involved in the social event, believes it to be accurate. It

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is only after the event has passed that he is capable of analyzing the accuracy of this image and consider it distorted (Hackmann et al., 1998). These images are stable and recurrent, meaning that they hold very similar across time and different social events and they are activated spontaneously, more frequently in anticipation or during the anxiety provoking social events (Hackmann et al., 2000; Hackmann et al., 1998). They include visual components, as well as sounds, smells, tastes and bodily sensations. Hackmann et al. (2000) also found that these images’ content was associated to unpleasant or even traumatic social experiences that the individual had experienced in the past, at about the same time when the anxiety began, where the individual concluded to be socially inadequate or incompetent. These meaning is kept stable and activated when the entering a new social event. This image is described as seeing oneself being criticized or doing something wrong, fearing others will critically notice some anxiety symptom, feeling self-focused and uncomfortable about ones’ own self-image and around others, and fearing others will show no interest in the self. Hence, this negative self-image seems to consists of a picture of the socially anxious’ worst fears coming true in social events (Hackmann et al., 1998). That is to say that the individual sees himself as performing and looking exactly the way he fears to behave and he believes will lead to others disapproval, rejection, humiliation or any other form of negative evaluation. Because he believes this image to be accurate, it serves as confirmation of the social inability the individual has learnt and still believes to possess.

CONCLUSION The work presented in this chapter intended to review literature on cognition in social anxiety, in order to empirically validate cognitive models for social anxiety. To do that, we performed online search and selected fifty-one works, which were analyzed and categorize in order to answer our investigation objective. Even though our initial categorization of content for the sources selected for analyses seemed to point to each source evaluating rather isolated aspects of cognition in social anxiety (Table 1), our content analysis proved otherwise. About a quarter of the works analyzed intended to or merely stumbled on results pertaining to more than one category of cognition in social anxiety, according to our definition and categorization. This speaks very well of research in the area, as being open to multiple influences on each of the steps proposed by cognitive models for social anxiety, which, in turn, prove to be inseparable and work to sustain one another. Yet, only a few works selected for this review explicitly tried to evaluate multiple influences of different aspects of cognition in social anxiety (Baldwin and Main, 2001; Beard and Amir, 2009; Mansell and Clark, 1999). We recognize that evaluating these multiple influences represents a methodological endeavor, but still believe it to be a necessary next step in validating cognitive models for social anxiety. Also, learning to evaluate and differentiate which cognitive bias is characteristic of an individuals’ social anxiety may better inform idiosyncratic intervention strategies. We cannot forget that there are several types of social anxiety (namely generalized or specific social anxiety, social anxiety with or without social skills deficit, inhibit or aggressive social anxiety; Hofmann et al., 1999; Kashdan and McKnight, 2010; Vagos, 2010), and so the better

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we understand what we don’t see when helping a socially anxious individual, the highest the probability of therapeutic success. For now, this chapter allows us to conclude on the evidence found for each of the three components we considered to be part of cognitive models for social anxiety, namely Clarks’ (2005), which has grounded our work. Social anxiety seems to be keep, despite social exposure the individual may face, because of a cognitive self-perpetuating cycle. As an emotional, physiological and behavioral response, social anxiety only becomes maladaptive if social events are perceived as more threating then they actually are. Such perception derives from several steps in cognition. The first of these proposed steps is the activation of negative core relational or interpersonal beliefs or schemas. Evidence reviewed in this chapter ascertains for a negative representation of the self, others and relationships in socially anxious individuals. They believe themselves to be socially incompetent and fated to fail in interaction and social performance, because they will be incapable of living up to the highly standards they believe others hold for their performance. Others are, they believe, attentive critics and prone to be punitive of personal failures. Inevitably, relationships are seen as conditional on perfect social performance, and when one believes he will never be able to accomplish this condition, relationships become threatening and frightening. Social anxiety can be said to spring from the discrepancy resulting from perceiving others to hold high standards for personal performance and, at the same, believing to be incapable of meeting those standards. This important cognitive vulnerability to social anxiety has been highlighted by other authors trying to explain social anxiety. To name a few, Rapee and Heimbergs’ cognitive model for social anxiety (Rapee and Heimberg, 1997; which Clark assumes to have integrated in his own) focused more on this initial step of cognitive vulnerability to social anxiety, by stating that the discrepancy between what the individual believes he can do and what he believes others expect him to do in social events leads to increased levels of fear of negative evaluation and social anxiety. Hofmann (2007) went a little further with this idea. He relied on evidence taken from attention and interpretation bias in social anxiety to emphasize that social anxiety may be the result of failure to establish adequate and realist social goals. When placing social success at an unattainable level, the individual is bound to fail and again confirm his perspective of how he is incapable and how others are in control and strict judges of personal behavior. Alden and Taylor (2004) also stressed the importance of these cognitive core beliefs, but analyzed it under an interpersonal perspective. They emphasized that cognitive beliefs are developed through social meanings repeatedly taken from early social experiences, and concern perceptions about the self, others and relationships, which are indissoluble. When activated, these perceptions dictate what the individual should fear (social encounters) and how he should act (safety behaviors or avoidance), which had proven successfull in early relationships. These emotional and behavioral symptoms, however, became maladaptive over time, and elicit negative social responses from others, again confirming initial core beliefs held by socially anxious individuals. How the individual sees himself and others should, therefore, be considered as an important vulnerability factor for the onset and maintenance of social anxiety. These cognitive structures are proposed to have a very low threshold, and be activated when any given event is subjectively interpreted as resembling the interpersonal meanings that originally associated with these structures’ development. Once activated, they interfere with social information processing, in order to achieve cognitive consonance. This brings us

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to the second step in biased cognitive processes in social anxiety, involving attention, interpretation and memory processes. Evidence reviewed concurs to social information processing serving to confirm and reinforce negative perceptions of self, others and relationships. Attention is usually self-focused, overestimating negative reactions or symptoms that could be negatively evaluated by others. Concerning other persons’ behavior, attention is either focused on negative reactions that could lead to rejection, humiliation or any other form of negative evaluation, or is allocated away from the stimuli, so as to avoid processing threat. In both cases, no information is processed that could question or disconfirm the initial beliefs and representation of the social world. This attention focus is eminently associated with interpretation. When we say individuals attend to negative internal or external clues, we are assuming negative meaning was already given to these clues. Evidence in fact indicates that socially anxious individuals are predisposed to make more negative and less positive attributions in social events, namely of the probability of social failure, due to their personal incompetence which will, consequently, bring about negative or catastrophic social costs. This attention and interpretation negative bias may be placed upon memorized information, which justifies why socially anxious individuals seem able to accurately recall factual information, but describe it in a more negative perspective, particularly when off-line memory is evaluated. Even so, this chapters’ review points out that findings in memory processing in social anxiety are still controversial and contingent on how and when memory biases are accessed. Moreover, we believe the findings reviewed above for attention, memory and interpretation processes fit well with the vigilance-avoidance hypothesis, which was elaborated on by Bogels and Mansell (2004) relating only to attention. This hypothesis generally states that when under perceived threat, socially anxious individuals may be particularly vigilant of negative internal and external information and, at the same time or later on, avoid processing information from the event, for fear of increased anxiety. We are not usually aware of our social information processing, that is to say, of where our attention in focusing, of what meanings we are attributing, or of what information we are memorizing, especially when we are particularly concerned with fear of negative evaluation, as is the case in social anxiety. Instead, we are aware of our own thoughts (what comes to our mind) and images (how we see ourselves), which derive directly from the above mentioned social information processes. Socially anxious individuals endorse more negative thoughts, concerning their social inability, their low attractiveness, likeability or how interesting they come about to others. They also endorse less positive thoughts, namely less coping, selfefficacy or trust thoughts. While negative thoughts hold very similar, positive thoughts seem to vary according to the kind of social events one is facing. Social anxiety is also characterized by recurrent and spontaneous activation of negative images of how one perceives to be seen by others. That is to say that the images socially anxious individuals hold when in social events are usually negative and taken from an observer perspective. They see themselves as badly as they believe others are seeing them, but are incapable of putting this image to the test. As we can clearly see, cognition in social anxiety is fundamentally tainted by tendencies to highlight all that is bad and neglect all that could potentially be good. There is little chance then that new social exposures will serve to change this cognitive cycle, because they are not really processed; new social events are merely seen as reflecting internal experiences and are taken as a priori absolute truths. It seems only logical that if negative information, which is not weighted against the opinion and perspective of others, is the focus of core beliefs, of

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attention and interpretation processes, and of cognitive products, it will also be present whenever the socially anxious individual anticipates or leaves a social interaction or performance event. The cognitive cycle that maintains social anxiety must, therefore, also include anticipatory processing and rumination after the social event is finished (Heinrichs and Hofmann, 2001; Mellings and Alden, 2000). Taken together, this biased processes in cognition in social anxiety make it so that the socially anxious individual starts his “social race” already with a setback and handicap: the fact that he honestly beliefs he will fail, based on the personal database of failures he has built over previous social events and hasn’t checked against objective external information. The image created of every new social event is shadowed by past ones, and that is why simple behavioral exposure won’t be enough for dealing with social anxiety.The individual will need help in reevaluating current social events he may face, but, in addition, he may also need help in reevaluating his past memories and appending self-image, which block adequate social information processing in the present. If not, every new social event will be contaminated with previous negative beliefs, which places the individual in a vicious cycle that maintains and exacerbates social anxiety. This social handicap starts as young as adolescence and may serve as a precipitating and maintaining factor for social anxiety (Rheingold et al., 2003). Socially anxious adolescents present higher number of negative self-talk in social performance tasks, when compared to socially anxious children and non-anxious adolescents. Even though their overall number of negative thoughts is low (Alfano et al., 2006), they still seem to be the higher at risk group for increased or psychopathological levels of social anxiety. Regardless of the risk they face, there were only a minority of works focusing on cognition in adolescents’ social anxiety, namely Alfano et al. (2006), Miers et al. (2008), and Rheingold et al. (2003). We found a similar scenario for children’s social anxiety, that was addressed by only six of the selected works (Alfano et al., 2006; Bogels and Zigterman, 2000; Higa and Daleiden, 2008; Muris et al., 2000; Spence et al., 1999; Tuschen-Caffier et al., 2011). Their findings indicate children have very few thoughts in social events, which may be because children are not yet able to easily think abour and name their thoughts (Beidel, 1998). This does not mean that cognition may not play an important role in childhood social anxiety, but rather that we weren’t yet able to evaluate if it does. Maybe the use of stories, drawings and speech in bubbles for each character may help us to better address what goes on in the mind of socially anxious children. Also, understanding their temperament and parental styles as etiological factors for social anxiety may help to better understand how children cognitively represent their social world. Only one of the works revised in this chapter presented conclusions on gender differences, related to bias in social information processing. Adolescent girls usually present higher anxiety levels then boys (Essau, Conradt, and Petermann, 1999) and, consistent with this, they also selected more frequently a negative interpretation of hypothetical social scenarios and less frequently a positive interpretation. Also, they more strongly believed their interpretation to be accurate (Miers et al., 2008). How gender differences manifest in children or adults, or in other dimensions of cognition in social anxiety remains to be considered. Several of the works reviewed in this chapter give clinical implications for their findings, which we considered important to present to the reader, organizing them according to the cognitive model under scrutiny in this chapter. First of all, changing the schema content and activation processes should be considered one of the main intervention goals for social anxiety, because it would make the individual less vulnerable to experiencing social anxiety

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prior, during and after the social event occurs (Wenzel, 2004). In order to change biased core beliefs, it will be necessary to help the individual to encode and attend to external clues that may disconfirm them (Hirsch and Mathews, 2000). We may also add that we need to practice cognitive restructuring of internal and external clues that the individual may attend to and process, to achieve a more precise interpretation of the ongoing social exchange occurring in social events and, in consequence, give a more adequate social response. Yet, merely instructing to focus attention on external clues may not be enough, because when attention should be focused externally, socially anxious individuals tend to focus it on an image of the self that they built and believe is seen by others. Their resources are, thus, misdirected automatically (Ingram et al., 2003) and so conditions need to be created to force the allocation of attentional resources outside personally built representations of the social event. For instance, instructing socially anxious individuals to engage in the conversations, to ask questions, and adequately training them in the use of social skills may help them refocus and better respond to external clues given by interaction partners or performance observers. Referring to interpretation bias, it should be important, especially with non-clinical socially anxious individuals, to promote a more positive interpretation bias, and not only to diminish the negative bias (Beard and Amir, 2009; Constans et al., 1999). Nevertheless, the very act of diminishing negative bias may highlight possible positive interpretations and should therefore be the focus of intervention, especially with adolescents (Miers et al., 2008). Concerning the self-image that is usually activated in social events, from an observer perspective, it seems to have a maintaining effect on social anxiety, by increasing anxiety, and by increasing the belief that others see how one is anxious and how poorly one is performing. On the contrary, holding a more positive self-image in interaction and social performance events seems to contribute to diminished anxiety and better social performance (Hirsch, Clark, Mathews, and Williams, 2003), and so psychotherapeutic efforts should be directed at generating and maintaining this positive image while in social events. The frequent negative image experienced by socially anxious individuals is usually stable, recurrent, intrusive and associated to memories of past social events that were unsuccessful. Because these events were traumatic to the individual, he avoided processing them and never integrated them into his autobiography. The meaning attributed to these memories remains extremely painful, stressful and anxiety provoking. Thus, restructuring the meaning attributed to this image has proven to be helpful in diminishing anxiety levels (Wild, Hackmann, and Clark, 2007). Again, adding all this intervention strategies into one intervention plan or program for social anxiety seems to be herculean and may even be contra productive. Most intervention programs focus on cognitive restructuring of automatic negative thoughts and exposure, and have proven to be efficient (e.g. Albano and DiBartolo, 2007; D. Hope, Heimberg, and Turk, 2006). Most also include an implicit social skills training module. Explicit social skills training, along with cognitive restructuring and behavioral exposure, has also proved to be efficient in diminishing social anxiety in adolescents with social anxiety conjugated with assertiveness deficits (Vagos, Oliveira, and Pereira, 2010). A recently developed program in Portugal had shifting attention focus as its main intervention objective and proved successful in diminishing social anxiety levels in adolescence (Salvador, 2010). Why do all these interventions work? Because we are dealing with different weaknesses and problematic areas in social anxiety. We need not include all potential useful interventions with one single patient; we need to carefully assess his needs and shape the intervention to them. One

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problematic area that has been neglected in intervention programs is changing core beliefs. As so, we cannot, at this moment, ascertain on their efficiency, but based on our review, we can speculate of its importance, especially with chronic social anxiety. Several limitations to the work developed in this chapter should be noticed. First of all, we choose to address an ongoing topic in the literature. Even as we were writing this chapter we frequently came across new publications on the subject and had to forbid ourselves of looking at them for fear of never finishing the work. Thus, this work by no means assumes to be conclusive or include all the work in the area. We merely intended to gather important works on the subject and organize the evidence they found, providing a stepping stone for others to step on. For instance, we recognize that several works reviewed by Musa and Lepine (2000), Heinrichs and Hofman (2001), Clark and McManus (2002), Bogels and Mansell (2004)a nd Hirsch and Clark (2004) were not included in the present review. Even though we reached similar conclusions, we cannot assume this chapter to be a complete substitute forthose works, but merely to draw on them and explicit information they did not, concerning core beliefs and cognitive symptoms in social anxiety. Another limitation to be noticed it that works included in this chapter may be considered to suffer from “publication bias” because there is tendency to only publish significant results. Non-significant study outcomes are usually underreported in the literature and so future works should consider other search methods. For instance, the authors know of undergraduate work done on the subject that remained unpublished that found no differences in social information processing biases when interpersonal schemas were and were not activated. Despite all the methodological limitations that may account for these results, this kind of works still shed light into under-researched areas of cognition in social anxiety and should, therefore, be considered. Nevertheless, this chapter includes works where results were not significant, so we expect this review not to be too tainted by the so called publication bias. We should also note limitations in the cultural background of the samples evaluated in the selected studies. The majority of the samples were American, with only one study reporting to include children from Asian cultural backgrounds (Hertel et al., 2008). Thus, different cultural expressions of social anxiety and of the cognitive processes that underlie it may have been underrepresented in this chapter, as they seem to be in the literature in general. This chapter set out to present evidence on the various processes involved in Clarks’ cognitive model for social anxiety (Clark, 2005), and we believe to have accomplished our goal. The works reviewed above lead us to conclude not only that attention, interpretation and memory processes may be biased in social anxiety, as others had so effectively done before us, but also they there seems to be a core cognitive vulnerability to experiencing social anxiety and that cognitive bias are reflected in specific cognitive symptoms. We can conclude that there is sufficient evidence found in the literature to confirm and validate Clarks’ model, and consequently recommend it to be used in understanding and intervening in social anxiety. Nevertheless, endeavors still need to be done to evaluate how and under what conditions these cognitive core beliefs, processes and symptoms relate to one another and activate each other, not only in adult clinical and non-clinical populations, but also in clinical and nonclinical adolescent and children samples.

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In: Advances in Psychology Research. Volume 93 Editor: Alexandra M. Columbus

ISBN: 978-1-62081-470-3 © 2013 Nova Science Publishers, Inc.

Chapter 2

CRITICAL VARIABLES IN COGNITIVE-BEHAVIORAL THERAPY FOR PEDIATRIC AND ADULT OBSESSIVECOMPULSIVE DISORDERS Adam Reid, Joseph McNamara, Maria Constantinidou, Johanna Meyer, Yonnette Forde and Gary Geffken Division of Medical Psychology in the Department of Psychiatry University of Florida Health Science Center, Jacksonville, FL, US

Abstract Cognitive-Behavioral Therapy (CBT) has been empirically validated as an effective first-line treatment for both pediatric and adult Obsessive-Compulsive Disorder (OCD). However, OCD is a highly heterogeneous disorder, causing many treatment refractory cases that leave clinicians baffled. This chapter reviews the past ten years of research on several of the most challenging OCD presentations, including OCD with poor insight, high family accommodation, comorbid oppositional defiant disorder, scrupulosity, and post-partum onset. Each of these presentations are discussed in terms of identifying characteristics, treatment augmentation and case examples. Research supporting innovative assessment for these OCD presentations is outlined as well. CBT is a highly adaptable treatment approach. This chapter aims to summarize past findings and facilitate future research that will guide clinicians in adapting CBT for treatment refractory OCD, thus improving overall treatment outcome.

INTRODUCTION Obsessive Compulsive Disorder (OCD) is an anxiety disorder that plagues 1-3% of the United States population (Kessler et al., 2005) and is one of the 10 most disabling medical conditions according to the World Health Organization (Murray & Lopez, 1996). OCD is characterized by unwanted feelings, ideas, and thoughts (obsessions), as well as behaviors (compulsions) that the individual feels compelled to carry out to alleviate the anxiety caused

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by their obsessions. When a person with OCD performs a compulsion, his/her anxiety temporarily decreases but next time the obsession returns the anxiety related to the need to perform the compulsion is increased, as the individual feels a greater requirement to negate the obsession. Thus, a negative feedback loop is created and this is why over 50% of individuals with OCD are severely impaired in functioning (Kessler et al., 2005). Numerous treatments for OCD exist, but two treatments are extensively emperically supported. These include pharmocological treatment with Selective Serotonin Reuptake Inhibitors (SSRIs) and Cognitive-Behavioral Therapy with Exposure and Response Prevention (CBT). However, this review will focus on CBT for OCD which has been demonstrated as effective and empirically validated for children and adults. Medication will only be discussed in terms of an augmentation strategy for individuals who receive little benefit from standard CBT therapy. Many studies have revealed CBT’s efficacy when treating OCD. The original Pediatric OCD Treatment Study published in the Journal of the American Medical Association concluded “Children and adolescents with OCD should begin treatment with the combination of CBT plus a selective serotonin reuptake inhibitor or CBT alone” (POTS, 2004). Research suggests that whether the treatment is intensive or weekly, the effectiveness of CognitiveBehavioral Therapy is still supported (Storch, 2008). Multiple studies have found a high level of efficacy for CBT in children and adolescents (Freeman et al., 2008), as well as adults (see Stein, Ipser, Baldwin, and Bandelow, 2007 for a review). The efficacy of CBT has been observed outside of the United States as well, such as in Norway (Valderhaug, 2007). While CBT has been shown to effectively reduce OCD symptoms, there are frequent instances in which remission is not achieved. There are many factors that can relate to a lack of improvement in OCD symptomatology.The success of CBT is highly dependent on patient adherence with recommendations for treatment. Short-term increases in distress and anxiety are critical to the success of CBT, and if a patient is unwilling to increase their short term distress, treatment will not be successful. Another factor that affects the efficacy of treatment is the duration of the treatment; while CBT is often effective, it involves repeated trials of ERP over numerous sessions; if there is insufficient ERP and/or an inadequate number of trials over the treatment sessions, the obsessions and/or compulsions will not be sufficiently treated. If a case is treatment refractory it means that the case is unresponseive to standard treatments; a treatment refractory case is illustrated by a patient who has gone to multiple treatment providers in an effort to be treated for a disorder without experiencing significant symptom reduction. Hofmann & Smits (2008) have speculated that Obsessive-Compulsive Disorder is one of the most treatment refractory anxiety disorders, as a result of the large heterogeneity in symptom presentation. This chapter will present multiple examples of illustrative OCD presentations, including OCD with poor insight, high family accommodation, comorbid Oppositional Defiant Disorder in children, scrupulosity and post-partum onset in adults. The goal of this chapter is to provide clinicians with insight into the OCD presentations that are likely to respond minimally to standard CBT and describe innovative treatment approaches that may be implemented in cases where patients are experiencing marginal reduction in their obsessions or compulsions. The chapter is not intended to provide a comprehensive review of all treatment refractory cases of OCD.

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OCD WITH POOR INSIGHT Presentation The term “OCD with poor insight” has previously been known as “obsessive psychosis” (Robinson, Winnik, & Weiss, 1976; Tanzi & Lugaro, 1923), “OCD with psychotic features” (Insel & Akiskal, 1986)and “OCD with overvalued ideas” (Kozak & Foa, 1994); however, the presentation of the disorder has remained the same. The DSM-IV-TR identifies a patientas having OCD with poor insight if, “for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable (American Psychiatric Association. OCD patients with poor insight bear several clinical characteristics that are distinct from their insightful counterparts. These patients typically do not believe that their obsessions and compulsions are unusual or extreme, and may not consider them to be OCD symptoms at all. These patients have also been shown to have more severe obsessive and compulsive symptoms, depression, anxiety and a higher comorbidity rate (Catapano, Sperandeo, Perris, Lanzaro, & Maj, 2001; Kishore, Samar, Reddy, Chandrasekhar, & Thennarasu, 2004; Türksoy, Tükel, Özdemir, & Karali, 2002). Health concerns also exist at a higher rate among OCD patients with poor insight (Abramowitz, Brigidi, & Foa, 1999). The course and nature of the obsessions and compulsions experienced by these individuals with poor insight is unique from individuals with good insight, as the former may have a longer duration of the illness, an early age-of-onset, a larger number of obsessivecompulsive symptoms, a history of psychiatric disorders during childhood, as well as more first-degree relatives who also have OCD (Bellino, Patria, Ziero, & Bogetto, 2005; Catapano et al., 2001; Kishore et al., 2004). Previously, it was thought that poor insight was not linked to poor treatment outcome. Unfortunately, more recent literature has shown that patients with poor insight have poorer treatment outcome with both behavioral and pharmaceutical approaches (Foa, Abramowitz, Franklin, & Kozak, 1999; Kishore et al., 2004).

Treatment Augmentation As highlighted above, poor insight can adversely affect treatment response when clinicians utilize a standard CBT or phramacological approach to the treatment of the obsessions and compulsions. Thus, a line of future research for both pediatric and adult OCD need to focus on treatment augmentation, or the development of alternative approaches to the treatment of OCD with poor insight that may yield higher treatment outcome. Comorbid schizotypal traits have been suggested as one possible contributor to poor insight in OCD (Catapano et al., 2010; Poyurovsky et al., 2008; Moritz et al., 2004). Researchers who take this perspective point to the neurological and symptom presentation overlap between OCD patients with comorbid schizotypal symptoms and OCD with “poor insight” (for a review, see Poyurovsky & Koran, 2005). Patient groups identified these ways have significantly higher frontal lobe dysfunction (Kitis et al., 2007; Shin et al., 2008), executive functioning (Berman et al.,1998), graphesthesia deficits (Tumkaya, Karadag, & Oguzhanoglu, 2010), and present with earlier age of onset, increased obsession and

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compulsion severity, and worse treatment response (Eisen et al.,2001; Sobin et al., 2000; Moritz et al., 2008). It is possible that OCD with elevated schizotypal symptoms may have worse response to treatment as a result of a dysfunctional dopaminergic neurotransmitter pathway, instead of a traditional OCD serotoninergic dysregulation (Catapano et al., 2010, Westenberg, Fineberg, & Denys, 2007). Treatment augmentation for comorbid schizophrenia should include psychopharmacologic adaptations to traditional approaches to the treatment of OCD. Some encouraging findings on the pharmacological front have been reported in the treatment of refractory OCD cases. In the treatment of SRI-refractory OCD cases, clinicians who augment with antipsychotics following three months of unresponsive SRI treatment found significant improvements in 1/3 of these cases (for a review, see Bloch et al., 2006). Bloch and colleagues (2006) identified haloperidol and risperdone as the most efficacious antipsychotics, followed by quetiapine and olanzapine. Less research has been done in pediatric populations, but limited findings indicate that risperdone is an effective augmentation strategy (Thomsen, 2004; Fitzgerald, Steward, Tawile, & Rosenberg, 1999). Though limited, a summary for the treatment guidelines of OCD with psychotic features was published by The American Psychiatric Association (2007). Poor insight is not always associated with schizophrenia, and clinicians may need to augment traditional therapeutic approaches to increase treatment response. Hoarding, a subtype of OCD known for poor insight (Tolin et al., 2010), commonly has poor insight that manifests in anosognosia (lack of awareness regarding the severity of the hoarding), overvalued ideation (unreasonable belief regarding the potential value of items), and defensiveness (resistance in discarding objects) (Frost, Tolin, & Maltby, 2010). While empirical literature is lacking, experts in the field suggest a few techniques to help combat the barriers created by the poor insight in these patients (Frost, Tolin, & Maltby, 2010; Merlo et al., 2009). Specifically, they suggest using motivational interviewing techniques (Miller & Rollnick, 2002) to decrease anosognosia, hypothesis testing to lower overvalued ideation, and work with the patient to develop an increased sense of control to lessen defensiveness. Clearly, poor insight has a heterogeneous presentation in OCD patients. In addition to OCD with psychosis or OCD with hoarding, many other OCD patients struggle to see the irrationality in their obsessions and compulsions, such as OCD in combination with a developmental delay (Ruta, Mugno, D’Arrigo, Vitello & Mazzone, 2010) or severe depression (Turksoy, Tukel, Ozdemir, & Karah, 2002). For these patients, contingency management can be used to augment CBT in order for clinicians to address low insight (Ellis et al., 2006; Pence, Aldea, Sulkowski, & Storch, 2010; Krebs & Heyman, 2010). Simplistically stated, contingency management is based on basic reinforcement principles and uses a token economy approach, where compliance with exposures and homework are rewarded. Augmenting CBT with contingency management involvesdefining compliance and identifying a reward with enough stimulus value to motivate the patient. A case example is provided below in order to illustrate how to address these barriers and to highlight how contingency management may ameliorate refractoriness in refractory OCD cases.

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Case Study Both children and adults suffer from OCD with poor insight. An example of a child case who suffered from OCD with poor insight is AB, a 12-year old female. AB’s main concern was a fear of contamination and her main compulsions were washing excessively with soap or using large amounts of hand sanitizers. AB was convinced that her behaviors were reasonable because she believed that she would get sick without washing. AB was reluctant to engage in therapy because she did not see her behavior as problematic. Initially, motivational interviewing techniques were used to highlight the limitations the child was experiencing because of her OCD. The next steps were identifying items the child would find rewarding. The child responded positively to playing a game with mom, video game time, or a slightly later bed time. The child could earn these rewards for different instances of “being brave”. The next stage was developing a hierarchy with the child and her mother. Many of the initial steps in the hierarchy focused on watching someone, generally her therapist, take on contamination challenges. The child agreed to take on the challenge the next session if her therapist was not sick. The benefits of taking on these challenges were discussed both in the context of earning rewards as well as any additional benefit from being able to function while being “dirty.” At the conclusion of treatment, AB was able to use public bathrooms, touch door knobs, walk in “dirty” stores, and play sports.

OCD WITH HIGH FAMILY ACCOMMODATION Presentation Family accommodation is the process and extent to which family members aid and partake in a patient’s symptoms. This can occur through direct involvement (e.g., repeated verbal reassurance) or indirect involvement (e.g., modification of daily routines to prevent a patient’s distress). Although most families do not believe that accommodation improves the patient’s symptoms or functionality (Calvocoressi et al., 1999), family accommodation is extremely prevalent in both pediatric and adult OCD cases, with roughly 70% of families accommodating some, if not all, OCD symptoms (Allsopp & Verduyn, 1990; Storch et al., 2007). The ways in which family members may accommodate to the patient are unlimited. A parent might allow their child to stay home from school, because the child fears answering a question incorrectly in class. A spouse may allow his or her house to be cluttered with old newspapers because the OCD-sufferer does not want to throw them away. The most common modes of accommodation are providing verbal reassurance, facilitating avoidance and actual participation in rituals (Storch et al., 2007). Accommodation exists for several reasons. Often a family member dislikes seeing the patient distressed, and accommodates in order to relieve the patient of his or her suffering. Another reason may be to lessen the amount of distress felt by the family member themselves (Piacentini, Bergman, Keller, & McCracken, 2003). Many families also believe that family functionality is facilitated through accommodation (Merlo, Lehmkuhl, Geffken, & Storch, 2009).

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Unfortunately, familial accommodation’s impact is a negative one. Family and patient global functioning is actually hindered by accommodation (Calvocoressi et al., 1999; Peris et al., 2008). A decrease in family accommodation is also predictive of better treatment outcome (Merlo et al., 2009; Amir, Freshman, & Foa, 2000; Storch et al., 2007). In order for therapy to be effective, family accommodation must be systematically targeted because it prevents the patient from being able to work through anxiety-provoking situations and prevent rituals. Often, gains made in session are mitigated by accommodation at-home.

Treatment Augmentation Familial accommodation occurs, to a certain extent, in a majority of families with an OCD-afflicted love one. These accommodating behaviors will have a detrimental effect on treatment outcome. Thus, clinicians treating OCD need to be equipped with tools to educate and systematically minimize any accommodation. While the negative effects of family accommodation on treatment outcome are well-researched, augmentation of CBT to address this issue has received little attention (see Steketee & Noppen, 2003). Thus, recommendations discussed below come from clinical experience of the authors of this chapter, as well as what has been recommended in the literature. Psychoeducational groups for family members of OCD patients was the first augmentation strategy to be researched (Marks, Hodgson, & Rachman, 1975), and later research found that relatives of refractory OCD patients who received psychoeducation designed to help reduce family accommodation had lower post-training family accommodation and their loved ones responded to standard CBT treatment more favorably (Grunes, Neziroglu, & McKay, 2001). Many of the current experts agree that educating family members (wife, siblings, parents, etc.) on the adverse effects of accommodation, as well as appropriate responses to their loved ones with OCD, is an imperative first step (Krebs & Heyman, 2010; Merlo et al., 2009). However, conducting separate educational sessions for family members is both time intensive and costly. The most empirically supported innovative augmentation strategy is called Family-Based Cognitive Behavioral Therapy (FB-CBT, see Freedman et al., 2003; Freeman & Garcia, 2009), which involves psychoeducation of the family members but also encourages family members to actively participate in treatment exercises so that they can become “coaches” or “at-home therapists.” FB-CBT generally requires less separate psychoeducation with the parent as parents learn techniques through the modeling of therapists and instruction during in-vivo exposures. Both weekly and intensive family-based treatment approaches were found to significantly reduce the intensity and frequency of children’s obsessions and compulsions (Storch et al., 2007). Furthermore, FB-CBT has shown strong treatment effects 7 years post-treatment, in both individual and group therapy approaches (O’Leary, Barrett, & Fjermestad, 2009). Most importantly, FB-CBT has been found to significantly decrease family accommodation (Merlo et al., 2009). A case example of augmenting traditional CBT with family-based approaches is provided below.

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Case Study An example of an adult case who suffered from OCD with high family accommodation is BD, a 45-year old female. BD’s main concerns were in the aggressive, contamination and symmetry domains. BD’s daughter drove her mother everywhere because of her mother’s concern that BD would cause an accident. BD’s husband started doing all the laundry and all shopping because of BD’s concerns with contamination and symmetry. In order to effectively treat BD, both her husband and daughter needed to be involved in her sessions. Psychoeducation was provided to all family members at the beginning of treatment. Initially the family was encouraged to maintain the initial level of accommodation and gradually reduce the level of accommodation as part of the treatment. Both BD’s husband and daughter participated in ERP exercises.This was important for the family to see the process of habituation and to develop their confidence in the process as well as BD’s confidence. The importance of changing the family’s focus from short-term alleviation of symptoms to longterm alleviation of symptoms was frequently discussed. As part of BD’s hierarchy, she started driving with her daughter and eventually alone. Additionally, she resumed doing laundry and shopping. Both family members praised BD for her efforts. After completing treatment, the family focused on helping BD continue in these behaviors to assure that she did not relapse.

OCD WITH COMORBID ODD Presentation Oppositional Defiant Disorder (ODD) is a Disruptive Behavior Disorder (DBD) characterized by “negativistic, defiant, disobedient and hostile behaviors toward authority figures” (American Psychiatric Association. When combined with OCD, however, ODD can have aggregate negative impacts, especially on the clinical presentation of OCD and course of treatment (Storch et al., 2008). At first glance, OCD might be masked by ODD in that during exposure to anxietyprovoking stimuli, the patient reacts with intense disruptive behavior. Further characteristics of comorbid OCD and ODD include: greater OCD symptom severity; more OCD-related impairment; higher levels of anxiety; and higher levels of internalizing, externalizing and overall problems (Hanna, Yuwiler, & Coates, 1995; Storch, Lewin, Geffken, Morgan, & Murphy, 2010). Limited motivation, insight and symptom resistance may also lead the child to resist therapeutic interventions through aggression and defiance. Unfortunately, these symptoms have been linked to poorer treatment response (Lewin et al., 2010). Although furthering future impairment and perpetuating family discord, high family accommodation is also frequent and elevated in these types of cases (Steketee & Van Noppen, 2003). Accommodation is even more tempting to the family members of these children, as allowing the child to engage in their OCD rituals avoids an “explosion”, subsequent negative interactions and family discord. Parental requests to complete homework, engage in exposure tasks, and even perform daily chores are often met with defiance and oppositional behavior.

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Treatment Augmentation A total of 12% of OCD children present with a comorbid ODD diagnosis (Garcia et al., 2009), yet little research has been done to validate augmentation strategies, despite the empirical evidence highlighting the negative impact a comorbid diagnosis can have on treatment outcome (Storch et al., 2008; Lewin et al., 2010). The minimal research that has been published suggests parenting training may be an effective augmentation strategy for these patients (Ale & Krackow, 2011; Lehmkuhl et al., 2009), as would be expected knowing that parenting training is one of the most effective treatment approaches to ODD (Mash & Wolfe, 2002). Parenting training can be conducted beforeor concurrently with CBT, and essentially teaches the parent proper reinforcement and punishment strategies to utilize with their child. Different parent training strategies exist (Defiant Child Program: Barkley, 1997; Parent-Child Interaction Therapy: Eyberg & Matarazzo, 1980, etc.) and future research will need to investigate which of these approaches is most productive and feasible to combine with CBT. While augmenting CBT with parent training stands as the most promising strategy to treat pediatric OCD with comorbid ODD, substantial treatment outcome research is warranted considering the poor long-term effects of parent training (Eyberg, Edwards, Boggs, & Fotte, 1998). However, case studies have found that this treatment augmentation approach has merit (Ale & Krackow, 2011; Lehmkuhl et al., 2009). Ale & Krackow (2011) provide a developmental conceptualization of how these two impairing disorders become maintaining factors of the severity of the other disorder. Specifically, they highlight how genetic vulnerably along with environmental triggers (e.g. parent modeling) likely make a children vulnerable to developing OCD (Swedo, Rapoport, Leonard, Lenane, & Cheslow, 1989). Then it is believed that a stressful event occurs which triggers the OCD maturation (Gothelf, Aharonovsky, Horesh, Carty, & Apter, 2004). Ale & Krackow (2011) discuss how aggressive behaviors acted out by the child when not allowed to avoid the feared stimulus can quickly become generalized if the parents continue to accommodate the behavior and stop enforcing limits. Finally, it is proposed that clinical ODD develops and non-compliance is observed. While substantial etiological research is required, with the high comorbid rates between OCD and ODD, it is plausible that these two disorders can quickly become intertwined in their development, maintenance and presentation. An additional, brief case study is provided below to provide additional guidance on how to tease apart these disorders.

Case Study An example of a child case who suffered from OCD with comorbid ODD is RT, a 9-year old male whose behaviors led to his expulsion from school. RT’s main obsessions were in the contamination domain and main compulsions were in the washing domain. According to his father, RT also “militantly avoided” anything he thought might be dirty. At the intake interview, the severity of both his OCD and ODD were apparent. The importance of focusing on the ODD first was explained to the parents. Although his parents were initially hesitant about having initial sessions focus on ODD instead of both disorders, they understood the rationale. A modified version of parent child interaction therapy (PCIT) that was adjusted for a 9-year old was used. PCIT is an empirically-supported treatment for children with ODD that

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places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns (Zisser & Eyberg, 2010). The importance and procedure for both child directed interactions (CDI: strengthening the relationship with the child through play) and parent directed interactions (PDI: behavior management techniques to be used by the parent) were reviewed. RT’s ODD behaviors significantly reduced during the first month of treatment. At this point traditional CBT with ERP was started. The parents and therapist used the PCIT skills while interacting with the child during exposure exercises. At the end of treatment, RT was enrolled in a new school. From his parents’ report, at the end of the school year, his teacher stated that RT was a pleasure to have in the classroom.

SECTION 4: SCRUPULOSITY Presentation Scrupulosity refers to the set of OCD symptoms related to the feeling of right and wrong, and typically involves extreme religious beliefs and practices. These individuals may obsess on minor components of their religion, and suffer from unwanted excessive fear of committing a sin, or doubting that one has performed a religious act correctly. In order to cleanse themselves of their perceived offenses, patients often perform extreme religious rituals (e.g., hours per day ofconfession or prayer) (Deacon & Nelson, 2008). While scrupulosity is not caused by religion, it is more prevalent in highly religious individuals with OCD (Steketee, Quay, & White, 1991). Healthy religious practices such as being present at weekly services do not suffice for these individuals to purge themselves of their sins. Examples of religious obsessions include but are not limited to: sinning, not facing the correct direction to pray, breaking dietary regulations, family impurity, having impure thoughts, not understanding a religious text perfectly, and/or sexual immorality (Huppert & Siev, 2010). It is not uncommon for members of the religious community to drive these obsessions and compulsions, whether advertently or inadvertently. Clergy and other religious leaders may express admiration for the devout nature and dedication of the patient. They may also create a belief in the patient that more intense prayer or reading of religious doctrines may alleviate obsessional and compulsive symptoms, or may even go as far as to suggest religious rituals to negate intrusive thoughts. Scrupulosity is not, however, limited to religion. The anxiety may be related to other secular moral standards, such as the rules and regulations placed for individuals by society. For example, a patient might engage in rituals that are believed to protect against breaking a law (Huppert & Siev, 2010). A higher symptom severity has not been linked between OCD with scrupulosity when compared to OCD without scrupulosity (Nelson, Abramowitz, Whiteside, & Deacon, 2006). However, a presence of scrupulosity has been shown in some studies to result in poorer treatment outcome (Alonso et al., 2001; Ferrao et al., 2006; Mataix-Cols, Marks, Greist, Kobak, & Baer, 2002; Rufer, Grothusen, Maß, Peter, & Hand, 2005). This likely stems from the highly complex and abstract nature of scrupliosity, which often leaves clinicians overwelmed or baffled with some of the more severe scrupliosity patients.

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Treatment Augmentation It is our impression that CBT therapists must use additional skills than when treating more traditional contamination based OCD. A few augmentation strategies have been purposed in the literature, such using pastoral counseling (Kennemer, 2007), Acceptance and Commitment Therapy (Twohig & Crosby, 2010) orpsychodynamic techniques (Garcia, 2008; Deacon & Nelson, 2008). While there likely is some merit in all these approaches, research is so sparse that further discussion is premature without additional research. Thus, it is the authors’ opinion, based from experience, that several alternative CBT grounded augmentation strategies can be utilized to increase treatment outcome of scrupulosity. Several barriers to standard CBT occur in the treatment of scrupulositythatrequire skilled navigation to circumvent, such as distinguishing ordinary religious practices and judging from those that may exacerbate scrupulosity in a vulnerable individual with OCD. A therapist may work with a patient to identify practices (e.g., teachings that emphasize damnation) that may exascerbate scrupulosity in a patient with OCD. Therapists may need to be aware of cultural sensitivities when identifying acceptable exposure exercises for these particular problems. Therapists have used specific strategies which have had positive results in our clinic. First of all, in-line with the augmentation strategy of Kennemer (2008), seeking religious standards (e.g. what are normal amounts of praying?, are unwanted thoughts sins?, etc.) from the most influential religious figure in the patient’s life (e.g. father, pastor, Sunday school teacher) can help lessen the patient’s worries about “normal” religious practices. This counters a frequent view taken by patients that therapist’s domain of expertise is psychology, not religion (Ciarrocchi, 1995). It is important that the therapist is confident that these will not accommodate the patient’s anxiety. Further, Socratic religious questioning may facilitate cognitive restructuring and ultimately help the patient become aware that their religious compulsions are not endorsed, to such an extreme degree, in religious doctrine. However, it is our impression that to be effective, the therapist must have a satisfactory understanding of the patient’s religion in order to not offend the patient or get into a “Bible battle.” Finally, it is often helpful to guide the patient in a discussion of intentional unacceptable thoughts for enjoyment versus unintentional thoughts with a negative emotional response. From a religious perspective, the latter is often permissible (a discussion with a religious leader on this topic may be useful). Once the patient accepts this distinction, the patient is much more likely to be receptive of CBT principles. A case study exemplifying the application of these points is provided below.

Case Study A case example of an adult who suffered from OCD with scrupulosity is JL, a 24 year old female. JL’s obsessions were in the scrupulosity domain and her compulsions involved measures to prevent harm coming to her and others area. JL described herself as a Christian. She would spend 8 to 10 hours a day praying that God would forgive her and keep her safe. The trigger for these prayers were her unwanted intrusive thoughts that she classified as sinful. The idea of her unwanted thoughts being sinful and that she needed to repeat prayers to God were both challenged within her religious values and framework. A few of the items

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on her hierarchy were: 1) praying to God ‘incorrectly’ (e.g. instead of praying “Our Father who art in Heaven …,” praying “Our Daddy who lives in Heaven …”), 2) discussing intrusive thoughts that Jesus might have, 3) pray once per day, and eventually 4) not pray everyday.At the end of treatment, JL had gone several days without praying and become comfortable with the process of challenging her thoughts in the scrupulosity domain.

SECTION 5: POSTPARTUM ONSET Presentation OCD with postpartum onset involves the emergence of OCD symptoms following the birth of a child. This problem has traditionally been acknowledged in the women who give birth. However, it has recently been suggested that new fathers are also susceptible to postpartum onset (Abramowitz, Moore, Carmin, Wiegartz, & Purdon, 2001). The symptoms of OCD with postpartum onset are rapid and usually begin within about one to three weeks of birth (Sichel, Cohen, Dimmock, & Rosenbaum, 1993).Whether the disorder manifests in fathers or mothers, the obsessions commonly revolve around protection of the newborn. Examples of possible intrusive thoughts may include, but are not limited to: the newborn could be subjected to toxic agents; the parent injuring or killing the newborn; the newborn becoming ill; sexually abusing the newborn. Parents may develop avoidance strategies to cope with these thoughts, such as avoiding bathing the infant, excessively checking the infant’s temperature to see if he or she has become ill, or avoiding holding or being alone with the infant. Other compulsions may also be present, often in the form of rituals to reassure themselves that they will not make a reality the terrible scenes and images in their obsessional thoughts. Aside from the obsessions and compulsions that are intrinsic in OCD, women with postpartum onset OCD often present with severe anxiety complaints that are distinct from the aggressive, unpredictable behavior that is seen with postpartum psychosis (Abramowitz, Schwartz, Moore, & Luenzmann, 2003). Sufferers may or may not have a psychiatric history. However, women with pre-existing OCD symptoms may be at an increased risk toexperience magnified symptoms after the birth of their newborns (Epperson, McDougle, Brown, Leckman, & Goodman, 1995).

Treatment Augmentation Postpartum OCD is debilitating to the extent that mothers are unable to be left alone with their child, and as a result husbands are required to accommodate to take care of the child (even to the point of losing their jobs) (Jennings et al., 1999). Thus, a family based approach to treatment is likely warranted in many augmentation approaches. In general, the literature is limited but due to the overlap in symptom presentation, several case series, and one controlled CBT oriented treatment trial (Challacombe & Salkovskis, 2011; McGuinness, Blissett & Jones, 2011; Timpano, et al., 2011), it appears CBT is the first-line treatment for postpartum OCD. Timpano & colleagues (2011) found that incorporating a CBT-based prevention

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program into the standard childbirth education training for expectant mothers lowered obsessions and compulsions postpartum. Unfortunately, clinicians receive these OCD patients after the birth of their child and subsequently do not have the luxury of addressing these issues prenatally. While several potential pharmacological treatments have shown positive outcomes (see Brandes, Soares & Cohen, 2004 for a review), claims of serious side effects and birth defects pose present limitations for this approach to mothers concerned with risks that breastfeeding may harm their infant. However, there are specific variables to capitalize on during treatment of postpartum OCD that otherwise is generally not the case. The most significant of these variables is the work leave given to recent mothers, which allows for an intensive treatment design. In fact, a case series highlights the effectiveness and practical nature of this approach (Challacombe & Salkovskis, 2011). While intensive approaches have equivalent symptom reduction compared to weekly treatment in OCD (Storch et al., 2007; Storch et al., 2008), intensive approaches theoretically offer symptom relief twelve weeks sooner, which has major implications in terms of infant development. Another important factor is the ability to incorporate babies into exposure exercises and likely increasing the generalizability of the treatment effects. Other important factors to consider in the treatment of postpartum OCD involve comorbid mood and sleep problems. Mothers often expect early motherhood to be a joyful experience, and when afflicted with postpartum obsessions and/or compulsions, this is often not the case. In a case series, Challacombe & Salkovskis (2011) had a 50% comorbid depression rate. Thus, identifying and treating the mood and grief related problems is important, in the least to improve motivation for treatment. Also, sleep problems are associated with OCD severity in adults (Robinson, Walseben, Pollack & Lerner, 1998) and during pregnancy and early parenthood. Thus incorporating elements of Cognitive Behavioral Therapy for Insomnia may also facilitate treatment response. A case study outlining how to address some of these important factors in treatment is described below.

Case Study An example of a postpartum OCD is TA, a 32 year old female. TA’s obsessions were in the aggressive domain and compulsions were in the checking domain. TA also avoided being alone with her newborn child and other children. TA had a large and close family that accomodated her anxiety and did not leave her alone with her children. TA’s mother, husband, and sister all participated in TA’s treatment. TA had two primary concerns, 1) that people she cared about would be injured by a sharp object (especially her children) and 2) that her newborn child would develop a flat head. In order to effectively treat TA numerous hierarchies were created. The first hierarchy focused on developing a hierarchy of sharp objects. Items on the first hierarchy ranged from a paint can opener to a large chopping knife. The second hierarchy focused on the people she was concerned would be hurt by sharp objects. People on the second hierarchy ranged from her lead therapist to her newborn child. Lastly, the third hierarchy focused on engaging in behaviors that might lead to her newborn child developing a flat head. Activities on the third hierarchy ranged from not checking on the newborn’s head hourly to taking a 3 hour car ride with the newborn in his car seat. For this patients’ final exposure exercises, 1) she drove her newborn around in her car with a large

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chopping knife on the floor board for several hours and 2) she chopped vegetable with a large chopping knife with her two year old running around the table and her newborn lying on a baby blanket next to the chopping the block. After she completed treatment, she reported feeling extremely proud of herself and her family worked with the patient to remain in remission by 1) leaving her alone with the children and pointing out sharp objects and 2) frequently telling her that the newborn child’s head seemed like it was getting flat.

ASSESSMENT OF CRITICAL VARIABLES IN CBT FOR OCD Using a thorough multimethod assessment to accurately diagnose and treat a psychiatric patient is of great importance for ethical and quality care. In addition, a thorough initial assessment is essential in building rapport with the patient, as well as understanding the intensity of obsessions and compulsions. This is especially significant for treatment refractory cases, where many perplexing variables, including comorbid disorders, as well as family dynamics could play a major role in successfully treating the patient.It is also, particularly important to detect the specific symptoms of OCD, the level of insight, and what type of treatments worked in the past, and why. In this section, we will discuss the main assessment tools used to measure severity level and/or detect specific symptoms in OCD with poor insight, OCD with comorbid ODD, high family accommodation, scrupulosity and postpartum.

OCD with Poor Insight When a clinician suspects an OCD diagnosis, two reliable and valid structured interviews, such as the Anxiety Disorders Interview Schedule for DSM-IV (Brown, DiNardo, & Barlow, 1994) and the Structured Clinical Interview for DSM-IV (First et al. 2002), should be considered to help with differential diagnosis and targeting specific symptoms. However, when dealing with difficult cases, in which the level of insight is imperative in treatment, a clinician should use more specialized assessment instruments to detect specific problem areas. For example, Eisen and colleagues (2001) argued that insight in OCD exists on a continuum, which ranges from good insight to poor insight to no insight. The same authors determined that insight also exists in different dimensions within its continuum, which are measured in the Brown Assessment of Beliefs Scale (BABS); a semi-structured interview with strong psychometric qualities. This measure is especially reliable and valid in detecting the different degrees of insightof an individual with OCD (Eisen et. al, 1998). The BABS consists of seven categories that characterize delusional and nondelusional beliefs. The patient is asked to think of one or two obsessive beliefs and then the rater determines the degree of the patient’sconviction, perception of other’s views of beliefs, explanation of differing views, fixity of ideas, attempt to disprove beliefs, insight, and ideas/delusions of reference. These domains are rated from 0 to 4, from least to most severe (Eisen et. al.,2001). It is however, strongly recommended that the BABS is used after the Yale-Brown Obsessive

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Compulsive Scale (Y-BOCS), which is a better instrument in helping the patient to identify specific obsessions. The Y-BOCS includes the Symptom Checklist, which identifies over 50 different types of obsessions, and the severity ofinterference, time occupied, and distress the patient has due to obsessions and compulsions (Goodman et. al., 1989). Item 11 of the Y-BOCS screens for the level of insight into obsessions and compulsions and it measures it from 0 (excellent insight/fully rational) to 4 (lacks insight/delusional). The same researchers developed the CYBOCS for the children populations, which is a similar questionnaire, with the main difference being that the parents or caregivers are also involved when asking the questions. Another assessment that could be very useful when assessing OCD with poor insight is the Overvalued Ideas Scale (OVIS), which also has good psychometric qualities (Nerizoglu et. al., 1999). In this measure the rater assesses the strength, reasonableness and accuracy of the belief, the extent to which others share the same beliefs, how the patient attributes similar or differing beliefs, how effective the compulsions are, the extent to which their disorder has caused their obsessive belief, and their degree of resistance to the belief. These items are rated from 0-10, and the overall score indicates the degree to which the patient has an overvalued ideation.

OCD with Family Accommodation Steward and colleagues (2008) reported that 96.9% of OCD cases included some kind of daily family accommodation, including reassurance and waiting until the OCD family members complete their rituals. Family accommodation is a very common “hazard” in the treatment of OCD, and it is important to be assessed and addressed from the beginning through psychoeducation and inclusion of family members in behavioral exposures. During the initial assessment, it is also important that family members who are close to the patient are also assessed for family accommodation. The Family Accommodation Scale (FAS) is a clinician-rated measure, which includes 13 items assessing the degree to which family accommodation occurs, as well as assessing the impairment level of both the patient and the relative. Some accommodation areas the FAS assesses includes: level of reassurance, objects needed for compulsions that the family members provide, reduction of behavioral expectations of the child, adjustment of family activities, and assistance of the child in keeping away from “feared” items, places, or encounters that may cause him or her distress. The FAS has good psychometric properties and is widely used in clinical settings (Calvocoressi et al., 1999.) The OCD Family Functioning Scale (OFF) is another measure developed to assess the milieu, degree, and prospect of impairment in families affected by OCD (Steward et al., 2011). It is a self-report measure designed to assess accounts of both the patient and relatives.While the OFF is not entirely a measure of family accommodation, it can provide an estimate of how much the family adjusts their behaviors because of an individuals’ OCD while also providing a quantitative assessment of overall family functioning while living with the individual with OCD. Thus, it captures accommodation as well as the impairment caused in family functioning, often as a result of these accommodation behaviors.

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OCD with Comorbid ODD Although literature does not include any specific scales for children with ODD, a careful assessment to rule out this diagnosis is warranted, as the presence of ODD as a comorbid disorder with OCD significantly influences the course of treatment. When assessing children, it is important to consider the inclusion of multiple informants when possible, as a broader picture of the child’s behavior in different settings will yield a more accurate diagnosis. The Diagnostic Interview Schedule-IV (Schaffer et. al, 2000) and the Diagnostic Interview for Children and Adolescents (Reich, 2000) (available in parent, teacher and child versions) are useful as they specifically detect if any ODD criteria described in the DSM-IV. In addition to structured interviews, which could be limited in providing environmental conditions of the child’s problematic behaviors, rating scales are excellent tools in gathering comprehensive information about the child’s daily life. Problematic behaviors consistent with ODD such as lying, stealing, aggression and oppositional behavior are addressed in The Behavioral Assessment System of Children (Reynolds & Kamphaus, 2004). The Conners Rating Scales (Conners, 1997) and the Achenbach System of Empirically Based Assessment (Achenbach & Rescorla, 2001) are also some other rating scales commonly used, which come in parent, teacher and child versions.

OCD with Scrupulosity In understanding scrupulosity, an understanding of the patient’s religious background is of clinical value. Interviews with pastors, priests,rabbis, etc., as well as relatives and people with the same religious background may be useful in understanding the individual’s spiritual life. Furthermore, a detailed record of their scrupulous behavior is to be taken, which includes types of obsessions and compulsions, places they are performed, and time it takes to perform them. It is also important to note the timeframe within which scrupulosity started in order to rule out any possible trauma, which could cause excessive guilt and could support an investigation into possible Post-Traumatic Stress Disorder. The Y-BOCS and CY-BOCS are the main measures which include a specific scrupulosity category. The patient is asked to report whether they currently or in the past had excessive concerns or fear of offending God or excessive concern with morality (Goodman et al., 1986).

OCD with Post-Partum Onset Guiseppe and colleagues (1999) reported that the postpartum period represents a risk factor for OCD in some women. Specifically, women with a previous OCD diagnosis were more likely to develop post-partum OCD, as well as those with more obstetric complications. Although this area of OCD has not been widely studied, and a specific postpartum OCD measures have not been developed, the Y-BOCS (Goodman et al., 1986) addresses violent and horrific thoughts and many other symptom domains that are often present in OCD with post-partum onset. It is also important to gather an exhaustive medical and psychiatric history of women who may be susceptible to this type of OCD. When conducting the clinical

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interview, asking about previous pregnancies, labor and delivery, as well as postpartum depression is of critical importance in assessing these patients’ OCD symptoms.

CONCLUSION The goal of this chapter was to present some of the more challenging OCD presentations that often comprise the 40-60% of OCD patients who do not benefit from standard CBT (Pallanti et al., 2002). We aimed to provide clinicians with a brief overview of how to identify these patients, as well as treatment augmentation strategies that may help improve outcome. However, even when implementing these strategies, roughly 20% of patients in our clinic have unremarkable responses or clinicallly insignificant responses to treatment, creating is a need for empirically supported augmentation strategies for standard CBT that could increase the number of patients who benefit from treatment. This could involve combining two common treatments, such as CBT and PCIT for children with comorbid ODD, or a novel treatment strategy that targets the maintaining factors the drive the non-responsiveness, such as FB-CBT for OCD with high family accommodation.

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Shin, N. Y., Lee, A. R., Park, H. Y., Yoo, S. Y., Kang, D. H., Shin, M. S., & Kwon, J. S. (2008). Impact of coexistent schizotypal personality traits on frontal lobe function in obsessive-compulsive disorder. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 32, 472-478. doi:10.1016/j.pnpbp.2007.09.020 Sichel, D. A., Cohen, L. S., Dimmock, J. A., & Rosenbaum, J. F. (1993). Postpartum obsessive compulsive disorder: a case series. The Journal of Clinical Psychiatry, 54, 156159.http://www.psychiatrist.com Sobin, C., Blundell, M.L., Weiller, F., Gavigan, C., Haiman, C., Karayiorgou, M. (2000). Evidence of a schizotypy subtype in OCD. Journal of Psychiatric Research, 34 , 15-24. doi:10.1016/S0022-3956(99)00023-0 Stein, D. J., Ipser, J. C., Baldwin, D. S., & Bandelow, B. (2007). Treatment of obsessivecompulsive disorder. CNS Spectrums, 12, 28-35. Steketee, G., & Van Noppen, B. (2003). Family approaches to treatment for obsessive compulsive disorder. Revista Brasileira De Psiquiatria, 25, 43-50.http://dx.doi.org /10.1590/S1516-44462003000100009 Steketee, G.& Noppen, B. V. (2003). Family Responses and Multifamily Behavioral Treatment for Obsessive-Compulsive Disorder.Brief Treatment and Crisis Intervention, 3, 231-248.http://www.oxfordjournals.org/our_journals/btcint/about.html Steketee, G., Quay, S., & White, K. (1991). Religion and guilt in OCD patients. Journal of Anxiety Disorders, 5, 359-367. doi:10.1016/0887-6185(91)90035-R Stewart, S.E., Beresin, C., Haddad, S., Egan Stack, D., Fama. J., &Jenike M. (2008). Predictors of family accommodation in obsessive-compulsive disorder. Annual Clinical Psychiatry, 20, 65-70.DOI: 10.1080/10401230802017043 Stewart, S.E., Hu, Y.P., Hezel, D.M., Proujansky, R., Lamstein, A., Walsh,. C., …Pauls, D.L. (2011). Development and psychometric properties of the OCD Family Functioning (OFF) Scale. Journal of Family Psychiatry, 25,434-43.doi:10.1037/a0023735 Storch, E. A., Geffken, G. R., Merlo, L. J., Jacob, M. L., Murphy, T. K., Goodman, W. K., …Grabill, K. (2007). Family accommodation in pediatric obsessive-compulsive disorder. Journal of Clinical Child and Adolescent Psychology, 36, 207-216. doi:10.1080 /153744 10701277929 Storch, E. A., Geffken, G. R., Merlo, L. J., Mann, G., Duke, D., Munson, M., & ... Goodman, W. K. (2007). Family-based cognitive-behavioral therapy for pediatric obsessivecompulsive disorder: Comparison of intensive and weekly approaches. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 469-478. doi:10.1097/chi. 0b013e31803062e7 Storch, E. A., Lewin, A. B., Geffken, G. R., Morgan, J. R., & Murphy, T. K. (2010). The role of comorbid disruptive behavior in the clinical expression of pediatric obsessivecompulsive disorder. Behaviour Research and Therapy, 48, 1204-1210. doi:10.1016/j.brat.2010.09.004 Storch, E. A., Merlo, L. J., Larson, M. J., Geffken, G. R., Lehmkuhl, H. D., Jacob, M. L., Goodman, W. K. (2008). Impact of Comorbidity on Cognitive-Behavioral Therapy Response in Pediatric Obsessive-Compulsive Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 47, 583-592. doi:10.1097/CHI.0b 013e31816774b1

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Storch, E.A., Merlo, L.J., Lehmkuhl, H., Geffken, G.R., Jacob, M., Ricketts, E., & Goodman, W. K, (2008). Cognitive-behavioral therapy for obsessive-compulsive disorder: A nonrandomized comparison of intensive and weekly approaches. Journal of Anxiety Disorders, 22, 1146-1158. Doi: 10.1016/j.janxdis.2007.12.001 Storch, E. A., Murphy, T. K., Lack, C. W., Geffken, G. R., Jacob, M. L., & Goodman, W. K. (2008). Sleep-related problems in pediatric obsessive-compulsive disorder. Journal of Anxiety Disorders, 22, 877-885. doi:10.1016/j.janxdis.2007.09.003 Swedo, S. E., Rapoport, J. L., Leonard, H., Lenane, M., Cheslow, D. (1989).ObsessiveCompulsive Disorder in Children and Adolescents.Archives of General Psychiatry, 46, 335-341. http://bjp.rcpsych.org/content/supplemental Tanzi, E., & Lugaro, E. (1923). Trattato delle malattie mentali. Milano, Italy: Società Editrice Libraria. Thomsen, P. (2004). Risperidone Augmentation in the Treatment of Severe Adolescent OCD in SSRI-refractory Cases: A Case-series. Annals of Clinical Psychiatry, 16, 201-207. http://www.ingentaconnect.com/ Timpano, K. R., Abramowitz, J. S., Mahaffey, B. L., Mitchell, M. A., & Schmidt, N. B. (2011). Efficacy of a prevention program for postpartum obsessive–compulsive symptoms. Journal of Psychiatric Research (in press). doi:10.1016/j.jpsychires. 2011.06.015 Tolin, D. F., Frost R.O., Steketee G. (2010). A brief interview for assessing compulsive hoarding: The Hoarding Rating Scale-Interview. Psychiatry Research, 178 (1), pp. 147152.doi:10.1016/j.psychres.2009.05.001 Tumkaya, S., Karadag, F.,& Oguzhanoglu, N. K. (2010). Neurological soft signs in schizophrenia and obsessive compulsive disorder spectrum. European Psychiatry(in press). doi:10.1016/j.eurpsy.2010.03.005 Türksoy, N., Tükel, R., Özdemir, Ö., & Karali, A. (2002). Comparison of clinical characteristics in good and poor insight obsessive–compulsive disorder. Journal of Anxiety Disorders, 16, 413-423. doi:10.1016/S0887-6185(02)00135-4 Twohig, M. P., & Crosby, J. M. (2010). Acceptance and Commitment Therapy as a Treatment for Problematic Internet Pornography Viewing. Behavior Therapy, 41, 285295. doi:10.1016/j.beth.2009.06.002 Valderhaug, R., Larsson, B., Götestam, K., & Piacentini, J. (2007). An open clinical trial of cognitive-behaviour therapy in children and adolescents with obsessive-compulsive disorder administered in regular outpatient clinics. Behaviour Research and Therapy, 45, 577-589. Doi: 10.1016/j.brat.2006.04.011 Westenberg, H. G., Fineberg, N. A.,& Denys, D. (2007).Neurobiology of obsessivecompulsive disorder: serotonin and beyond.CNS Spectrums,12, 14-27. Zisser, A., & Eyberg, S.M. (2010). Treating oppositional behavior in children using parentchild interaction therapy. In A.E. Kazdin & J.R. Weisz (Eds.) Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 179-193). New York: Guilford.

In: Advances in Psychology Research. Volume 93 Editor: Alexandra M. Columbus

ISBN: 978-1-62081-470-3 © 2013 Nova Science Publishers, Inc.

Chapter 3

THE BANDWAGON MAY DRIVE MATERIALISTS’ DIETARY CHOICES Michael W. Allen, Sik Hung Ng, Marc Wilson and Shaun Saunders 1

University of Sydney, Discipline of Marketing, Economics and Business Building, Sydney, Australia 2 Department of Applied Social Studies, City University of Hong Kong, Kowloon, Hong Kong 3 School of Psychology, Victoria University of Wellington, Wellington, New Zealand 4 Faculty of Business, University of the Sunshine Coast, Australia

ABSTRACT We suggest that public self-consciousness affects whether one pursues a Bandwagon or Distinctiveness status-seeking strategy, where low public self-consciousness leads to Distinctiveness, and high public self-consciousness leads to Bandwagon. Moreover, we propose that materialism involves high public self-consciousness and a high statusseeking drive, hence materialists pursue Bandwagon, not Distinctiveness. We investigated these possibilities by examining how materialism is expressed in food choice. Study 1 showed that materialism and status-seeking behavior differ according to one’s public self-consciousness and status-seeking drive, as speculated; that materialists prefer high-status foods and reject low-status ones; and that materialists do so for Bandwagon, not Distinctiveness. Study 2 found that increasing participants’ public selfconsciousness (using a mirror) decreased Distinctiveness and increased Bandwagon and materialism. Our data suggest that materialism and status-seeking behavior depend heavily on public self-consciousness and status-seeking drive, and that materialists’ food choices may be shaped by their desire to achieve Bandwagon status.



Telephone: +61 2 9036 6421, Fax: +61 2 9351 6732, Email: [email protected].

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Social scientists conceptualize materialism in subtly different ways: as a combination of personality traits (Belk, 1984), defining oneself through material objects (Claxton and Murray, 1994), a style of consumption (Holt, 1995), or as cultural-level goals (Inglehart, 1977). We pursued another conception of materialism: personal value materialism (Richins and Dawson, 1992). Personal value materialists may be motivated by generalized statusseeking, where “individuals strive to improve their social standing through the conspicuous consumption of consumer products that confer and symbolize status both for the individual and surrounding significant others” (Eastman et al., 1999, p. 42). Indeed, individuals who score high on the Richins and Dawson (1992) Materialism Scale (hereafter, “Materialism Scale”) also score high on Eastman et al.’s generalized Status-Seeking Scale (Eastman et al., 1999; Heaney et al., 2005). However, conceptualizations that consider materialism and status-seeking to be synonymous fail to recognize different forms of status-seeking, and do not consider a crucial potential moderator: public self-consciousness (hereafter, “PSC”; Figure 1). Some status-seekers are motivated by a desire to conform to the wealthy group (Bandwagon); others by a desire to be unique, to be different than others (Distinctiveness; Bearden and Etzel, 1982; Leibenstein, 1950; Mason, 1981; Veblen, 1899; Vigneron and Johnson, 1999). Further, Vigneron and Johnson (1999) speculated that Bandwagon status-seeking involves a high PSC (i.e., being mindful of how others perceive you), whereas Distinctiveness involves a lower PSC. Thus, as elaborated below, we suggest that materialists have high PSC and high statusseeking drive (Figure 1), and hence should pursue Bandwagon status-seeking, not Distinctiveness. If status-seeking motivation and PSC levels are essential to materialism and forms of status-seeking, then experimentally manipulating either of these factors should affect one’s endorsement of materialism and status-seeking. We investigated these possibilities by examining how materialism is expressed in food choice.

Figure 1. Conceptual framework of public self-consciousness, status seeking drive, materialism, and forms of status seeking.

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MATERIALISM AND STATUS-SEEKING Richins and Dawson (1992) viewed materialism as a personal value that embodies acquisition centrality (i.e., obtaining/possessing material goods/services is a central goal), happiness as the pursuit of acquisition (i.e., one believes that material items substantially contribute to life satisfaction; e.g., Belk, 1984), and possession-defined success (i.e., possessions are used to increase social status as an indicator of success and achievement). This latter dimension emerged as the strongest component in their Materialism Scale. Indeed, materialists are commonly considered status-seekers (Fournier and Richins, 1991). However, various forms of status-seeking, each with a different motivation, have been identified in the past 100 years (Bearden and Etzel, 1982; Leibenstein, 1950; Mason, 1981; Veblen, 1899; Vigneron and Johnson, 1999). Of these, two are notable: Bandwagon, a desire to conform to the wealthy group; and Distinctiveness, a desire to be unique and buy products that distinguish oneself from others (Figure 1). Bandwagon status-seekers “try to imitate stereotypes of affluence by consuming similar prestige products” (Vigneron and Johnson, 1999, p. 6), induced by a need to conform (Leibenstein, 1950). Vigneron and Johnson (1999) speculated that Bandwagon status-seeking typifies individuals with high PSC. Such people tend to direct attention outward, are mindful about how other people perceive them (Fenigstein et al., 1975), and are likely high self-monitors (Snyder, 1974). In contrast, Distinctiveness status-seekers buy high-status products to be different from other people, a phenomenon also known as the Snob Effect (Leibenstein, 1950). Such people prefer high-status products in limited supply, presumably because “rare items command respect and prestige” (Solomon, 1994, p. 570). More generally, they are driven by nonconformity, or what Snyder and Fromkin (1973) termed a “need for uniqueness.” Vigneron and Johnson (1999) speculated that Distinctiveness status-seekers have a lower PSC, in part because they are not driven by conformity, and could buy prestige products for non-social reasons (e.g., their aesthetic qualities). They also argued that PSC may differentiate Bandwagon from Distinctiveness status-seeking. If so, and if personal value materialists were status-seekers, then we could delineate the form of status-seeking that materialists are likely to pursue by identifying whether materialists have a high or low PSC (Figure 1). To this end, it is noteworthy that materialists prefer expensive and visible products (Richins, 1992) and conform to normative social influences more than non-materialists (Chang and Arkin, 2002; Schroeder and Dugal, 1995). For instance, they tend to base their purchase decisions on the opinions and approval of significant others (Schroeder and Dugal, 1995). In this way, materialists’ use of products to signal success and their need for conformity may drive them to try to “pass” as part of the wealthy group. If true, materialists would have to constantly evaluative themselves to ensure that their possessions were characteristic of the wealthy group and this would mandate an elevated PSC. Indeed, materialists have a greater tendency to self-monitor (Chatterjee and Hunt, 1996). Thus, personal value materialism is characterized by a combination of status-seeking and high PSC, and hence materialists likely pursue Bandwagon status-seeking, not Distinctiveness (Figure 1).

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MATERIALISM, STATUS-SEEKING, AND BASIC FOOD GROUPS Might materialism be expressed in the diet? Many factors shape food choice. Climate, geography, and transportation, for example, determine the foods that are available to consumers (Fernandez-Armesto, 2002), who then consider a complex set of attributes, such as taste, nutrition, cost, quality, and whether the food will be accepted by their household (Bell et al., 1981; Furst et al., 1996). However, preferences may also be influenced by the symbolic meaning and cultural association of foods (Fieldhouse, 1995; Lewin, 1943). Chief among these types of influences is the status or prestige a society ascribes to a food. The Structuralism approach to social science inquiry most directly attempts to classify and order basic foods according to their status and other cultural meanings, by examining how food habits are maintained by broader social structures and forces (Cuff and Payne, 1977). This makes it the most relevant framework for examining how materialists use the status value of foods to enhance status-seeking, even though the approach has been criticized for overlooking the dynamic and embodied facets of food and eating (Lupton, 1996). Sociologists and anthropologists pursuing the Structuralism approach to understanding food habits and preferences have primarily focused on one dimension or ordering: red and white meat at one end; fruits, vegetables, and cereals at the other end; and dairy and seafood in the middle (Adams, 1990; Caplan, 1987; Fiddes, 1991; Fieldhouse, 1995; Lupton, 1996; Twigg, 1983). These researchers have suggested that this dimension or ordering may be the predominant way Western culture conceptualizes and organizes foods, and that, at its most elementary level, represents high vs. low status. The most detailed summary of the status of each of the seven basic foods is provided by Twigg (1983). At the top of the hierarchy are those items of such high-status that they are taboo as food (human flesh, carnivores, and uncastrated animals). Red meat has the highest status of non-taboo items, followed by white meat. At midrange are animal products (e.g., eggs and cheese), and at the lowest status levels are fruits, root and leaf vegetables, and cereals. There are three main perspectives on this rationale. One view, consonant with Mason’s (1981) suggestion that status symbolism is ascribed to products that are scarce or expensive, is that meats and other animal products have historically been costly and in short supply (Adams, 1990; Fiddes, 1991; Fitchen, 1988). A related theoretical position is that meats have greater status because they are consumed and (initially) procured by higher-status groups (i.e., higher income, males, whites, adults), whereas fruits and vegetables are produced and consumed by lower-status groups (i.e., lower incomes, females, non-whites, children; Adams, 1990; Fiddes, 1991; Lupton, 1996). For instance, individuals with higher incomes tend to derive a greater portion of their fats, proteins, and calories from meats and other animal products (Perisse et al., 1969). Similarly, meats may symbolize greater status because of the common perception (not necessarily reality) that, historically, men obtained the meat (i.e., hunters) and women the fruits and vegetables (i.e., gatherers; see Adams, 1990), and the work of men has typically been more highly prized than that of women. Finally, the procurement of meat (i.e., hunting and slaughtering) may represent important cultural values, such as aggressiveness, domination over nature, and the demarcation between culture and nature (Fiddes, 1991). Although most Structuralist studies of food meanings have qualitatively explored rituals, books, and the like, some quantitative studies have been conducted. For instance, Allen and

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Ng (2003) randomly surveyed the Australian public, asking participants to rate the symbolism or image of each food group. The results showed that meats symbolized dominance and hierarchy more so than fruits, vegetables, and cereals, and that meats symbolized social power more than other values. Moreover, individuals who endorsed social power had more favorable attitudes toward red meat (also see Allen et al., 2008; Lea and Worsley, 2001).

Summary Based on the Structuralist hierarchy of food symbolism and status in Western culture, materialists should prefer food in the following order, from most to least desirable: red meat, white meat, fish/seafood, eggs and dairy products, fruit, vegetables, and cereals. Further, if materialists pursue Bandwagon status-seeking, not Distinctiveness, they should favor highstatus food groups (e.g., red meat, white meat) and reject low-status ones (e.g., fruit, vegetables, and cereals), to conform to the wealthy group, not to distinguish themselves from others. Using a correlational design, Study 1 investigated the food choices of materialists, and the more general issue of whether materialism and Bandwagon status seeking involve a fusion of status-seeking motivation and high public self-consciousness, whereas Distinctiveness entails status-seeking motivation and low public self-consciousness (see Fig. 1). Further, if status-seeking motivation and public self-consciousness levels are essential determining elements, then experimentally manipulating either of these factors should affect one’s endorsement of materialism and status seeking. Thus, Study 2 used a mirror to increase participants’ public self-consciousness. If our assumptions are correct, this would shift one away from Distinctiveness status seeking, toward Bandwagon and materialism.

STUDY 1 Method Participants A snowballing procedure was used to recruit participants. Second-year business students at a university in a moderate-sized city in Australia were asked to take six copies of the questionnaire: one to complete at home themselves, and five to give to friends, family, and co-workers. They were given 2 weeks to return the completed questionnaires. Seventy were returned; 64 were usable. The sample was 46% male and 54% female, with an age range of 16–63 years (mean = 31) and a median education level of high school completion. Questionnaire In addition to demographic information and eight items from the Crowne and Marlow (1960) Social Desirability Scale, the 12-page questionnaire included: Richins and Dawson (1992) Materialism. Eighteen items in three domains: possessiondefined success (e.g., “I like to own things that impress people”), acquisition as the pursuit of happiness (e.g., “I’d be happier if I could buy more things”), and acquisition centrality (e.g.,

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“I enjoy spending money on things that aren’t practical”). Richins and Dawson (1992) demonstrated that their scale was reliable, not correlated with social desirability, exhibited external validity, and that the three domains captured a single materialism construct. In the present study, each item was rated on a scale of 1–7, “Strongly Disagree” to “Strongly Agree” (Cronbach’s Alpha = .80). Fenigstein, Scheier, and Buss (1975) Public Self-consciousness. This measures the tendency to direct attention inward or outward, and comprises seven private selfconsciousness items (e.g., “I’m always trying to figure myself out”) and seven public selfconsciousness items (e.g., “I’m concerned about the way I present myself”). Only the public items were used in the present study, rated on a scale of 1–7, “Strongly Disagree” to “Strongly Agree” (Cronbach’s Alpha = .86). Eastman, Goldsmith, and Flynn (1999) Status-Seeking Scale. This measures generalized status seeking (e.g., “I would buy a product just because it has status”), and comprises five items rated on a scale of 1–7, “Strongly Disagree” to “Strongly Agree” (Cronbach’s Alpha = .84). General Bandwagon Food Status Seeking. Six original items that measure the extent one eats high-status foods to fit into a high-status group (e.g., “I think that to fit in, I have had to start eating the foods that people with high standing eat”; see Appendix). Again, participants were advised that the phrase “people of high standing” refers to people of high social class and standing. Items were rated on a 7-point Likert scale (Cronbach’s Alpha = .93). General Distinctiveness Food Status seeking. Nine original items that measure the extent an individual eats high-status foods to be different from other people (e.g., “One thing that sets me apart from people I know is that I like more expensive foods”; see Appendix). Participants rated items on a 7-point Likert scale (Cronbach’s Alpha = .95). Food Group Liking, Behavior, and Perception. To measure the consumption of each food, participants indicated the total number of servings of each food group they’d eaten in the three days prior to responding to the questionnaire (the food groups were listed in a different sequence from the proposed status typology to avoid creating artificial support for our hypothesis). The three-day period was chosen because it is long enough to reduce floor effects but short enough for respondents to make accurate accounts. A serving size was not defined. To measure anticipated consumption, participants listed the number of servings of each food group they anticipated they would eat in the three days following the survey. Participants reported their liking of each food group (e.g., “How much do you like red meat?”) on a scale of 1–7, “Not At All” to “Very Much.” To measure food group status perceptions, participants reported the prestige of each food group on a scale of 1–7, “Not At All Prestigious” to “Very Prestigious.” Food Group Bandwagon and Distinctiveness Status Seeking. To measure Food Group Bandwagon Status Seeking, the survey listed each of the food groups, and instructed participants “For each of the foods listed below, indicate whether you think you feel that you have to eat the food in order to keep up with your friends, neighbors and business associates”. Participants rated each food group on a 1 “Don’t Use This Food To Fit In” to 7 “Use This Food To Fit In”. To measure Food Group Distinctiveness Status Seeking, participants indicated how much they like each food group more than people they know (scale of 1-7).

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Procedure Respondents were told that the study was examining consumer behavior. No scales were identified. Participants first completed a distracter task in which they reported the product features they seek in cars. We randomly selected the sequence of scales and constructs in the questionnaire, which turned out as follows: PSC, food group consumption, food group behavior intention, food group liking, general status-seeking, Materialism Scale, perceived food group status, forms of food status-seeking, social desirability, and demographics.

RESULTS To assess whether status-seeking (Bandwagon and Distinctiveness) and materialism are shaped by an interaction between general status-seeking motivation and PSC, we divided participants according to their scores (high and low) on two scales: Fenigstein et al.’s (1975) Public Self-consciousness Scale (split at the median of 5.0; hereafter, “PSC Scale”) and Eastman, Goldsmith, and Flynn’s (1999) Status Seeking Scale (split at the median of 3.5). A 2 × 2 between-subjects ANOVA (high vs. low PSC × high vs. low status-seeking motivation) on the General Distinctiveness status-seeking scale showed a significant interaction (F(1,58)=5.9, p