Psychological Interventions For Pre-Event And Post-Event Rumination In Social Anxiety

Individuals with social anxiety often experience rumination as persistent, intrusive thoughts focused on perceived social failures or potential negative outcomes.

Before social events (pre-event rumination), they might obsessively think: “What if I say something stupid?” or “Everyone will notice how nervous I am.”

After social interactions (post-event rumination), they may replay the event, fixating on perceived mistakes: “I stumbled over my words; they must think I’m an idiot” or “I barely contributed to the conversation; they probably found me boring.”

These repetitive negative thoughts maintain anxiety, reinforce negative self-perceptions, and can lead to avoidance of future social situations, perpetuating the cycle of social anxiety.

Donohue, H. E., Modini, M., & Abbott, M. J. (2024). Psychological interventions for pre-event and post-event rumination in social anxiety: A systematic review and meta-analysis. Journal of Anxiety Disorders, 102823. https://doi.org/10.1016/j.janxdis.2023.102823

Key Points

• The primary methods of treating pre-event and post-event rumination in social anxiety disorder (SAD) include cognitive-behavioral therapy (CBT), mindfulness-based interventions, and metacognitive therapy.
• Factors like baseline social anxiety levels, baseline depression levels, and whether treatments directly target rumination significantly affect treatment outcomes for pre-event and post-event rumination.
• Psychological interventions, particularly CBT, demonstrate large significant effects in reducing both pre-event rumination (g = 0.86) and post-event rumination (g = 0.83) from pre- to post-treatment in individuals with SAD.
• Treatments that directly target rumination show significantly larger effects in reducing pre-event rumination compared to non-targeted treatments. A similar trend was observed for post-event rumination but did not reach statistical significance.
• The research, while enlightening, has certain limitations such as a relatively small number of included studies, overrepresentation of CBT treatments, and lack of follow-up data.
• Understanding effective treatments for pre-event and post-event rumination is crucial, as these processes maintain and exacerbate social anxiety symptoms and are associated with poorer treatment outcomes when not directly addressed.

Rationale

Social Anxiety Disorder (SAD) is a common and debilitating condition characterized by intense anxiety in social or performance situations due to fear of scrutiny and negative evaluation (American Psychiatric Association, 2022).

SAD is associated with impaired psychosocial functioning, psychiatric comorbidity, and high health service use and costs (Crome et al., 2015; Konnopka & König, 2020; Patel et al., 2002).

Cognitive-behavioral therapy (CBT) is the first-line psychological treatment for SAD, with meta-analyses indicating large treatment effect sizes (Mayo-Wilson et al., 2014).

However, CBT is not universally effective, with response rates around 45.3% at post-treatment (Loerinc et al., 2015).

One possible reason for these modest response rates is that key psychological processes identified by cognitive models, such as pre-event and post-event rumination, are not adequately targeted by standard CBT protocols.

Pre-event and post-event rumination refer to repetitive negative thoughts about perceived social shortcomings and subsequent negative judgments from others, occurring before and after social situations respectively.

Cognitive models propose these processes maintain and exacerbate SAD symptoms (Clark & Wells, 1995; Hofmann, 2007; Rapee & Heimberg, 1997).

Research has consistently associated pre-event and post-event rumination with increased SAD symptom severity (e.g., Kocovski et al., 2005; Mills et al., 2013) and slower responses to CBT treatment (Price & Anderson, 2011; Wong et al., 2017).

Despite the theoretical and empirical importance of pre-event and post-event rumination in SAD, no previous meta-analyses have specifically evaluated the effectiveness of psychological interventions in reducing these processes.

This presents a significant gap in the literature that the current study aimed to address.

Method

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Search strategy and terms: A comprehensive literature search was conducted in PsychINFO, Medline, Scopus, and Web of Science databases.

Key search terms included variations of: (pre-event rumination OR anticipatory processing OR post-event rumination OR post-event processing) AND (social anxiety OR social phobia OR social anxiety disorder) AND (treatment OR intervention OR therapy OR trial OR outcome)

Inclusion and exclusion criteria:

Studies were included if they:

1. Involved adults with SAD or elevated social anxiety symptoms
2. Measured pre-event and/or post-event rumination as a treatment outcome
3. Provided within-group (pre- to post-treatment) or between-groups treatment effects
4. Used a SAD-specific rumination measure

Studies were excluded if they:

1. Used non-SAD-specific rumination measures
2. Lacked suitable control conditions for between-groups comparisons
3. Did not report post-treatment outcomes
4. Involved non-psychological interventions or non-clinical populations

Statistical measures

Meta-analytic statistics were computed using Comprehensive Meta-Analysis software.

The random effects model was used due to variation in study designs and protocols.

Within-group effect sizes were calculated using Hedges’ g statistic.

Heterogeneity was evaluated using Cochran’s Q statistic and I² statistic. Publication bias was assessed via funnel plots and the Classic fail-safe N calculation.

Results

Study characteristics:

• 26 studies met inclusion criteria (total N = 1524 participants)
• 34 treatment groups (n = 1197 participants)
• Study designs: 62% randomized controlled trials (RCTs), 12% non-randomized controlled trials (NRCTs), 26% uncontrolled trials (UCTs)
• Most common treatment: CBT (59% of treatment conditions)
• 35% of interventions directly targeted pre-event or post-event rumination

Overall treatment effects:

• Pre-event rumination: Large significant pooled mean effect size (g = 0.86, 95% CI [0.64, 1.08], p < .001)
• Post-event rumination: Large significant pooled mean effect size (g = 0.83, 95% CI [0.67, 0.99], p < .001)

Subgroup analyses:

1. CBT treatments:
   • Pre-event rumination: Large significant effect (g = 0.97, 95% CI [0.75, 1.20], p < .001)
   • Post-event rumination: Large significant effect (g = 0.85, 95% CI [0.66, 1.05], p < .001)
2. Targeted vs. non-targeted treatments:
   • Pre-event rumination: Targeted treatments showed significantly larger effects (g = 1.38) compared to non-targeted treatments (g = 0.70), p = .006
   • Post-event rumination: Targeted treatments showed larger effects (g = 1.07) compared to non-targeted treatments (g = 0.74), but the difference was not statistically significant (p = .082)
3. Individual vs. group treatment format:
   • No significant differences in effectiveness between individual and group formats for either pre-event or post-event rumination

Meta-regression analyses:

1. Treatment duration: Longer duration associated with increased effect sizes for pre-event rumination (p = .027), but not for post-event rumination
2. Baseline social anxiety: Higher levels predicted greater reductions in pre-event rumination (p < .001), but not post-event rumination
3. Baseline depression: Higher levels predicted greater reductions in post-event rumination (p = .002), but not pre-event rumination

Insight

This systematic review and meta-analysis provides the first comprehensive evaluation of the effectiveness of psychological interventions in reducing pre-event and post-event rumination in social anxiety disorder.

The findings demonstrate that psychological treatments, particularly CBT, are effective in significantly reducing both pre-event and post-event rumination, with large effect sizes observed.

A key insight from this study is that treatments directly targeting rumination show enhanced effectiveness, especially for pre-event rumination.

This suggests that incorporating specific modules or techniques to address rumination processes may improve overall treatment outcomes for individuals with SAD.

The differential effects of baseline social anxiety and depression levels on pre-event and post-event rumination reductions also provide interesting insights into the nature of these processes.

Pre-event rumination appears more closely linked to anxious anticipation, while post-event rumination may share characteristics with depressive rumination.

These findings extend previous research by providing a quantitative synthesis of treatment effects on pre-event and post-event rumination, which had previously only been examined in narrative reviews.

The results support cognitive models of SAD that emphasize the role of these processes in maintaining symptoms and highlight the importance of directly addressing them in treatment.

Future research should focus on:

1. Developing and evaluating targeted interventions specifically designed to reduce pre-event and post-event rumination in SAD
2. Investigating the long-term effects of rumination-focused treatments through follow-up studies
3. Exploring the mechanisms by which pre-event and post-event rumination are reduced in effective treatments
4. Examining the relationship between rumination reduction and overall SAD symptom improvement

Strengths

The study had many methodological strengths, including:

1. Adherence to PRISMA guidelines for systematic reviews and meta-analyses
2. Comprehensive literature search across multiple databases
3. Rigorous inclusion/exclusion criteria to ensure focus on SAD-specific rumination
4. Use of established quality assessment tools (JBI Critical Appraisal Tools) to evaluate included studies
5. Employment of random effects models and heterogeneity assessments in meta-analyses
6. Examination of publication bias through multiple methods
7. Conducting subgroup analyses and meta-regressions to explore factors influencing treatment effectiveness

Limitations

This study also had some methodological limitations, including:

1. Relatively small number of studies meeting inclusion criteria (K = 26), limiting the power of some analyses
2. Overrepresentation of CBT interventions, restricting comparisons between different treatment types
3. Lack of follow-up data in most studies, precluding analysis of long-term treatment effects
4. Variability in rumination measures used across studies, potentially introducing measurement heterogeneity
5. Inclusion of both controlled and uncontrolled trials, which may affect the reliability of some findings
6. Limited geographical diversity in included studies, potentially reducing generalizability to non-Western populations

These limitations suggest caution in interpreting some results, particularly those involving comparisons between different treatment types or long-term effectiveness.

Future research should address these limitations by conducting more diverse treatment studies, including longer follow-up periods, and using consistent, well-validated measures of pre-event and post-event rumination.

Implications

The findings of this meta-analysis have significant implications for clinical practice and future research in the treatment of social anxiety disorder:

1. Clinical practice: The large effect sizes observed for psychological treatments, particularly CBT, in reducing pre-event and post-event rumination support their continued use as first-line interventions for SAD. Clinicians should consider incorporating targeted rumination-focused techniques into their treatment protocols, especially for addressing pre-event rumination.
2. Treatment development: The enhanced effectiveness of treatments directly targeting rumination suggests that developing more specialized interventions focused on these processes could improve overall treatment outcomes for SAD.
3. Personalized treatment approaches: The differential effects of baseline social anxiety and depression levels on pre-event and post-event rumination reductions indicate that tailoring treatments based on individual symptom profiles may be beneficial.
4. Theoretical implications: The results support cognitive models of SAD that emphasize the role of pre-event and post-event rumination in maintaining symptoms, highlighting the importance of addressing these processes in comprehensive treatment approaches.
5. Research focus: The findings underscore the need for more studies examining non-CBT interventions, long-term treatment effects, and the specific mechanisms by which rumination is reduced in effective treatments.
6. Measurement considerations: The variability in rumination measures used across studies suggests a need for more consistent, well-validated assessment tools specifically designed for pre-event and post-event rumination in SAD.
7. Transdiagnostic implications: The association between baseline depression levels and post-event rumination reduction suggests potential overlap with depressive rumination, highlighting the importance of considering comorbid conditions in treatment planning.

These implications emphasize the importance of directly addressing pre-event and post-event rumination in SAD treatments and suggest several avenues for improving clinical outcomes and advancing our understanding of these processes in maintaining social anxiety symptoms.

References

Primary reference

Donohue, H. E., Modini, M., & Abbott, M. J. (2023). Psychological interventions for pre-event and post-event rumination in social anxiety: A systematic review and meta-analysis. Journal of Anxiety Disorders, 102823. https://doi.org/10.1016/j.janxdis.2023.102823

Other references

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). Washington, DC: Author.

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social Phobia: Diagnosis, Assessment and Treatment (pp. 69–93). New York: Guildford Press.

Crome, E., Grove, R., Baillie, A. J., Sunderland, M., Teesson, M., & Slade, T. (2015). DSM-IV and DSM-5 social anxiety disorder in the Australian community. Australian & New Zealand Journal of Psychiatry, 49(3), 227-235. https://doi.org/10.1177/0004867414546699

Hofmann, S. G. (2007). Cognitive factors that maintain social anxiety disorder: A comprehensive model and its treatment implications. Cognitive behaviour therapy, 36(4), 193-209. https://doi.org/10.1080/16506070701421313

Kocovski, N. L., Endler, N. S., Rector, N. A., & Flett, G. L. (2005). Ruminative coping and post-event processing in social anxiety. Behaviour research and therapy, 43(8), 971-984. https://doi.org/10.1016/j.brat.2004.06.015

Konnopka, A., & König, H. (2020). Economic burden of anxiety disorders: a systematic review and meta-analysis. Pharmacoeconomics, 38, 25-37. https://doi.org/10.1007/s40273-019-00849-7

Loerinc, A. G., Meuret, A. E., Twohig, M. P., Rosenfield, D., Bluett, E. J., & Craske, M. G. (2015). Response rates for CBT for anxiety disorders: Need for standardized criteria. Clinical psychology review, 42, 72-82. https://doi.org/10.1016/j.cpr.2015.08.004

Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), 368-376. https://doi.org/10.1016/S2215-0366(14)70329-3

Mills, A. C., Grant, D. M., Lechner, W. V., & Judah, M. R. (2013). Psychometric properties of the anticipatory social behaviours questionnaire. Journal of Psychopathology and Behavioral Assessment, 35, 346-355. https://doi.org/10.1007/s10862-013-9339-4

Patel, A., Knapp, M., Henderson, J., & Baldwin, D. (2002). The economic consequences of social phobia. Journal of affective disorders, 68(2-3), 221-233. https://doi.org/10.1016/S0165-0327(00)00323-2

Price, M., & Anderson, P. L. (2011). The impact of cognitive behavioral therapy on post event processing among those with social anxiety disorder. Behaviour Research and Therapy, 49(2), 132-137. https://doi.org/10.1016/j.brat.2010.11.006

Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour research and therapy, 35(8), 741-756. https://doi.org/10.1016/S0005-7967(97)00022-3

Wong, Q. J., Gregory, B., McLellan, L. F., Kangas, M., Abbott, M. J., Carpenter, L., … & Rapee, R. M. (2017). Anticipatory processing, maladaptive attentional focus, and postevent processing for interactional and performance situations: treatment response and relationships with symptom change for individuals with social anxiety disorder. Behavior therapy, 48(5), 651-663. https://doi.org/10.1016/j.beth.2017.03.004

Keep Learning

Socratic questions for a college class to discuss this paper:

1. How might the finding that targeted interventions are more effective for pre-event rumination inform the development of new treatment protocols for social anxiety disorder?
2. What are the potential implications of the differential effects of baseline social anxiety and depression on pre-event and post-event rumination reduction? How might this inform our understanding of these processes?
3. Given the limitations of the current research, what specific study designs would you propose to address the gaps in our knowledge about treating pre-event and post-event rumination in SAD?
4. How might the effectiveness of rumination-focused interventions for SAD inform our approach to treating other anxiety disorders or depression? Are there potential transdiagnostic applications?
5. Considering the large effect sizes found for CBT, what ethical considerations should be taken into account when developing and testing new treatments for pre-event and post-event rumination in SAD?
6. How might cultural factors influence the experience and treatment of pre-event and post-event rumination in SAD? How could future research address this?
7. What are the potential mechanisms by which effective treatments reduce pre-event and post-event rumination? How could these be investigated in future studies?
8. Given the variability in rumination measures used across studies, what key features should be included in a standardized measure of pre-event and post-event rumination for SAD?