The Effect of Rumination and Reappraisal on Social Anxiety Symptoms During Cognitive-Behavioral Therapy for Social Anxiety Disorder Faith A. Brozovich,1 Philippe Goldin,2 Ihno Lee,1 Hooria Jazaieri,3 Richard G. Heimberg,4 and James J. Gross1 1

Stanford University University of California, Davis 3 University of California, Berkeley 4 Temple University 2

Objective: There is growing interest in the role of transdiagnostic processes in the onset, maintenance, and treatment of mental disorders (Nolen-Hoeksema & Watkins, 2011). Two such transdiagnostic processes–rumination and reappraisal–are the focus of the present study. The main objective was to examine the roles of rumination (thought to be harmful) and reappraisal (thought to be helpful) in adults with social anxiety disorder (SAD). Method: We conducted a randomized controlled trial of cognitive-behavioral therapy (CBT) with 75 adults with SAD and examined pre- to post-CBT changes as well as weekly fluctuations in rumination, reappraisal, and social anxiety symptoms. Results: Socially anxious individuals’ baseline rumination (brooding) scores predicted weekly levels of social anxiety, rumination, and reappraisal, whereas baseline reappraisal scores did not. Greater weekly rumination was associated with greater weekly social anxiety, but reappraisal was not related to social anxiety. Conclusion: These findings suggest that rumination may have a more significant role than reapC 2014 Wiley Periodicals, praisal in understanding fluctuations in social anxiety during CBT for SAD.  Inc. J. Clin. Psychol. 00:1–11, 2014. Keywords: CBT; social anxiety; emotion regulation; cognitive reappraisal; rumination; brooding

Social anxiety disorder (SAD) is characterized by an intense fear of negative evaluation in social situations (American Psychiatric Association [APA], 2013). SAD can be extremely debilitating, causing considerable impairment in education, employment, and social functioning (Aderka et al., 2012). Thus, the effect of SAD is substantial. Cognitive-behavioral models of SAD highlight aberrant emotional responses, cognitions, and behaviors that are unique to social anxiety (Clark & Wells, 1995; Rapee & Heimberg, 1997). According to these models, problems with emotional reactivity and regulation in SAD are a result of distorted beliefs and interpretations, as well as safety behaviors and other avoidance behaviors employed to cope with heightened levels of anxiety. These models have focused on specificity, illustrating the ways in which social anxiety is distinct from other psychological disorders. However, as clinical science progresses, there is growing interest in the role of transdiagnostic processes in the onset, maintenance, and treatment of mental disorders (Nolen-Hoeksema & Watkins, 2011). Many potential mechanisms exist; however, in the present study, we chose to focus on two cognitive emotion regulation phenomena: the maladaptive process of rumination, specifically brooding, and the adaptive process of reappraisal. We were particularly interested in these two mechanisms because both are cognitive and malleable in nature. We also were interested in examining the effects of cognitive-behavioral therapy (CBT) on these mechanisms.

Please address correspondence to: Faith A. Brozovich, Department of Psychology, Jordan Hall, Bldg. 420, Stanford, CA 94205-2130. E-mail: [email protected] JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 00(0), 1–11 (2014) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).

 C 2014 Wiley Periodicals, Inc. DOI: 10.1002/jclp.22132

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Rumination as a Maladaptive Process The largest body of empirical work examining the maladaptive process of rumination has employed Nolen-Hoeksema’s (1991) definition of rumination: a cognitive process in which individuals unproductively perseverate on their mood and related symptoms, causes, and consequences. Early studies identified rumination as an important component of major depressive disorder (MDD; Nolen-Hoeksema, 1991). Since that time, rumination has been linked to increases in symptoms of several other disorders, including anxiety, alcohol, substance use, and eating disorders (Aldao, Nolen-Hoeksema, & Schweizer, 2010). Treynor, Gonzalez, and Nolen-Hoeksema (2003) delineated two subtypes of rumination, brooding–“a passive comparison of one’s current situation with some unachieved standard”– and reflective pondering–“purposefully turning inward to engage in cognitive problem-solving” (p. 256). Brooding has been identified as a particularly insidious form of rumination in MDD (Pearson, Watkins, Kuyken, & Mullan, 2010). Brooding also has been strongly associated with anxiety symptoms in a clinical setting (Watkins, 2009). Interestingly, although studies have shown a link between rumination and anxiety, research on rumination and particularly brooding in SAD, a disorder characterized by increased levels of negative ruminative thinking, is limited. Cognitive-behavioral models of SAD posit that after a social event, individuals with SAD engage in a “post mortem” or review of the social situation (Clark & Wells, 1995; Heimberg, Brozovich, & Rapee, 2010). During these episodes of post-event processing (also known as post-event rumination), individuals with SAD tend to focus on negative information about themselves and others’ opinions of them during the social situation and compare this to an unrealistically high standard (for a review, see Brozovich & Heimberg, 2008). Research on socially anxious individuals who engage in rumination suggests that they experience increases in anxiety and negative affect over time (Brozovich & Heimberg, 2011) and have distorted memories of the actual event (Morgan & Banjeree, 2008). Studies that have experimentally manipulated rumination have also shown that rumination maintains negative beliefs in persons with social anxiety (Vassilopoulos & Watkins, 2009). A few treatment studies have demonstrated that CBT reduces rumination (e.g., Price & Anderson, 2011). Although rumination has been identified as a maladaptive factor in MDD (Pearson et al., 2010), only two studies have investigated maladaptive rumination (brooding) in socially anxious individuals. Thus far, brooding has been shown to be elevated in socially anxious individuals compared to healthy individuals, but similar to individuals with MDD (Joormann, Dkane, & Gotlib, 2006) and to mediate the relationship between social anxiety and trait anger (Trew & Alden, 2009). These studies provide preliminary support for the association between brooding and social anxiety. Further research is needed to examine the effect of brooding on fluctuations in social anxiety symptoms and whether brooding affects SAD treatment outcome.

Reappraisal as an Adaptive Process Alternatively, cognitive reappraisal is considered an adaptive emotion regulation process. Reappraisal refers to reinterpreting a potentially evocative stimulus in a way that alters an emotional response (Gross, 2014). It is generally considered adaptive because it reduces emotional reactivity, decreases physiological arousal, and improves well-being (Gross, 2014). It is thus no accident that reappraisal is a fundamental component of cognitive restructuring, a prominent therapeutic technique in CBT. It is implemented to reduce anxiety or distress when individuals are faced with negative automatic thoughts or challenging situations. The duration of a full course of individual CBT provides an excellent time frame in which to study changes in the development of an adaptive emotion regulation strategy (i.e., reappraisal) over time. Emerging evidence suggests that individuals with SAD are less able to implement reappraisal and have lower self-efficacy regarding actually applying reappraisal (Goldin, ManberBall, Werner, Heimberg, & Gross, 2009; Werner, Goldin, Ball, Heimberg, & Gross, 2011). As might be expected given the link between cognitive restructuring and reappraisal, CBT increases reappraisal use (Moscovitch et al., 2012). Moreover, Goldin and colleagues (2012) found that reappraisal self-efficacy mediated the effect of CBT on social anxiety symptoms and that

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increases in reappraisal self-efficacy predicted decreases in social anxiety symptoms at 1-year post-CBT. Unfortunately, few studies have directly compared generally adaptive processes, such as reappraisal, with generally maladaptive processes, such as rumination. What we know from studies of anxiety and depression suggests that these forms of psychopathology are more highly associated with increased maladaptive processes (rumination and expressive suppression) and more weakly associated with adaptive processes (reappraisal and problem solving; Aldao et al., 2010). D’Avanzato, Joormann, Siemer, and Gotlib (2013) found greater use of maladaptive strategies (rumination and expressive suppression) and lesser use of adaptive strategies (reappraisal) in individuals with SAD and MDD. Specifically in individuals with SAD, rumination predicted state anxiety levels. Clearly, cross-sectional designs have provided valuable insight, highlighting rumination as a maladaptive process linked to social anxiety; however, the broader issue of how maladaptive and adaptive processes predict symptoms and unfold with respect to changes in symptom patterns in social anxiety disorder has yet to be examined prospectively.

The Present Study The goal of the present study was to contrast a generally maladaptive cognitive form of emotion regulation, rumination, with a generally adaptive one, reappraisal. More specifically, we sought to examine the associations with social anxiety symptoms as rumination and reappraisal fluctuated during CBT for SAD. We selected a sample of adults with generalized SAD and conducted a randomized controlled trial (RCT) of individual CBT for SAD. We measured baseline rumination (brooding) and reappraisal as well as assessed weekly fluctuations in rumination, reappraisal, and social anxiety symptoms. We hypothesized that (a) greater baseline rumination (brooding) would predict greater weekly social anxiety and rumination and lesser weekly reappraisal during CBT, whereas greater baseline reappraisal would predict lesser weekly social anxiety and rumination and greater weekly reappraisal. Directly comparing the two predictors, we hypothesized that brooding would be a more robust predictor of fluctuations in social anxiety than reappraisal. We also expected that (b) greater weekly rumination during CBT would be related to greater weekly social anxiety and that greater use of reappraisal would be related to lower levels of weekly social anxiety.

Method Participants To assess eligibility for an RCT of CBT for SAD, 436 individuals were screened by telephone, and of these, 110 were administered a clinical diagnostic interview (see Figure 1). As part of a larger project focused on the neural bases of CBT for SAD, the 75 socially anxious individuals who met Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV; APA, 1994) criteria for a principal diagnosis of generalized SAD were randomly assigned to either immediate CBT (n = 38) or a waitlist (WL) group (n = 37). Individuals assigned to WL were subsequently offered CBT. We offered individuals with SAD free treatment in exchange for their participation. See Table 1 for information on demographic characteristics. All participants provided informed consent in accordance with the Institutional Review Board at Stanford University.

Inclusion and Exclusion Criteria We required that all participants be 21–55 years of age, speak fluent English, be right-handed, pass a Magnetic Resonance Imaging safety screen, and be free of current pharmacotherapy or psychotherapy, history of medical disorders (e.g., hypertension, thyroid disorders, diabetes, or anemia), head trauma, and neurological disorders. Participants also met the DSM-IV criteria for a principal diagnosis of generalized SAD as assessed by the Anxiety Disorders Interview Schedule for the DSM-IV-Lifetime version (ADIS-IV-L; DiNardo, Brown, & Barlow, 1994).

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Table 1 Characteristics of Participants in Immediate Versus Delayed Treatment Groups Variable Gender (males, n, %) Age (yrs, M ± SD) Education (yrs, M ± SD) Ethnicity (n, %) Caucasian Asian Hispanic Other Multiracial Baseline brooding (M ± SD) Baseline reappraisal (M ± SD) Baseline weekly rumination (M ± SD) Baseline weekly reappraisal (M ± SD) Baseline weekly social anxiety (M ± SD)

I-CBT n = 38 19 (50.0%) 33.38 ± 7.60 16.68 ± 2.21

WL n = 37 20 (54.1%) 33.63 ± 10.37 16.96 ± 2.51

22 (57.9%) 9 (23.7%) 3 (7.9%) 2 (5.3%) 2 (5.3%) 12.84 ± 4.29 28.42 ± 11.96 70.63 ± 25.64 32.81 ± 24.53 61.88 ± 20.70

21 (56.8%) 9 (24.3%) 5 (13.5%) 2 (5.4%) 0 (0%) 12.72 ± 3.24 28.77 ± 11.22 68.18 ± 19.18 36.82 ± 24.38 68.18 ± 19.18

t or χ χ2 = 0.35, p = .55 t = −0.12, p = .91 t = −0.51, p = .61 χ2 = 4.41, p = .62

t = 0.14, p = .89 t = −0.13, p = .90 t = 0.38, p = .71 t = −0.59, p = .58 t = −1.13, p = .26

Note. I-CBT = individual cognitive-behavioral therapy; WL = waitlist; M = mean; SD = standard deviation.

Figure 1. Consolidated standards of reporting trials diagram for randomized controlled trial of individual cognitive-behavioral therapy (I-CBT) versus wait-list (WL) control. ITT = intent-to-treat analyses; tx = treatment.

Generalized SAD was defined as experiencing greater than moderate fear in five or more social situations as well as receiving a rating of 4 or greater for SAD on the 0–8 clinician severity scale. We excluded individuals with comorbid psychiatric disorders other than generalized anxiety disorder, specific phobia, panic disorder, and dysthymia. Of the 75 socially anxious participants, 15 were diagnosed with one or more current comorbid disorders, none of which was judged primary: three panic disorder, 14 generalized anxiety disorder, five specific phobia, and three dysthymic disorder.

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Clinical and Individual Difference Materials Before entering the study, individuals underwent a semistructured diagnostic interview, the ADIS-IV-L (DiNardo, Brown, & Barlow, 1994). Two Ph.D. clinical psychologists, both of whom were trained to conduct the interview by watching training tapes and completing test cases, administered the ADIS-IV-L in this study. The ADIS-IV-L is a highly reliable interview for the diagnosis of anxiety disorders and related conditions (Brown, Di Nardo, Lehman, & Campbell, 2001). Specifically, in a sample of patients with a range of anxiety disorders, it has shown excellent reliability for a principal diagnosis of SAD (ĸ = .77; Brown, Di Nardo, Lehman, & Campbell, 2001). At baseline and post-CBT, participants completed the Ruminative Responses Scale (Treynor et al., 2003). The scale comprises two subscales: brooding and reflective pondering. We focused solely on the brooding subscale given that we were mostly interested in brooding as a maladaptive form of rumination, and its subscale is least contaminated by depressive symptoms. The brooding subscale depicts moody rumination or “a passive comparison of one’s current situation with some unachieved standard” (Treynor et al., 2003, p. 256; e.g., Why do I always react this way?). Five items are rated on Likert-type scales ranging from 1 (almost never) to 4 (almost always). The brooding subscale has been shown to have good reliability in other studies (α = .77; Treynor et al., 2003) as well as in the current study (α = .80). At baseline and post-CBT, reappraisal was assessed using an expanded version of the Emotion Regulation Questionnaire (ERQ; Goldin, Manber-Ball, Werner, Heimberg, & Gross, 2009; Gross & John, 2003). This scale comprises 52 items, divided between reappraisal and suppression items. We focused solely on the reappraisal scale. Items measuring reappraisal form two subscales: frequency of use and self-efficacy. For the purposes of this study, we focused on the frequency of use of reappraisal since it was the best counterpart for brooding frequency. The reappraisal frequency scale comprises eight items (e.g., I control my emotions by changing the way I think about the situation I’m in). Participants rated the items on Likert-type scales ranging from 1 (strongly disagree) to 7 (strongly agree). The original ERQ reappraisal scale has shown good reliability (α = .79; Gross & John, 2003), as has the expanded version of the ERQ reappraisal scale in the present study (α = .89). During the 16 weeks of CBT, weekly fluctuations in rumination, reappraisal, and social anxiety were measured using a brief weekly questionnaire designed for this study. Rumination was assessed with the question: How often have you gone over and over in your mind social interactions after they have finished? Reappraisal was assessed with the question: How often did you try to change the way you were thinking about the situation you were in? Participants rated their responses on Likert-type scales ranging from 0 (not at all; 0%) to 100 (always; 100%). Weekly social anxiety symptoms were measured with another item: “How intense has your social anxiety been?” Participants rated this question on a Likert-type scale ranging from 0 (not at all) to 100 (extremely). Participants completed this assessment–along with additional items to be reported elsewhere–at baseline, weekly during CBT, monthly during WL, and immediately post-WL CBT.

CBT for SAD Participants received individual CBT for SAD based on the therapist manual by Hope, Heimberg, and Turk (2006). The individual treatment was completed over the course of 16 weeks in 1-hour weekly sessions, with one 1.5-hour session at the start of in-session exposures. Treatment comprised five phases: (a) psychoeducation, approximately four sessions; (b) cognitive restructuring training, two to three sessions; (c) in-session and in vivo exposure, eight to nine sessions; (d) advanced core beliefs work, one to two sessions; and (e) treatment consolidation and termination, one session. Individuals received a workbook (Hope, Heimberg, Juster, & Turk, 2000) and were asked to read the appropriate chapters before each therapy session and complete the relevant homework assignments. All participants completed all 16 sessions and at least seven in-session exposures. Therapists worked with clients to reschedule sessions due to illness or vacations.

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Four Ph.D. clinical psychologists delivered the treatment. Richard Heimberg, one of the developers of the treatment protocol, trained all therapists. Therapists needed to achieve competence conducting this CBT protocol with training cases before treating individuals in the study. All therapy sessions were audio-recorded and then rated for adherence and fidelity using the Cognitive-Behavioral Therapy for Social Anxiety Disorder: Therapist Adherence Scale (Hope, VanDyke, Heimberg, Turk, & Fresco, 2001). The adherence raters made their responses on Likert-type scales ranging from 1 (ineffective) to 5 (extremely effective). A one-way random effects model was conducted with absolute agreement to compute the average intraclass correlation (.81) between raters. Ratings for each of the five components had to be ࣙ 4 to be considered “in protocol.” The four therapists achieved this standard (overall mean [M] = 4.61, standard deviation [SD] = 0.24), and a one-way analysis of variance (ANOVA) showed no differences among the therapists F(3,33) = 0.11, p = .96.

Procedure Participants were recruited through referrals, community flyers, and Web listings. After passing an initial telephone interview and an in-person diagnostic interview, participants were invited to enroll in the study. After completing baseline assessments, socially anxious individuals were randomly assigned to CBT or WL using Efron’s biased coin randomization procedure (Efron, 1971), which ensures equal sample sizes throughout the clinical trial. During the 16 weeks of CBT, participants completed weekly assessments of social anxiety, rumination, and reappraisal (described in more detail above). After CBT or WL, individuals with SAD were readministered the same battery of assessments that were completed at baseline.

Statistical Analyses As part of our preliminary analyses, we conducted between-group t tests on the baseline and weekly variables to ensure there were no differences between our immediate CBT participants and post-WL CBT participants. In addition, we conducted repeated measures ANOVAs to examine pre- to post-CBT changes in rumination (RRS brooding subscale) and reappraisal (ERQ). For all analyses, we report partial eta-squared (η2 p ) as an index of effect size. Cohen (1988) identified parameters for η2 p effect sizes as follows: small = .01, medium = .09, and large = .25. We conducted multilevel modeling (MLM) analyses to examine average levels of weekly social anxiety, rumination, and reappraisal, as a function of person-level variables (baseline rumination [brooding] and reappraisal) as well as the relationship between weekly social anxiety and weekly rumination and reappraisal. See Hox (2002) and Snijders and Bosker (1999) for additional MLM details and specification. We ran two sets of MLM analyses to determine (a) whether baseline rumination (brooding) or reappraisal predict social anxiety, rumination, and reappraisal throughout CBT, and (b) whether weekly rumination and reappraisal are associated with the intensity of weekly social anxiety over the course of CBT. All intercepts and slopes associated with week-level (vs. person-level) variables were specified as random (i.e., varying across individuals; represented by u components in Models 1 and 2). To investigate the effects of baseline rumination (brooding) and reappraisal on social anxiety, rumination, and reappraisal measured weekly during CBT, we constructed the following model with week of assessment as a within-person predictor and baseline brooding and reappraisal as between-person predictors: Model 1: Weekly anxiety (or rumination/reappraisal)ij = γ00 + γ01 (baseline brooding) + γ02 (baseline reappraisal)+ γ10 (week) + u0j + u1j (week)+ eij The fixed effects of interest are γ01 and γ02 , which represent the fixed (or average) effects of baseline rumination (brooding) and baseline reappraisal on weekly social anxiety, rumination, and reappraisal levels throughout CBT.

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To determine whether weekly rumination and reappraisal were associated with the intensity of weekly social anxiety during CBT, we constructed the following model with week of assessment, rumination, and reappraisal and within-person predictors: Model 2: Weekly social anxietyij = γ00 + γ10 (week) + γ20 (rumination) + γ30 (reappraisal) + u0j + u1j (week) + u2j (rumination) + u3j (reappraisal) + eij The fixed effects of interest are γ20 and γ30 , which represent the average weekly effects of rumination and reappraisal, respectively, on social anxiety intensity. The random effects of interest are the variance parameters (τ22, τ33 elements associated with u2j , u3j , variance–covariance matrix not displayed) for the rumination and reappraisal slopes, which indicate whether the average weekly effects of rumination and reappraisal vary across individuals. All fixed effects are reported as unstandardized estimates. Effects (baseline rumination [brooding] vs. baseline reappraisal, weekly rumination vs. weekly reappraisal) were compared using deviance tests; significance was evaluated using the difference in -2 log-likelihood values obtained from a baseline model (with freely estimated effects) and a nested model (with focal effects constrained to equality), which is chi-square distributed. All multilevel analyses were run in Mplus v.6.1 (Muth´en & Muth´en, 1998–2010).

Results Preliminary Analyses Socially anxious individuals randomized to CBT or WL groups did not differ significantly on demographic, rumination (brooding), reappraisal, or weekly variables, ps > .25 (see Table 1). There were no differences in dropout rates, χ2 (1, N = 75) = 0.05, p = .81, from CBT (n = 6; 15%) and WL (n = 5; 14%). Given no differences were found between immediate and post-WL CBT completers, we combined the samples for the remainder of the analyses. Baseline rumination (brooding) and reappraisal were not related, r(68) = –.10, p > .44. We examined pre- to post-CBT changes in rumination (brooding) and reappraisal. Repeated measures ANOVAs demonstrated significant decreases in rumination (brooding), ࢞ = –1.71, F(1, 37) = 9.71, p = .004, η2 p = .21, and significant increases in reappraisal, ࢞ = 10.78, F(1, 34) = 31.65, p < .001, η2 p = .48.

Baseline Rumination (Brooding) and Reappraisal Predict Weekly Social Anxiety, Rumination, and Reappraisal Controlling for week, greater rumination (brooding) at baseline predicted greater average weekly levels of social anxiety (γ01 = .97, standard error [SE] = 0.44, p = .03), rumination (γ01 = .94, SE = 0.47, p = .02), and reappraisal (γ01 = 1.28, SE = .49, p = .008) during 16 weeks of CBT. However, controlling for week, baseline reappraisal did not predict the average weekly level of social anxiety (γ02 = -.05, SE = .15, p = .76), rumination (γ02 = -.03, SE = .20, p = .87), or reappraisal (γ02 = .18, SE = .17, p = .29). All estimates are displayed in Table 2. A deviance test showed that baseline rumination (brooding) was a stronger predictor of average weekly social anxiety, ࢞χ2 (1) = 4.84, p = .03, weekly rumination, ࢞χ2 (1) = 3.95, p = .05, and weekly reappraisal, ࢞χ2 (1) = 4.73, p = .03, than was baseline reappraisal.

Within-Person Associations Among Social Anxiety, Rumination, and Reappraisal During CBT During 16 weeks of CBT, greater weekly rumination was associated with greater weekly social anxiety, γ20 = 0.66, SE = 0.05, p < .001. However, weekly reappraisal was not associated with weekly social anxiety (γ30 = 0.04, SE = 0.03, p = .10). A deviance test showed that weekly rumination was a significantly stronger predictor of weekly social anxiety than weekly reappraisal, ࢞χ2 (1) = 78.38, p < .001.

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Table 2 Effects of Baseline Rumination (Brooding) and Reappraisal on Weekly Social Anxiety, Rumination, and Reappraisal Effect Fixed effects Intercept (γ00 ) Baseline brooding (γ01 ) Baseline reappraisal (γ02 ) Week (γ10 ) Random effects Intercept (τ00 ) Week (τ11 ) Intercept-week (τ10 ) Residual (σ2 )

Social anxiety

Rumination

Reappraisal

55.67 (8.05)** 0.97 (0.44)* −0.05 (0.15) −1.45 (0.24)**

60.85 (10.29)** 1.04 (0.58)* −0.03 (0.20) −1.45 (0.21)

15.50 (8.91) 1.28 (0.49)** 0.18 (0.17) 1.42 (0.22)**

368.07 (77.75)** −1.36 (0.24)** −21.60 (6.19)** 151.30 (8.70)**

263.75 (57.48)** 1.74 (0.45)** −21.48 (6.22)** 177.69 (10.46)**

367.34 (86.49)** 1.63 (0.54)** −17.26 (5.98)** 277.52 (15.92)**

Note. Unstandardized estimates are reported; standard errors are in parentheses. * p < .05. ** p < .01.

Discussion The goal of the present study was to examine the roles of rumination and reappraisal in generalized SAD and to better understand how these cognitive processes relate to changes in social anxiety symptoms during CBT. Consistent with hypotheses, (a) greater baseline rumination (brooding) predicted greater weekly social anxiety and rumination, and (b) greater weekly rumination during CBT was associated with greater weekly social anxiety. Contrary to our hypotheses, greater baseline rumination (brooding) also predicted greater weekly reappraisal.

Toward a Broader Conception of Rumination and Reappraisal The finding that rumination (brooding) was a stronger predictor than reappraisal and more closely associated with weekly changes in social anxiety may come as a surprise because changes in reappraisal appear to be an active ingredient in CBT. However, cross-sectional studies comparing the two processes have shown rumination to be more strongly associated than reappraisal with anxiety (Aldao et al., 2010) and with SAD specifically (D’Avanzato, Joormann, Siemer, & Gotlib, 2013). Reductions in maladaptive rumination were more informative regarding changes in social anxiety symptoms than increases in adaptive reappraisal. We provided further support for this relationship by showing that rumination was specifically predictive of social anxiety symptoms, rumination, and reappraisal over time. It was unexpected that greater baseline rumination (brooding) predicted greater reappraisal. Two potential reasons for the finding may be that (a) persons with SAD may have a greater need for reappraisal due to the magnifying lens of rumination, or (b) they may engage in more unproductive attempts at reappraisal. Further research is needed to replicate these results to have a better sense of the reasons why rumination (brooding) is associated with increases in reappraisal. The process model of emotion regulation (Gross, 2014) provides a helpful context to study various types of emotion (dys)regulation. Using this framework, rumination can be conceptualized as an attentional deployment strategy, in which individuals focus their attention on a given stimulus to modify their emotional response. However, this deployment of attention is maintained or repeated without engaging in cognitive change (Ray, Wilhelm, & Gross, 2008). Brooding may become particularly dysregulated when individuals are caught in a cognitive cycle of unproductively mulling over their negative thoughts. Socially anxious individuals’ interpretations of the situation also become increasingly negative over time (Brozovich & Heimberg, 2013). Reappraisal, as discussed earlier, is a generally more adaptive form of cognitive change, in which individuals aim to change the way they are thinking about a situation to modify their emotional reactivity to a provocative experience. Viewing brooding as an attentional deployment

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strategy that may interfere with cognitive change (i.e., reappraisal) elucidates how these emotion regulation processes may interact with one another.

Conceptual and Clinical Implications for SAD Among individuals with SAD, rumination has been associated with a number of negative consequences, such as heightened anxiety (Brozovich & Heimberg, 2011), interpretation biases (Vassilopoulos & Watkins, 2009), and memory biases (Morgan & Banjeree, 2008). The present study adds to this literature by showing that brooding, a particularly negative form of rumination, predicts greater social anxiety and rumination during treatment. But why does rumination play such an important role in SAD? Rumination is a binding process that occurs before, during, and after social anxiety-evoking events, thus perpetuating individuals’ anxiety and cognitive biases (Brozovich & Heimberg, 2013). Brooding can be conceptualized as a particularly sticky manifestation of rumination that focuses on the negative aspects of one’s behaviors and compares them to an unrealistic standard. The more individuals examine past information, the more distorted their memories and interpretations become (Heimberg, Brozovich, & Rapee, 2010). When an upcoming social anxiety-provoking situation looms on the horizon, the distorted and negative interpretations are easily accessible, activating greater anticipatory processing of the next event (Brozovich & Heimberg, 2013). The cycle of brooding continues after the social event ends. Training in cognitive restructuring during CBT allows individuals with SAD to develop a new way of thinking. CBT helps individuals to increase reappraisal, which directs their attention to entertain alternative perspectives and challenges the veracity of their thoughts. This occurs before, during, and after social situations. At the same time, CBT helps individuals increase exposure to feared situations. In the present study, rumination (brooding) predicted social anxiety over the course of 4 months of CBT above and beyond reappraisal. It may be that CBT freed individuals’ attention from brooding, thereby helping to reduce social anxiety. CBT has clearly been effective in diminishing rumination and increasing reappraisal in social anxiety in the present RCT. A handful of other studies have also shown that rumination decreases during CBT (e.g., Price & Anderson, 2011). Our study provides evidence that baseline rumination (brooding) predicts social anxiety and rumination and changes in rumination during treatment inform us about social anxiety symptom changes. If future studies substantiate our findings, it may be useful for clinicians to measure rumination during the course of treatment to better assess improvement in ruminative habits alongside changes in social anxiety.

Limitations and Future Directions The present study examined rumination and reappraisal, as well as their associations with social anxiety during CBT for SAD. We collected socially anxious individuals’ self-reports of their ruminative tendencies using the brooding subscale of the RRS before CBT. The present study is the first to use the RRS to examine brooding in SAD during an RCT of CBT. The RRS is a psychometrically sound instrument measuring rumination (Treynor et al., 2003). However, the RRS was not designed to measure rumination in social anxiety and has often been criticized for overlapping with symptoms of depression. We utilized the brooding subscale, which is less influenced by depression-related items; yet we did not include other rumination measures that have been developed specifically for social anxiety (e.g., Post-Event Processing Questionnaire; Rachman, Gruter-Andrew, & Shafran, 2000). Future studies would benefit from including postevent processing measures alongside the RRS to examine rumination and how it specifically relates to social anxiety after social situations. Our focus in this study was on a sample of individuals with generalized SAD with limited comorbidity. This research strategy allowed us to isolate the role of rumination (brooding) and reappraisal in a relatively homogeneous clinical context. However, as clinical science moves toward a more transdiagnostic approach (Nolen-Hoeksema & Watkins, 2011), it is essential to examine maladaptive mechanisms that may exacerbate symptoms across disorders, as well as adaptive ones that may ameliorate symptoms.

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Journal of Clinical Psychology, September 2014

Although we focused solely on Nolen-Hoeksema’s conceptualization of maladaptive rumination (brooding), Watkins (2008) points out that rumination has adaptive purposes and consequences as well. An interesting area to pursue may be to measure individuals’ ruminative habits using scales that capture maladaptive and adaptive components and how these may fluctuate within the same individual after receiving treatment for social anxiety or other diagnoses. There are also other facets to reappraisal. For example, reappraisal self-efficacy, or one’s cognitive evaluation of one’s ability to implement reappraisal, has proven to affect treatment response in social anxiety both immediately after and 1 year after treatment (Goldin et al., 2012). Thus, people’s appraisals of how successful they are at using a given emotion regulation strategy may affect frequency of use as well. These are additional variables to consider when studying any emotion regulation strategy.

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