Targeting fear of positive evaluation in patients with social anxiety disorder via a brief cognitive behavioural therapy protocol: a proof-of-principle study

Abstract

Background: Our aim was to develop a brief cognitive behavioural therapy (CBT) protocol to augment treatment for social anxiety disorder (SAD). This protocol focused specifically upon fear of positive evaluation (FPE). To our knowledge, this is the first protocol that has been designed to systematically target FPE. Aims: To test the feasibility of a brief (two-session) CBT protocol for FPE and report proof-of-principle data in the form of effect sizes. Method: Seven patients with a principal diagnosis of SAD were recruited to participate. Following a pre-treatment assessment, patients were randomized to either (a) an immediate CBT condition (n = 3), or (b) a comparable wait-list (WL) period (2 weeks; n = 4). Two WL patients also completed the CBT protocol following the WL period (delayed CBT condition). Patients completed follow-up assessments 1 week after completing the protocol. Results: A total of five patients completed the brief, FPE-specific CBT protocol (two of the seven patients were wait-listed only and did not complete delayed CBT). All five patients completed the protocol and provided 1-week follow-up data. CBT patients demonstrated large reductions in FPE-related concerns as well as overall social anxiety symptoms, whereas WL patients demonstrated an increase in FPE-related concerns. Conclusions: Our brief FPE-specific CBT protocol is feasible to use and was associated with large FPE-specific and social anxiety symptom reductions. To our knowledge, this is the first treatment report that has focused on systematic treatment of FPE in patients with SAD. Our protocol warrants further controlled evaluation.

The role of fear of positive evaluation in social anxiety: A systematic review and meta-analysis.

“…For example, treatments may not address FPE as systematically as FNE and not reach fear exposures adequate to reduce symptoms; clients may disqualify positive social outcomes to cognitively avoid compliments and positive evaluation in a way that maintains their symptoms, and, finally, treatment may be ineffective and lead to patient dropout, owing to the positive evaluation from a therapist inadvertently and paradoxically exacerbating client anxiety symptoms. To date, only one study has developed and evaluated a treatment protocol that systematically targets FPE (Weeks et al, 2020), and no protocol has been developed that targets both FPE and FNE. In line with the conclusions made by Weeks et al (2020), the outcomes of the current study suggest that cognitive and behavioral treatment interventions address FPE in addition to FNE to not only avoid these described treatment barriers but also address a broader range of social anxiety symptoms and potentially enhance patient outcomes.…”

Please Don’t Compliment Me! Fear of Positive Evaluation and Emotion Regulation—Implications for Adolescents’ Social Anxiety

“…Weeks and colleagues [ 103 ] developed a brief cognitive–behavioral treatment protocol specifically targeted at FPE. It included psychoeducation related to FPE, cognitive restructuring of FPE-specific negative automatic thoughts, and implementation of in-session and in-vivo exposure tasks focused on either self-presentation or accepting and receiving compliments.…”

“From meta-analysis to meta-interpretations and implications”: Fears of positive and negative evaluation and the bivalent fear of evaluation model of social anxiety.

“…It logically follows that further research which systematically restricts safety behaviors and avoidance geared at minimizing positive evaluations is necessary to truly conclude with confidence whether FNE remains the most salient socio-evaluative fear (e.g., see Weeks & Zoccola, 2016, for an example involving public speeches on why one would be an ideal candidate for a hypothetical job [i.e., positive social threat cue]; see also Weeks et al, 2020, for examples of cognitive-behavioral exposures focusing on accepting/receiving compliments and engaging in self-promotion ). This issue will be addressed in further detail below (see Future Directions section below).…”

“…Lastly, and perhaps most importantly, as noted by Cook et al (2022), there are enormous steps yet to be made regarding translational implications of the BFOE model. To date, only one study has developed and evaluated a (cognitive-behavioral therapy [CBT]) protocol that systematically targets FPE (Weeks et al, 2020), and no protocol has been developed that systematically targets both FPE and FNE. In line with the findings and assertions of Cook et al (2022), there is ample evidence that CBT interventions should address FPE in addition to FNE to not only mitigate potential treatment barriers (e.g., clients may disqualify positive social outcomes as an FPE-based safety behavior, e.g., see Weeks & Howell, 2012, to cognitively avoid compliments and positive evaluation in a way that maintains their symptoms; positive evaluation from therapists may paradoxically exacerbate SAD symptoms), but also to maximize treatment outcomes for SAD.…”

“…On the basis of the latest evidence, it is reasonable for Cook et al (2022) to have recommended that patients with SAD be standardly treated using both the protocol outlined by Weeks et al (2020) and gold-standard interventions which focus systematically only upon FNE (see Footnote 1), with no current recommendations regarding the ordering of these treatment components—this would of course especially be the case if SAD patients score above recommended cutoffs on measures of both FPE and FNE (see Footnote 1). It is interesting to note, however, that in line with the typically graduated nature of CBT with regard to exposure work, and given that FNE has been highlighted as a somewhat more salient fear within the context of SAD (see Cook et al, 2022), that some patients may find focusing on FPE to be initially more palatable, which could ostensibly lead to increased overall exposure completion in the long term and reduced treatment dropout.…”