2. Video feedback (VF)

that the distorted self-perception about performance is one type of negative cognition that maintains social anxiety symptoms in SAD patients and socially anxious individuals. Moreover, previous studies have reported that SAD patients and socially anxious individuals show

There are two subtypes of SAD, the generalized type and the performance only type [12]. Individuals diagnosed with the generalized type experience excessive fear in almost all social situations, including performance and social interactions. Individuals diagnosed with the performance only type experience excessive fear only in performance situations, such as making a presentation in front of the class, with no major anxiety associated with social interaction per se, such as talking with friends or strangers. Furmark et al. reported that individuals with the generalized type exhibit more social distress and impairment [13]. These impairments might include holding a cup firmly, avoiding eye contact, or speaking softly. People with SAD use such safety behaviors to reduce their anxiety, but these behaviors can exclude opportunities to learn what happens in social situations and might cause further anxiety due to decreased coping efficacy. Their physical symptoms might involve displays of physiological arousal in social situations that include shaking, sweating, heart throbbing, and other manifestations of anxious arousal. People with SAD also tend to exaggerate the extent to which these symptoms are visible to others, which leads to more concerns about negative

Many previous studies have indicated that cognitive-behavioral therapy (CBT) techniques are effective in the psychological treatment of SAD [14–16]. According to Rodebaugh et al. [16], typical CBT techniques for the treatment of SAD include exposure, applied relaxation, social skills training, and cognitive restructuring. In a meta-analytic review, they reported that the most recommended treatment component of CBT programs is exposure and cognitive

Video feedback is also included in most CBT treatment programs. After exposure and cognitive restructuring sessions, individuals with SAD try to watch videos of themselves, before receiving cognitive preparation. Clark et al. reported the high efficacy of individual CBT [17]. Their program consisted of developing personal safety behaviors and self-focused attention with patients by shifting the focus of attention to social situations. Based on Clark and Wells' model, patients try to identify the relationship between their own cognition and SAD symptoms on psycho-education sessions. Additionally, video feedback was used to modify distorted self-imagery. Participants try to improve the discrepancy between their negative,

In video feedback sessions, individuals with SAD watch themselves doing actual social tasks, such as public speaking and conversation tasks. They often recognize their performance to be worse than their actual performance. Then, therapists try to improve the discrepancy between subjective and objective perceptions of social performance. For example, Shirotsuki et al. attempted to examine the effects of an individual CBT program that included exposure, cognitive restructuring, and video feedback techniques [18] using video feedback of speech tasks. The results indicated that the program was effective for improving social anxiety symptoms and selfperception during speech tasks, suggesting that individuals with SAD can improve their negative self-perceptions and negative estimations before a speech task. Previous research has also

lower self-ratings than other ratings of their performance [9–11].

66 Cognitive Behavioral Therapy and Clinical Applications

distorted self-images and their objective social performance.

evaluation from others.

restructuring [16].

VF, which is based on the cognitive model of SAD [7], involves providing highly socially anxious individuals and people with SAD with video playback of their social performance following the participation in a social task, such as making a public speech or a one-on-one conversation [37]. Participants then watch the situation using the video recording. It is anticipated that the review of the recording would correct their distorted self-evaluations, including the underestimation of their own social skills [38]. It is suggested that the experience of viewing video recordings of their own social performances would enable socially anxious individuals to correct their underestimation of their social abilities. This, in turn, is expected to lead to reduced symptoms of anxiety when anticipating in future social events [39–41]. Moreover, objective information about the self is expected to result in changes in the negative self-image and lead to confidence about social performance. (See Figure 1 for an illustration of an actual video feedback session).

addition of a pre-VF cognitive preparation phase [39, 40, 43]. In addition, Orr and Moscovitch examined the effect of cognitive review (CR) with video feedback and cognitive preparation (CR) [37]. The results showed that participants in the CP, VF, and CR conditions demonstrated marginally significant reductions in anxiety from Speech 1 to Speech 2. Furthermore, only those who received CP, VF, and CR demonstrated significant improvements in self-perception and performance expectations relative to the only exposure condition. In CR, participants received open-ended questions asking them to provide elaborate written answers (e.g., "How does this feedback make you feel?" or "What is the significance of this feedback to your sense of self?"). However, certain studies have also indicated that neither VF alone nor VF with cognitive preparation succeeded in facilitating significant reductions in social anxiety symptoms above and beyond exposure alone [9, 40, 44]. It is suggested that the null findings pertaining to the reduction of social anxiety in previous VF studies could be at least partially related to the absence of a post-VF review period, during which time participants would be encouraged to elaborate the processing and encoding of feedback information. Orr and Moscovitch indicated that the post-VF review period, which encourages individuals to elaborate, could lead to the processing of new information about themselves and facilitate improvements in self-perception, leading to the subsequent reductions in social anxiety symptoms [37].

Video Feedback Techniques Used in Social Anxiety Disorders

http://dx.doi.org/10.5772/intechopen.71278

69

It has been suggested that the negative interpretation bias in social situations and social information might interfere with the effectiveness of video feedback in SAD. Certain studies have reported the effects of negative interpretations on social anxiety symptoms. Foa et al. found that individuals with social phobia rated negative social events as more probable and costly than nonclinical anxious controls [45]. Stopa and Clark showed that patients with generalized social phobia were more likely to interpret ambiguous social events negatively and to catastrophize in response to unambiguous, mildly negative events relative to other anxiety disorder groups or a nonpatient control group [46]. Constans et al. reported that socially anxious individuals showed a less positive interpretation of ambiguous interpersonal events [47]. In summary, the interpretation bias regarding social situations seen in individuals

with social anxiety is characterized by more negative and less positive cognitions.

It is possible that socially anxious individuals negatively evaluate their appearance on video. This negative interpretation could interfere with the effectiveness of video feedback. In addition, SAD patients may also lack positive interpretations about their appearance on video. Therefore, it is possible that SAD patients and high socially anxious individuals interpret their video as more negative and less positive. However, the relationship between negative and positive interpretations of their appearance on video and social anxiety symptoms has not

Based on the above considerations, Shirotsuki et al. examined differences in efficacy between video only (VW) and video with cognitive interventions (VW + CI) [44]. They divided participants into a video only group (VW group) and a video with cognitive intervention group (VW + CI group). Only VW + CI group was instructed to watch a video of their speech

3. Cognitive biases in SAD

been investigated to date.

Warnock-Parkes et al. [42] suggested five broad categories of interference that results from video feedback [43]: (a) reexperiencing feelings when watching the video, (b) selectively searching for behaviors that could be interpreted negatively, (c) discounting the accuracy of the video image, (d) mistaking safety behaviors for social deficits, and (e) reactivating habitual patterns of self-criticism. Warnock-Parkes et al. [42] suggested that patients with social anxiety disorder have these processing biases that would make it difficult for them to see the videos differently from their habitual negative self-perception. It is important to reduce processing biases to identify the effects of video feedback.

Several studies have reported that video feedback techniques improve distorted selfperceptions when used as a psychological intervention for social anxiety [9, 11, 39]. Rapee and Hayman showed that high and low socially anxious individuals improved their distorted self-perceptions after video feedback [9]. Harvey et al. demonstrated that 7 min of cognitive preparation before video feedback enhanced the effect of video feedback on distorted selfperceptions [39]. Rodebaugh also reported that cognitive preparation enhanced selfperceptions about speech performance [11]. On the other hand, Smits et al. failed to find any difference between exposure and exposure with video feedback [40]. They suggested that their technique might have targeted probability bias by providing performance feedback, which interferes with the necessary reappraisal of cost bias.

Orr and Moscovitch summarized previous VF studies [37]. They described that experimental research on social anxiety and VF has typically examined the efficacy of VF on its own (i.e., with neither a pre-VF preparation phase nor a post-VF review phase) [37, 41] or only with the

Figure 1. Image of the state of actual video feedback.

addition of a pre-VF cognitive preparation phase [39, 40, 43]. In addition, Orr and Moscovitch examined the effect of cognitive review (CR) with video feedback and cognitive preparation (CR) [37]. The results showed that participants in the CP, VF, and CR conditions demonstrated marginally significant reductions in anxiety from Speech 1 to Speech 2. Furthermore, only those who received CP, VF, and CR demonstrated significant improvements in self-perception and performance expectations relative to the only exposure condition. In CR, participants received open-ended questions asking them to provide elaborate written answers (e.g., "How does this feedback make you feel?" or "What is the significance of this feedback to your sense of self?"). However, certain studies have also indicated that neither VF alone nor VF with cognitive preparation succeeded in facilitating significant reductions in social anxiety symptoms above and beyond exposure alone [9, 40, 44]. It is suggested that the null findings pertaining to the reduction of social anxiety in previous VF studies could be at least partially related to the absence of a post-VF review period, during which time participants would be encouraged to elaborate the processing and encoding of feedback information. Orr and Moscovitch indicated that the post-VF review period, which encourages individuals to elaborate, could lead to the processing of new information about themselves and facilitate improvements in self-perception, leading to the subsequent reductions in social anxiety symptoms [37].
