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A Cognitive Model of Social Phobia: Applicability in a Large Adolescent

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International Journal of Cognitive Therapy, 5(3), 341–358, 2012
© 2012 International Association for Cognitive Psychotherapy
SCHREIBER ET AL.
A COGNITIVE MODEL IN ADOLESCENT SOCIAL ANXIETY

A Cognitive Model of Social Phobia:

Applicability in a Large Adolescent
Sample
Franziska Schreiber, Volkmar Höfling, Ulrich Stangier,
Christiane Bohn, and Regina Steil
Goethe University, Frankfurt am Main, Germany

Clark and Wells’s (1995) cognitive model of social phobia has been extensively
evaluated in adults. However, very little data is available on the applicability to so-
cial anxiety in adolescence. This study examines the model’s applicability in a large
adolescent sample. 581 students (aged 14–20) completed questionnaires assessing
social anxiety, depression, and variables of the cognitive model (namely safety be-
haviors, negative social cognitions and social attitudes, self-focused attention, re-
current self-images, pre- and post-event processing). The results revealed that high
and low socially anxious youths differed significantly on all cognitive variables. Se-
quential regression analysis indicated that social attitudes, social cognitions, safety
behaviors, and self-imagery were predictive for social anxiety, after controlling for
depression and gender. Additionally, a path analysis model examining the relation-
ships between the cognitive variables supported the model’s applicability, yielding
differential moderating effects of gender. The cognitive model is at least partly ap-
plicable to adolescent social anxiety and it might be useful to develop a cognitive
treatment for this population.

InTRoduCTIon

Social phobia is described as “a marked and persistent fear of social or performance

situations in which embarrassment may occur” by the American Psychiatric Associa-
tion (DSM-IV-TR, 2000, p. 450). The disorder has an estimated prevalence of 3–10%
among children and adolescents (Ranta, Kaltiala-Heino, Rantanen, & Marttunen,
2009; Wittchen & Fehm, 2003) and is therefore one of the most common psychiatric
disorders. Social phobia in young people is associated with severe impairment in daily
life and negative consequences, including an increased risk of comorbid disorders,

The authors have no actual or potential conflict of interest to declare that may have a direct bearing on the
subject matter of the article.
Correspondence concerning this article should be addressed to Franziska Schreiber, Department of Clinical
Psychology and Psychotherapy, Goethe University, Varrentrappstr. 40-42, 60486 Frankfurt am Main, Ger-
many. E-mail: Schreiber@psych.uni-frankfurt.de.

341
342 SCHREIBER ET AL.

academic failure, and impairment of social development (Rao et al., 2007; Wittchen
& Fehm, 2003).
Over the last few years, a cognitive model of social phobia (Clark & Wells, 1995)
has provided a theoretical framework on the development and maintenance of the
disorder in adults (Roth & Heimberg, 2001). According to the model, dysfunctional
beliefs about oneself and one’s social world provoke socially anxious individuals to
interpret ambiguous social situations as threatening (Stopa & Clark, 2000). These be-
liefs are maintained by several factors: first, excessive self-focused attention, decreased
external-focused attention, and a misattribution of internal information lead to nega-
tive inferences about one’s appearance to others (Mellings & Alden, 2000). Second,
in anxiety-provoking situations, socially anxious individuals frequently experience
distorted negative self-images related to their fears that contribute to the evidence
of behaving in an embarrassing way (e.g., Hackmann, Clark, & McManus, 2000).
Third, the use of safety behaviors leads to the maintenance of socially phobic beliefs,
by preventing the perception and processing of corrective information from the envi-
ronment, thus impeding change in the appraisal of the feared situation (Clark, 2001).
In addition, safety behaviors impair the social performance and are partly responsible
for the unfavorable impression socially phobic individuals sometimes make on oth-
ers (Stangier, Heidenreich, & Schermelleh-Engel, 2006). Finally, excessive pre- and
post-event processing maintains social anxiety (Clark & Wells, 1995). By reviewing
a social interaction in detail and reappraising its appearance much more negatively
than it actually was, socially phobic people consolidate their negative self-beliefs and
encode these negative self-perceptions strongly in memory (Mellings & Alden, 2000;
Rachman, Grüter-Andrew, & Shafran, 2000). Additionally, they worry about upcom-
ing social situations through retrieving specific memories of past social failures, thus
increasing their self-focused attention and the likelihood of avoidance (Clark, 2001).
In contrast to the evidence for adults, to date, empirical support for the use of the
model in adolescents and the significance of cognitive factors in adolescent social anxi-
ety remains marginal (Alfano, Beidel, & Turner, 2002). Hence, the question arises as
to whether the components of the cognitive model (e.g., self-focused attention, safety
behaviors) are as strongly associated with social anxiety in adolescents as in adults. To
the authors’ knowledge, only a few studies have examined the effects of interpreta-
tion bias in an adolescent analogue sample (e.g., Miers, Blöte, Bögels, & Westenberg,
2008), whereas evidently no study exists with respect to a clinical adolescent popu-
lation. Miers et al. (2008) showed that negative interpretations of social situations
were more frequently reported in high socially anxious youths, in comparison to non-
anxious controls. This has also been found for children (e.g., Muris, Merckelbach,
& Damsma, 2000; Vassilopoulos, Banerjee, & Prantzalou, 2009). The construct of
self-focused attention was analyzed experimentally in only two published studies of
socially phobic children, yielding results consistent with findings for adults (Higa &
Daleiden, 2008; Kley, Tuschen-Caffier, & Heinrichs, 2011). The latter study from
Kley et al. (2011) also revealed that socially phobic children used safety behaviors
significantly more frequently than high and low socially anxious comparison groups.
To our knowledge, the use of safety behaviors has not been addressed specifically by
experimental studies in adolescents.
Only two experimental analogue studies have examined the role of distorted self-
images in youths. Parr and Cartwright-Hatton (2009) showed that video-feedback
was a useful technique for correcting distorted self-images in high socially anxious
adolescents. Alfano, Beidel, and Turner (2008) did not find any significant differences
A COGNITIVE MODEL IN ADOLESCENT SOCIAL ANXIETY 343

in anxiety-levels between a low socially anxious group instructed to hold a negative

self-image in mind during two social tasks, in comparison to a low socially anxious
group without the instruction of negative self-imagery. A third socially phobic group
in addition to the imagery group revealed levels of negative performance thoughts
comparable to the no-imagery control group. One can conclude from the two stud-
ies that, while video-feedback is useful for correcting negative self-images, ultimately,
it seems that negative self-images do not correlate with anxiety levels. Unfortunately,
neither study assessed the extent to which negative social images actually occurred in
the experimental groups. Thus, in the current study, we examined the frequency of
negative social images and its relationship to the level of social anxiety.
Alfano, Beidel, and Turner (2006) found that adolescents with social phobia had
significantly lower expectations of their own performance during a social interaction
task than non-anxious controls. This supports the evidence of anticipatory processes,
whereas Schmitz, Krämer, Blechert, and Tuschen-Caffier (2010) recently demonstrat-
ed that children with social phobia also engage in post-event processing, correspond-
ing to the cognitive model of Clark and Wells (1995).
As outlined, there are few experimental studies using adolescent samples that
demonstrate the influence of the individual cognitive components of the model. Hod-
son, McManus, Clark, and Doll (2008) examined the applicability of the cognitive
model of social phobia in a sample of 11-to-14 year-old high and low socially anxious
adolescents (N = 171). Using self-reports, the researchers found that high socially
anxious youths scored significantly higher on negative social cognitions, self-focused
attention, safety behaviors, and pre- and post-event processing, in comparison to low
socially anxious adolescents. Furthermore, these cognitive variables accounted for
48% of the variance in social anxiety, but only for 34% of the variance in depression.
The authors concluded that the model seems to be equally applicable to adolescent
populations. However, the sample size was only moderate with regard to the applied
statistical analysis. In addition, Hodson et al. (2008) neither assessed self-images nor
negative social attitudes.
The aim of the current study was to investigate the validity of Clark and Wells’s
model of social phobia for use in adolescent populations (14–20 year olds). To in-
crease external validity, we assessed a sample with a substantially increased sample size
of N = 613. Dysfunctional social attitudes and the role of recurrent images as cogni-
tive components were included, so as to evaluate their contribution to social anxiety
in youths. Hodson et al. (2008) examined the variable self-focused attention, by using
a total score of the Focus of Attention Questionnaire (FAQ; Woody, 1996). This total
score comprises two variables (scales on the measure), namely self-focused and external-
focused attention. We specifically addressed this fact, by disentangling the effect of
self-focused attention from that belonging to external-focused attention, according
to Clark and Wells’s (1995) cognitive model. Thus, social anxiety was expected to be
associated with high self-focused and low external-focused attention in the current
study. Another aim of the study was to explore the various relationships between the
cognitive variables, as described by the cognitive model. Our study is among the first
to examine the model’s applicability by using an extensive approach concerning the
included variables. However, since our study relies on cross-sectional self-report data,
we wish to emphasize that we do not attempt to draw any causal conclusion about the
viability of the model with respect to socially anxious adolescents.
Based on the literature review relating to adults and adolescents, we first hypoth-
esized that high socially anxious students would score significantly higher than low so-
344 SCHREIBER ET AL.

cially anxious students on the following variables: negative social cognitions, negative
social attitudes, safety behaviors, self-focused attention, recurrent self-images as well as
pre- and post-event processing. Second, we hypothesized that the cognitive variables
of the model account significantly for the variability in social anxiety, even when con-
trolling for effects of depression and gender. Third, the cognitive model of Clark and
Wells (1995) postulates various relationships between cognitive variables. Therefore,
we hypothesized that safety behaviors would be influenced positively by self-focused
attention, social cognitions, and social attitudes. Furthermore, we expected social cog-
nitions and social attitudes to be positively affected by self-focused attention, recurrent
self-images, and pre- and post-event processing. Finally, since there is evidence of the
mediating effect of social cognitions (Hofmann, 2004), we assumed mediating effects
on safety behaviors from self-focused attention, recurrent self-images, and pre- and
post-event processing via social cognitions and social attitudes. With regard to the ex-
amined relationships between the abovementioned variables, gender differences were
additionally explored.

MeThod

Participants

Six hundred thirteen adolescent students (age 13–21, grade 8–13) were recruited from
six high schools in a large urban and rural area in Germany. In order to control for dif-
ferences in education, students were recruited from all three distinct types of German
secondary schools (basic, general level, and advanced secondary schools). Since only
students aged 14 to 20 were included in the study, 32 adolescents had to be excluded
due to being 13 or 21 years old.1 Ten students declined to take part in the assessments.
Controlling for multivariate outliers on the measures, four students were excluded
prior to analysis. Thus, the final sample consisted of N = 567 adolescents. The mean
age was M = 16.49 (SD = 1.67). Three hundred thirteen participants (55.2 %) were
female. A total of 46 students attended basic secondary school, 151 were assessed at
general secondary schools, and 371 students went to advanced secondary schools.

Procedures

The study was approved by the local ethics committee of the Department of Medicine.
Pilot data was collected for six adolescents (14 to 19 years old) in order to test the
comprehensibility of the measures and the time needed to complete the questionnaire
set. This pre-test was crucial, since some of the measures had not yet been validated
in German adolescents. It revealed that some words in the questionnaires needed to
be replaced by easier ones for use with an adolescent population (e.g., “odd/peculiar”
was replaced by “weird”).
In order to assess a characteristic sample of German students, data of the current
number of students attending the various secondary school types in the relevant areas
1.
The fact that, despite the inclusion criteria, some 13- and 21-year-old students initially participated in
the study is due to the German school system and the class-wise assessments. Students in 8th (13th) grade
could be 13 or 14 (respectively 19–21) years old. Excluding the 13(21)-year-olds prior to assessments was
prohibited, due to our duty to supervise all students.
A COGNITIVE MODEL IN ADOLESCENT SOCIAL ANXIETY 345

was requested from the regional statistical state office (State Statistical Office, Hessen,
Germany, 2010). The number of students for each school type and living area was cal-
culated from this data. To rule out reputational differences between the schools poten-
tially influencing school-assessment, a random sample of 15 high schools was chosen
using a statistical software program (SPSS, version 17). These schools were contacted.
Nine refused to take part in the study, because of organizational concerns or a lack of
interest. In summary, six schools participated and 28 classes were included in the study.
To explain the purpose of the study and to obtain consent, school directors and
teachers received written detailed information via e-mail and a personal telephone
call. In exchange for participation, the investigators offered to give a lecture on social
anxiety in adolescence at school, after the assessments. The participation rate in a
school-based assessment is thought to increase significantly if assessments are con-
ducted anonymously due to the fact that then no written informed consent has to be
obtained by parents and/or students. In this study, both received an information letter
one week before the scheduled assessment and students gave oral consent prior to as-
sessments. This procedure was approved by the ethical committee.
Assessments took place in class during regular school hours. The students com-
pleted a set of nine questionnaires and were asked to answer a few demographic items
on the age, sex, grade, and school-type of the participant. The questionnaire set in-
cluded a short introduction emphasizing that there were no right or wrong answers.
It was stated that participation was voluntary, anonymous, and could be withdrawn
at any time during the assessment process. The class teacher and two investigators
were present to answer questions prior to and during the assessments. The students
returned the set of questionnaires to the investigators after completion. The return
rate was 99.99%. Depending on the grade level and school type, the required time for
completing the assessments varied from 35 to 60 minutes.

Measures
The Social Phobia and Anxiety Inventory (SPAI; Turner, Beidel, Dancu, & Stanley,
1989; German version: Fydrich, 2002). The German version consists of 22 items assess-
ing somatic, cognitive, and behavioral symptoms of social phobia on a 7-point Likert
scale ranging from 0 (never) to 6 (always). The SPAI has good internal consistency
(Cronbach’s α = .93–.96) and good retest reliability (rtt = .85) for socially anxious
adults as well as for controls (Fydrich, 2002). Although the SPAI was developed origi-
nally for adults, several studies showed that it is a valid and reliable measure in adoles-
cents (e.g., Clark et al., 1994; Olivares et al., 2002). In this sample, the Cronbach’s α
for the SPAI was .96.
Social Behaviour Questionnaire (SBQ; Clark, Wells, Salkovskis, & Hackman, 1995;
German version: Stangier, Heidenreich, Ehlers, & Clark, 1996a). The SBQ assesses the
use of safety behaviors in social situations with 27 items. The frequency of use of
each behavior is rated on a 4-point scale (0 = not at all; 3 = very much). “Avoid eye
contact” is an example of safety behavior. Hodson et al. (2008) demonstrated that
the SBQ can also be used in young people. In the present study, the SBQ yielded
sufficient internal consistency (Cronbach’s α = .77). Studies with adult populations
revealed satisfactory internal consistencies and good discriminant validity (McManus,
Sacadura, & Clark, 2008; Mörtberg, Clark, Sundin, & Wistedt, 2007).
346 SCHREIBER ET AL.

Social Cognitions Questionnaire (SCQ; Wells, Stopa, & Clark, 1993; German version:
Stangier, Heidenreich, Ehlers, & Clark, 1996c). The SCQ requires participants to rate
the frequency of thoughts about social situations on a 1 (never occurs) to 5 (always oc-
curs) point scale. In addition, people indicate the strength of believing this thought on
a 0 (I do not believe this thought) to 100 (I am completely convinced that it is true)
point scale. Due to problems in comprehensibility, item 17 was replaced by a simpler
wording with an equivalent meaning, after an expert’s rating (“I am vulnerable” to “I
get hurt easily”). The questionnaire consists of 22 items such as “I am foolish.” The
psychometric properties from adult samples indicate good to high internal consistency
(Cronbach’s α = .95) and good retest reliability (rtt = .79; Stopa, 1995 as cited in
Tanner, Stopa, & De Houwer, 2006; McManus et al., 2008). In an adolescent sample,
the internal consistency was high (Hodson et al., 2008). Cronbach’s α was .88 in our
study.
Social Attitudes Questionnaire (SAQ; Clark, 1995; German version: Stangier, Heiden-
reich, Ehlers, & Clark, 1996b). The SAQ is a 50-item measure, which was used to assess
dysfunctional socially phobic attitudes such as “I must not show signs of weakness to
others.” Each item is answered on a 0 (totally disagree) to 6 (totally agree) rating scale.
Item 31 was replaced, due to lack of comprehension, after an expert’s rating for this
study (“I am odd/peculiar” to “I am weird”). The SAQ has good internal consistency
(Cronbach’s α = .90–.95; Mörtberg et al., 2007; Tanner et al., 2006). The measure
was chosen, given that no other validated questionnaire assessing socially phobic at-
titudes exists. In the present sample, internal consistency was high (Cronbach’s α =
.92), indicating good use in adolescent populations.
Focus of Attention Questionnaire (FAQ; Woody, 1996). The FAQ was translated by
the authors, using the method of back translation by a bilingual native speaker. The
questionnaire assesses self- and external-focused attention with two brief subscales
(five items each). Respondents are asked to answer on a 5-point Likert scale from 1
(not at all) to 5 (totally). The self-focused scale measures the monitoring of oneself
in a previous social situation, whereas the external-focused attention scale assesses at-
tention toward other people or external stimuli. An example from the FAQself is “I was
focusing on what I would say or do next,” whereas the item “I was focusing on what
the other person was saying or doing“ belongs to the FAQexternal scale. Studies in adults
yielded acceptable internal consistencies (self-focused scale: Cronbach’s α = .76–.83,
external-focused scale: .72–75; Derakshan & Eysenck, 2001; Woody, Chambless, &
Glass, 1997). Hodson et al. (2008) showed that the questionnaire is applicable to
youths. The present study found moderately reliable consistency scores, given the
brevity of the subscales (self-focused scale Cronbach’s α = .75; external-focused scale:
Cronbach’s α = .63). This is in line with another adolescent study by Higa and Da-
leiden (2008; Cronbach’s α self-focus = .68, external-focus = .66).
Post-Event Processing Questionnaire (PEPQ–revised version; Fehm, Hoyer, Schneider,
Lindemann, & Klusmann, 2008; originally developed by Rachman et al., 2000). The re-
vised form of the questionnaire comprises 17 items assessing how much people pro-
cess a social situation after it is over. Participants judge the amount of ruminative and
negative thinking about the past social event on a 100-point visual analogue scale.
According to Fehm et al. (2008), the questionnaire has excellent internal consistency,
as well as good convergent and discriminant validity. These sound psychometric char-
acteristics were confirmed in our (Cronbach’s α = .92) and in another adolescent
sample (Hodson et al., 2008).
A COGNITIVE MODEL IN ADOLESCENT SOCIAL ANXIETY 347

Social Phobia Weekly Summary Scale (SPWSS; Clark et al., 2003). The SPWSS
contains six items on social anxiety. In the current study, item 4 (“over the past week,
how often have you gone over in your mind things that you think might go wrong in
a social situation before entering the situation”) was used to measure pre-event process-
ing over the previous week on a 9-point visual analogue scale. The internal consistency
can be rated as satisfactory (Cronbach’s α = .81) and the scale has been useful as an
outcome measure in various treatment studies in adults (e.g., Clark et al., 2003; Mört-
berg et al., 2007).
Questionnaire of Recurrent Images in Social Phobia (QRI-SP; Schreiber, Stangier, &
Steil, 2009). This 12-item questionnaire was developed for a treatment manual on
cognitive therapy for adolescent social phobia (Steil, Matulis, Schreiber, & Stangier,
2011). It assesses the presence and quality of recurrent distorted social images in ado-
lescents. The questionnaire is an adapted version of a semi-structured interview used
by Hackmann et al. (2000), dealing with distinct characteristics of negative social im-
ages. Prior to responding to the items, an introduction component provides a defini-
tion of what recurrent images are. Next, the participant is asked to recall and describe
an image that he or she experiences in social situations (e.g., “I see myself in front of
the class blushing like a tomato and everyone laughs”). With this image in mind, the
adolescent is then asked to answer questions on co-occurring emotions or sensations,
such as shame and sensual components of the image on a 0 to 100 visual analogue
scale (e.g., “Within this image, I worry that others will notice my anxiety” or “Within
the image, I feel nervous”). Item 6 assesses the frequency of such distorted images
within the last 14 days on a 5-point scale from 1 (never) to 5 (very often). Only this
item from the questionnaire was used for analysis in the present study.
Depression Inventory for Children and Adolescents (DICA; Stiensmeier-Pelster, Schür-
mann, & Duda, 2000). The DICA is a widely used self-report inventory for measuring
depressive symptoms in children and adolescents. It was developed from Kovacs Chil-
dren’s Depression Inventory (CDI, 1985). Participants decide between three response
categories for each item, reflecting differences in symptom severity. Higher scores
indicate higher levels of depressive symptoms. This 26-item questionnaire has good
psychometric properties regarding internal consistency (Cronbach’s α = .91), as well
as convergent and discriminate validity (Stiensmeier-Pelster et al., 2000).

data Analysis

Prior to analysis, the data set was carefully screened for correctness of data entry, miss-
ing values and fit between the distributions and the assumptions of multivariate analy-
sis, according to Tabachnick and Fidell (2007). Four cases were found to be multivari-
ate outliers through Mahalanobis distance with p < .001. All outliers were deleted,
leaving 567 participants for further analysis. A total of 1.5 % missing values occurred
within the analysis sample (N = 567). Since the missing values were at random, the
data screening and imputation of missing values were conducted using the statistical
application PRELIS 2 (Jöreskog & Sörbom, 1996).
In order to compare students with different levels of social anxiety, the sample
was split into quartiles in line with Hodson et al. (2008). The high socially anxious
group was based on the top 25% of the SPAI-scores and the low socially anxious group
consisted of the participants scoring in the lowest 25% on the SPAI. The groups were
348 SCHREIBER ET AL.

compared regarding demographic variables such as age, sex, and school type, using an
independent sample t-test or χ²-test.
In order to compare the two groups on the different variables of the Clark and
Wells model (1995), a multivariate analysis of variance was employed. To further
examine the unique effects of self-focused attention, in contrast to external-focused
attention according to the cognitive model, a MANOVA was computed with the two
scales of the FAQ. In addition, sequential regression was used to determine whether
(and which of) the variables suggested by the model significantly predict social anxiety
after controlling for depression and gender. The regression approach was chosen, in
order to account for a potential information loss caused by splitting the file into two
groups post-hoc in the MANOVA. In this way and in line with MacCallum, Zhang,
Preacher, and Rucker (2002), negative effects of post-hoc dichotomization should
have been ruled out. In a sequential regression, depression and gender entered the re-
gression first. In a second step, all seven measures of cognitive variables were entered.
A second sequential regression analysis was conducted predicting depression by the
cognitive variables, after controlling for social anxiety and gender in order to examine
the specificity of the cognitive factors for social anxiety, over and above another fre-
quent psychological disorder, such as depression.
In order to examine the relationships between the model´s cognitive variables,
path analysis models were analyzed with self-focused attention, self-images, and pre-
and post-event processing as independent variables, social cognitions and social atti-
tudes as mediating variables and safety behaviors as the dependent variable. Intercorre-
lations between the independent and mediating variables, respectively, were specified.
The path analysis models were estimated with Mplus version 6 (Muthén & Muthén,
2010), applying the maximum-likelihood estimator (ML). For the procedure of mod-
el fit evaluation (Schermelleh-Engel, Moosbrugger, & Müller, 2003), the c2-value and
the degrees of freedom (df) were reported, as well as the root mean square error of
approximation (RMSEA), the Tucker-Lewis Index (TLI), and the standardized root
mean square residual (SRMR). For the analysis of gender effects, multi-sample path
χ2 > 3.84,
df = 1) between the χ2-value of an unconstrained model (with two parameters es-
timated separately for the group of boys and the group of girls respectively) and the
χ2-value of a constrained model (with one parameter estimated for boys and girls),
should demonstrate a substantial moderation effect of gender with regard to this pa-
rameter. This procedure was carried out for each effect within the previously specified
path analysis model and should lead to a modified path analysis model with separately
estimated parameters for those relationships with substantial gender effects. Further-
more, mediating effects from the independent variables to safety behaviors via social
cognitions and social attitudes were examined. This was done with Mplus computing
standardized indirect effects (Muthén & Muthén, 2010, p. 37f) and bias-corrected
bootstrapping confidence intervals (MacKinnon, Lockwood, & Williams, 2004), to
test whether the indirect effects were significant (α = .01).
A COGNITIVE MODEL IN ADOLESCENT SOCIAL ANXIETY 349

ResulTs

demographic statistics and self-Report Measures

The complete sample had a mean SPAI-score of M = 1.71 (SD = .79). A total of
12.7% of the students scored above the clinical cut-off (> 2.6) for the presence of
social phobia on the SPAI, as indicated by Fydrich (2002). The high socially anxious
group (n = 145, SPAI: M = 2.72, SD = .51) differed significantly from the low
socially anxious group (n = 143, SPAI: M = .77, SD = .26) for social anxiety and
depression scores (SPAI: t[286] = -40.61, p < .001; depression: t[286] = -7.95, p
< .001). No significant differences were found between the groups regarding age,
t(286) = -.85, p = .40, and school-type, χ²(2, 288) = .79, p = .69, whereas the
groups differed significantly regarding gender, with more female participants in the
high socially anxious group, χ²(1, 288) = 5.00, p = .03.

Group differences on Measures of the Cognitive Model

The high socially anxious group differed significantly from the low socially anxious
group over all cognitive variables, Wilks λ =.50, F(7, 280) = 40.4, p < .001, partial
η² = .50. To reveal significant differences between the two groups for each variable in
the cognitive model, the p-value (p < .05) was adjusted using the Bonferroni-correc-
tion. As indicated in Table 1, high socially anxious adolescents displayed significantly
higher scores for safety behaviors, negative social attitudes, negative social cognitions,
pre- and post-event processing, frequency of self-images and self-focused attention,
compared to the low socially anxious group. To control for the significant divergence
between the groups on gender and depression scores, a multivariate analysis of cova-
riance (MANCOVA) was conducted, with depression and gender as covariates. The
analysis also yielded significant group differences for all cognitive variables, Wilks λ
= .61, F(7, 278) = 25.39, p < .001, partial η² = .39. Similarly, high socially anxious
participants scored significantly higher compared to low socially anxious youths for
the individual variables, even after controlling for depression and gender.
The effect of focus of attention was examined after the main group comparisons
revealed significantly higher scores in high socially anxious youths on the self-focused
attention scale (p < .001) than in the low socially anxious students (Table 1). No
significant differences between high and low socially anxious youths could be found
concerning external-focused attention, p = .07; FAQexternal: high socially anxious: M =
13.61, SE = .31; low socially anxious: M = 12.83, SE = .31, F(1, 287) = 3.23.

Results of sequential Regression Analyses

To examine whether the addition of the cognitive variables of Clark and Wells’s model
of social anxiety would improve the prediction of social anxiety beyond prediction by
depression and gender, a sequential multiple regression analysis was conducted. Table
2 shows the standardized regression coefficients (β) and R, R², and R² change, after
entering all nine predictors. R differed significantly from zero after each step. When
entering the measures of the cognitive model in the second step of regression, depres-
350 SCHREIBER ET AL.

TABLE 1. Means (SE) and Between Group Differences on the Cognitive Variables
High socially Low socially F statistics from
anxious anxious MANOVA
Variable Measure M (SE) M (SE) (partial ²)
Safety behaviors SBQ 28.16 (.62) 18.07 (.63) 130.28** (.31)
Social attitudes SAQ 129.9 (2.48) 78.76 (2.49) 211.68** (.43)
Frequency of social cognitions SCQ 49.98 (.88) 33.35 (.88) 179.00** (.39)
Pre-event processing SPWSS Item 4 5.24 (.20) 3.25 (.20) 49.54** (.15)
Post-event processing PEPQ 52.6 (1.72) 33.73 (1.79) 62.98** (.18)
Focus of attention FAQself 13.93 (.31) 9.78 (.31) 89.04** (.24)
Frequency of recurrent images QRI-SP Item 6 2.65 (.09) 1.83 (.09) 44.98** (.14)

Note. ** = p < .001.

sion and gender added no further prediction. R² was .45 in the second step, F(9, 557)
= 49.53, p < .001. While the use of safety behaviors, frequency of negative social
cognitions, negative social attitudes and the frequency of recurrent images within the
last 2 weeks contributed significantly to the prediction (see Table 2), pre- and post-
event processing, as well as self-focused attention, were not found to be independent
predictors of social anxiety.
To rule out a common mental health problem, such as depression, being equally
explained by the cognitive variables in comparison to social anxiety, a second sequen-
tial regression analysis was computed predicting depression by means of the cognitive
variables. The results are presented in Table 2. The adjusted R² was .34 in the second
step. Thus, about one-third of the variability in depression was found to be signifi-
cantly explained by negative cognitions (p < .001), dysfunctional attitudes (p < .01),
frequency of recurrent self-images (p < .001) and pre- and post-event processing (p
< .01).
Comparisons of the results from the two hierarchical regression analyses revealed
that some of the model variables were predictive for both social anxiety and depres-
sion. However, a comparison of R² showed that they were significantly more predic-
tive in social anxiety than in depression (Steiger’s Z = 3.19; p < .01). This indicates
that the apparent differential structure of the regression weights derived from both
models underlines the specificity of cognitive variables for social anxiety.

Path Analyses Models

The path analysis model, without differences between boys and girls, yielded a good
model fit with χ2 = 42.88, df = 33 (p = .12), RMSEA = .03 [.00; .06], TLI =
.99, and SRMR = .05. It should be noted that there was no significant effect from
recurrent self-images on social cognitions and from pre-event processing on social at-
titudes. The multi-sample analysis models revealed moderation effects of gender on
the relationships between the independent variables of self-focused attention, recur-
rent self-images, pre- and post-event processing, and the mediating variables of social
χ2 exceeded the
value of 3.84. The modified path analysis model (see Figure 1), that is, a partly multi-
sample path analysis model with separate estimations for boys and girls, received a
A COGNITIVE MODEL IN ADOLESCENT SOCIAL ANXIETY 351

TABLE 2. Summary of Sequential Regression Analyses for Variables Predicting Social Anxiety
(Controlled for Depression) and for Variables Predicting Depression (Controlled for Social Anxiety)
Social anxiety (model 1) Depression (model 2)
Variable R² R²
Step 1 .16*** .16***
Depression/Social anxiety .39*** .39***
Gender .06 .07
Step 2 .28*** .21***
Depression/Social anxiety .05 .06
Gender .03 .00
Safety behaviors .20*** -.08
Social attitudes .29*** .16**
Frequency of social cognitions .22*** .32***
Pre-event processing .02 .12**
Post-event processing -.01 .13**
Self-focused attention -.02 -.08
Frequency of recurrent .10** .16***
images
Total R² .45*** .35***

Note. Model 1 (predicting social anxiety): for Step 1 R² = .16***, adjusted R² = .16, for Step 2 adjusted R² = .44; Model 2
(predicting depression): for Step 1 R² = .16***, adjusted R² = .16; for Step 2 adjusted R² = .34. **p < .010; ***p < .001.

good model fit with χ2 = 29.13, df = 27 (p = .35), RMSEA = .02 [.00; .05], TLI =
1.00, and SRMR = .04.
Several mediating effects, via social cognitions and social attitudes, on safety
behaviors were examined. A significant specific indirect effect was found from self-
focused attention via social cognitions with .05 [.01; .10], whereas this effect was
smaller for boys (.04) than for girls (.06). An indirect effect was also detected from
self-focused attention via social attitudes with .08 [.04; .13]. The indirect effects from
recurrent self-images via social attitudes and from pre-event processing via social cog-
nitions did not differ significantly from 0. The same was true for the indirect ef-
fect from post-event processing via social cognitions. Significant indirect effects were
found from post-event processing via social attitudes with .08 [.02; .15], with .09 for
boys and .06 for girls.

dIsCussIon

The objective of this study was to investigate the applicability of the cognitive model
of social phobia (Clark & Wells, 1995) in adolescents. In line with our expectations,
high socially anxious students scored significantly higher than low socially anxious
students on all cognitive variables. Moreover, at a multivariate level, this difference was
independent of gender and depression. Second, several cognitive variables accounted
for the variability in social anxiety. The adjusted R² of .44 indicates that almost half
of the variability in social anxiety was predicted by the use of safety behaviors, fre-
quency of negative social cognitions, negative social attitudes, and the frequency of
352 SCHREIBER ET AL.

FIGURE 1. Completely standardized solution of a path analysis model with the

four independent variables self-focused attention, self-images, pre-event process-
ing, and post-event processing. Social cognitions and social attitudes mediate the
effect of the independent variables on safety behaviors. Gender moderates the
relations between the independent and mediating variables whereas the first
coefficient indicates the strength of relations for boys and the second for girls.
Note. *p < .05, **p < .01, ***p < .001.

recurrent images within the last 2 weeks. While negative social attitudes, followed by
negative social cognitions and safety behaviors were the strongest predictors of social
anxiety, the frequency of recurrent images contributed to a lesser degree to the predic-
tion. Overall, these results are in accordance with those of Hodson et al. (2008) and
consistent with other studies identifying cognitive factors in social anxiety in adoles-
cents (e.g., Parr & Cartwright-Hatton, 2009; Rheingold, Herbert, & Franklin, 2003).
Third, a path model with self-focused attention, self-images, pre- and post-event pro-
cessing as independent, social cognitions and social attitudes as mediating, and safety
behaviors as dependent variables, was confirmed.
After controlling for depression and gender, only four of the seven variables (neg-
ative social attitudes, negative social cognitions, safety behaviors, and frequency of
recurrent self-images) significantly predicted social anxiety in youths. Self-focused at-
tention and pre- and post-event processing were significantly increased in high socially
anxious, as opposed to low socially anxious adolescents, but were not found to be
independent predictors of social anxiety in the regression analysis. Thus, contrary to
our expectations, the second hypothesis, that all cognitive variables would significantly
account for the variability in social anxiety, was not confirmed.
Although we found evidence of the specificity of the four cognitive variables
mentioned above for social anxiety, several variables proposed by the cognitive model
of social phobia (Clark & Wells, 1995) also significantly accounted for the variability
in depression. This result is not surprising, given that both ruminative processes and
dysfunctional cognitions are often suggested as maintaining depression, according to
cognitive models of depression (Beck, 1976; Roelofs et al., 2009). In line with these
cognitive models, negative cognitions, negative social attitudes, negative self-images
and pre- and post-event processing also significantly predicted depression in the pres-
ent study. However, significantly higher percentages of variance could be explained
A COGNITIVE MODEL IN ADOLESCENT SOCIAL ANXIETY 353

in social anxiety than in depression by these variables, with the exception of pre- and
post-event processing. Moreover, in the Hodson et al. (2008) study, the latter vari-
ables were predictive for social anxiety. There were also significant group differences
between these variables for high and low socially anxious adolescents in our sample.
Therefore, our results do not indicate that pre- and post-event processing is specific
to social anxiety, whereas for the other variables, specificity for social anxiety can be
assumed.
Consistent with the Clark and Wells model, the hypothesis of stronger self-mon-
itoring in high socially anxious adolescents, in comparison to the low socially anxious
group, was confirmed. Contrary to our expectations, the level of external-focused at-
tention was equally high and did not differ significantly between the groups. This find-
ing might be explained by the lack of specification with regard to the type of external
focus. For instance, although high and low socially anxious youths might not differ
in the amount of externally directed attention, high social anxiety might be associated
with a selective attention to threatening external information (e.g., negative facial ex-
pression by others), whereas low socially anxious adolescents might direct their atten-
tion to different social cues (Rapee & Heimberg, 1997). Since attention processes are
highly automatic, the use of self-report measures may not enable a valid distinction to
be made between these attention biases, particularly for adolescents (Vasey, Dalgleish,
& Silverman, 2003). Moreover, the internal consistency score for the external-focus
subscale of the FAQ was only moderate in this study.
In contrast to the findings of Hodson and colleagues (2008), safety behaviors
were one of the strongest predictors of social anxiety. Moreover, we found that re-
current self-images seem to play an important role in adolescent social anxiety. The
frequency of negative self-images significantly predicted social anxiety, and group com-
parisons showed that recurrent negative self-images occur significantly more often in
high socially anxious compared to low socially anxious youths. This is an important
addition to the findings of Hodson and colleagues. However, the amount of explained
variance (present sample: 44%; Hodson et al.: 48%) was comparable. The contrasts
might be explained by the differences in the set of variables assessed in the studies, as
well as by differences in ages of the two samples (Hodson et al.: 11–14; current study:
14–20 years). The wider range of age in the current study may indicate an increased
heterogeneity, which in turn should have favored higher correlations. One explanation
might be that developmental changes in children’s cognitions, in their language, and
in psychosocial functioning, influence the validity of assessment methods (Campbell
& Rapee, 1996). It remains unclear whether the validity of our questionnaires might
be impaired for certain subsamples. One might also speculate whether variables like
parental rearing behavior (Knappe, Beesdo, Fehm, Lieb, & Wittchen, 2009), peer-
relations (La Greca & Harrison, 2005; Starr & Davila, 2008), or social skills (Inder-
bitzen-Nolan, Anderson, & Johnson, 2007) could further increase the prediction of
social anxiety.
According to our path analyses and in line with the cognitive model of social pho-
bia, safety behaviors in adolescents seem to be influenced substantially by self-focused
attention, social attitudes, and social cognitions (Clark, 2001; Clark & Wells, 1995).
One might speculate that adolescents who reveal higher levels of self-monitoring in
social situations are likely to draw on safety behavior strategies, while existing nega-
tive social cognitions and attitudes are activated. However, to the authors’ knowledge,
there is no experimental study on the role of safety behaviors in adolescents, and em-
pirical evidence in adults is sparse (Taylor & Alden, 2010). Therefore, future studies
354 SCHREIBER ET AL.

with sound research designs are needed to address the role of safety behaviors, since
this is a key component of the model (Taylor & Alden, 2010). In our study, social cog-
nitions and social attitudes were demonstrated to be positively affected by self-focused
attention, self-images, pre- and post-event processing, in accordance with Clark and
Wells (1995). Interestingly, for these relations, moderation effects of gender could be
proved, for example, girls with higher levels of self-focused attention display stronger
activation of negative social cognitions and attitudes than boys. However, boys with
higher levels of post-event rumination showed stronger activation of negative social
cognitions and attitudes than girls.
Furthermore, social cognitions and social attitudes proved to be mediator vari-
ables. The role of mediation of social cognitions has been revealed in previous findings
(Hofmann, 2004). We detected indirect effects between self-focused attention and
safety behaviors via social cognitions and social attitudes. One might speculate that,
in line with the hypothesized relationships of the model (Clark & Wells, 1995), an
increase in self-focused attention would activate safety behavior strategies both directly
and indirectly, via the activated negative social cognitions and attitudes. Furthermore,
post-event processing might consolidate existing negative social attitudes, resulting in
an increased use of safety behavior strategies. Altogether, the findings of our path anal-
yses are consistent with the assumptions of the Clark and Wells model (Clark, 2001).

limitations

The study has several limitations. First, the causality of the relationship between cogni-
tive variables according to the model and social anxiety is not warranted, due to the
cross-sectional design of the study. Moreover, since an analogue adolescent sample
was recruited, conclusions on the transferability of the results to clinical samples and a
clinical diagnosis of social phobia, must be drawn with caution. However, 72 adoles-
cents scored above the cut-off-point for social phobia. Thus, half of the high socially
anxious group might have also fulfilled the criteria for diagnosis. Therefore, the results
from this study might also be valid for clinical populations. Since other psychiatric
disorders (except for depression) were not assessed, we cannot rule out that some of
the elevated scores on the measures may have occurred due to conditions other than
social phobia (e.g., body dysmorphic disorder). In order to prove the specificity of
the results to social phobia, research on clinical samples including different psychiatric
conditions, would be needed.
Due to the lack of validated measures of cognitive factors in social anxiety for
the examined age range, we had to include measures that have not yet been validated
for adolescents. Nonetheless, all the instruments, with the exception of the SAQ and
the imagery-questionnaire, were successfully applied to adolescent samples in previ-
ous studies regarding reliability and validity issues, as outlined in the method section.
Moreover, the pre-test and results from psychometric analysis in the present sample
did not give rise to concerns about the validity of the questionnaires as described in
the method section. Yet, we cannot rule out the possibility that self-reports are un-
derstood differently in terms of language (e.g., inappropriate wording, Campbell &
Rapee, 1996), lack of adequate reading ability (Vasey et al., 2003), or native language
(Alfano et al., 2002) in adolescents compared to adults. Also, adolescents might lack
self-awareness of cognitions and emotions, in comparison to adults, when completing
scales validated for adults. Furthermore, the results are based on retrospective reports
A COGNITIVE MODEL IN ADOLESCENT SOCIAL ANXIETY 355

on the questionnaires, which are susceptible to recollection bias. The use of self-re-
ports might not be appropriate for assessing highly idiosyncratic process variables such
as safety behaviors or self-imagery. Moreover, the questionnaire assessing recurrent
self-images was developed on the basis of a semi-structured interview (Hackmann et
al., 2000). Thus, it may be that higher amounts of explained variance in social anxiety
could have been observed by a guided therapist-induced imagination, as may occur
in interviews, as opposed to just reading the instructions of a questionnaire. Overall,
the sole use of self-report data remains questionable regarding validity (Alfano et al.,
2002). Also, higher amounts of explained variance might only be achievable prior to,
during, or after a social-threat activation in adolescent social anxiety, because cogni-
tive bias is only then activated and probably more accurately measurable, according
to the assumptions of the cognitive model (Alfano et al., 2002). Finally, another bias
might be the class-wise assessment. It cannot be ruled out that completing the ques-
tionnaires in the presence of classmates had an influence on social anxiety, in terms of
responding in a socially desirable manner. This bias is especially likely in high socially
anxious students, since they would want to be more conscious of their answers than
the low socially anxious students. However, since the questionnaires were completed
anonymously, self-favoring statements are supposedly less likely and there is no strong
evidence of selection bias.
Despite these limitations, the current investigation is among the first to provide
comprehensive insights into crucial cognitive processes or factors associated with so-
cial anxiety in a large adolescent sample. The results yield preliminary evidence that
several aspects of the cognitive model of social phobia of Clark and Wells (1995)
might be applicable to adolescent populations. However, replications with clinical ad-
olescent samples are needed, as well as longitudinal assessments of the cognitive com-
ponents, in order to control for developmental cognitive characteristics (Alfano et al.,
2002). In adult populations, the model has stimulated a substantial body of research
and provided a sound basis for cognitive treatment protocols for adults that yielded
high effect sizes in randomized controlled trials (e.g., Clark et al., 2006; Stangier,
Schramm, Heidenreich, Berger, & Clark, 2011). The findings of the current study
could serve as a starting point for future studies attempting to derive a cognitive treat-
ment protocol for youths. The prevalence rates of adolescent social phobia are high.
Effective interventions derived from a sound theoretical background at an early stage
of social anxiety disorder are needed to prevent long-term developments and severe
impairment in adulthood.

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