Cognitive Processes Mediate the Relation Betweein Mindfulness

8/12/2019 Cognitive Processes Mediate the Relation Betweein Mindfulness

1/10

Cognitive Processes Mediate the Relation Between Mindfulness

and Social Anxiety Within a Clinical Sample

Stefan K. Schmertz, Akihiko Masuda, and Page L. Anderson

Georgia State University

Objectives: The researchers investigated the relation between mindfulness and social anxietysymptoms, and examined whether this relation is mediated by cognitive appraisals commonly asso-

ciated with social anxiety. Participants: Ninety-eight individuals diagnosed with social phobia.Design: Using a cross-sectional design, ordinary least squares regression and bootstrapping media-tion analyses were used to test the study hypotheses. Results: Mindfulness was negatively relatedto symptoms of social anxiety. This relation was partially mediated by cognitive appraisals about the

likelihood and cost of a negative social outcome. Conclusion: Further research using a longitudinaldesign and other measures of mindfulness is needed to replicate these findings and further explicate

the mechanism by which mindfulness might be associated with negative cognitive appraisals. C 2012

Wiley Periodicals, Inc. J. Clin. Psychol 68:362371, 2012.

Keywords: social phobia; mindfulness; cognitive appraisal; outcome cost; outcome probability; psy-

chopathology; mediation

There has been a growing interest in mindfulness and its relation to psychopathology and well-

being. Empirical findings consistently show a negative relation between self-report mindfulness

and depression, negative affect, and anxiety among college-student samples (Baer, Smith, &

Allen, 2004; Lau et al., 2006; Brown & Ryan, 2003; Feldman, Hayes, Kumar, Greeson, &

Laurenceau, 2007). Furthermore, clinical samples score lower on mindfulness than nonclinical

samples (Baer et al., 2004; Feldman et al., 2007; Roemer et al., 2009), and studies have found

a negative linear relation between mindfulness and symptoms of pathology in some clinicalsamples of adults (Smalley et al., 2009; Wupperman, Neumann, Whitman, & Axelrod, 2009).

Mindfulness interventions are now receiving broad attention in outpatient settings (Kabat-Zinn,

2003), and meta-analysis reveals that mindfulness interventions have demonstrated promise in

the treatment of chronic pain, stress, anxiety, depressive relapse, and disordered eating (Baer,

2003).

Recently, interest has arisen in using mindfulness interventions to treat social phobia. This is

largely based on the documented role of maladaptive attentional processes in the maintenance

of social anxiety (e.g., attention toward internal cues of negative thinking and self-imagery;

Bogels, Sijbers, & Voncken, 2006; Hope, Gansler, & Heimberg, 1989). In contrast to the habitual,

self-focused, judgmental attention typically associated with social apprehension, increased mind-

fulness might help one to refocus attention to the social task at hand. Several studies suggest thatindividuals with social anxiety report reductions in symptomatology after mindfulness-based

interventions (Bogels, Sijbers, & Vocncken, 2006; Goldin, Ramel, & Gross, 2009; Kocovski,

Fleming, & Rector, 2009; Koszycki, Benger, Shlik, & Bradwejn, 2007). However, no published

study to date has examined the relation between mindfulness and symptom severity within a

sample diagnosed with social phobia, nor has there been a study on the potential mediators of

this relation.

The work performed for this study was conducted at Georgia State University.

This work was supported by NIMH R42 MH 60506-02, awarded to the last author.Correspondence concerning this article should be addressed to: Page Anderson, Department of Psychology,

Georgia State University, 140 Decatur Street, Atlanta, GA 30302; e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 68(3), 362371 (2012) C 2012 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.20861


2/10

Mindfulness and Cognitive Processes 363

Part of the difficulty in examining how mindfulness relates to psychopathology is that the

conceptualization of mindfulness varies among researchers and practitioners (Hayes & Wilson,

2003). However, the notion that mindfulness involves enhanced attention to and awareness of

the present moment is a commonality across a variety of definitions (e.g., Kabat-Zinn, 2003;

Shapiro, Carlson, Astin, & Freedman, 2006). The enhanced awareness of the present moment

cultivated in mindfulness is thought to be in contrast to automatic or habitual cognitive processesthat are more prone to rumination, preoccupation with the past, and anxiety about the future

(Brown & Ryan, 2003). Habitual cognitive processes also figure in models of social anxiety

(Clark & Wells, 1995; Rapee & Heimberg, 1997). Cognitive theories highlight the importance

of two types of threat appraisal in the maintenance of anxiety disorders: overestimating the

likelihood that something bad will happen as a result of an encounter with the feared stimulus

(probability bias) or overestimating the negative consequence of the encounter (cost bias; Foa &

Kozak, 1986). There is good empirical evidence that such biases contribute to the maintenance

of the disorder and serve as a mechanism for change as a result of treatment (Foa, Franklin,

Perry, & Herbert, 1996; Smits, Rosenfield, McDonald, & Telch, 2006). Therefore, it is possible

that mindfulness (or lack thereof) might be related to symptoms of social anxiety via its impact

on cognitive appraisals, such as probability and cost biases.Theoretical support for this can be found in the mindfulness literature that suggests that

increased mindfulness might reduce ruminative tendencies (Bishop et al., 2004). It is thought

that directing ones attention to present experience inherently engages attentional resources that

would otherwise be used to ruminate (Brown & Ryan, 2003). This might allow one to disengage

from common ruminative patterns that comprise appraisals about the likelihood and cost of

negative social interactions. Indeed, mindfulness is negatively related to rumination, concern for

social impression, and anxiety in social situations (Brown & Ryan). Furthermore, results from

mindfulness interventions show that reduction in rumination is related to reduction in distress

(Jain, Shapiro, & Swanick, 2007; Ramel, Goldin, Carmona, & McQuaid, 2004).

The hypotheses of the current study are that self-report mindfulness will be negatively related

to levels of social anxiety and that cognitive appraisals about the likelihood and cost of a negativesocial outcome will mediate this relation. These hypotheses are tested within a clinical sample

with a primary diagnosis of social phobia using a cross sectional design.

Method

Participants

Participants (N = 98) completed the procedures of this study as part of participation in a ran-

domized controlled trial comparing virtual reality exposure therapy (VRE; Anderson, Zimand,

Hodges, & Rothbaum, 2005), exposure group therapy (EGT; Hofmann, 2004), and a wait-list

control group. For the larger study, participants self-referred in response to advertising and pub-licity efforts, or they were referred by professionals in the greater Atlanta area. Inclusion criteria

included literacy in English, as well as a primary diagnosis of social phobia with a predominant

fear of public speaking as determined by the Structured Clinical Interview for the Diagnostic

and Statistical Manual of Mental Disorders, Fourth Edition (SCID-IV; First, Gibbon, Spitzer,

& Williams, 2002). Exclusion criteria included history of seizure disorder, mania, schizophrenia,

or other psychoses, as well as prominent suicidal ideation or current alcohol or drug abuse

or dependence. Meditation experience or past exposure to mindfulness was not an inclusion

criterion. Thus, mindfulness assessed in the current study is conceptualized as trait mindfulness

(Brown & Ryan, 2003), rather than mindfulness developed through instruction or meditative

practice. All participants meeting inclusion criteria and completing the pretreatment assessment

(N = 98) were included in the current study.The sample was predominantly female (60%), with a mean age of 39.09 (standard deviation

[SD] = 11.27; range = 1969). Most participants self-identified as either Caucasian (47%) or

African American (36%). Four self-identified as Hispanic, two as Asian American, two as Asian,

one as African, one as Ethiopian, and two as biracial. Sixty-six percent of the sample reported

completing college. Forty-five percent of the sample met criteria for the generalized subtype


3/10

364 Journal of Clinical Psychology, March 2012

of social phobia. The mean number of the Diagnostic and Statistical Manual, Fourth Edition

(DSM-IV) diagnoses was 1.38 (SD = .77; range = 15).

Measures

The Brief Fear of Negative Evaluation Brief Form (BFNE; Leary, 1983) . Thisis a 12-item self-report questionnaire that measures fear of negative evaluation by others. It is

derived from Watson and Friends (1969) original measure of this construct, with which it is

highly correlated (r = .96; Leary). Items are rated on a 5-point scale, and scores range from 12

to 60, with higher scores representing increased evaluative concerns. Results from two recent

studies using clinical samples of socially anxious adults indicate that the BFNE shows excellent

psychometric properties, including test-retest reliability (r = .94), internal consistency( = .89

.97),convergent validity, and discriminant validity (Collins, Westra, Dozois, & Stewert, 2005;

Weeks et al., 2005).

Liebowitz Social Anxiety Scale-Self Report (LSAS-SR; Fresco et al., 2001). This

widely used self-report measure is adapted from a clinician administered measure of socialanxiety (Liebowitz, 1987). The LSAS-SR contains 24 items that measure fear and avoidance

experienced in a variety of social and performance situations in the past week using a 4-point

rating scale, ranging from 0 (never) to 3 (usually 67%100% of the time). Scores range from

072, with higher scores indicating greater fear and avoidance. The self-report version shows

good psychometric properties and is comparable to the clinician-administered format (Baker,

Heinrichs, Kim, Hofmann, 2002; Fresco et al.; Mennin et al., 2002; Rytwinski et al., 2009).

Internal reliability estimates range from .88 to .95 (Oakman, Amerigen, Mancini, & Favolden,

2003).

Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003). The MAAS is

a 15-item, single factor, self-report measure assessing individual differences in the frequency ofmindful states over time. Participants rate the degree to which they function without awareness

in daily life (e.g., I rush through activities without being really attentive to them and I drive

places on automatic pilot and then wonder why I went there). Respondents indicate how often

they have the experiences referenced by each item using a 6-point Likert-type scale, anchored

from 1 (almost always) to 6 (almost never). Scores range from 16 (average item score), with

lower scores indicating greater mindlessness. Authors report internal consistency alphas ranging

from .82 to .87.

The Outcome Probability Questionnaire (OPQ) and Outcome Cost Questionnaire(OCQ; Uren, Szabo, & Lovibond, 2004). The OPQ and OCQ were developed from a set of

items used by Butler and Mathews (1983) and Foa et al. (1996) to measure cognitive biases. Thequestionnaire includes 12 items assessing feared outcomes related to social threat (e.g., You will

feel embarrassed by something you did). For the OPQ, participants are asked to rate how likely

it is that an outcome would happen in a public speaking situation and for the OCQ, participants

rate how bad or distressing the outcome would be if it happened. Items are scored on a 9-point

Likert scale, ranging from 0 (not at all likely/distressing) to 8 (extremely likely/distressing), with

summary scores ranging from 0 to 96. Internal consistency is excellent (OPQ; = .92 .94;

OCQ; = .89 .90). The authors report good convergent validity and that individuals with

social anxiety score higher on the OPQ and OCQ than nonanxious controls.

Procedure and Data Analysis

All study procedures took place in the Georgia State University psychology clinic in Atlanta,

Georgia. Eligibility for the study was determined through a two-part process, including a brief

telephone screening and an in-person diagnostic interview. Four doctoral candidates in clinical

psychology conducted all assessment procedures. Doctoral students were trained in diagnostic

interviewing by watching training tapes and by practice interviews, which were reviewed by a


4/10


Table 1Correlations, Descriptive Statistics, and Internal Consistency of Study Variables (N= 98)

MAAS BFNE LSAS-SR OCQ OPQ

MAAS 1.00

BFNE .38** 1.00

LSAS-SR .44** .32** 1.00

OCQ .33** .50** .38** 1.00

OPQ .47** .46** .45** .62** 1.00

Mean 4.07 31.87 53.00 64.63 53.00

SD 1.00 7.48 19.46 18.12 19.10

Cronbachs alpha .91 .88 .93 .85 .87

Note.MAAS = Mindful Attention Awareness Scale; BFNE = Fear of Negative Evaluations Brief form;

LSAS-SR = Liebowitz Social Anxiety Scale; OCQ = Outcome Cost Questionnaire; OPQ = Outcome

Probability Questionnaire; SD = standard deviation.

*p < .05; **p < .01.

licensed clinical psychologist. Doctoral student assessors received weekly supervision, which

included review of videotapes.

During the phone screen, potential participants were asked a series of questions to rule out

obvious exclusion criteria (e.g., prior seizures). After the phone screen, interested and eligi-

ble individuals were scheduled for a face-to-face interview. After consent, the anxiety, mood,

and substance abuse modules of the SCID were administered to establish inclusion criteria

(e.g., diagnosis of social phobia that included a fear of public speaking) and rule out exclusion

criteria (e.g., current substance dependence). Inter-rater reliability for the primary diagnosis was

examined for 12 randomly selected participants and revealed 100% agreement. After the diag-

nostic interview, participants completed a self-report battery, including the previously described

measures.Prior to any analyses, data were inspected for normalcy, excessive missing cases, and outliers,

defined as scores greater or less than three standard deviations from the mean (Field, 2005).

A BFNE score of 11 that fell 3.17 standard deviations below the mean was removed from the

relevant analyses. Ordinary least squares regression analyses were used to examine the relation

between self-report mindfulness scores and levels of social anxiety. Mediation was tested using

the bootstrapping analysis described by Preacher and Hayes (2008). For each proposed mediator

(OPQ and OCQ), separate analyses were conducted to test whether they mediated the relation

between mindfulness (MAAS) and each measure of social anxiety (BFNE and LSAS-SR).

Results

Correlations, descriptive statistics, and internal consistencies for all measures are shown in

Table 1. As expected, the social anxiety measures were positively correlated with each other.

All study measures demonstrated adequate internal consistency. Demographic variables were

examined as possible covariates, but were not significantly associated with levels of social anxiety

or mindfulness.

Hypothesis I

There was a significant negative relation between mindfulness scores (MAAS) and social anx-

iety as measured by both the BFNE, b = .19, standard error [SE] = .05, t(97) = 4.01,

p < .001,R2

= .14, and the LSAS-SR,b = .61,SE= .11,t(97) = 5.67,p < .001,R2

= .20.

Hypothesis II

The Preacher and Hayes (2008) bootstrapping macro was used in conjunction with ordinary

least squares regression analyses to examine whether outcome probability and outcome cost


5/10


Figure 1. (top panel) The relation between mindfulness (MAAS) and social anxiety symptoms (BFNEand LSAS-SR) mediated by the expectancy for a negative social interaction (OPQ). (bottom panel) Therelation between mindfulness (MAAS) and social anxiety symptoms (BFNE and LSAS-SR) mediated by

the expectancy for high social cost (OCQ). (both panels) A = relation between the independent variableand mediator; B = the relation mediator and dependent variable; C = the direct effect of the independentvariable on the dependent variable; C the indirect effect of the independent variable on the dependentvariable controlling for the mediator. *p < .05. **p < .01. ***p < .001.

expectancies mediated the relation between mindfulness and social anxiety symptoms. As with

other mediation analyses (i.e., Baron & Kenny, 1986), it is informative to examine the association

between variables in each pathway of the mediation model (e.g., between independent variable

and mediators and mediators and dependent variable). The total effects of the model are reported

above in the testing of hypothesis 1, in which mindfulness scores (MAAS) were significantly re-

lated to each measure of social anxiety (BFNE and LSAS-SR). The least squares regression

analyses for the other pathways of the mediation model, including the indirect effect of mindful-ness on social anxiety symptoms while controlling for outcome probability and outcome cost,

are presented in Figure 1.

On the recommendation of Preacher and Hayes (2008), 2,000 bootstrap samples were gen-

erated to obtain unbiased confidence intervals of these indirect effects. Ninety-five percent

confidence intervals (CIs) for the indirect effects that do not overlap with zero indicate that the


6/10


indirect effects are different from zero at p < .05 (two-tailed). Results indicate that outcome

probability scores (OPQ) significantly mediated the relation between mindfulness and both

BFNE scores, mean [M] = .09 (SE= .03),CI95 = .15 to .04, and LSASSR scores,M =

.19 (standard error [SE] = .08),CI95 = .34 to .02. Outcome cost (OCQ) also significantly

mediated the relation between mindfulness and both measures of social anxiety, BFNE,M =

.07 (SE= .03),CI95 = .13 to .03; LSASSR,M= .11 (SE= .05),CI95 = .22 to .03.

Discussion

This is the first study to show that mindfulness is related to symptom levels within a sample of

people with a diagnosis of social phobia, and to test a theoretically driven hypothesis of how

they might be related, via participants appraisals of the perceived probability and cost of a

negative social outcome. The results of the current study are consistent with cognitive theories

of social anxiety that emphasize that assumptions about the probability and cost of a negative

outcome are maintaining factors of the disorder.

These findings also are consistent with studies showing positive benefit from mindfulness-based interventions for social phobia (Bogels et al., 2006; Goldin & Gross, 2010; Goldin et al.,

2009; Kocovski, Fleming, & Rector, 2009; Koszycki et al., 2007). Results from the current study

suggest that mindfulness might reduce symptoms in part via their relation to negative cognitive

appraisals. However, to truly answer this question requires a longitudinal and experimental de-

sign. The partial mediation observed in this study suggests that there might be other mechanisms

by which mindfulness is related to symptoms of social anxiety. For example, Bogels and Mansell

(2004) have emphasized the role of mindfulness in reducing self-focused attention, whereas oth-

ers have focused on the potential for mindfulness to attenuate attentional biases for social threat

(Chen, Ehlers, Clark, & Mansell, 2002; Mogg, Philppot, & Bradley, 2004). Recent research also

has highlighted the importance of the nonjudgmental, compassionate attention encouraged in

mindfulness as one of the strongest predictors of well-being (Baer, Smith, Hopkins, Kriete-meyer, & Toney, 2006). Thus, future research should use other measures of mindfulness and

explore other theoretically driven hypotheses about the way they might be related. Furthermore,

it would be interesting to test whether cognitive behavioral therapy for social phobia augmented

with mindfulness interventions that specifically target biased cognitive appraisals would result

in better treatment outcome than cognitive behavioral interventions alone.

This study assessed individual differences in the frequency of mindful states over time or

what might be termed trait mindfulness, which is in contrast to state mindfulness, or

the ability for one to enter a mindful state. As state mindfulness might be more relevant to

mindfulness cultivated through mindfulness interventions, future work should measure the

impact of state mindfulness on cognitive appraisals and social anxiety symptoms. Measures of

state mindfulness such as the Toronto Mindfulness Scale (Lau et al., 2006) could be employedin such research.

The present study is subject to several methodological and conceptual concerns. A primary

limitation of the current study is that it is cross sectional; thus, one cannot conclude that

mindfulness (or lack thereof) leads to biased cognitive appraisals or to social anxiety symptoms.

Longitudinal work tracking the change in cognitive processes over the course of an intervention

is needed. One possible source of bias in this study is that participants volunteered knowing that

their treatment was part of a research project. Therefore, these findings might not generalize to

clinical populations, especially given the documented difficulty in engaging people diagnosed

with social phobia in therapy. Another caveat is that trait mindfulness scores (MAAS) in this

sample (M= 4.07,SD = 1) are higher than those obtained in other clinical samples (M= 3.68,

SD = .66; Evans et al., 2008), and more similar to those reported from a student sample (M=3.93,SD = .64; Brown & Ryan, 2003). It is thus unclear whether the relations observed in the

present study would generalize to samples with lower levels of mindfulness. It is also important

to note that although statistically significant, the correlation between the MAAS and social

anxiety symptoms is modest (.14 and .20). Other measures of mindfulness might show stronger

(or weaker) relations with social anxiety symptoms.


7/10


Additionally, the measurement of mindfulness is a topic of much debate. Thus, our choice

of the MAAS, and more general issues related to self-report measures of mindfulness, deserves

some mention. On the positive side, the MAAS is widely used as a measure of mindfulness

(e.g., Shapiro, Brown, Thoresen, & Plante, 2011; Keng, Smoski, & Robbins, 2011), and the

empirical research shows that the MAAS has theoretically consistent relationships to neural ac-

tivity (Creswell, Way, Eisenberger, & Lieberman, 2007) and is a known mediator of outcome as aresult of mindfulness-based interventions (Nyklcek & Kuijpers, 2008). However, there are many

criticisms of the MAAS as a measure of mindfulness. The MAAS indirectly assesses mindfulness

by asking one to rate functioning without awareness in daily life, or mindlessness (Brown &

Ryan, 2003). Furthermore, the MAAS is a single-factor instrument that conceptualizes mind-

fulness as awareness of present experience in daily life (Brown & Ryan). Thus, it is a limited

measure of mindfulness. Indeed, other researchers have argued that mindfulness includes addi-

tional factors, such as nonjudgmental attention to the present moment (Baer et al., 2004; Baer

et al., 2006). Finally, important questions have been raised about the fields current ability to mea-

sure mindfulness by self-report. In its traditional form, mindfulness is learned through practice,

as an experiential exercise that transcends intellectualized rote learning of skills (Gunaratana,

2001). From this perspective, the ability of nonmeditators to report on levels of mindfulness isdrawn into question. Thus, the present research is limited by the lack of agreement regarding

self-report or behavioral measurement of this construct (Grossman, 2008).

Despite these limitations, the present study is the first to show that mindfulness is related

to social anxiety symptoms within a clinical sample and to show that this relation is partially

mediated by participants cognitive appraisals. Another strength is that the sample in the current

study is relatively racially diverse, answering the call from many researchers for more clinical

research with diverse samples (Masuda, Anderson, & Sheehan, 2010; Iwamasa, Sorocco, &

Koonce, 2002). We believe the results of the present study should stimulate further research

on the nature of the relation between mindfulness and social anxiety. Research using a lon-

gitudinal design, other measures of mindfulness, and diverse clinical samples is particularly

needed.

References

Anderson, Zimand, E., Hodges, L.F., & Rothbaum. B.O. (2005). Congitive behavioral therapy for

public-speaking anxiety using virtual reality for exposure. Depression and Anxiety, 22, 156158.

doi:10.1002/da.20090

Baer, R.A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review.

Clinical Psychology: Science and Practice, 10, 125143. doi:10.1093/clipsy/bpg015

Baer, R.A., Smith, G.T., & Allen, K.B. (2004). Assessment of mindfulness by self-report. Assessment, 11,

191206. doi:10.1177/1073191104268029

Baer, R.A., Smith, G.T., Hopkins, H., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment

methods to explore facets of mindfulness. Assessment, 13, 2745. doi:10.1177/1073191105283504

Baker, S.L., Heinrichs, N., Kim, H.J., Hofmann, S.G. (2002). The Liebowitz Social Anxiety Scale as a self-

report instrument: A preliminary psychometric analysis. Behaviour Research & Therapy. 40, 701715.

doi:10.1016/S0005-7967(01)00060-2

Baron, R.M., & Kenny, J.A. (1986). The moderator-mediator variable distinction in social psychological

research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psy-

chology, 51, 11731182. doi:10.1037/0022-3514.51.6.1173

Bishop, S.R., Lau, M., Shapiro, S., Carlson, L., Anderson, N.D., Carmody, J., . . . Devins, G. (2004).

Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11, 230241.

doi:10.1093/clpsy.bph077

Bogels, S.M., & Mansell, W. (2004). Attention processes in the maintenance and treatment of social pho-bia: Hypervigilance, avoidance and self-focused attention. Clinical Psychology Review, 24, 827856.

doi:10.1016/j.cpr.2004.06.005

Bogels, S.M., Sijbers, G.F.V.M., & Vocncken, M. (2006). Mindfulness and task concentration train-

ing for social phobia: A pilot study. Journal of Cognitive Psychotherapy, 20, 3344. doi:10.1891/

jcop.20.1.33


8/10


Brown, K.W., & Ryan, R.M. (2003). The benefits of being present: Mindfulness and its role in psychological

well-being. Journal of Personality and Social Psychology, 84, 822848. doi:10.1037/0022-3514.84.4.822

Butler, G., & Mathews, A. (1983). Cognitive processes in anxiety. Advances in Behavior Research and

Therapy, 24, 461470. doi:10.1016/0146-6402(83)90015-2

Chen, Y.P., Ehlers, A., Clark, D.M., & Mansell, W. (2002). Patients with generalized social phobia direct

their attention away from faces. Behaviour Research and Therapy, 40(6), 677687. doi:10.1016/S0005-7967(01)00086-9

Clark, D.M., & Wells, A. (1995). A cognitive model of social phobia, In R.G. Heimberg, M.R. Liebowitz,

D.A. Hope, & F.R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 6993. New

York: Guilford Press.

Collins, K., Westra, H.A., Dozois, D.J.A., & Stewart, S.H. (2005). Thevalidity of the brief form of theFearof

Negative Evaluation Scale. Journal of Anxiety Disorders, 19, 345359. doi:10.1016/j.janxdis.2004.02.003

Creswell, J.D., Way, B.M., Eisenberger, N.I., & Lieberman, M.D. (2007). Neural correlates

of dispositional mindfulness during affect labeling. Psychosomatic Medicine, 69, 560565.

doi:10.1097/PSY.0b013e3180f6171f

Evan, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., & Haglin, D. (2008). Mindfulness-based cognitive

therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 22, 716721.

Feldman, G., Hayes, A., Kumar, S., Greeson, J., & Laurenceau, J. (2007). Mindfulness and emotion regula-

tion: The development and initial validation of the Cognitive and Affective Mindfulness Scale-Revised

(CAMS-R). Journal of Behavioral Assessment, 29, 177190. doi:10.1007/s10862-006-9035-8

Field, A. (2005). Discovering statistics using SPSS (2nd Ed.). London: Sage.

First, M.B., Gibbon, M., Spitzer, R., & Williams, J.B.W. (2002). Structured Clinical Interview for DSM-IV

(SCID I/R). New York: Biometrics Research Department, New York State Psychiatric Institute.

Foa, E.B., Franklin, M.E., Perry, K.J., & Herbert, J.D. (1996). Cognitive biases in generalized social phobia.

Journal of Abnormal Psychology, 105, 433439. doi:10.1037/0021-843X.105.3.433

Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective information. Psy-

chological Bulletin, 99, 2035. doi:10.1037/0033-2909.99.1.20

Fresco, D.M., Coles, M.E., Heimberg, R.G., Liebowitz, M.R., Hami, S., Stein, M.B. & Goetz, D. (2001). TheLiebowitz Social Anxiety Scale: A comparison of the psychometric properties of self-report and clinician-

administered formats. Psychological Medicine, 31, 10251035. doi:10.1017/S0033291701004056

Goldin, P.R., & Gross, J.J. (2010). Effects of mindfulness-based stress reduction (MBSR) on emotion

regulation in social anxiety disorder. Emotion, 10, 8391. doi:10.1037/a0018441

Goldin, P., Ramel, W., & Gross, J. (2009). Mindfulness meditation training and self-referential processing in

social anxiety disorder: Behavioral and neural effects. Journal of Cognitive Psychotherapy, 23, 242257.

doi:10.1891/0889-8391.23.3.242

Grossman, P. (2008). On measuring mindfulness in psychosomatic and psychological research. Journal of

Psychosomatic Research, 64, 405408. doi:10.1016/j.jpsychores.2008.02.001

Gunaratana, B.H. (2001). Eight mindful steps to happiness. Walking the Buddhas path. Somerville, MA:

Wisdom Publications.

Hayes, S.C., & Wilson, K.G. (2003). Mindfulness: Method and process. Clinical Psychology: Science and

Practice, 10, 161165. doi:10.1093/clipsy/bpg018

Hofmann, S.G. (2004). Cognitive mediation of treatment change in social phobia. Journal of Consulting

and Clinical Psychology, 72, 393399. doi:10.1037/0022-006X.72.3.392

Hope, D.A., Gansler, A.D., & Heimberg, R.G. (1989). Attentional focus and causal attributions in social

phobia: Implications from social psychology. Clinical Psychology Review, 9, 4960. doi:10.1016/0272-

7358(89)90046-9

Iwamasa, G., Sorocco, K., & Koonce, D. (2002). Ethnicity and clinical psychology. A content analysis of

the literature. Clinical Psychology Review, 22, 931944.

Jain, S., Shapiro, S.L., & Swanick, S. (2007). A randomized controlled trial of mindfulness mediation versus

relaxation training effects on distress, positive states of mind, rumination, and distraction. Annals of

Behavioral Medicine, 33, 1121.Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and Future. Clinical

Psychology: Science and Practice, 10, 144156. doi:10.1093/clipsy/bpg016

Keng, S., Smoski, M.J., & Robins, C.J. (in press). Effects of mindfulness on psychological health: A review

of empirical studies. Clinical Psychology Review, 31, 10411056. doi:10.1016/j.cpr.2011.04.006


9/10


Kocovski, N.L., Fleming, J.E., & Rector, N.A. (2009). Mindfulness and acceptance based group ther-

apy for social anxiety disorder: an open trial. Cognitive and Behavioral Practice, 16, 276289.

doi:10.1016/j.cbpra.2008.12.004

Kocovski, N.L., Segal, Z.V., & Battista, S.R. (2009). Mindfulness and psychopathology: Problem formula-

tion. In Didonna, F. (Ed.), Clinical handbook of mindfulness (pp. 8598). New York: Springer Science

& Business Media.Koszycki, D., Benger, M., Shlik, J., & Bradwejn, J. (2007). Randomized trial of a meditation based stress

reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behavior

Research and Therapy, 45, 25182526. doi:10.1016/j.brat.2007.04.011

Lau, M., Bishop, S.R., Segal, Z.V., Buis, T., Anderson, N.C., Carlson, L., . . . Devins, G. (2006). The

Toronto Mindfulness Scale: development and validation. Journal of Clinical Psychology, 62, 14451467.

doi:10.1002/jclp.20326

Leary, M.R. (1983). A brief version of the Fear of Negative Evaluation Scale. Personality and Social

Psychology Bulletin, 9, 371375. doi:10.1177/0146167283093007

Liebowitz, M.R. (1987). Social phobia. Modern Problems in Pharmacopsychiatry, 22, 141173.

Masuda, A., Anderson, P., & Sheehan, S. (2009). Mindfulness and mental health among African American

college students. Contemporary Health Practice Review, 14, 115127.

Mennin D.S., Fresco, D.M., Heimberg R.G., Schneier, F.R., Davies, S.O., Liebowitz, M.R. (2002). Screening

for social anxiety disorder in the clinical setting: Using the Liebowitz Social Anxiety Scale. Journal of

Anxiety Disorders, 16, 661673. doi:10.1016/S0887-6185(02)00134-2

Nyklcek, I., & Kuijpers, K.F. (2008). Effects of mindfulness-based stress reduction intervention on psy-

chological well-being and quality of life: Is increased mindfulness indeed the mechanism? Annals of

Behavioral Medicine, 35, 331340.

Oakman, J., Van Ameringen, M., Mancini, C., & Farvolden, P. (2003). A confirmatory factor analysis of a

self-report version of the Liebowitz Social Anxiety Scale. Journal of Clinical Psychology, 59, 149161.

doi:10.1002/jclp.10124

Preacher, K.J., & Hayes, A.F. (2008). Asymptotic and resampling strategies for assessing and com-

paring indirect effects in multiple mediator models. Behavior Research Methods, 40, 879891.

doi:10.3758/BRM.40.3.879

Ramel, W., Goldin, P.R., Carmona, P.E., & McQuaid, J.R. (2004). The effects of mindfulness meditation

on cognitive processes and affect in patients with past depression. Cognitive Therapy and Research, 28,

433455.

Rapee, R.M., & Heimberg, R.G. (1997). A cognitive behavioral model of anxiety in social phobia. Behavior

Research and Therapy, 35, 741756. doi:10.1016/S0005-7967(97)00022-3

Roemer, L., Lee, J.K., Salters-Pedneault, K., Erisman, S.M., Orsillo, S.M., & Mennin, D.S. (2009). Mind-

fulness and emotion regulation difficulties in generalized anxiety disorder: Preliminary evidence for

independent and overlapping contributions, Behavior Therapy, 40, 142154. doi:10.1016/j.beth.2008.

04.001

Rytwinski, N.K., Fresco, D.M., Heimberg, R.G., Coles, M.E., Liebowitz, M.R., Cissell, S., . . . Hofmann,

S.G. (2009). Screening for social anxiety disorder with the self-report version of the Liebowitz SocialAnxiety Scale. Depression & Anxiety, 26, 3438. doi:10.1002/da.20503

Shapiro, S.L., Brown, K.W., Thoreses, C., & Plante, T.G. (2011). The moderation of mindfulness based

stress reduction effects by trait mindfulness: Results from a randomized control trial. Journal of Clinical

Psychology, 67, 267277. doi:10.1002/jclp.20761

Shapiro, S.L., Carlson, L.E., Astin, J.A., & Freedman, B,(2006). Mechanisms of mindfulness. Journal of

Clinical Psychology, 62, 373386. doi:10.1002/jclp.20237

Smalley, S.L., Loo, S.K., Hale, T.S., Shrestha, A., McGough, J., Flook, L., et al. (2009). Mindful-

ness and attention deficit hyperactivity disorder. Journal of Clinical Psychology, 65, 10871098.

doi:10.1002/jclp.20618

Smits, J., A., Rosenfield, D., McDonald, R., & Telch, M.J. (2006). Cognitive mechanisms of social anxiety

reduction: An examination of specificityand temporality. Journal of Consultingand Clinical Psychology,

74, 12031212. doi:10.1037/0022-006X.74.6.1203

Uren, T.H., Szabo, M., & Lovibond, P.F. (2004). Probability and cost estimates for social and phys-

ical outcomes in social phobia and panic disorder. Journal of Anxiety Disorders, 18, 481498.

doi:10.1016/S0887-6185(03)00028-8


10/10

Cognitive Processes Mediate the Relation Betweein Mindfulness

Documents

Transcript of Cognitive Processes Mediate the Relation Betweein Mindfulness