Individuals with social anxiety often experience rumination as persistent, intrusive thoughts focused on perceived social failures or potential negative outcomes.
Before social events (pre-event rumination), they might obsessively think: “What if I say something stupid?” or “Everyone will notice how nervous I am.”
After social interactions (post-event rumination), they may replay the event, fixating on perceived mistakes: “I stumbled over my words; they must think I’m an idiot” or “I barely contributed to the conversation; they probably found me boring.”
These repetitive negative thoughts maintain anxiety, reinforce negative self-perceptions, and can lead to avoidance of future social situations, perpetuating the cycle of social anxiety.
Key Points
Rationale
SAD is associated with impaired psychosocial functioning, psychiatric comorbidity, and high health service use and costs (Crome et al., 2015; Konnopka & König, 2020; Patel et al., 2002).
Cognitive-behavioral therapy (CBT) is the first-line psychological treatment for SAD, with meta-analyses indicating large treatment effect sizes (Mayo-Wilson et al., 2014).
However, CBT is not universally effective, with response rates around 45.3% at post-treatment (Loerinc et al., 2015).
Pre-event and post-event rumination refer to repetitive negative thoughts about perceived social shortcomings and subsequent negative judgments from others, occurring before and after social situations respectively.
Cognitive models propose these processes maintain and exacerbate SAD symptoms (Clark & Wells, 1995; Hofmann, 2007; Rapee & Heimberg, 1997).
Research has consistently associated pre-event and post-event rumination with increased SAD symptom severity (e.g., Kocovski et al., 2005; Mills et al., 2013) and slower responses to CBT treatment (Price & Anderson, 2011; Wong et al., 2017).
Despite the theoretical and empirical importance of pre-event and post-event rumination in SAD, no previous meta-analyses have specifically evaluated the effectiveness of psychological interventions in reducing these processes.
This presents a significant gap in the literature that the current study aimed to address.
Method
Thissystematic reviewandmeta-analysisfollowed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Search strategy and terms: A comprehensive literature search was conducted in PsychINFO, Medline, Scopus, and Web of Science databases.
Key search terms included variations of: (pre-event rumination OR anticipatory processing OR post-event rumination OR post-event processing) AND (social anxiety OR social phobia OR social anxiety disorder) AND (treatment OR intervention OR therapy OR trial OR outcome)
Inclusion and exclusion criteria:
Studies were included if they:
Studies were excluded if they:
Statistical measures
Meta-analytic statistics were computed using Comprehensive Meta-Analysis software.
The random effects model was used due to variation in study designs and protocols.
Within-group effect sizes were calculated using Hedges’ g statistic.
Heterogeneity was evaluated using Cochran’s Q statistic and I² statistic. Publication bias was assessed via funnel plots and the Classic fail-safe N calculation.
Results
Study characteristics:
Overall treatment effects:
Subgroup analyses:
Meta-regression analyses:
Insight
This systematic review and meta-analysis provides the first comprehensive evaluation of the effectiveness of psychological interventions in reducing pre-event and post-event rumination in social anxiety disorder.
The findings demonstrate that psychological treatments, particularly CBT, are effective in significantly reducing both pre-event and post-event rumination, with large effect sizes observed.
A key insight from this study is that treatments directly targeting rumination show enhanced effectiveness, especially for pre-event rumination.
This suggests that incorporating specific modules or techniques to address rumination processes may improve overall treatment outcomes for individuals with SAD.
The differential effects of baseline social anxiety and depression levels on pre-event and post-event rumination reductions also provide interesting insights into the nature of these processes.
Pre-event rumination appears more closely linked to anxious anticipation, while post-event rumination may share characteristics with depressive rumination.
The results support cognitive models of SAD that emphasize the role of these processes in maintaining symptoms and highlight the importance of directly addressing them in treatment.
Future research should focus on:
Strengths
The study had many methodological strengths, including:
Limitations
This study also had some methodological limitations, including:
These limitations suggest caution in interpreting some results, particularly those involving comparisons between different treatment types or long-term effectiveness.
Implications
The findings of this meta-analysis have significant implications for clinical practice and future research in the treatment of social anxiety disorder:
These implications emphasize the importance of directly addressing pre-event and post-event rumination in SAD treatments and suggest several avenues for improving clinical outcomes and advancing our understanding of these processes in maintaining social anxiety symptoms.
References
Primary reference
Donohue, H. E., Modini, M., & Abbott, M. J. (2023). Psychological interventions for pre-event and post-event rumination in social anxiety: A systematic review and meta-analysis.Journal of Anxiety Disorders, 102823.https://doi.org/10.1016/j.janxdis.2023.102823
Other references
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. 69–93). New York: Guildford Press.
Crome, E., Grove, R., Baillie, A. J., Sunderland, M., Teesson, M., & Slade, T. (2015). DSM-IV and DSM-5 social anxiety disorder in the Australian community.Australian & New Zealand Journal of Psychiatry,49(3), 227-235.https://doi.org/10.1177/0004867414546699
Hofmann, S. G. (2007). Cognitive factors that maintain social anxiety disorder: A comprehensive model and its treatment implications.Cognitive behaviour therapy,36(4), 193-209.https://doi.org/10.1080/16506070701421313
Kocovski, N. L., Endler, N. S., Rector, N. A., & Flett, G. L. (2005). Ruminative coping and post-event processing in social anxiety.Behaviour research and therapy,43(8), 971-984.https://doi.org/10.1016/j.brat.2004.06.015
Konnopka, A., & König, H. (2020). Economic burden of anxiety disorders: a systematic review and meta-analysis.Pharmacoeconomics,38, 25-37.https://doi.org/10.1007/s40273-019-00849-7
Loerinc, A. G., Meuret, A. E., Twohig, M. P., Rosenfield, D., Bluett, E. J., & Craske, M. G. (2015). Response rates for CBT for anxiety disorders: Need for standardized criteria.Clinical psychology review,42, 72-82.https://doi.org/10.1016/j.cpr.2015.08.004
Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis.The Lancet Psychiatry,1(5), 368-376.https://doi.org/10.1016/S2215-0366(14)70329-3
Mills, A. C., Grant, D. M., Lechner, W. V., & Judah, M. R. (2013). Psychometric properties of the anticipatory social behaviours questionnaire.Journal of Psychopathology and Behavioral Assessment,35, 346-355.https://doi.org/10.1007/s10862-013-9339-4
Patel, A., Knapp, M., Henderson, J., & Baldwin, D. (2002). The economic consequences of social phobia.Journal of affective disorders,68(2-3), 221-233.https://doi.org/10.1016/S0165-0327(00)00323-2
Price, M., & Anderson, P. L. (2011). The impact of cognitive behavioral therapy on post event processing among those with social anxiety disorder.Behaviour Research and Therapy,49(2), 132-137.https://doi.org/10.1016/j.brat.2010.11.006
Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia.Behaviour research and therapy,35(8), 741-756.https://doi.org/10.1016/S0005-7967(97)00022-3
Wong, Q. J., Gregory, B., McLellan, L. F., Kangas, M., Abbott, M. J., Carpenter, L., … & Rapee, R. M. (2017). Anticipatory processing, maladaptive attentional focus, and postevent processing for interactional and performance situations: treatment response and relationships with symptom change for individuals with social anxiety disorder.Behavior therapy,48(5), 651-663.https://doi.org/10.1016/j.beth.2017.03.004
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Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
