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Patients with social phobia often experience negative self-images in social situations. The current study investigated whether negative self-images have a causal role in maintaining social phobia. Patients with social phobia participated twice in a conversation with a stranger, once whilst holding their usual negative self-image in mind and once whilst holding a less negative (control) self-image in mind, with order counterbalanced across participants. Compared to the control image condition, when participants held the negative image in mind they experienced greater anxiety, rated their anxiety symptoms as being more visible, and rated their performance as poorer. An assessor who did not know which image was being held also rated participants’ anxiety as more evident and their behaviour as less positive when the negative image was being held in mind. Finally, when participant and assessor ratings were compared, participants underestimated their performance and overestimated the visibility of their anxiety to a significantly greater extent in the negative imagery condition. Taken together, these results support the hypothesis that negative self-imagery has a causal role in maintaining social phobia.

Cognitive theorists (Beck, 1976, Clark and Beck, 1988 and Hackmann, 1999) have suggested that imagery plays a key role in the development and maintenance of anxiety disorders. In particular, it is suggested that patients’ distorted beliefs about the dangerousness of feared situations and/or internal states are often encapsulated in spontaneous mental images and that the occurrence of these images increases the perceived probability of feared outcomes. In addition, it is suggested that part of the subjective evidence for the occurrence of a future feared outcome is the occurrence of mental images representing past feared outcomes. Consistent with cognitive theories, several studies have shown that anxiety disorders are associated with negative imagery. Beck, Laude, and Bohnert (1974) interviewed a group of patients with a mixture of anxiety disorders. Spontaneous images were common, tended to depict physical and/or psychosocial danger and followed the same themes as the patients’ verbal thoughts. Ottaviani and Beck (1987) interviewed patients with panic disorder and reported a high frequency of images concerned with personal physical or mental catastrophes. De Silva (1986) focused on obsessive–compulsive disorder. Spontaneous images were again common with their themes being similar to those of obsessive thoughts: death, decay, illness, injury, violence, disaster, sex and blasphemy. Wells and Hackmann (1993) investigated images in health anxiety. As with verbal automatic thoughts (Warwick & Salkovskis, 1990), the themes of images involved misinterpretation of symptoms, and overestimates of the likelihood of illness and death. Further illuminating cognitive conceptualisations of health anxiety, an additional theme concerned the interpersonal consequences of dying or being ill. The observed correlation between negative images and the presence of anxiety disorders does not necessarily mean that the images play a causal role in generating anxiety. On the basis of correlation of data alone, one could equally well argue that negative images are simply a consequence of anxiety or an epiphenomenon. In order to provide more convincing evidence for a causal role, it is necessary to experimentally manipulate imagery and demonstrate that such manipulations can modulate anxiety. The present paper reports an experiment that manipulated imagery in social phobia. Clark and Wells’ (1995) model is arguably the most detailed recent theoretical account of the role of imagery in social phobia. Central to Clark and Wells’ model is the suggestion that social anxiety is associated with an increase in self-focussed attention and monitoring of one’s performance. It is suggested that when attention shifts onto the self, negative images that involve seeing one’s self as if from an external observer’s perspective are synthesised. Rather than representing how the patient actually looks, the content of the images involves visualising feared outcomes (Hackmann, Surway and Clark, 1998 and Hackmann, Clark and McManus, 2000). For example, a young teacher who was shy about asking colleagues questions reported feeling tension around her mouth before asking a question. The tense feelings triggered a mental image in which she saw herself with a twisted mouth ‘looking like the village idiot’ (Clark, 1997, p. 141). Often the content of the negative image appears to be based upon adverse social experiences from earlier in the patient’s life (see Hackmann et al., 2000). Clark and Wells suggest that patients use the occurrence of the images as a major source of evidence for their negative beliefs about the way they appear to other people. In addition, it is argued that the occurrence of images increases anxiety and motivates safety behaviours, which are attempts to prevent or minimise the feared catastrophes encapsulated in the images (Salkovskis, 1991). Some safety behaviours are mental operations (e.g. memorising what one has said and comparing it with what one is about to say whilst speaking in order to avoid appearing foolish), while others are more obvious behavioural manoeuvres (e.g. averting one’s face to avoid others seeing one’s blushing). It is suggested that many safety behaviours have the unintended consequence of making the patient appear distracted and preoccupied, which leads to poorer performance and is interpreted by others as a sign that the patient is not interested in them or does not like them. The present experiment assesses the causal role of imagery in social anxiety by asking patients with social phobia to have a conversation with a stranger while holding in mind their usual negative, observer-perspective image or a control self-image. If imagery plays a role in generating anxiety, the negative imagery condition should be associated with higher levels of anxiety. In line with Clark and Wells’ (1995) theory, it is predicted that negative imagery will also be associated with lower ratings of performance by both the patient and an independent assessor.