Discussion

The aims of this study were to explore: (1) whether SAD individuals actually derive the benefits from PEP that they expect; (2) if this is not the case, how their positive beliefs are maintained; and (3) if they are aware of the counterproductive effects of PEP, why they still perform PEP.

Firstly, this qualitative study demonstrated that SADs rarely obtain the benefits from PEP that they expect. Consistent with previous studies and proposed theories of PEP, the presence of positive metacognitive beliefs seems to play a central role in initial motivation to engage in PEP. However, contrary to the initial motivation, SADs recognize that PEP has few (or almost no) benefits and a range of harmful effects.

Secondly, results suggest that SADs may, on occasion, find solutions during PEP, which maintain their PEP as a form of intermittent reinforcement. However, these solutions may turn into safety behaviours, which can perpetuate dysfunctional beliefs. Thus, PEP can be one of the processes through which SADs can reflect on and develop new safety behaviours. Although preliminary, this finding has not been highlighted in the theoretical framework of PEP: future experimental research will need to examine how PEP contributes to developing new safety behaviours.

Lastly, we clarified that SADs weigh up the costs and benefits, but continue PEP while feeling conflicted about it. The presence of such conflict between positive and negative metacognitive beliefs has also never been taken up as a phenomenon of PEP in SAD. Most previous studies in line with metacognitive theories of PEP have focused on positive metacognitive beliefs, so further questionnaire or experimental studies should assess both positive and negative metacognitive beliefs as well as discrepancies between them in an effort to better understand how these beliefs are linked to the maintenance of PEP. SAD individuals may hold on to PEP for two reasons. First, PEP ironically maintains and exacerbates negative self-beliefs and images, which in turn motivate them to improve their social performance. Second, they believe that PEP is the only safe and useful way to improve their social performance. They may have tried other strategies and sometimes may have actually improved their performance, but they cannot process positive feedback from other people due to their self-focused attention and biased ways of interpreting such feedback. They may want to know what other people really think about their performance, but it can be too frightening to ask due to the fear of negative evaluation. They may also fear that asking for feedback might offend or irritate others. This is in contrast to individuals suffering from obsessive-compulsive disorder, who often seek reassurance from others in order to reduce anxiety or to feel safe (e.g. Halldorsson and Salkovskis, Reference Halldorsson and Salkovskis2017) even though they know that seeking reassurance bothers and annoys other people. On the other hand, PEP is a private activity, which SADs can do on their own, whenever and wherever. Thus, SADs may have positive beliefs about PEP, while feeling irrational, ambivalent and conflicted about it.

The current study also has potential implications for the treatment of SAD. As mentioned, SAD individuals both believe that reviewing past events is useful for improving social performance and feel conflicted about it; thus, practitioners need to carefully examine both the ‘usefulness’ and the counterproductive effects of PEP, so that SADs can understand how ‘a solution becomes a problem’. Clark and Wells (Reference Clark, Wells, Heimberg, Michael, Hope and Schneier1995) proposed a treatment technique that explicitly targets PEP and anticipation. More specifically, SADs are initially encouraged to identify the particular ways they think and behave before and after social events. The advantages and disadvantages of their PEP and anticipation are discussed in detail, with the aim of showing that the disadvantages predominate. They are then encouraged to experiment with banning such maladaptive processes before and after social events. The results obtained from this study could help therapists to clarify more detailed disadvantages by introducing real refined examples of the counterproductive effects of PEP, which would discourage SADs from having positive beliefs about PEP. Furthermore, as most SADs rarely seek third-person perspectives, seeking other people’s opinions and perspectives may be useful in order to gather all the overlooked information and to look at various interpretations of ambiguous social cues within situations that may help to prevent PEP. At the same time, therapists need to be careful about patients becoming excessively reassurance-seeking. Further experimental studies are needed to determine whether encouraging SADs to seek other people’s opinions/perspectives is helpful in preventing or terminating PEP.

Several limitations in this study require attention when interpreting the findings. A major limitation is that we focus on individuals with SAD deemed information-rich for PEP, so sample restrictions are considered a threat to external validity. Future studies should employ a larger sample including unselected SADs and a suitable control group. Second, the researchers were specialists in behavioural and cognitive theory, possibly influencing the language available in the analysis. Third, as most participants had at least one additional diagnosis, it is difficult to conclude on the specificity of findings for SAD. Fourth, the wording of the question ‘Why do you still review past events?’ may imply a discrepancy and be suggestive. Fifth, we did not assess baseline levels of PEP using established measurements and specify the type of social situation where the reviewing occurs, making it difficult to evaluate the internal validity of the results. Sixth, there was no specified timeframe within which participants were asked to recall their reviewing behaviours, which may have introduced recall bias. Seventh, the initial codes were generated only by the first author, so it is possible that other coders might view certain codes differently. Lastly, although this study targeted PEP, it is difficult to distinguish clearly between PEP and anticipatory processing because both are self-focused thought processes that occur at various times before and after social events.

To summarize, the findings of this study suggest that: (1) SAD individuals rarely derive the benefits from PEP that they expect; (2) they may, on occasion, find solutions during PEP, which maintain their PEP as a form of intermittent reinforcement; however, these solutions may turn into safety behaviours, perpetuating dysfunctional beliefs; and (3) they choose to perform PEP while feeling conflicted because PEP ironically maintains and exacerbates negative self-beliefs and images; and for SADs, PEP is the only safe and useful way to improve their social performance. These findings support and elaborate upon the phenomenology of PEP in SAD proposed in the Clark and Wells (Reference Clark, Wells, Heimberg, Michael, Hope and Schneier1995) model, and have possible treatment implications.