Effects of Mindfulness-Based Stress

Reduction (MBSR) on Emotion

Regulation in Social Anxiety Disorder
Philippe R. Goldin , James J. Gross
Abstract

Mindfulness-based stress reduction (MBSR) is an established program shown to
reduce symptoms of stress, anxiety, and depression. MBSR is belieed to alter
emotional responding by modifying cognitie!affectie processes. "ien that social
anxiety disorder (S#$) is characteri%ed by emotional and attentional biases as well as
distorted negatie self-beliefs, we examined MBSR-related changes in the brain!
behaior indices of emotional reactiity and regulation of negatie self-beliefs in
patients with S#$. Sixteen patients underwent functional MR& while reacting to
negatie self-beliefs and while regulating negatie emotions using ' types of attention
deployment emotion regulation(breath-focused attention and distraction-focused
attention. )ost-MBSR, *+ patients completed neuroimaging assessments. ,ompared
with baseline, MBSR completers showed improement in anxiety and depression
symptoms and self-esteem. $uring the breath-focused attention tas- (but not the
distraction-focused attention tas-), they also showed (a) decreased negatie emotion
experience, (b) reduced amygdala actiity, and (c) increased actiity in brain regions
implicated in attentional deployment. MBSR training in patients with S#$ may reduce
emotional reactiity while enhancing emotion regulation. .hese changes might facilitate
reduction in S#$-related aoidance behaiors, clinical symptoms, and automatic
emotional reactiity to negatie self-beliefs in adults with S#$.
KEYWORDS:
social anxiety, neroima!in!, mind"lness, attention, emotion
#he concept o" mind"lness has attracted attention in the domains o" $asic emotion
research, clinical science, and social%co!niti&e%a""ecti&e neroscience. #he most
stdied "orm o" mind"lness trainin! in the 'nited States is mind"lness($ased stress
redction )*+SR,, a strctred !rop pro!ram o" mind"lness trainin! de&eloped $y
Ka$at(-inn ).//0,. #here is also increasin! interest in mind"lness($ased exercises in
the context o" clinical inter&entions "or anxiety and depression disorders, as 1ell as
other clinical pro$lems )2llen, 3ham$ers, 4 Kni!ht, 50067 3armody, 500/,.
2t this sta!e in the "ield8s de&elopment, 1e $elie&e it is se"l to apply Western
psycholo!ical models o" co!niti&e%a""ecti&e processes to the stdy o" mind"lness in
order to clari"y ho1 mind"lness trainin! 1or9s )3armody, 500/,. *ore speci"ically,
1e s!!est that an emotion re!lation "rame1or9 )Gross, 500:, may help clari"y the
processes that nderlie *+SR, processes that may $e distinct "rom those implicated in
other more traditional modalities sch as co!niti&e%$eha&ioral therapy );o"mann 4
2smndson, 500<,.
Mindfulness-Based Stress Reduction

MBSR consists of multiple forms of mindfulness practice, including formal and informal
meditation practice, as well as hatha yoga (/abat-0inn, *112). .he formal practice
consists of breath-focused attention, body scan-based attention to the transient nature
of sensory experience, shifting attention across sensory modalities, open monitoring of
moment-to-moment experience, wal-ing meditation, and eating meditation. &nformal
practice entails brief pauses inoling olitionally shifting attention to present moment
awareness. .ogether, this pac-age of mindfulness practices aims to enhance the
ability to obsere the immediate content of experience, specifically, the transient nature
of thoughts, emotion, memories, mental images, and physical sensation.
.wo specific forms of nonelaboratie, nonconceptual attention-focusing meditations
that are introduced in MBSR are (a) focused attention defined as ob3ect-based (e.g.,
sensations induced during breathing) olitional selectie attention in the present
moment with ongoing assessment of the 4uality of attention, and (b) open monitoring
defined as settling attention into a state of mere obseration or monitoring in the
present moment on any experience (thought, emotion, physical sensation) without any
explicit focus on an ob3ect (5ut%, Slagter, $unne, 6 $aidson, '227).
#lthough there is no explicit instruction in changing the nature of thin-ing, or emotional
reactiity, MBSR has been shown to diminish the habitual tendency to emotionally
react to and ruminate about transitory thoughts and physical sensations (Ramel,
"oldin, ,armona, 6 Mc8uaid, '22+9 .easdale et al., '222)9 reduce stress, depression,
and anxiety symptoms (,hiesa 6 Serretti, '2219 :ans et al., '2279 Segal, ;illiams, 6
.easdale, '22')9 modify distorted patterns of self-iew ("oldin, Ramel, 6 "ross, '221)9
amplify immune functioning ($aidson et al., '22<)9 enhance behaioral self-regulation
(5y-ins 6 Baer, '221)9 and improe olitional orienting of attention (=ha, /rompinger, 6
Baime, '22>). Recent functional neuroimaging studies of MBSR hae proided
eidence of reduced narratie and conceptual and increased experiential and sensory
self-focus at post-MBSR (?arb et al., '22>) and decreased conceptual!linguistic self-
referential processing from pre- to post-MBSR ("oldin, Ramel, et al., '221).
MBSR and Emotion Regulation

.heorists hae suggested that MBSR may reduce symptoms of stress, anxiety, and
depression by modifying emotion regulation abilities, but it is not yet clear which
specific abilities may be enhanced by MBSR (,hambers, "ullone, 6 #llen, '221). .his
is because emotion regulation refers to a ariety of strategies that can be implemented
at different points during the emotion-generatie process to influence which emotions
arise, when and how long they occur, and how these emotions are experienced and
expressed ("ross, '22>). $istinct forms of emotion regulation hae their own neural
circuitry and temporal features ("oldin, McRae, Ramel, 6 "ross, '227).
.he process model of emotion regulation ("ross, *117) proposes fie families of
emotion regulation strategies, including situation selection, situation modification,
attentional deployment, cognitie change, and response modulation. .here is eidence
that MBSR and long-term mindfulness meditation practice may directly influence
attentional deployment, specifically the ability to exert cognitie control of negatie
rumination (Ramel et al., '22+), self-focused attention ("oldin, Ramel, et al., '221),
attention allocation and regulation (Slagter, 5ut%, "reischar, @ieuwenhuis, 6 $aidson,
'227), and orienting to a spatial cue (=ha et al., '22>). 5ut% et al. ('227) hae proposed
that such training of attention is expected to result in Aimproement in the capacity to
disengage from aersie emotional stimuliB enabling greater emotional flexibilityC (p.
+). Doweer, the proposed effects of MBSR on emotional reactiity and attentional
deployment re4uire empirical inestigation.
MBSR, Emotion Regulation, and Social Anxiety Disorder

Ene clinical context in which MBSRFs effects of emotion regulation might be
inestigated is social anxiety disorder (S#$). S#$ is a ery common psychiatric
condition that is characteri%ed by intense fear of ealuation in social or performance
situations (=efferys, *11>). )atients with S#$ hae a strong tendency to focus on both
internal cues (e.g., negatie thoughts and self-imagery) and external cues (e.g., otherFs
facial expressions) during social situations (Schult% 6 Deimberg, '227). .his attentional
focus seres to maintain social anxiety symptoms by interfering with habituation
processes that lead to correctie learning in io and during cognitie!behaioral
therapy (Deimberg 6 Bec-er, '22').
Recent electrophysiological studies hae demonstrated that adults with S#$
demonstrate abnormal attentional processes consisting of early hyperigilance followed
by attentional aoidance (i.e., reduced isual processing) of social threat stimuli
(Mueller et al., '227). Studies hae shown that adults with S#$ show diminished
recruitment of brain networ-s implicated in cognitie regulation (dorsolateral prefrontal
cortex G)?,H, dorsal anterior cingulate cortex) and in attention regulation (posterior
cingulateIprecuneus, inferior parietal lobe, supramarginal gyrus) during cognitie
reappraisal of emotional reactiity to social threat ("oldin, Manber, Da-imi, ,anli, 6
"ross, '221) and to negatie self-beliefs ("oldin, Manber Ball, ;erner, Deimberg, 6
"ross, '221).
.wo studies hae examined the impact of MBSR on S#$. Ene study found e4uialent
improement in patients with generali%ed S#$ on mood, functionality, and 4uality of life
with either 7-wee- MBSR or *'-wee- cognitie!behaioral group therapy (,B".), but
significantly lower scores on clinician- and patient-rated measures of social anxiety for
,B". compared with the MBSR group (/os%yc-i, Benger, Shli-, 6 Bradwe3n, '22>). #
recent study of MBSR for adults with generali%ed S#$ showed reduced anxiety,
negatie self-iew, and conceptual!linguistic self-referential processing along with
increased self-esteem and positie self-iew ("oldin, Ramel, et al., '221). Doweer,
little is yet -nown about how MBSR influences the neural bases of emotional reactiity
and emotion regulation, particularly when someone with S#$ is challenged with social
anxiety-related negatie self-beliefs, which are a core feature of S#$.
The Present Study

.o inestigate MBSR-related changes in emotion reactiity and regulation of negatie
self-beliefs in patients with S#$, we assessed clinical symptoms and obtained
behaioral and neural measures of emotional reactiity and regulation at baseline and
post-MBSR. ,linically, we expected MBSR-related changes, including reduced
symptoms of anxiety and depression and enhanced self-esteem in patients with S#$.
&n the emotion regulation tas-, we examined two forms of attention deploymentJ breath-
focused attention (the target regulation strategy) and distraction-focused attention (a
control regulation strategy). ;e expected MBSR-related changes in relation to the
breath-focused mindful attention, including (a) decreased negatie emotion after
implementing breath-focused attention, (b) decreased brain actiity in emotion-related
limbic actiity (i.e., amygdala), and (c) increased actiity in attention-related brain
regions, but (d) no change related to distraction-based attention.
Method

Participants
Sixteen right-handed adult patients (nine women) diagnosed with primary generali%ed
S#$ met DSMIV criteria based on the #nxiety $isorders &nteriew Schedule for
DSMIV (#$&S-&K9 $i@ardo, Brown, 6 Barlow, *11+). Based on the interiew, past
comorbid conditions included two patients with obsessie!compulsie disorder, three
with dysthymia, and four with ma3or depressie disorder9 current conditions included
three with generali%ed anxiety disorder, three with specific phobia, and one with panic
disorder without agoraphobia. )atients were on aerage middle age (M L <M.' years,
SD L **.1), college educated (M L *N.< years of education, SD L <.M), and dierse in
raceJ eight #nglo #mericans, fie #sian #mericans, two 5atino #mericans, and one
@atie #merican. )atients proided informed consent in accordance with Stanford
OniersityFs Duman Sub3ects ,ommittee guidelines for ethical research. .wo patients
(one men and one women) declined the post-MBSR magnetic resonance (MR)
assessment because of distress about scanning.
Inclusion and Exclusion Criteria
.o be eligible for the study, patients had to pass a MR scanning safety screen on three
occasions, as well as not report current use of psychotropic medication, prior
meditation training, history of neurological or cardioascular disorders, or met
diagnostic criteria for current #xis & psychiatric disorders other than social anxiety,
generali%ed anxiety, agoraphobia, or specific phobia disorders.
Clinical Assessment
&n addition to the clinical diagnostic interiew (#$&S-&K), self-report inentories were
used to assess social anxiety (5iebowit% Social #nxiety Scale9 5iebowit%, *17>),
depression (Bec- $epression &nentory(&&9 Bec-, Steer, 6 Brown, *11N), rumination
(Rumination Style 8uestionnaire9 @olen-Doe-sema, *11*), state anxiety (Spielberger
State!.rait #nxiety &nentory9 Spielberger, "orsuch, 6 5ushene, *1>2), and self-
esteem (Rosenberg Self-:steem Scale9 Rosenberg, *1NM).
Procedure
Recruitment strategies consisted of electronic bulletin-board listings and referrals from
mental health clinics. )atients completed a phone screen to establish initial eligibility for
the study. @ext, patients were administered a structured clinical diagnostic interiew in
the laboratory. #fter meeting MR scanning and diagnostic criteria, eligible patients
completed online 4uestionnaires and a brain imaging session within the following wee-.
#t the scanning session, patients were introduced to the emotion regulation tas- and
gien two practice trials with negatie self-beliefs not used during the fMR& experiment.
)articipants attended MBSR for ' months and then returned to the laboratory to
complete all assessments again.
Mindfulness-Based Stress Reduction
.he standard MBSR protocol deeloped by /abat-0inn (*112) was deliered in an
academic setting. MBSR consisted of a '.M-hr once-wee-ly small-group (eight
members in a group) format for eight sessions plus one half-day meditation retreat.
)articipants were gien meditation ,$s created by /abat-0inn to support home formal
practice. )articipants were instructed to complete a self-report daily monitoring form
each eening to record both formal and informal meditation practices. )articipants
attended most MBSR classes (M L >.2>, SD L 2.7<) and completed a moderate
amount of wee-ly hours of home meditation practice (M L '.'N hr, SD L 2.MM) separate
from the '.M-hr wee-ly class. MBSR was deliered by a member of the team ()") who,
while not being board certified in the ;estern tradition of MBSR, lied and studied in
Buddhist monasteries in @epal and &ndia for N years prior to returning to the Onited
States and being trained in and leading MBSR courses in medical and academic
settings for *2 years.
Regulation of Negative Self-Beliefs Tas
.he regulation tas- consisted of *7 experimenter-selected social anxiety-related
negatie self-beliefs that refer to self-focused, self-critical personal beliefs (e.g., A& am
ashamed of my shyness,C A)eople always 3udge meC). :ach trial consisted of reacting
to a negatie self-belief for *' s, implementation of attention regulation based on a cue
to either AShift attention to the breathC (breath-focused attention9 nine trials) or A,ount
bac-ward from *N7C (distraction-focused attention9 nine trials) for *' s (see ?igure *).
#2+=ES 2>D ?@G'RES
?i!re .. Strctre "or $reath( and distraction("ocsed attention trials and asteris9
contin! trials. )2, Reactin! to a ne!ati&e sel"($elie" "ollo1ed $y a ce to implement
$reath("ocsed or distraction("ocsed attention re!lation 1hile the same ne!ati&e sel"(
$elie" remains on the screen. )+, 2 sin!le $loc9 o" asteris9 contin!.
.he two attention regulation conditions were presented in a fixed pseudorandom
se4uence. #fter implementing breath-focused attention or distraction-focused attention,
participants proided a negatie emotion rating (Dow negatie do you feel right nowP *
L not at all, ' L slight, < L moderate, + L very much) for < s. Ratings were recorded
using :prime software (Kersion '9 )sychology Software .ools, &nc., )ittsburgh, )#)
with a button response pad positioned in the participantFs right hand (< s).
.he comparison baseline condition consisted of identifying the number of asteris-s on
the screen eery < s (rangeJ *!M asteris-s) and ma-ing a button press to indicate the
number of asteris-s on the screen at any gien time. .here were six 1-s bloc-s of
asteris- counting randomly inserted throughout the experiment. )rior to scanning,
participants were trained on the regulation tas- with four negatie self-beliefs not used
in the experiment. .hey were instructed to read repeatedly a single negatie self-belief
presented in white against a blac- bac-ground on a screen mounted on the head coil
inside the scanner. ;hen a cue appeared aboe the belief, participants shifted
attention to the physical sensation of their own inhalation and exhalation (breath-
focused attention) or began subtracting by ones from a three-digit number pro3ected
aboe the statement (distraction-focused attention). .he regulation tas- was 1 min *' s
(<N7 time points Q *.M s L MM' s) in duration.
Image Ac!uisition
# "eneral :lectric < .esla Signa magnet was used to ac4uire anatomical and
functional images. ;e used a custom-built 4uadrature AdomeC elliptical bird cage head
coil and a .'R-weighted gradient echo spiral-inIout pulse se4uence to obtain blood
oxygenation leel-dependent (BE5$) contrast ("loer 6 5aw, '22*). # wax bite bar,
padding, and plungers were used to reduce head moement. # single functional run
was used to ac4uire <N7 olumes consisting of '' se4uential axial slices each.
Scanning parameters also included .R L *,M22 ms, .: L <2 ms, flip angle L N2, field of
iew L '' cm, fre4uency encoding L N+, single shot, oxel resolution L <.++ mm' in-
plane and M mm through-plane. # fast spin-echo spoiled-grass pulse se4uence was
used to obtain a high-resolution anatomical image (oxel resolution L .7N' Q *.' mm9
field of iew L '' cm, fre4uency encoding L 'MN).
fMRI "ata Preprocessing
BE5$ signal preprocessing and statistical analysis was conducted with #nalysis of
?unctional @euro&magesJ #?@& ersion '227S2>S*7S*>*2, @o *7 '227 (,ox, *11N).
Kisual and computational examination of each olume yielded no signal artifacts or
moement outliers greater than *.2 mm motion correction in the x, y, or z directions.
.hus, no scans were omitted. .he first N s of images obtained while the magnet field
was gaining stabili%ation were eliminated. Kolume registration, realignment, and
calculation of six motion parameters (three translations and three rotations) were
conducted on an empirically determined optimal base image deried from an
automated recursie analysis of the root-mean-s4uare ad3ustment for motion correction
at each time point. .here was no eidence of stimulus-correlated motion for any of the
tas- conditions. # high-pass temporal filter (2.2** D%) was used to remoe low-
fre4uency oscillations in the BE5$ signal time series in each oxel. BE5$ signal was
conerted to percentage signal deiation from the mean signal per oxel.
fMRI Statistical Anal#sis
.he #?@& <d$econole program was used to implement a single multiple regression
model that included baseline parameters to remoe nuisance ariance in each oxelFs
time series related to mean, linear, and 4uadratic drifts and the six motion correction
parameters. Reference ectors for each condition (asteris- counting, react negatie
self-beliefs, breath-focused attention, distraction-focused attention) were conoled
with a gamma ariate model (,ohen, *11>) of the hemodynamic response function to
account for the hemodynamic delay to pea- BE5$ responses. Resultant statistical
parametric maps were then sub3ected to spatial smoothing with a +-mm< isotropic
"aussian -ernel to enhance signal-to-noise. .he through-plane dimension of each
oxel was resampled to <.+<7 mm to create isotropic oxels. Maps were transformed to
the standard .alairach space (.alairach 6 .ournoux, *177). Second-leel t tests were
conducted according to a random-effects model. @eural results are reported for the
contrast of react negatie self-belief ersus asteris- counting, breath-focused attention
regulation ersus react negatie self-belief, and distraction-focused attention ersus
react negatie self-belief.
,orrection for the multiple comparisons obtained in fMR& data analysis was applied.
.he #?@& #lphaSim program, a Monte ,arlo simulation bootstrapping procedure, was
employed to identify a 3oint-probability threshold consisting of a oxel-wise threshold of
p T .22M and minimum cluster-olume threshold U *N< mm< (+ oxels Q <.+<7 mm<)
that resulted in protection against false positie cluster detection at p T .2* in the
whole-brain analyses.
Results

Clinical Results
)aired t tests showed that from baseline to post-MBSR patients had decreased social
anxiety, depression, rumination, and state anxiety, as well as increased self-esteem
(see .able *).
#2+=ES 2>D ?@G'RES
#a$le .. 3linical *easres
.here were no missing self-report responses.
Be$avioral Results
Baseline
,ompared with reacting to negatie self-beliefs, both breath-focused attention, t(*M) L
N.'7, p T .22*, and distraction-focused attention, t(*M) L >.+7, p T .22*, resulted in
reduced negatie emotion (see ?igure ').
#2+=ES 2>D ?@G'RES
?i!re 5. >e!ati&e emotion experience ratin!s pre( and post(mind"lness($ased stress
redction )*+SR,. #he ne!ati&e emotion ratin!s );o1 ne!ati&eA . B not at all, 5 B
slight, C B moderate, D B very much, 1hen reactin! to ne!ati&e sel"($elie"s and 1hen
re!latin! sin! $reath("ocsed attention and distraction("ocsed attention drin! the
"*R@ experimental tas9 pre( and a!ain post(*+SR. Ratin!s "or reactin! to ne!ati&e
sel"($elie"s 1ere collected post("*R@. E p F .0.. Error $ars represent standard error o"
the mean.
@egatie emotion did not differ between breath- and distraction-focused attention
regulation (p V .**).
MBSR-related changes
)aired t tests showed that from pre- to post-MBSR patients had no changes in self-
reported negatie emotion when reacting to negatie self-beliefs, t(*+) L *.'*, p V .<*,
and when using distraction-focused attention, t(*+) L 2.+*, p V .>*. Doweer, there was
a reduction in negatie emotion when implementing breath-focused attention from pre-
to post-MBSR, t(*+) L <.'M, p T .2*.
Neural Results
Baseline
#t baseline, a one-sample t test for the contrast of react negatie self-belief ersus
asteris- counting yielded greater BE5$ responses in brain regions implicated in self-
referential processing (entromedial and dorsomedial )?, and posterior
cingulateIprecuneus), emotion (right dorsal amygdala), dorsal and entral isual
processing (bilateral middle and inferior temporal lobes, cuneus, precuneus, angular
gyrus, lingual gyrus, inferior and superior parietal cortex), and memory (bilateral
parahippocampal gyrus). "reater BE5$ responses for asteris- counting ersus react
negatie self-belief included posterior cingulate and lingual gyrus (see ?igure <
#2+=ES 2>D ?@G'RES
?i!re C. Greater $lood oxy!enation le&el(dependent )+O=D, contrast responses at
$aseline "or the contrast o" reactin! to ne!ati&e sel"($elie"s &erss asteris9 contin!.
#hresholded at t G C.6/, &oxel p F .00H, clster &olme G .6C mmC, clster p F .0..
dmP?3 B dorsomedial pre"rontal cortex7 mP?3 B medial pre"rontal cortex7 &mP?3 B
&entromedial pre"rontal cortex7 p3G B posterior cin!late !yrs7 2my! B amy!dala7
P;G B parahippocampal !yrs. x re"ers to the location o" the sa!ittal slice )I B le"t7 J B
ri!ht,. z re"ers to the location o" the axial slice )I B in"erior7 J B sperior,.
and #a$le 5,.
#2+=ES 2>D ?@G'RES
MBSR-related changes
?rom pre- to post-MBSR, there were no results for the contrast of distraction-focused
attention ersus react negatie self-beliefs. ?or breath-focused attention ersus react
negatie self-belief, howeer, there were greater BE5$ responses at post-MBSR
ersus pre-MBSR in brain regions implicated in isual attention (inferior and superior
parietal lobule, cuneus, precuneus, middle occipital gyrus), as well as parahippocampal
gyrus. .here were no areas of brain actiity greater for react ersus breath-focused
attention (see ?igure +
#2+=ES 2>D ?@G'RES
?i!re D. Greater $lood oxy!enation le&el(dependent )+O=D, contrast responses "or
post( &erss pre(mind"lness($ased stress redction )*+SR, "or the contrast o" $reath(
"ocsed attention &erss reactin! to ne!ati&e sel"($elie"s. #hresholded at t G C.5., &oxel
p F .00H, clster &olme G .6C mmC, clster p F .0.. *OG B middle occipital !yrs7
P;G B parahippocampal !yrs7 @P= B in"erior parietal lo$le7 SP= B sperior parietal
lo$le. x re"ers to the location o" the sa!ittal slice )I B le"t7 J B ri!ht,. z re"ers to the
location o" the axial slice )I B in"erior7 J B sperior,.
and #a$le C,.
#2+=ES 2>D ?@G'RES
#a$le C. 3han!es in +O=D Responses ?rom Pre( to Post(*+SR "or +reath(?ocsed
2ttention Kerss React >e!ati&e Sel"(+elie"s
#o $etter nderstand ho1 *+SR trainin! in"lences the e""ect o" $reath("ocsed
attention on a neral index o" emotional reacti&ity to ne!ati&e sel"($elie"s, 1e
in&esti!ated the +O=D si!nal time series o" the ri!ht dorsal amy!dala acti&ation
o$ser&ed at $aseline in response to react ne!ati&e sel"($elie"s )see ?i!re H,.
#2+=ES 2>D ?@G'RES
?i!re H. Ri!ht dorsal amy!dala $lood oxy!enation le&el(dependent )+O=D, contrast
si!nal time series drin! reactin! to ne!ati&e sel"($elie"s and $reath("ocsed attention in
social pho$ics )SP, at $oth pre( and post(mind"lness($ased stress redction )*+SR,. E
p F .0H. Rate B ne!ati&e emotion ratin!7 React B reactin! to the ne!ati&e sel"($elie"7
+reath(?ocs B instrction to "ocs attention on $reath sensation.
#t baseline, there was a delay of approximately N s before amygdala actiity began to
ramp up toward a pea- response at the end of the *'-s react negatie self-belief
component of the bloc-. ,ompared with pre-MBSR, at post-MBSR patients with S#$
demonstrated a significant decrease of right amygdala response prior to the cue to shift
attentional focus to breath sensation.
Relations Bet%een Clinical and Neural "omains
;e examined whether MBSR-related changes in social anxiety symptom seerity were
associated with MBSR-related changes in BE5$ responses for the breath-focused
attention ersus react negatie self-belief contrast. 5arger reductions in social anxiety
symptoms oer the course of MBSR were associated with greater BE5$ responses
during breath-focused attention ersus reactiity to negatie self-beliefs in isual
attention brain regions, including medial cuneus (r L .N7, p L .2<), left cuneus (r L .NM, p
L .2+), and right middle occipital gyrus (r L .NM, p L .2*).
Discussion

.he goal of this study was to inestigate MBSR-related changes in patients with S#$
on behaioral and neural bases of emotional reactiity and regulation of negatie self-
beliefs. MBSR was hypothesi%ed to reduce clinical symptoms and negatie emotional
reactiity to negatie self-beliefs ia reductions in brain actiity related to emotion
reactiity with increases in attention-related brain networ-s.
Clinical Measures
MBSR-related changes included reduction in symptoms of social anxiety, depression,
rumination, state anxiety and increased self-esteem in adults with S#$. MBSR-related
reductions in social anxiety symptoms hae been obsered preiously in adults with
S#$ (/os%yc-i et al., '22>). MBSR-related changes for anxiety, depression, and self-
esteem in S#$ are similar to the moderate effect si%es found in a recent meta-analysis
of behaioral and pharmacological interentions (<7 studies) for S#$ (#lca%ar, Meca,
Rodrigue%, 6 Saura, '22').
Be$avioral Measures
?rom pre- to post-MBSR, patients with S#$ reported reduced negatie emotion
experience when implementing breath-focused attention during the fMR& experiment,
but not for attention distraction. .his suggests MBSR-related down-regulation of
emotional reactiity to negatie self-beliefs when redirecting attention to breath
sensation. .he lac- of change from pre- to post-MBSR in negatie emotion experience
during the react negatie self-belief condition may be due to oerlearned responses
(e.g., an automatic tendency to perceie statements about the self as threatening) to
negatie self-beliefs in patients with S#$. Similarly, the lac- of change from pre- to
post-MBSR in attention distraction may be due to its not haing been a treatment
focus.
Neural Measures
Baseline neural responses showed that reacting to negatie self-beliefs resulted in
actiation of the midline cortical regions implicated in self-referential process, including
entromedial )?,, dorsomedial )?,, and posterior cingulateIprecuneus (@orthoff et
al., '22N), as well as emotion (amygdala) and memory (parahippocampal gyrus)
processes.
.he absence of any significant MBSR-related changes in neural responses during
attention distraction is not surprising primarily because this form of attention regulation
is not trained during the course. &n contrast, there were robust MBSR-related changes
associated with breath-focused attention regulation in isual attention-related parietal
and occipital brain regions, perhaps more specifically related to alerting to a stimulus
(?an, Mc,andliss, ?ossella, ?lombaum, 6 )osner, '22M). &n addition, MBSR-related
reductions in social anxiety symptom seerity were associated with increased MBSR-
related neural responses in cuneus and middle occipital brain regions implicated in
isual attention. .his suggests two possible interpretations. ?irst, MBSR may hae
helped adults with S#$ be more isually engaged in (i.e., less aoidant of) negatie
self-beliefs. #lternatiely, greater neural recruitment of attention-related brain regions
may be due to more refined isuali%ation of the moement of the breath at the nostrils,
which also inoles better allocation of attention to the tas-.
@umerous studies hae shown exaggerated amygdala response in adults with S#$ in
response to social anxiety-related stimuli, including harsh faces ()han, ?it%gerald,
@athan, 6 .ancer, '22N9 Stein, "oldin, Sareen, 0orrilla, 6 Brown, '22') and critical
comments (Blair et al., '227). ?urthermore, one study has demonstrated that adults
with S#$ who were classified as responders to either citalopram medication or ,"B.
had a reduced amygdala actiity from baseline to posttreatment (?urmar- et al., '22').
.he MBSR-related change in amygdala BE5$ signal time series during react and
regulate components suggests enhanced initial emotion reactiity or detection of
emotional salience of negatie self-beliefs as suggested by the initial amygdala spi-e at
the post-MSBR assessment. .he enhanced initial emotion response indexed by
amygdala actiity is transient as eidenced by a significant decrease in amygdala
actiity at the end of the react trials well before the onset of the cue to shift attention to
the breath. .his might reflect an effortful attempt to implement breath-focused attention
emotion regulation at baseline and a MBSR-related shift to a more automatic
implementation of breath-focused attentional regulation een before being cued to do
so. .his highlights the possibility that one potential outcome of MBSR is to change
specific aspects of attention regulation from explicit (i.e., more effortful) to an implicit
(i.e., more automatic) process.
Clinical Implications
.hese results suggest that MBSR-related changes in attention processes may modify
habitual reactiity in the context of negatie self-beliefs. &n patients with S#$ who
would normally show attentional aoidance of threat stimuli, MBSR might help
attenuate aoidance and increase attentional allocation, as eidenced by the
association of reduced S#$ symptoms with increased neural response in isual
attention-related brain regions. MBSR may be associated with facilitating the ability to
implement attentional deployment, a specific emotion regulation strategy that may be
aberrant in adults with S#$ specifically when encountering social threat stimuli (Schult%
6 Deimberg, '227). .he ability to redirect attention to thoughts, emotions, and physical
sensations, a -ey feature of MBSR, may be an important s-ill for adults with S#$ to
deelop because it may enhance the efficacy of exposure therapy for S#$.
&imitations and "irections for 'uture Researc$
.his study is limited by the lac- of a control group or actie comparison clinical
interention that would proide a basis for ma-ing a stronger inference about how
MBSR might modify the behaioral and neural bases of different types of emotion
regulation. ;e examined the effect of attentional emotion regulation on a small set of
experimenter-selected negatie self-belief stimuli. #lthough the use of experimenter-
selected emotional probes confers greater experimental control, use of participant-
generated negatie self-beliefs may result in more robust brain!behaioral responses
in S#$, which could support a more ecologically alid test of the effects of MBSR on
emotion regulation. Osing idiographic stimuli can often proide greater fidelity to the
actual clinical phenomenology under inestigation. Doweer, this can also proide
greater ariability in the specific targets of emotion regulation.
.his study examined only breath-focused attention on sensation at the nostrils. .here
are many other important mindfulness practices taught in MBSR that desere empirical
inestigation, for example, the effects of body scan meditation and mere obseration of
the changing or transient nature of experience. .hus, results from this study cannot be
generali%ed to other forms of mindful attention such as mindful attention of taste,
sound, mental states and other bodily sensations. .o begin to specify how MBSR
wor-s, it may be instructie to compare the effects of clinical interentions with different
mechanisms of change (e.g., cognitie disputation, acceptance, attention training) on
the neural bases of mindful attention.
?uture studies will benefit from using a randomi%ed clinical trail methodology with at
least two groups that undergo two types of stress reduction courses in order to
delineate factors that might contribute to changes in attentional deployment, attention
brain networ-s, and specificity of changes in clinical symptoms as well as address
other potential confounds such as practice effects and habituation to the scanner
enironment. Osing experimental paradigms that present a ariety of linguistic and
nonlinguistic emotional probes and assess the effectieness of seeral types of
emotion regulation strategies may help delineate underlying mechanisms in MBSR.
?urthermore, future studies should consider using self-report measures of mindfulness
pre-, during, and post-MSBR to examine change during and post-MBSR compared with
baseline trait mindfulness.
,onducting an analysis of indiidual differences at baseline to enhance effectie
treatment matching to different types of meditation practices (not 3ust mindfulness) and
to different combinations or doses of clinical therapies (e.g., pharmacological,
cognitie!behaioral, meditation-based interentions) would be a ma3or contribution.
?inally, understanding how mindfulness practice in the health care proider interacts
with mindfulness practice of the indiidual receiing health care is a domain of in4uiry
that has not yet been inestigated.
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