Search

Social anxiety disorder (SAD) is associated with marked physiological reactivity in social-evaluative situations. However, objective measurement of biomarkers is rarely evaluated in treatment trials, despite potential utility in clarifying disorder-specific physiological correlates. This randomized controlled trial sought to examine the differential impact of imagery-enhanced vs. verbal-based cognitive behavioral group therapy (IE-CBGT, n = 53; VB-CBGT, n = 54) on biomarkers of emotion regulation and arousal during social stress in people with SAD (pre- and post-treatment differences in heart rate variability (HRV) and skin conductance). We acquired psychophysiological data from randomized participants across four social stress test phases (baseline, speech preparation, speech, interaction) at pre-treatment, and 1- and 6-months post-treatment. Analyses revealed that IE-CBGT selectively attenuated heart rate as indexed by increases in median heart rate interval (median-RR) compared to VB-CBGT at post-treatment, whereas one HRV index showed a larger increase in the VB-CBGT condition before but not after controlling for median-RR. Other psychophysiological indices did not differ between conditions. Lower sympathetic arousal in the IE-CBGT condition may have obviated the need for parasympathetic downregulation, whereas the opposite was true for VB-CBGT. These findings provide preliminary insights into the impact of imagery-enhanced and verbally-based psychotherapy for SAD on emotion regulation biomarkers., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Social anxiety (SA) is thought to be maintained in part by avoidance of social threat, which exacerbates fear of negative evaluation. Yet, relatively little research has been conducted to evaluate the connection between social anxiety and attentional processes in realistic contexts. The current pilot study examined patterns of attention (eye movements) in a commonly feared social context - public speaking. Participants (N = 84) with a range of social anxiety symptoms gave an impromptu five-minute speech in an immersive 360°-video environment, while wearing a virtual reality headset equipped with eye-tracking hardware. We found evidence for the expected interaction between fear of public speaking and social threat (uninterested vs. interested audience members). Consistent with prediction, participants with greater fear of public speaking looked fewer times at uninterested members of the audience (high social threat) compared to interested members of the audience (low social threat) b = 0.418, p = 0.046, 95% CI [0.008, 0.829]. Analyses of attentional indices over the course of the speech revealed that the interaction between fear of public speaking and gaze on audience members was only significant in the first three-minutes. Our results provide support for theoretical models implicating avoidance of social threat as a maintaining factor in social anxiety. Future research is needed to test whether guided attentional training targeting in vivo attentional avoidance may improve clinical outcomes for those presenting with social anxiety., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

People with social anxiety disorder (SAD) lack non-socially anxious individuals' tendency to interpret ambiguous social information in a positively biased manner. To gain a better understanding of the specific in-vivo social consequences of positive interpretation bias, we recruited 38 individuals with SAD and 31 healthy controls (HC) to participate in an in-vivo social task. We tested whether a positive interpretation bias, measured using a sentence completion task, might confer benefits for the adaptive emotion regulation strategy of cognitive reappraisal, and whether such benefits depended on participants' emotional states. We also examined whether positive interpretation bias might confer additional benefits such as improved self-perceived and observer-rated social performance. In support of prior research, HC participants exhibited a positive interpretation bias on the sentence completion task, whereas participants with SAD did not. Regression analyses revealed that positive interpretation bias predicted greater cognitive reappraisal during social stress, particularly when state positive affect was low. Moreover, positive interpretation bias predicted more positive self-perception of social performance and reduced underestimations of performance relative to observer ratings. These results suggest that positive interpretations of ambiguous social information may be related to increased use of cognitive reappraisal and more positive self-perceptions of social performance., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: Sudden gains (SGs) have been found to occur during randomized controlled trials (RCTs) for social anxiety disorder (SAD). Evidence is mixed whether SGs relate to treatment outcome in SAD. We examined SGs in two RCTs for SAD., Method: Study 1 (N = 68) examined SGs in individual cognitive-behavioral therapy (CBT), and Study 2 (N = 100) compared SGs in group CBT and Mindfulness-Based Stress Reduction (MBSR). Weekly ratings of social anxiety were used to calculate SGs. The Liebowitz Social Anxiety Scale-Self-Report and the Social Interaction Anxiety Scale were completed at pretreatment, posttreatment, and follow-up to assess outcome., Results: In Study 1, 17.6% of participants experienced a SG. Participants with SGs started and ended treatment with lower social anxiety. SGs were not associated with greater decreases in social anxiety from pre-to posttreatment or 12-month follow-up. In Study 2, SGs occurred in 27% of participants and at comparable rates in MBSR and group CBT. SGs were not associated with changes in social anxiety during treatment in either condition., Conclusion: SGs occurred during treatment for SAD. In both RCTs, participants improved regardless of experiencing a SG, suggesting that SGs are not predictive of greater improvement during treatment for SAD., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Several meta-analyses to date have confirmed the efficacy of attentional bias modification (ABM) in shifting reaction times away from threatening stimuli, reducing anxiety symptoms, and buffering against stressor vulnerability. The reliability of reaction time differences, however, has been found to show unacceptable psychometric properties. In this study, we tested the impact of an extensive Dot-Probe ABM procedure, consisting of close to 7000 trials, concurrently with behavioral and electrophysiological measures within a large sample of over 100 highly socially anxious participants. Results indicated that the N2pc component demonstrates superior internal consistency and more statistical power in detecting attentional biases and their modification than reaction time (RT) differences. RTs were neither indicative of an attentional bias before ABM nor of a modification over time. In contrast, the N2pc indexed both an initial attentional preference for threatening stimuli and an alteration of this relationship after training. Outcomes were not specific for attentional training away from threat but also occurred in the no-contingency control procedure, casting doubt on the theoretic underpinnings of ABM. Electrophysiological measures are an important complement to the ABM literature and should be further utilized to assess attentional biases with excellent reliability., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Social anxiety disorder (SAD) is marked by persistent fear of being scrutinized by others. This and most diagnostic symptoms relate to some form of fear of negative evaluation (FNE). More recent accounts of SAD, such as the Bivalent Fear of Evaluation Model, however, complement FNE with fear of positive evaluation (FPE), described as distress and avoidance of positive feedback. An explicit test of the incremental validity of FPE in discriminating SAD patients from controls - over and on top of the explanatory power of FPE - is currently missing and generally, well controlled laboratory experiments with positive and negative social stimuli in this patient group are rare. To fill this gap, we exposed 35 patients with SAD and healthy controls (HCs) to short social-evaluative video clips with actors expressing negative and positive as well as neutral statements while recording reactivity on experiential measures (valence, arousal, and approval ratings) as well as on facial electromyography and electrocardiography. In addition, participants completed questionnaire measures of FNE and FPE. Results revealed that FPE questionnaire scores as well as experiential (valence and appreciation) and electromyographical reactivity measures to positive videos improved prediction of group membership beyond the predictive power of FNE questionnaires scores and reactivity to negative videos. Results document the importance of FPE to more fully characterize and understand social anxiety and SAD. Implications include amendments to future diagnostic criteria, theoretical models, and treatment approaches for SAD., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Attention bias modification (ABM) is a novel therapy designed to modulate attentional biases towards threat typically observed among anxious individuals. Bias modification is allegedly achieved via extraction of a statistical regularity embedded within the treatment task. However, no prior study examined prediction of ABM therapeutic response in relation to patients' capacity to extract statistical properties from the environment, a capacity known as "statistical learning". Here, 30 treatment-seeking patients with social anxiety disorder completed a gold-standard statistical learning task at baseline and then received six sessions of ABM therapy. Results indicate that baseline statistical learning capacity predicts treatment outcome: the better patients' statistical learning capacity, the greater their reduction in clinician-rated and self-reported social anxiety symptoms. Restricted capacities for statistical learning could account for the moderate effect sizes of ABM therapy in clinical trials. Poor response may occur in patients who fail to extract the underlying contingency embedded in ABM., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Individuals with social anxiety disorder (SADs; n = 41) and healthy controls (HCs; n = 40) were administered the Waterloo Images and Memories Interview, in which they described mental images that they tend to experience in both anxiety-provoking and non-anxiety-provoking social situations. Participants then recalled, in as much detail as possible, specific autobiographical memories of salient aversive and non-aversive social experiences that they believed led to the formation of these images. Audio-recorded memory narratives were transcribed and coded based on the procedure of the Autobiographical Interview, which provides a precise measure of the degree of episodic detail contained within each memory. Participants also rated the subjective properties of their recalled memories. Results revealed that participants across the two groups retrieved equivalent rates of both aversive and non-aversive social memories. However, SAD participants' memories of aversive events contained significantly more episodic detail than those of HCs, suggesting that they may be more highly accessible. Moreover, participants with SAD appraised their memories of aversive experiences as more distressing and intrusive than HCs, and perceived them as having a significantly greater influence on their self-perception. In contrast, no group differences were observed for memories of non-aversive events. Findings have the potential to shed new light on autobiographical memory in SAD, with implications for psychotherapeutic intervention., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Pilot and open trials suggest that imagery-enhanced group cognitive behaviour therapy (CBT) is highly effective for social anxiety disorder (SAD). However, before being considered reliable and generalisable, the effects of the intervention need to be replicated by clinicians in a setting that is independent of the protocol developers. The current study compared outcomes from clients with a principal diagnosis of SAD at the Australian clinic where the protocol was developed (n = 123) to those from an independent Canadian clinic (n = 46) to investigate whether the large effects would generalise. Trainee clinicians from the independent clinic ran the groups using the treatment protocol without any input from its developers. The treatment involved 12 2-h group sessions plus a one-month follow-up. Treatment retention was comparable across both clinics (74% vs. 78%, ≥9/12 sessions) and the between-site effect size was very small and non-significant on the primary outcome (social interaction anxiety, d = 0.09, p = .752). Within-group effect sizes were very large in both settings (ds = 2.05 vs. 2.19), and a substantial minority (41%-44%) achieved clinically significant improvement at follow-up. Replication of treatment effects within an independent clinic and with trainee clinicians increases confidence that outcomes are generalisable., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Negative rumination in social anxiety disorder (SAD) occurs in anticipation of a social event (pre-event rumination) and in its aftermath (post-event rumination). Both are proposed to be key maintaining factors of the vicious cycle of social anxiety. Despite this, there is a dearth of research investigating the processes that mediate the relationship between social anxiety and pre-event rumination and uncertainty regarding the cognitive and attentional processes that mediate the relationship between social anxiety and post-event rumination. To investigate this further, the current study utilised a clinical sample of participants with SAD to determine the hypothesised mediators of a social anxiety and pre-event model (N = 239) and a social anxiety and post-event rumination model (N = 216). Results from path analyses were broadly consistent with cognitive models of SAD that posit several interrelated processes mediate the relationship between social anxiety and pre- and post-event rumination. Results also indicated slightly different processes showed stronger prediction of pre-event rumination (i.e., biased performance appraisals) and post-event rumination (i.e., negative attentional focus). Treatment recommendations that aim to address the maladaptive role of negative rumination in social anxiety are made in keeping with the inter-connected and dynamic role played by cognitive and attentional processes in heightening social anxiety., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The cognitive theory of social anxiety disorder (SAD) is one of the most widely accepted accounts of the maintenance of the disorder in adults, yet it remains unknown if, or to what extent, the same cognitive and behavioral maintenance mechanisms that occur in adult SAD also apply to SAD among pre-adolescent children. In contrast to the adult literature, current models of SAD in children mostly account for etiology and maintenance processes are given limited attention. Consequently, their clinical utility for the treatment of SAD in children may be limited. This narrative review, first, critically examines the different theoretical conceptualizations of the maintenance of social anxiety in the child and adult literature and illustrates how these have resulted in different treatment approaches and clinical understanding. Second, it reviews the available evidence relating to hypotheses about the maintenance of SAD in children as derived from adult cognitive and etiological models. Third, it highlights the need to attend directly to child specific maintenance mechanisms in SAD, to draw on cognitive theory, and to account for the influence of childhood-specific contextual (e.g. family and school-based interactions) and developmental factors on children's social experiences., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Cognitive-Behavioral Group Therapy (CBGT) and Mindfulness-Based Stress Reduction (MBSR) are efficacious in treating social anxiety disorder (SAD). It is not yet clear, however, whether they share similar trajectories of change and underlying mechanisms in the context of SAD. This randomized controlled study of 108 unmedicated adults with generalized SAD investigated the impact of CBGT vs. MBSR on trajectories of social anxiety, cognitive reappraisal, and mindfulness during 12 weeks of treatment. CBGT and MBSR produced similar trajectories showing decreases in social anxiety and increases in reappraisal (changing the way of thinking) and mindfulness (mindful attitude). Compared to MBSR, CBGT produced greater increases in disputing anxious thoughts/feelings and reappraisal success. Compared to CBGT, MBSR produced greater acceptance of anxiety and acceptance success. Granger Causality analyses revealed that increases in weekly reappraisal and reappraisal success predicted subsequent decreases in weekly social anxiety during CBGT (but not MBSR), and that increases in weekly mindful attitude and disputing anxious thoughts/feelings predicted subsequent decreases in weekly social anxiety during MBSR (but not CBGT). This examination of temporal dynamics identified shared and distinct changes during CBGT and MBSR that both support and challenge current conceptualizations of these clinical interventions. CLINICALTRIALS., Gov Identifier: NCT02036658., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: This study examined the effectiveness of manualized cognitive therapy (mCT) following the Clark-Wells approach versus non-manualized cognitive-behavioral treatment-as-usual (CBTAU) for social anxiety disorder (SAD) in routine practice., Methods: Forty-eight private practitioners were recruited within a multi-center trial and either received training in manualized CT for SAD or no such training. Practitioners treated 162 patients with SAD in routine practice (N = 107 completers, n = 57 for mCT, n = 50 for CBTAU). Social anxiety symptoms (Liebowitz Social Anxiety Scale; LSAS) and secondary measures were assessed before treatment, at treatment-hour 8, 15, and 25, at end of treatment, as well as 6 and 12 months after treatment., Results: Patients in both groups showed significant reductions of SAD severity after treatment (d = 1.91 [mCT] and d = 1.80 [CBTAU], within-group effect sizes, intent-to-treat analyses, LSAS observer ratings), which remained stable at follow-up. There were no differences between groups in terms of symptom reduction and treatment duration., Conclusions: The present trial confirms the high effectiveness of CBTAU and mCT for SAD when practitioners conduct the treatments in routine practice. Additional training in the CT manual did not result in significant between-group effects on therapy outcome. Explanations for this unexpected result are discussed., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Recent evidence suggests that reduced generosity among individuals with social anxiety disorder (SAD) in behavioral economic tasks may result from constraint in changing behavior according to interpersonal contingencies. That is, people with SAD may be slower to be more generous when the situation warrants. Conversely, more global effects on generosity may be related to interpersonal vindictiveness, a dimension only somewhat related to SAD. A total of 133 participants, 73 with the generalized form of SAD, completed self-report instruments and a behavioral economic task with simulated interpersonal (friend, romantic partner, stranger) interactions. In a separate visit, friends (n = 88) also came to the lab and rated participants on vindictiveness. Interpersonal vindictiveness was associated with reduced initial and overall giving to simulated friends. SAD predicted a lack of increased giving to a simulated friend, and attenuated an increase in giving to simulated known versus unknown players compared to participants without SAD. Friend-reported vindictiveness predicted in the same direction as diagnosis. However, the findings for SAD were less robust than those for vindictiveness. SAD is perhaps weakly related to behavioral constraint in economic tasks that simulate interpersonal interactions, whereas vindictiveness is strongly related to lower overall generosity as well as (via friend report) behavioral constraint. Further study is needed to better characterize the construct of vindictiveness. Our findings dovetail with the suggestion that SAD is related to impairment in the proposed affiliation and attachment system, but further suggest that direct study of that system may be more fruitful than focusing on disorders., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

We investigated the role of self-focused attention (SFA) in social anxiety (disorder) in an ecologically valid way. In Experiment 1 high (n = 26) versus low (n = 25) socially anxious single women between 18 and 30 years had a video ("Skype") conversation with an attractive male confederate, while seeing themselves and the confederate on-screen. The conversation was divided in four phases: (I) warm-up, (II) positive (confederate was friendly to the participant), (III) critical (confederate was critical to the participant), and (IV) active (participant was instructed to ask questions to the confederate). Participant's SFA was measured by eye-tracked gaze duration at their own image relative to the confederates' video image and other places at the computer screen. Results show that high socially anxious participants were more self-focused in the critical phase, but less self-focused in the active phase than low socially anxious participants. In Experiment 2 women diagnosed with SAD (n = 32) and controls (n = 30) between 18 and 30 years conducted the same experiment. Compared to controls participants with SAD showed increased SFA across all four phases of the conversation, and SFA predicted increased self-rated anxiety during the conversation. In conclusion, in subclinical social anxiety SFA is high only when the interaction partner is critical, whereas instructions to ask questions to the confederate reduces subclinical socially anxious' SFA, while clinical SAD is characterized by heightened self-focused attention throughout the interaction. Results support theories that social anxiety disorder is maintained by SFA, and imply that interventions that lower SFA may help prevent and treat social anxiety disorder, but that SFA can also be adaptive in certain types of interaction, such as when receiving compliments., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Post-event processing (PEP) is defined as repetitive negative thinking following anxiety provoking social events. PEP is thought to maintain anxiety symptoms in Social Anxiety Disorder (SAD) but little is known about the specific factors that contribute to the maintenance of PEP., Aims: The current study investigated how perceptions of performance and positive metacognitive beliefs might contribute to the persistence of PEP., Method: Participants with SAD (n = 24) as well as anxious (n = 24) and healthy (n = 25) control participants completed a standardized social performance task in the lab. Their engagement in PEP and perceptions of performance were assessed in the week that followed., Results: Immediately following the social task, individuals with SAD rated their performance more negatively and endorsed a greater number of positive metacognitive beliefs about PEP than did participants in both control groups. Importantly, both metacognitive beliefs and initial negative self-ratings of performance mediated the relationship between group status and PEP in the days following the event., Conclusions: These results are consistent with cognitive and metacognitive models of SAD and enhance our understanding of the cognitive processes which may function to initiate and maintain negative thinking patterns in SAD., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Causal attributions of social events are crucial for understanding emotional responses. Aim of the study was to identify appraisal processes in response to social exclusion in borderline personality disorder (BPD) and social anxiety disorder (SAD). Twenty-five patients with BPD, 25 patients with SAD and 25 healthy controls played Cyberball, a virtual ball-tossing paradigm that experimentally induces social exclusion. Causal attributions, subjective feelings and action tendencies in response to social exclusion were assessed. Both clinical groups showed more internal attributions and less control attributions than the control group, reported a higher increase in self-focused negative emotions, along with more escape tendencies and less intent to engage in pleasant activities. But only the BPD group reported higher hostile-intent attributions and more aggressive action tendencies compared to healthy controls., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Social anxiety disorder (SAD) is associated with elevated negative and diminished positive affective experience. However, little is known about the way in which individuals with SAD perceive and respond emotionally to the naturally-unfolding negative and positive emotions of others, that is, cognitive empathy and affective empathy, respectively. In the present study, participants with generalized SAD (n = 32) and demographically-matched healthy controls (HCs; n = 32) completed a behavioral empathy task. Cognitive empathy was indexed by the correlation between targets' and participants' continuous ratings of targets' emotions, whereas affective empathy was indexed by the correlation between targets' and participants' continuous self-ratings of emotion. Individuals with SAD differed from HCs only in positive affective empathy: they were less able to vicariously share others' positive emotions. Mediation analyses revealed that poor emotional clarity and negative interpersonal perceptions among those with SAD might account for this finding. Future research using experimental methodology is needed to examine whether this finding represents an inability or unwillingness to share positive affect., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Excessive post-mortem processing after social situations, a core symptom of social anxiety disorder (SAD), is thought to contribute to the perpetuation of social anxiety by consolidating negative self-schemata. Empirical findings on actual mechanisms underlying this so-called Post-Event Processing (PEP) are still scarce. The present study sought to identify variables associated with the experience of PEP after real-life social situations in a sample of 49 individuals diagnosed with SAD. Using an ambulatory assessment approach, individuals were asked to report on each distressing social event experienced during one week. A total of 192 events were captured. Hierarchical linear modeling indicated that next to trait social anxiety, the type of social situation (performance vs. interaction situations), self-focused attention, safety behavior use, and negative affect predicted levels of PEP after social situations. These findings add to the growing literature that emphasizes the importance of situational factors for the experience of PEP, and highlight potential venues to prevent it., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

This randomized controlled trial investigated the efficacy of a stand-alone virtual reality exposure intervention comprising verbal interaction with virtual humans to target heterogeneous social fears in participants with social anxiety disorder. Sixty participants (Mage = 36.9 years; 63.3% women) diagnosed with social anxiety disorder were randomly assigned to individual virtual reality exposure therapy (VRET), individual in vivo exposure therapy (iVET), or waiting-list. Multilevel regression analyses revealed that both treatment groups improved from pre-to postassessment on social anxiety symptoms, speech duration, perceived stress, and avoidant personality disorder related beliefs when compared to the waiting-list. Participants receiving iVET, but not VRET, improved on fear of negative evaluation, speech performance, general anxiety, depression, and quality of life relative to those on waiting-list. The iVET condition was further superior to the VRET condition regarding decreases in social anxiety symptoms at post- and follow-up assessments, and avoidant personality disorder related beliefs at follow-up. At follow-up, all improvements were significant for iVET. For VRET, only the effect for perceived stress was significant. VRET containing extensive verbal interaction without any cognitive components can effectively reduce complaints of generalized social anxiety disorder. Future technological and psychological improvements of virtual social interactions might further enhance the efficacy of VRET for social anxiety disorder., (Copyright © 2015 Elsevier Ltd. All rights reserved.)