Search

Cognitive-behavioural models of social phobia (Clark & Wells, 1995; Rapee & Heimberg, 1997) propose that biased information processing contributes to the maintenance of social phobia. Given the importance of facial expressions in social interactions, recent investigations of these information-processing biases have increasingly used facial stimuli. The current study utilised schematic faces of emotional expressions to investigate interpretations of facial expressions and specific facial features in individuals with high and low social anxiety. Individuals with elevated social anxiety demonstrated biases in their perceptions of negative valence from the faces, whereas group differences were not observed for perceptions of activity or potency. Further, although the two groups generally utilised the same facial features to interpret facial expressions, the results suggested that individuals with high social anxiety may be more lenient in perceiving threat in faces than individuals without social anxiety.

Exposure-based therapies are efficacious treatments for social anxiety disorder (i.e., Gould et al., 1997). Much of the theory behind these treatments is derived from Foa and colleagues' (Foa, Huppert, & Cahill, 2005; Foa & Kozak, 1986) work on emotional processing. However, there has been little research examining individual differences in emotional processing patterns within and between treatment sessions among clients with social anxiety disorder. This study utilized longitudinal data analytic methods to examine changes in subjective anxiety during the first 3 exposure sessions in group and individual cognitive-behavioral therapy for social anxiety disorder. The results of this study provide preliminary evidence that, although anxiety generally decreases across exposures, some individuals experience considerable fluctuations in anxiety during a single exposure. Although anxiety during the first exposure was not significantly related to outcome, the relationship between anxiety during exposure and outcome became stronger during subsequent exposures. Overall, this study highlights the need to conduct more fine-grained analyses to better understand the mechanisms underlying exposure-based therapies for social anxiety disorder.

We propose a cognitive model of social anxiety-related submission based upon psycho-evolutionary accounts of social anxiety and depression and present results of two studies supporting this model. We tested a confirmatory factor model consisting of three latent lower-order factors (fear of negative evaluation, fear of positive evaluation, and depressive cognitions), all of which load onto a single latent higher-order submissive cognitions factor. In essence, we propose that the symptoms associated with social anxiety and depression (in part) served adaptive functions for coping with social threats in the ancestral environment and that the cognitive symptoms associated with these disorders may function collectively as integrated components of a social anxiety-related submission mechanism. Confirmatory factor analysis indicated that the hypothesized model fit well. A score derived from the submissive cognitions factor correlated strongly with social anxiety-related measures and less strongly with measures of generalized anxiety/worry in Studies 1 and 2. Furthermore, this submissive cognitions score correlated in the expected direction with self-report measures of social comparison, negative affect, and positive affect in Study 2, and mediational analyses indicated that submissive cognitions may mediate the relationship between social comparison and submissive behaviors. Findings from both studies provide support for the proposed model.

Frequent assessment during therapy can improve treatments and provide accountability. However, clinicians often do not monitor progress because of the time it takes to administer and score assessments. In response, the Social Anxiety Session Change Index (SASCI) was developed. The SASCI is a short, easily administered rating of subjective improvement that asks clients with social anxiety disorder how much they have changed since the beginning of therapy. Change on the SASCI was related to change in fear of negative evaluation, a core aspect of social anxiety, and to clinician-rated improvement, but not to ratings of anxiety sensitivity or depression. Because it is brief and easily interpretable, the SASCI can be used in a variety of clinical settings to monitor change across therapy. The SASCI is presented along with examples of how the information gathered from frequent administration can inform clinical practice.

We describe two ways that participants may react to their internal experiences subsequent to stressful interpersonal interactions: Ambivalent engagement, consisting of attempts to avoid or dismiss the experiences arising from memories of the situation, and purposeful engagement, consisting of effortful attempts to approach the memories and internal experiences associated with the event. In a series of studies employing undergraduate samples, we evaluate a self-report method of measuring these trait-like constructs. The measure shows promising psychometric properties, including adequate to good factorial validity, good internal consistency, good test-retest reliability, and strong convergent and discriminant validity across a variety of theoretically related measures. This method of measuring ambivalent and purposeful engagement should be useful in investigating whether these constructs are related to the development of such disorders as social anxiety disorder and generalized anxiety disorder, as well as whether purposeful engagement is related to therapeutic change.

Preliminary investigations of disasters, including terrorism, have identified degree of exposure as a highly reliable predictor of trauma symptoms. However, this effect has not been consistently demonstrated in studies conducted in Israel. One explanation for this may be found in the different mechanisms that influence the relationship between exposure and symptoms in situations of recurrent versus one-time terror events. We examined traumatic symptoms and response to life events as variables which may be affected by repeated exposure to violence. Students from Tel Aviv University ( n = 65) and the College of Judea and Samaria, in the West Bank ( n = 47), completed measures of exposure to terrorism, trauma symptoms, life event stress reactions, and psychopathology. As in previous studies, no relationship between the overall degree of terror-related exposure and trauma symptoms was found for either group. General level of anxiety mediated the relationship between terror-related trauma symptoms and life event stress reactions. For the Ariel group, exposure to terror was related to anxiety and hostility. Direct terror-related exposure was negatively related to life event stress for the Tel Aviv group. In summary, our findings suggest that the exposure–symptom relationship may function differently in a context of ongoing threat than in a context of single-event terror.

Cognitive-behavioral models propose that fear of negative evaluation is the core feature of social anxiety disorder. However, it may be that fear of evaluation in general is important in social anxiety, including fears of positive as well as negative evaluation. To test this hypothesis, we developed the Fear of Positive Evaluation Scale (FPES) and conducted analyses to examine the psychometric properties of the FPES, as well as test hypotheses regarding the construct of fear of positive evaluation (FPE). Responses from a large (n = 1711) undergraduate sample were utilized. The reliability, construct validity, and factorial validity of the FPES were examined; the distinction of FPE from fear of negative evaluation was evaluated utilizing confirmatory factor analysis; and the ability of FPE to predict social interaction anxiety above and beyond fear of negative evaluation was assessed. Results provide preliminary support for the psychometric properties of the FPES and the validity of the construct of FPE. The implications of FPE with respect to the study and treatment of social anxiety disorder are discussed.

Taijin-Kyofu-Sho (TKS), an East Asian syndrome of interpersonal fear and avoidance, that has been considered culture-bound, overlaps with social anxiety disorder to an unknown extent. The offensive subtype of TKS is characterized by two features considered atypical of social anxiety disorder: the belief that one displays physical defects and/or socially inappropriate behaviors (offensive TKS symptoms) and fear of offending others (allocentric focus), but no studies have systematically evaluated these two features in patients with social anxiety disorder. The purpose of this study was to assess offensive TKS symptoms and allocentric focus of fear in US (n = 181) and Korean (n = 64) patients with DSM-IV social anxiety disorder, using the newly developed TKS Questionnaire. Seventy-five percent of patients with social anxiety disorder in the US and Korea endorsed at least one of the five offensive TKS symptoms surveyed. The severity of features of offensive TKS was significantly associated with severity of social anxiety symptoms, depressive symptoms, and disability in both samples. These results suggest that features of the offensive subtype of TKS are not uncommon among US patients with social anxiety disorder and may not be as culturally specific as previously believed. They also suggest that Western clinicians should assess patients with social anxiety for features of offensive TKS, and they support further consideration of integrating TKS features into conceptualizations of social anxiety disorder.

Although well-used and empirically supported, the Social Interaction Anxiety Scale (SIAS) has a questionable factor structure and includes reverse-scored items with questionable utility. Here, using samples of undergraduates and a sample of clients with social anxiety disorder, we extend previous work that opened the question of whether the reverse-scored items belong on the scale. First, we successfully confirmed the factor structure obtained in previous samples. Second, we found the reverse-scored items to show consistently weaker relationships with a variety of comparison measures. Third, we demonstrated that removing the reverse-scored questions generally helps rather than hinders the psychometric performance of the SIAS total score. Fourth, we found that the reverse-scored items show a strong relationship with the normal personality characteristic of extraversion, suggesting that the reverse-scored items may primarily assess extraversion. Given the above results, we suggest investigators consider performing data analyses using only the straightforwardly worded items of the SIAS.

Information processing models propose that anxious individuals are characterized by memory biases for mood-congruent threat information. However, evidence for memory biases in generalized anxiety disorder (GAD) has been mixed at best. Given the heterogeneity of concerns in GAD, previous use of nomothetic stimulus sets may have precluded detection of memory biases. Therefore, in order to guarantee the relevance of the stimuli used, in the current study individuals with GAD each individually selected words that were of personal relevance to them. Using these idiographically selected words with 23 individuals with DSM-IV GAD and 23 non-anxious controls (NACs), results showed an implicit memory bias for threat words in individuals with GAD compared with NACs. Furthermore, there was additional evidence that individuals with GAD may also be characterized by explicit memory bias for threat words. The magnitude of group differences for explicit recall of threat words was similar to those previously observed in panic disorder. Limitations and future directions are discussed.

Social phobia involves a persistent fear of negative evaluation by others and is associated with significant functional impairment. This contribution presents an introduction to the various cognitive processes (i.e., ways of thinking) that contribute to the maintenance of social phobia. The following areas of cognitive processing are discussed: attention; interpretation; memory; and imagery. Individuals with social phobia exhibit increased attention to potentially threatening social information. They also tend to interpret ambiguous social information as negative and fail to generate positive interpretations of social information. Initial research regarding memory processes suggests that people with social phobia exhibit increased memory for information that is related to negative evaluation from others and to negative self-related information. Negative self-imagery is often evoked in social situations. Such imagery has been associated with increased anxiety and poorer performance in social situations. The spontaneous imagery of people with social phobia is not simply negative in nature but is also viewed from the observer perspective; in other words, it comprises constructed images of the person as he or she may appear to others. Finally, support is emerging for the combined cognitive bias hypothesis, which proposes that these various cognitive biases do not work in isolation but rather combine and amplify the effects of each on social anxiety.

It has been suggested that a strong working alliance encourages clients to take risks during therapy (Raue, Castonguay, & Goldfried, 1993). This encouragement may be important for clients who fear negative evaluations as they engage in risk-taking elements of therapy. This study examined the relationship between working alliance, session helpfulness and measures of emotional processing in 18 clients undergoing cognitive behavior therapy (CBT) for social anxiety disorder. Results indicate a positive correlation between client-rated, but not observer-rated, working alliance and session helpfulness. Moderate levels of working alliance were associated with higher initial anxiety and deeper within-session habituation. Overall, a strong alliance was associated with clients engaging with the session and finding the session helpful. Implications for the use of CBT for social anxiety are discussed.

The Mini-Social Phobia Inventory (Mini-SPIN) is a 3-item, self-rated screening instrument to assess social anxiety disorder, but its psychometric properties have not yet been examined in a sample seeking treatment for psychiatric disorders. We analyzed responses from 291 adults who telephoned the Adult Anxiety Clinic of Temple (AACT) seeking treatment for social anxiety or generalized anxiety and worry. The Mini-SPIN demonstrated strong internal consistency. Support for the convergent validity of the Mini-SPIN was provided by moderate correlations with several self-report measures and a clinician-administered measure of social anxiety completed by the subsample of callers who later came to the AACT for evaluation. Furthermore, the Mini-SPIN correlated significantly with two of three measures of functional disability, but not with a measure of life satisfaction. Correlations with measures of other constructs were nonsignificant, providing support for the discriminant validity of the Mini-SPIN. In addition, a cutoff score of 6 on the Mini-SPIN yielded strong sensitivity and diagnostic efficiency in the subsample of treatment seekers that later completed pretreatment evaluation, although the specificity of this cutoff score was not optimal in this sample. Overall, the Mini-SPIN demonstrated sound psychometric properties in this treatment-seeking sample.

Once considered to be a disorder associated with minimal impairment, the link between generalized anxiety disorder (GAD) and impairment across a broad constellation of domains is now well established. However, less is known about how comorbidity affects these relationships or how GAD impacts one's perceived life satisfaction or quality of life. To investigate these questions, data from 52 treatment-seeking individuals with GAD (33 with comorbid Axis I diagnoses) were compared to data from 55 nonanxious controls. Individuals with GAD reported more impairment at work and in their social functioning than they did with home and family responsibilities. They also reported lower quality of life than nonanxious controls, particularly in regard to self-esteem, goals and values, money, work, play, learning, creativity, friends, and relatives. Trait worry was positively correlated with impairment and inversely related to life satisfaction within the clinical sample. Individuals with GAD, with and without comorbid Axis I diagnoses, showed few differences on measures of impairment (differing only on impairment in social functioning). However, individuals with GAD and comorbid disorders perceived their lives as less satisfying than did individuals with GAD without comorbid diagnoses.

Individuals with social anxiety disorder (SAD) experience functional impairment in social, educational, and occupational arenas, contributing to poor quality of life. Previous research using the Quality of Life Inventory (QOLI) has identified four distinct domains of quality of life among individuals with SAD: Achievement, Personal Growth, Social Functioning, and Surroundings. The present study was designed to investigate how fear of negative evaluation (FNE) and fear of positive evaluation (FPE) relate to the four QOLI domains among individuals with SAD. We also examined the relationships of FNE and FPE to Satisfaction and Importance ratings on the QOLI. Individuals with SAD (N=129) completed a battery of questionnaires prior to initiating treatment. FNE and FPE showed distinct relationships with the four QOLI domains, even after controlling for demographic characteristics and comorbid depression. Both FNE and FPE were associated with ratings of Satisfaction with the QOLI domains, but neither was associated with ratings of Importance. Our findings highlight the differential impacts of FNE and FPE on SAD. Treatment implications are discussed.

Social anxiety and depressive symptoms dramatically increase and frequently co-occur during adolescence. Although research indicates that general interpersonal stressors, peer victimization, and familial emotional maltreatment predict symptoms of social anxiety and depression, it remains unclear how these stressors contribute to the sequential development of these internalizing symptoms. Thus, the present study examined the sequential development of social anxiety and depressive symptoms following the occurrence of interpersonal stressors, peer victimization, and familial emotional maltreatment. Participants included 410 early adolescents (53% female; 51% African American; Mean age =12.84 years) who completed measures of social anxiety and depressive symptoms at three time points (Times 1-3), as well as measures of general interpersonal stressors, peer victimization, and emotional maltreatment at Time 2. Path analyses revealed that interpersonal stressors, peer victimization, and emotional maltreatment predicted both depressive and social anxiety symptoms concurrently. However, depressive symptoms significantly mediated the pathway from interpersonal stressors, peer victimization, and familial emotional maltreatment to subsequent levels of social anxiety symptoms. In contrast, social anxiety did not mediate the relationship between these stressors and subsequent depressive symptoms. There was no evidence of sex or racial differences in these mediational pathways. Findings suggest that interpersonal stressors, including the particularly detrimental stressors of peer victimization and familial emotional maltreatment, may predict both depressive and social anxiety symptoms; however, adolescents who have more immediate depressogenic reactions may be at greater risk for later development of symptoms of social anxiety.

Individuals with social anxiety disorder (SAD) exhibit elevated levels of anger and anger suppression, which are both associated with increased depression, diminished quality of life, and poorer treatment outcomes. However, little is known about how anger experiences differ among individuals with SAD and whether any heterogeneity might relate to negative outcomes. This investigation sought to empirically define anger profiles among 136 treatment-seeking individuals with SAD and to assess their association with distress and impairment. A latent class analysis was conducted utilizing the trait subscales of the State-Trait Anger Expression Inventory-2 as indicators of class membership. Analysis revealed four distinct anger profiles, with greatest distress and impairment generally demonstrated by individuals with elevated trait anger, a greater tendency to suppress the expression of anger, and diminished ability to adaptively control their anger expression. These results have implications for tailoring more effective interventions for socially anxious individuals.

Non-suicidal self-injury (NSSI) is a serious public health concern and remains poorly understood. This study sought to identify both cognitive and affective vulnerabilities to NSSI and examine their interaction in the prediction of NSSI. A series of regressions indicated that low levels of positive affect moderated the relationships between self-criticism and brooding and NSSI. The associations of self-criticism and brooding with greater frequency of NSSI were attenuated by higher levels of positive affect. The interaction of cognitive and affective vulnerabilities is discussed within the context of current NSSI theory.

Rector, Kocovski, and Ryder (2006, this issue) suggest that fear of causing discomfort to others is a unique form of social anxiety and that focusing on this concern may be clinically helpful. We argue that the fear of causing discomfort to others is dependent upon fear of negative evaluation, and provide evidence from the domains of evolutionary psychology, personality psychology, self–regulation theory, and our own clinical experience that support this argument. Given that fear of causing discomfort to others is dependent upon fear of negative evaluation, it is well addressed by current empirically supported cognitive behavioral interventions. Thus, although fear of causing discomfort to others may ultimately prove to be a useful construct, further evidence is required to demonstrate that it provides unique insights regarding social anxiety or social anxiety disorder.

Accepted February 5, 2005 The current study explored the relationship between recall of a form of bullying, specifically childhood teasing, and later interpersonal functioning in a sample of 414 college students. It was predicted that memories of frequent teasing during childhood would be associated with fewer close friends, a more anxious attachment style in the context of romantic relationships, and lower social self-esteem in early adulthood. Although recalled-teasing was not associated with number of friends later in life, it was related to other interpersonal difficulties. Specifically, frequent teasing was associated with less comfort with intimacy and closeness, less comfort in trusting and depending on others, a greater degree of worry about being unloved or abandoned in relationships, and poorer social self-esteem. The relationship of these difficulties to specific domains of teasing was also explored.

Social anxiety disorder is thought to be characterized by maladaptive self-views. This study investigated whether (a) patients with social anxiety disorder ( n = 75) differ at baseline from healthy controls ( n = 43) in negative and positive self-views, (b) cognitive-behavioral therapy (CBT) for social anxiety disorder versus wait-list control produces statistically and clinically significant changes in negative and positive self-views, (c) changes in self-views mediate the effect of CBT on social anxiety symptoms, and (d) changes in self-views during CBT related to social anxiety symptoms at 1-year post-CBT. As expected, patients endorsed more negative and fewer positive self-views than healthy controls at baseline. Compared to wait-list control, CBT yielded statistically and clinically significant changes, specifically, fewer negative and more positive self-views. Mediational analysis indicated that increased positive (but not reduced negative) self-views mediated the effect of CBT on social anxiety reduction. Correlational analyses determined that increased positive self-views were associated with social anxiety symptom reduction at 1-year post-CBT.

Despite strong support for the efficacy of cognitive behavioural therapy (CBT) for social anxiety disorder (SAD), little is known about mechanisms of change in treatment. Within the context of a randomized controlled trial of CBT, this study examined patients' beliefs about the fixed versus malleable nature of anxiety-their 'implicit theories'-as a key variable in CBT for SAD. Compared to waitlist (n = 29; 58% female), CBT (n = 24; 52% female) led to significantly lower levels of fixed beliefs about anxiety (Mbaseline = 11.70 vs. MPost = 7.08, d = 1.27). These implicit beliefs indirectly explained CBT-related changes in social anxiety symptoms (κ(2) = .28, [95% CI = 0.12, 0.46]). Implicit beliefs also uniquely predicted treatment outcomes when controlling for baseline social anxiety and other kinds of maladaptive beliefs (perceived social costs, perceived social self-efficacy, and maladaptive interpersonal beliefs). Finally, implicit beliefs continued to predict social anxiety symptoms at 12 months post-treatment. These findings suggest that changes in patients' beliefs about their emotions may play an important role in CBT for SAD.

There is growing interest in the role of transdiagnostic processes in the onset, maintenance, and treatment of mental disorders (Nolen-HoeksemaWatkins, 2011). Two such transdiagnostic processes-rumination and reappraisal-are the focus of the present study. The main objective was to examine the roles of rumination (thought to be harmful) and reappraisal (thought to be helpful) in adults with social anxiety disorder (SAD).We conducted a randomized controlled trial of cognitive-behavioral therapy (CBT) with 75 adults with SAD and examined pre- to post-CBT changes as well as weekly fluctuations in rumination, reappraisal, and social anxiety symptoms.Socially anxious individuals' baseline rumination (brooding) scores predicted weekly levels of social anxiety, rumination, and reappraisal, whereas baseline reappraisal scores did not. Greater weekly rumination was associated with greater weekly social anxiety, but reappraisal was not related to social anxiety.These findings suggest that rumination may have a more significant role than reappraisal in understanding fluctuations in social anxiety during CBT for SAD.

Pioneering models of social anxiety disorder (SAD) underscored fear of negative evaluation (FNE) as central in the disorder's development. Additional cognitive predictors have since been identified, including fear of positive evaluation (FPE), anxiety sensitivity, and intolerance of uncertainty (IU), but rarely have these constructs been examined together. The present study concurrently examined the variance accounted for in SAD symptoms by these constructs. Participants meeting criteria for SAD (n = 197; 65% women) completed self-report measures online. FNE, FPE, anxiety sensitivity, and IU all accounted for unique variance in SAD symptoms. FPE accounted for variance comparable to FNE, and the cognitive dimension of anxiety sensitivity and the prospective dimension of IU accounted for comparable variance, though slightly less than that accounted for by FNE and FPE. The results support the theorized roles that these constructs play in the etiology of SAD and highlight both FNE and FPE as central foci in SAD treatment.

Intolerance of uncertainty (IU) has been increasingly recognized as a transdiagnostic factor across anxiety disorders and depression and is associated with substantial cognitive, behavioral, and emotional impairment. IU is typically construed as a dispositional tendency to view ambiguous stimuli and unknown outcomes as unacceptably threatening regardless of context, but recent findings suggest that the domain in which uncertainty is encountered may be relevant. Taking that research to the next step, the aim of the present study was to determine whether IU is more salient in concern-congruent versus incongruent domains and whether domain-specific IU is a better predictor of anxiety symptoms than trait IU. A total of 102 undergraduates were recruited into analog socially anxious (SA), obsessive-compulsive contamination (OCC), and nonanxious control (NAC) groups based on responses to measures of SA and OCC symptoms. Both groups reported more domain-congruent IU than trait IU or domain-incongruent IU. The SA group reported more social interaction IU than the OCC and NAC groups; the OCC group reported more cleanliness IU than the SA and NAC groups. Domain-specific IU predicted social anxiety and OCC fears above and beyond trait IU. Results suggest that IU has a substantial context-specific component and should be examined both transdiagnostically and transsituationally.

Despite scant evidence of an advantage of combining medication and cognitive behavioral therapy (CBT) for social anxiety disorder, the advantages and disadvantages of the two approaches suggest the possibility that some form of combination may be helpful for many clients. At the same time, the available evidence and theoretical considerations suggest that some methods of combination could provide short-term benefits but long-term decreases in efficacy compared to either treatment alone. Thus, current knowledge suggests that, for social anxiety disorder, more treatment is no substitute for well-informed treatment. We provide guidelines for treatment based on available evidence, theoretical models, and clinical experience. Overall, the clearest case for combination treatment is for the addition of an empirically supported CBT for social anxiety disorder following the stabilization of response to an empirically supported psychopharmacological agent. The CBT should then be modified to address the use of medication, the possibility of relapse, and, ideally, the tapering of medication during CBT. Further research is called for in order to support these recommendations and extend the available literature. Keywords: social anxiety disorder; social phobia; treatment; psychotherapy; medication; CBT A review of the extant treatments for social anxiety disorder makes it dear that multiple psychological and pharmacological interventions produce beneficial effects (e.g., Rodebaugh, Holaway, & Heimberg, 2004) and that the psychotherapies that produce these effects are primarily forms of cognitive behavioral therapy (CBT). Both research and clinical practice are therefore not only concerned with the question of what works at all, which occupied the field for much of the past, but also with the additional question of how we can maximize the impact of generally effective techniques. In considering this question, it is vital to note that both medications and CBT have advantages and disadvantages. At least some research (e.g., Davidson et al., 2004; Heimberg et al., 1998) and general clinical opinion indicate that medications may work more quickly. However, medications also appear to be associated with significant rates of relapse (e.g., 30% to 60% for paroxetine; e.g., Stein, Veriani, Hair, & Kumar, 2002; Stein et al., 1996) that are in excess of those reported for CBT (e.g., 17% for group CBT; liebowitz et al., 1999). Conversely, CBT is typically thought to take more time but is associated with lower relapse rates. Thus, although there is no guarantee that any combination of a given medication and a given form of CBT will increase response or decrease relapse, it appears logical to explore their combination further. In addition, and more pragmatically, many clients requesting psychotherapy are already on a medication. For example, we recently completed a study of CBT in collaboration with Debra Hope of the University of Nebraska-Lincoln in which participants were permitted to stay on a stable dose of their current medication (Zaider, Heimberg, Roth, Hope, & Turk, 2003). Over half of the participants were on some form of psychoactive medication when they presented to one of the participating clinics. We have no reason to believe that these clients were substantively different from those presenting at other psychotherapy clinics, at least in terms of medication use. It is likely that the percentage of persons with social anxiety disorder who present for psychotherapy already on medication has increased since the beginning of direct-to-consumer advertising of medications for social anxiety disorder a few years ago. Therefore, psychotherapists may be increasingly forced to deal with the issue of combining treatments if they wish to treat the typical client with social anxiety disorder. This article reviews the current state of knowledge about combination treatments for social anxiety disorder and provides guidelines for the practicing clinician regarding combination treatments. …

Three studies provide preliminary support for an emotion dysregulation model of generalized anxiety disorder (GAD). In study 1, students with GAD reported heightened intensity of emotions, poorer understanding of emotions, greater negative reactivity to emotional experience, and less ability to self-soothe after negative emotions than controls. A composite emotion regulation score significantly predicted the presence of GAD, after controlling for worry, anxiety, and depressive symptoms. In study 2, these findings were largely replicated with a clinical sample. In study 3, students with GAD, but not controls, displayed greater increases in self-reported physiological symptoms after listening to emotion-inducing music than after neutral mood induction. Further, GAD participants had more difficulty managing their emotional reactions. Implications for GAD and psychopathology in general are discussed.

Individuals with obsessive-compulsive disorder (OCD) often report compulsions aimed at reducing feelings of something not being just right or sensations of incompleteness. Research using self-report questionnaires has demonstrated a link between not just right experiences (NJREs) and OCD symptoms (Behav. Res. Therapy 41 (2003) 681; Anxiety, 1 (1995) 208). Extending previous work, this paper presents experimental and self-monitoring data on NJREs in an undergraduate sample. NJREs produced distress and urges to change something, but feared consequences were rare. Stronger responses were found for naturally occurring self-monitored NJREs compared to NJREs elicited in the laboratory. Several significant relationships were found between features of NJREs and OC symptoms and constructs theoretically related to OCD (e.g., responsibility, incompleteness), but no significant relationships were found between features of NJREs and non-OCD-related constructs (worry, depressive symptoms, social anxiety). Further consideration of NJREs will be useful in improving our understanding of the phenomenology, neurobiological substrates, and treatment, of OCD.

From an emotion regulation framework, generalized anxiety disorder (GAD) can be conceptualized as a syndrome involving heightened intensity of subjective emotional experience, poor understanding of emotion, negative reactivity to emotional experience, and the use of maladaptive emotion management strategies (including over-reliance on cognitive control strategies such as worry). The current study sought to replicate previous findings of emotion dysregulation among individuals with GAD and delineate which aspects of emotion dysregulation are specific to GAD or common to GAD and another mental disorder (social anxiety disorder). Individuals with GAD reported greater emotion intensity and fear of the experience of depression than persons with social anxiety disorder and nonanxious control participants. Individuals with social anxiety disorder indicated being less expressive of positive emotions, paying less attention to their emotions, and having more difficulty describing their emotions than either persons with GAD or controls. Measures of emotion differentiated GAD, social anxiety disorder, and normal control groups with good accuracy in a discriminant function analysis. Findings are discussed in light of theoretical and treatment implications for both disorders.

Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry that is difficult to control; but methods of thought control among persons with GAD have not been previously investigated. Forty-two patients with GAD and 55 non-anxious controls (NACs) completed the Thought Control Questionnaire (TCQ; A. Wells & M. I. Davies, 1994). Patients with GAD reported significantly greater use of worry and punishment strategies, and less use of distraction and social control strategies, than NACs. Further, worry and punishment strategies were positively correlated with depressive symptoms and excessive worry, while distraction and social control strategies were negatively correlated with these measures of psychopathology. Higher life satisfaction was associated with greater use of distraction and social control strategies, and lesser use of worry and punishment strategies.

Studies using linguistic stimuli have provided little support for explicit memory biases among individuals with social phobia (SP). However, using facial stimuli rated on their criticalness, Lundh and Ost (1996) found that individuals with SP recognized more critical than accepting faces, whereas non-anxious controls tended to show the opposite pattern. Since the publication of Lundh and Ost's findings, additional studies using a variety of facial stimuli have produced inconsistent findings (J. Anxiety Disord. 14 (2000) 501; Behav. Res. Ther. 39 (2001) 967). Unfortunately, these inconsistencies are difficult to reconcile given great variation in methods and stimuli. Therefore, we designed a study to replicate and extend the work of Lundh and Ost (Behav. Res. Ther. 34 (1996) 787). Similar to Lundh and Ost, individuals with SP identified a significantly higher proportion of old critical faces as old than did non-anxious controls. Further, extending the work of Lundh and Ost, signal detection analyses revealed group differences on response bias according to face type. Specifically, controls showed a response bias towards indicating that accepting faces were previously seen, whereas individuals with SP did not. Finally, signal detection analyses failed to reveal group differences in the accuracy of memory.

The Brief Fear of Negative Evaluation Scale (BFNE; M. R. Leary, 1983a) is often used to assess fear of negative evaluation, the core feature of social anxiety disorder. However, few studies have examined its psychometric properties in large samples of socially anxious patients. Although the BFNE yields a single total score, confirmatory factor analysis indicated a 2-factor solution to be more appropriate, with the 1st factor consisting of all straightforwardly worded items (BFNE-S) and the 2nd of all reverse-scored items (BFNE-R). Support was obtained for the convergent and discriminant validity of the BFNE and BFNE-S, but not the BFNE-R. These results suggest that standard scoring of the BFNE may not be optimal for patients with social anxiety disorder.

Background: In most settings, generalized anxiety disorder (GAD) is highly comorbid with major depressive disorder (MDD). This raises uncertainty about the clinical relevance of GAD as a distinct diagnostic entity. The demonstration of functional impairment attached to GAD, independent of that attributable to MDD, would support the importance of GAD as a separate diagnostic category. Methods: The Ontario Health Survey Mental Health Supplement, a survey of more than 8000 residents aged 15–64 of the Canadian province of Ontario, used the University of Michigan Composite International Interview Schedule (also used in the US National Comorbidity Survey) to assign DSM-III-R diagnoses. Several indicators of disability and quality of life were included. Our analytic strategy was to compare these indices in persons with and without GAD, stratified by MDD comorbidity, and adjusting for the effects of relevant sociodemographic factors (e.g., social class, age, gender) and dysthymia. Odds ratios (ORs) are reported; SUDAAN was used to adjust for the sampling framework. Results: GAD was highly comorbid with MDD on both a lifetime and past-year basis. Both past-year and lifetime MDD and GAD were associated with an increased likelihood of low overall perceived well-being. Both lifetime MDD and GAD were associated with dissatisfaction in one’s main activity and with family relationships. Limitations: Other comorbid Axis I or II conditions might be confounders with impairment; a lower rate of GAD than in some prior surveys bears consideration. Conclusions: These observations confirm that GAD is associated with an increased likelihood of poor global well-being and life satisfaction, beyond that associated with MDD. Given the chronicity of GAD relative to the more often episodic course of MDD, the long-term functional benefits of treating GAD may be substantial.

This study examined the psychometric properties of the Teasing Questionnaire-Revised (TQ-R) and the relationships among recalled childhood teasing and current psychosocial distress in 414 undergraduate students. Participants were administered the TQ-R, Beck Depression Inventory-II, State-Trait Anxiety Inventory-Trait Version, Brief Fear of Negative Evaluation Scale, and UCLA Loneliness Scale. Confirmatory factor analysis supported a five-factor model assessing teasing related to performance, academic issues, social behavior, family background, and appearance. Internal consistency of the TQ-R and its factors was acceptable, and intercorrelations among subscales were moderate, suggesting that the factors measure related but conceptually distinct teasing experiences. Defining Pearson product-moment correlations with a magnitude of greater than.25 as conceptually meaningful, we found that the TQ-R Total score was meaningfully related to depressive symptoms, anxiety, fear of negative evaluation, and loneliness. Being teased in the Performance and Social domains as a child was moderately related to current psychopathology. Implications of these findings for clinical practice and future research are discussed.

Efficacious treatments for social anxiety disorder have become increasingly available, with approximately three-quarters of treatment completers showing significant improvement [Arch. Gen. Psychiatry 55 (1998) 1133.]. However, very few individuals with social anxiety disorder access these services. The present study reports on the path to initiation of treatment for social anxiety disorder among individuals contacting an anxiety disorder specialty clinic. Of 395 initial telephone inquiries, only 60 individuals (15%) started treatment. Three “critical points” associated with high pretreatment attrition were identified: scheduling an initial interview, attending a scheduled initial interview, and initiating a treatment program after receiving a principal diagnosis of social anxiety disorder. Several demographic variables (e.g., level of education, race) were related to attendance at the initial interview. However, no differences were found between those who did and did not initiate treatment on demographic variables, symptom severity, or quality of life. Given that most individuals who complete treatment for social phobia experience significant benefit, results of the current study suggest that future efforts should be devoted to increasing number of patients who access these services.

The current study sought to understand better the psychological characteristics of socially anxious individuals who seek information on the internet about social anxiety disorder and its treatment. Participants were 434 individuals who responded to an internet-based survey linked to the website of an anxiety specialty clinic. Using established cut-off scores, 92% of the sample met criteria for social anxiety disorder. Internet survey respondents who met these criteria reported greater severity of and impairment due to social anxiety than a treatment-seeking sample of persons with social anxiety disorder. Nevertheless, only about one-third of these internet respondents reported having received psychotherapy, and a similar percentage reported having received pharmacotherapy. Those with the most severe social interaction anxiety and who spent the most time interacting on the internet endorsed positive effects of internet use. However, a significant number of negative effects also were endorsed.

Social anxiety disorder (SAD, also known as social phobia) is characterised by marked anxiety about situations in which the individual may be scrutinised by others. SAD is one of the most common, e...

The current study aimed to extend the evaluation of the utility of the Social Performance Rating Scale (SPRS) [Behav. Res. Ther. 36 (1998) 995]. We examined the utility of a modified SPRS for the behavioral assessment of public-speaking anxiety among patients with social phobia (n = 49). The videotaped performance of public-speaking fearful patients in a public-speaking task was rated using four of the five SPRS ratings and was compared to global ratings by patients and observers, as well as to self-report and clinician-administered measures of social anxiety. The pattern of correlations with criterion measures of social anxiety provided evidence for the convergent and divergent validity of this modified SPRS for the behavioral assessment of public-speaking anxiety.

Individuals with obsessive-compulsive disorder (OCD) frequently report uncomfortable sensations of things not being just right ("not just right experiences"; NJREs) and a need to ritualize until they quiet these sensations. However, very little work has been conducted to empirically examine the nature and characteristics of this phenomenon. In this paper, we present two studies that systematically examine NJREs in large undergraduate samples. In Study 1, NJREs were shown to be related to both OCD features and maladaptive domains of perfectionism. In Study 2, NJREs were again significantly related to OCD features. Further, NJREs were shown to have particularly strong relationships with specific OCD symptom clusters (e.g., checking, ordering). Finally, NJREs were significantly more strongly correlated with features of OCD than symptoms from other domains of psychopathology (e.g., social anxiety, trait anxiety, worry, depression). General conclusions are drawn, and future directions are discussed.

The present paper examines the role of cognitive-behavioral therapy (CBT) in the treatment of social anxiety disorder (SAD). A cognitive-behavioral model of SAD is first presented. Different modalities of CBT for SAD are then described, including exposure, cognitive restructuring, relaxation training, and social skills training, and evidence supporting their efficacy is reviewed. The comparative and combined impact of CBT and pharmacotherapeutic interventions is also explored. CBT appears to be an efficacious treatment for SAD. However, the overall efficacy CBT may be increased by closer examination of the active ingredients of treatment. Such analyses may also enable more successful integration of the different CBT techniques and of CBT and pharmacotherapy in the treatment of SAD.

I have been asked to comment on the three articles on social phobia in this issue of Psychological Medicine. The three papers in one way or another concern themselves with important issues in the assessment and diagnosis of social phobia (also known as social anxiety disorder; Liebowitz et al. 2000). I do so with the caveat that I am an author on one of the papers and do not claim the same degree of objectivity in examining my own work as I do in examining the work of others. The three papers concern the psychometric evaluation of a modified version of the Clinical Global Impression (CGI) (Guy, 1976) in a sample of persons with social phobia (Zaider et al. 2003), the development of a self-report screening questionnaire for social phobia (Newman et al. 2003) and the characteristics of social phobia in the Australian National Survey of Mental Health and Wellbeing (NSMHWB) (Lampe et al. 2003).

This study examined whether social phobics differed from nonanxious controls in occupational adjustment. Results indicated that generalized and nongeneralized social phobics, in contrast to controls, were underemployed and believed that their supervisor would rate them as less dependable. Nongeneralized social phobics and controls believed their supervisor would rate them higher in work role conformance and likelihood of advancement than did generalized social phobics. Generalized socially phobic women, in contrast to nongeneralized and control group women, were more likely to be employed in noninterpersonally oriented jobs. Generalized social phobics were more anxious than controls when starting their current job but did not differ in job satisfaction. Results are discussed relative to the nature of social phobia, subtype differences, and counseling services.

The present study examined social anxiety, anger, and depression among 234 persons with social anxiety disorder and 36 nonanxious controls. In addition to greater social anxiety, persons with social anxiety disorder exhibited more severe depression, greater anger, and poorer anger expression skills than did nonanxious control participants. Analyses investigating attrition and response to cognitive-behavioral group treatment (CBGT) among a subset of 68 persons treated for social anxiety disorder indicated that patients who experienced anger frequently, perceived unfair treatment, and were quick-tempered were less likely to complete a 12-session course of CBGT. Among treatment completers, significant reductions in the frequent experience of anger to perceived negative evaluation and in anger suppression were noted. However, those who suppressed anger responded less favorably to CBGT. Future directions and clinical implications are discussed.

Cognitive-behavioral models (Clark & Wells, 1995; Rapee & Heimberg, 1997) and recent research suggest that individuals with social phobia (SP) experience both images (Hackmann, Surawy, & Clark, 1998) and memories (Coles, Turk, Heimberg, & Fresco, 2001; Wells, Clark, & Ahmad, 1998) of anxiety-producing social situations from an observer perspective. The current study examines memory perspective for two role-played situations (speech and social interaction) at multiple time points (immediate and 3 weeks post) in 22 individuals with generalized SP and 30 non-anxious controls (NACs). At both time points, SPs recalled the role-plays from a more observer/less field perspective than did NACs. Further, over time, the memory perspective of SPs became even more observer/less field while the memory perspective of NAC remained relatively stable.

The Interpersonal Sensitivity Measure (IPSM) was developed to assess hypersensitivity to interpersonal rejection, a suggested trait of depression-prone personality (Aust NZ J Psychiatry 23 (1989) 341). Although studies of the IPSM and interpersonal rejection sensitivity have primarily been conducted in depressed populations, it is important to investigate interpersonal rejection sensitivity as a relevant construct in the assessment of social anxiety. This study examined the psychometric properties of the IPSM in treatment-seeking individuals with social anxiety disorder. The results of this investigation support the convergent and divergent validity and internal consistency of the IPSM in socially anxious individuals. An exploratory factor analysis of the scale was also conducted after the original factor and subscale structure was shown to be a poor fit for the present data. Three factors emerged (Interpersonal Worry and Dependency, Low Self-Esteem, and Unassertive Interpersonal Behavior), and 29 items were retained. Because they demonstrated negative factor loadings on Factor 2, it is suggested that the scoring for four items of the original IPSM be reversed. In summary, the revised IPSM assesses three aspects of interpersonal rejection sensitivity and appears to be a valid and reliable instrument for its assessment in social anxiety disorder.

Information-processing models of emotional disorders suggest that anxious individuals may be characterized by a memory bias for threat-relevant information. This paper reviews and synthesizes evidence for explicit (conscious) and implicit (unconscious) memory biases in the anxiety disorders. Our review suggests variations among the anxiety disorders for explicit memory biases. Specifically, there is support for explicit memory biases for threat-relevant information in panic disorder (PD), particularly when information has been deeply encoded, but not in social phobia (SP) or generalized anxiety disorder (GAD). The few available studies suggest the presence of explicit memory biases in posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD), but further research is needed. In contrast, some degree of support for implicit memory biases has been demonstrated for each of the anxiety disorders. Inconsistencies in the existing literature, topics worthy of future research attention, and directions for revising existing information-processing models of anxiety are discussed.

Worry is often assessed with the 16-item Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990. Behaviour Research and Therapy, 28, 487-495), but the factor structure of the PSWQ is not well articulated. Three factor analyses of the PSWQ have been conducted, with two (Brown, Antony, & Barlow, 1992. Behaviour Research and Therapy, 30, 33-37; van Rijsoort, Emmelkamp, & Vervaeke, 1999) retaining a unifactorial solution and one (Stober, 1995) retaining a two-factor solution. We sought to determine the relative strengths of these solutions. Seven hundred eighty-eight undergraduates completed the PSWQ and measures of depression and anxiety. Confirmatory factor analyses indicated that the two-factor solution provided a better fit to the data. There was also evidence for a higher order worry factor. Multiple regression analyses revealed that factor 1 (Worry Engagement) explained the majority of the variance in the symptom measures. The higher order worry factor also accounted for variance in some measures. Compared to the PSWQ total score, Worry Engagement demonstrated slightly higher internal consistency and significantly stronger correlations with most measures of depression and anxiety. Factor 2 (Absence of Worry) demonstrated moderate negative correlations with Worry Engagement and the PSWQ Total Score but only modest correlations with depression and anxiety.

Integrative conceptualizations like that proposed byRoemer and Orsillo provide exciting new directions forunderstanding and treating generalized anxiety disorder(GAD). However, these approaches may be furtherstrengthened by adoption of an emotion regulationperspective. Persons with GAD may have difficulty un-derstanding their emotional experience and may pos-sess few skills to modulate their emotions. They mayexperience emotions as subjectively aversive and useworry and maladaptive interpersonal behaviors as de-fensive strategies to control, avoid, or blunt emotionalexperience. An emotion regulation perspective suggestsadding treatment components to help clients becomemore comfortable with arousing emotional experience,more able to access and utilize emotional informationin adaptive problem solving, and better able to modu-late emotional experience and expression according tocontextual demands.Key words: emotion regulation, generalized anxietydisorder. [Clin Psychol Sci Prac 9:85–90, 2002]

The present study examined ethnic differences in worry in a college student population. No differences were found between Caucasians, African Americans, and Asian Americans in pathological worry as measured by the Penn State Worry Questionnaire (PSWQ) or in the frequency with which they met self-report criteria for generalized anxiety disorder on the Generalized Anxiety Disorder Questionnaire for DSM-IV (GAD-Q-IV). Groups differed in Worry Domains Questionnaire (WDQ) total scores and on all WDQ domain subscales except for the Financial domain. Within ethnic groups, Caucasians and African Americans experienced variations in intensity of worry across the specific domains, but Asian Americans did not. These results suggest that ethnic groups may differ from each other in the degree to which they worry and in the breadth of their concerns. Further examination of ethnic differences and worry (and anxiety more generally) is suggested.

Worry and rumination are cognitive processes, often represented as verbal or linguistic activities. Despite similarities in definition and description, worry has been most closely examined in relation to anxiety whereas rumination has traditionally been related to depression. This distinction remains in spite of high rates of comorbidity between anxiety and depression. This study sought to better understand the distinct and overlapping features of worry and rumination as well as their relationship to anxiety and depression. Seven hundred eighty-four unselected college students completed self-report measures of worry, rumination, anxiety, and depression. Items from the respective worry and rumination scales were submitted to factor analysis, which revealed a four-factor solution comprised of 2 worry factors and 2 rumination factors. A Worry Engagement factor as well as a Dwelling on the Negative factor emerged as distilled measures of worry and rumination, respectively. Scores on these factors were highly correlated with each other and demonstrated equally strong relationships to both anxiety and depression. Findings from this study suggest that worry and rumination represent related but distinct cognitive processes that are similarly related to anxiety and depression.