Social anxiety and posttraumatic stress in combat veterans: relations to well-being and character strengths

There are few studies examining the relationship between psychopathology and positive experiences and traits. Although initial studies suggest persons with posttraumatic stress disorder (PTSD) are at increased risk for excessive social anxiety, there have been no studies to date evaluating how these conditions might interact to affect positive experiences and traits. Using self-report scales, informant ratings, and experience-sampling methodologies, we examined the association of social anxiety with well-being and character strengths in veterans with and without PTSD. Controlling for PTSD and trait negative affect, social anxiety was negatively related to global ratings of well-being and character strengths. Social anxiety also accounted for incremental variance in day-to-day well-being (i.e., daily affect balance, percentage of pleasant days, positive social activity, self-esteem, gratitude) over a 14-day assessment period. Although veterans with PTSD reported lower levels of global and daily well-being and character strengths than veterans without PTSD, a diagnosis of PTSD failed to exhibit unique relationships with these constructs. Building on a growing body of work, these data suggest that social anxiety is uniquely associated with disturbances in positive experiences, events, and traits. Our findings support the value of directly addressing social anxiety in the study and treatment of PTSD.     

Comorbid anxiety and mood disorders among persons with social anxiety disorder.

Axis I comorbidity is associated with greater severity of social anxiety disorder. However, the differential effects of comorbid mood and anxiety disorders on symptom severity or treatment outcome have not been investigated. We evaluated 69 persons with uncomplicated social anxiety disorder, 39 persons with an additional anxiety disorder, and 33 persons with an additional mood disorder (with or without additional anxiety disorders). Those with comorbid mood disorders reported greater duration of social anxiety than those with uncomplicated social anxiety disorder. They were also judged, before and after 12 weeks of cognitive-behavioral group treatment and at follow-up, to be more severely impaired than those with no comorbid diagnosis. In contrast, persons with comorbid anxiety disorders were rated as more impaired than those with no comorbid diagnosis on only a single measure. Type of comorbid diagnosis did not result in differential rates of improvement of social anxiety disorder.     

Social anxiety in body dysmorphic disorder

Although clinical impressions suggest that patients with body dysmorphic disorder (BDD) experience distress in social situations, social anxiety in BDD has received little investigation. This study examined social anxiety in 81 patients with BDD and change in social anxiety with pharmacotherapy. Subjects completed the Social Avoidance and Distress Scale (SADS) and were assessed with measures of BDD symptomatology. Participants in a placebo-controlled fluoxetine trial completed measures at baseline and endpoint. The mean SADS score was 1.3 SD units higher than nonclinical sample means but consistent with other clinical sample means. Social anxiety was significantly correlated with BDD severity. Greater depressive symptoms as well as comorbid avoidant personality disorder, but not comorbid social phobia, were also associated with higher SADS scores. Social anxiety did not improve more with fluoxetine than placebo, yet it improved significantly more in fluoxetine responders than in nonresponders. Understanding social anxiety in BDD has implications for reducing rates of misdiagnosis and treatment dropout.     

Social anxiety disorder in childhood and adolescence: descriptive psychopathology

Although the presentation of social anxiety disorder (SAD) in adults is well documented, less is known about its clinical manifestation in children and adolescents. To date, most studies have included combined samples of children and adolescents despite the fact that this age range represents an extensive period of growth and development. This study compares and contrasts the clinical presentation of SAD among children (ages 7-12) and adolescents (ages 13-17). One hundred and fifty children (n=74) and adolescents (n=76) with a primary diagnosis of SAD participated in the study. The assessment battery included clinical ratings and behavioral observation as well as parental and self-report. The results indicate that, although the symptom presentation of children and adolescents with primary SAD shares many features, children tend to present with a broader pattern of general psychopathology, while adolescents have a more pervasive pattern of social dysfunction and may be more functionally impaired as a result of their disorder. These findings suggest that interventions for SAD need to carefully consider clinical presentation of the disorder as it manifests in childhood and adolescence.     

Gratitude and hedonic and eudaimonic well-being in Vietnam war veterans

Little information exists on the contribution of psychological strengths to well-being in persons with post-traumatic stress disorder (PTSD). Data from other populations suggest that gratitude, defined as the positive experience of thankfulness for being the recipient of personal benefits, may have salutary effects on everyday functioning. We investigated whether dispositional gratitude predicted daily hedonic and eudaimonic well-being in combat veterans with and without PTSD. We also examined associations between daily gratitude and daily well-being across time. Veterans with PTSD, compared to those without PTSD, exhibited significantly lower dispositional gratitude; no differences were found on daily gratitude. Dispositional gratitude predicted greater daily positive affect, percentage of pleasant days over the assessment period, daily intrinsically motivating activity, and daily self-esteem over and above effects attributable to PTSD severity and dispositional negative and positive affect in the PTSD group but not the non-PTSD group. Daily gratitude was uniquely associated with each dimension of daily well-being in both groups. Although preliminary, these results provide support for the further investigation of gratitude in trauma survivors.     

The structure of feared social situations among individuals with a lifetime diagnosis of social anxiety disorder in two independent nationally representative mental health surveys

The present study employed both exploratory and confirmatory factor analytic approaches with nationally representative samples of individuals with a lifetime diagnosis of social anxiety disorder (n=1123; n=3091, respectively) using split-halves of the National Comorbidity Replication Survey (n=9282) and cross-validated with the Canadian Community Health Survey on Mental Health and Wellbeing (n=36,984). Strong support was found for a three-factor solution. This model was obtained from exploratory factor analysis and was further evaluated using two confirmatory factor analytic investigations in the two national samples. The three social situational domains reflected (1) Social Interaction Fears, (2) Observation Fears, and (3) Public Speaking Fears. Individuals with generalized social anxiety disorder (i.e., those who endorsed 7 or more of 13 feared social situations assessed in the survey) were significantly more likely to report Social Interaction Fears and Observation Fears compared to individuals with non-generalized social anxiety disorder (i.e., those who endorsed only 6 or fewer of 13 feared social situations). Individuals with generalized social anxiety were particularly characterized by combinations of Public Speaking Fears plus Social Interaction Fears and Observation Fears. The clinical and classification implications of our study for DSM-V are discussed.     

Differential effects of safety behaviour subtypes in social anxiety disorder

Clinical observations indicate that individuals with Social Anxiety Disorder (SAD) use a variety of safety behaviours; however, virtually no research has examined the functional effect of different safety-seeking strategies. Accordingly, we conducted two studies to address this issue. Study 1 measured global patterns of safety behaviour use in a large analogue sample. Factor analysis revealed two primary safety behaviour categories, avoidance and impression management. Study 2 assessed situational use of safety behaviours during a controlled social interaction in a clinical sample of 93 patients with Generalised SAD. Factor analysis again revealed support for avoidance and impression-management subtypes. Notably, the two types of safety behaviours were associated with different social outcomes. Avoidance safety behaviours were associated with higher state anxiety during the interaction and negative reactions from participants’ interaction partners. Impression-management strategies appeared to impede corrections in negative predictions about subsequent interactions. These findings suggest that it may be beneficial to consider the unique effects of different safety-seeking strategies when assessing and treating SAD.     

Safety behaviors and judgmental biases in social anxiety disorder

Two experiments were conducted to examine the link between safety behaviors and social judgments in social anxiety disorder (SAD). Safety behaviors were manipulated in the context of a controlled laboratory-based social interaction, and subsequent effects of the manipulation on the social judgments of socially anxious participants (N = 50, Study 1) and individuals meeting diagnostic criteria for generalized SAD (N = 80, Study 2) were examined. Participants were randomly assigned to either a safety behavior reduction plus exposure condition (SB + EXP) or a graduated exposure (EXP) control condition, and then took part in a conversation with a trained experimental confederate. Results revealed across both studies that participants in the SB + EXP group were less negative and more accurate in judgments of their performance following safety behavior reduction relative to EXP participants. Study 2 also demonstrated that participants in the SB + EXP group displayed lower judgments about the likelihood of negative outcomes in a subsequent social event compared to controls. Moreover, reduction in safety behaviors mediated change in participant self-judgments and future social predictions. The current findings are consistent with cognitive theories of anxiety, and support the causal role of safety behaviors in the persistence of negative social judgments in SAD.     

Sleep quality and treatment of social anxiety disorder

Background and Objectives: Poor sleep is prevalent among individuals with social anxiety disorder (SAD) and may affect treatment outcome. We examined whether: (1) individuals with SAD differed from healthy controls (HCs) in sleep quality, (2) baseline sleep quality moderated the effects of treatment (Cognitive–behavioral group therapy [CBGT] vs. mindfulness-based stress reduction [MBSR] vs. waitlist [WL]) on social anxiety, (3) sleep quality changed over treatment, and (4) changes in sleep quality predicted anxiety 12-months post-treatment.

Design: Participants were 108 adults with SAD from a randomized controlled trial of CBGT vs. MBSR vs. WL and 38 HCs.

Methods: SAD and sleep quality were assessed pre-treatment and post-treatment; SAD was assessed again 12-months post-treatment.

Results: Participants with SAD reported poorer sleep quality than HCs. The effect of treatment condition on post-treatment social anxiety did not differ as a function of baseline sleep quality. Sleep quality improved in MBSR, significantly more than WL, but not CBGT. Sleep quality change from pre- to post-treatment in CBGT or MBSR did not predict later social anxiety.

Conclusions: MBSR, and not CBGT, improved sleep quality among participants. Other results were inconsistent with prior research; possible explanations, limitations, and implications for future research are discussed. ClinicalTrials.gov identifier: NCT02036658.     

Social anxiety disorder in children and youth: A research update on aetiological factors

Social Anxiety Disorder (SAD) is a heterogeneous and distressing problem for many children and youth. This review focuses on the etiology and maintenance of SAD, and examines research findings in several key areas of investigation: genetic or hereditary factors (twin and family studies), temperament characteristics (behavioural inhibition), and parent–child interactions (attachment, parenting styles). It is concluded that genetic influences, behavioural inhibition, and parent–child interactions play significant and interactive roles in the development and maintenance of SAD. Other influences such as peer relationships, social skills deficits, and traumatic experiences are also acknowledged. Ultimately, an understanding of such pathways should facilitate effective early screening and intervention of children at risk for severe social anxiety.     

Perseverative thought: a robust predictor of response to emotional challenge in generalized anxiety disorder and major depressive disorder

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) frequently co-occur, yet the reasons for their comorbidity remain poorly understood. In the present experiment, we tested whether a tendency to engage in negative, repetitive thinking constitutes a common risk process for the two disorders. A mixed sample of adults with comorbid GAD–MDD (n = 50), GAD only (n = 35), MDD only (n = 34), or no lifetime psychopathology (n = 35) was administered noncontingent failure and success feedback on consecutive performance tasks. Perseverative thought (PT), measured by negative thought intrusions during a baseline period of focused breathing, emerged as a powerful prospective predictor of responses to this experimental challenge. Participants reporting more frequent negative thought intrusions at baseline, irrespective of thought content or diagnostic status, exhibited a stronger negative response to failure that persisted even after subsequent success. Higher PT over the course of the experiment was associated with later behavioral avoidance, with negative affect and other traits closely linked to anxiety and depression, and with the presence and severity of GAD and MDD. These findings provide evidence for a broadly-defined PT trait that is shared by GAD and MDD and contributes to adverse outcomes in these disorders.     

Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder

Mindfulness-based stress reduction (MBSR) has been reported to reduce anxiety in a broad range of clinical populations. However, its efficacy in alleviating core symptoms of specific anxiety disorders is not well established. We conducted a randomized trial to evaluate how well MBSR compared to a first-line psychological intervention for social anxiety disorder (SAD). Fifty-three patients with DSM-IV generalized SAD were randomized to an 8-week course of MBSR or 12 weekly sessions of cognitive-behavioral group therapy (CBGT). Although patients in both treatment groups improved, patients receiving CBGT had significantly lower scores on clinician- and patient-rated measures of social anxiety. Response and remission rates were also significantly greater with CBGT. Both interventions were comparable in improving mood, functionality and quality of life. The results confirm that CBGT is the treatment of choice of generalized SAD and suggest that MBSR may have some benefit in the treatment of generalized SAD.     

Effects of focus of attention on physiological,behavioural, and reported state anxiety in repressors,low-anxious,high-anxious,and defensive high-anxious individuals

Abstract

Discrepancies between physiological activity, behavioural anxiety, and self-reported anxiety were examined when focus of attention was manipulated in a public speech task for four groups of individuals: repressors, low-anxious, high-anxious, and the defensive high-anxious. They were exposed to self-focus (when their behaviour was socially evaluated) and other-focus (when their behaviour was not socially evaluated) conditions. Repressors had consistently the lowest level of self-reported anxiety, but had consistently greater physiological activity in all conditions and greater behavioural anxiety in the self-focus condition. The high-anxious showed the opposite pattern, i.e. their self-reported anxiety was greater than their physiological and behavioural anxiety, and this finding was significant in the self-focus condition. No significant pattern of discrepancy was found for the low-anxious or defensive high-anxious groups. The findings are discussed and interpreted within the framework of recent cognitive models of anxiety.     

Jumping to interpretations: social anxiety disorder and the identification of emotional facial expressions

A small body of research suggests that socially anxious individuals show biases in interpreting the facial expressions of others. The current study included a clinically anxious sample in a speeded emotional card-sorting task in two conditions (baseline and threat) to investigate several hypothesized biases in interpretation. Following the threat manipulation, participants with generalized social anxiety disorders (GSADs) sorted angry cards with greater accuracy, but also evidenced a greater rate of neutral cards misclassified as angry, as compared to nonanxious controls. The controls showed the opposite pattern, sorting neutral cards with greater accuracy but also misclassifying a greater proportion of angry cards as neutral, as compared to GSADs. These effects were accounted for primarily by low-intensity angry cards. Results are consistent with previous studies showing a negative interpretive bias, and can be applied to the improvement of clinical interventions.     

Social anxiety and problematic cannabis use: evaluating the moderating role of stress reactivity and perceived coping

Despite epidemiological reports indicating an association between social anxiety disorder (SAD) and cannabis use disorders (CUD), there is a paucity of research exploring the nature of this relationship. The present investigation examined potential moderators of this relationship that are consistent with a tension-reduction model of addiction. Specifically, physiological reactivity to stress and perceived coping with stress were evaluated as moderators of the relation between symptoms of SAD and CUD. Physiological (SCR) and subjective (perceived coping) responses to unpredictable white noise bursts were collected from non-clinical participants (n=123). Lifetime symptoms of CUD and anxiety disorders were assessed using a structured diagnostic interview. CUD symptomatology was associated with symptoms of SAD but not with symptoms of any other anxiety disorder. Only perceived coping to unpredictable stimuli moderated the relationship between SAD and CUD symptoms. Findings are discussed in the context of tension-reduction models of co-occurring social anxiety and problematic cannabis use.     

Interpretive cues and ambiguity in generalized anxiety disorder

The current study investigated whether generalized anxiety disorder (GAD) individuals rely on antecedent information to interpret ambiguity and whether reliance on such preceding cues persists in the absence of potential threat. Twenty-six GAD and 23 nonanxious control college students performed a lexical decision task, using homographs (i.e. words with multiple meanings) as ambiguous primes. In half the trials, a homograph prime that possessed both threat-related, as well as neutral meanings was followed by a target word related to one of these two meanings. In addition, each ambiguous prime was immediately preceded by a series of four antecedent words that were either: (a) associated with the threatening meaning of the prime; (b) associated with the neutral meaning of the prime; or (c) unrelated to either meaning of the homograph, as well as the target. Homographs for which both meanings were neutral in valence comprised the other half of the trials. Effect size statistics suggest that GAD participants utilized the antecedent words to interpret the homograph primes with threat-related meanings, unlike their nonanxious counterparts (p<0.06). When both meanings of the homograph prime were neutral in valence, the GAD group appeared deficient in the use of preceding information to interpret the ambiguous prime.     

An examination of the construct validity of posttraumatic stress disorder with veterans using a revised criterion set

Ongoing concerns exist in the literature regarding the construct of posttraumatic stress disorder (PTSD) and how to best conceptualize and measure this disorder. We compared the traditional DSM-IV PTSD symptom criteria (i.e., symptoms from clusters B, C, and D) to a revised criterion set that omits overlapping mood and other anxiety symptoms on PTSD prevalence, PTSD diagnostic caseness, associated psychiatric comorbidity, functional status, and structural validity using a cross-sectional, multi-site primary care sample of 747 veterans. After removing items theorized to overlap with mood and other anxiety disorders, PTSD prevalence was identical using both criterion sets (i.e., 12%). Overall, there were few statistically significant differences in PTSD caseness, associated psychiatric comorbidity, functional status, and structural validity across the two diagnostic criterion sets. These data provide further support that removing items that overlap with other psychiatric disorders does not significantly impact the prevalence of PTSD, its associated comorbidity and functional impairment, or its structural validity. Although the revised criterion set represents a more parsimonious model, the current study findings generally support the strong construct validity of PTSD. The implications of these study findings for research and clinical practice are discussed.     

Mediators in psychological treatment of social anxiety disorder: Individual cognitive therapy compared to cognitive behavioral group therapy

According to cognitive-behavioral models of social anxiety disorder (SAD), four of the important maintaining mechanisms are avoidance, self-focused attention, anticipatory processing and post-event cognitive processing. Individual cognitive therapy (ICT) and cognitive behavioral group therapy (CBGT) both have substantial empirical support. However, it is unclear whether they achieve their effects by similar or different mechanisms. The aim of this study was to investigate whether changes in the four maintenance processes mediate clinical improvement in ICT and CBGT for SAD. We analyzed data from participants (N = 94) who received either ICT or CBGT in two separate RCTs. The results showed that ICT had larger effects than CBGT on social anxiety and each of the four potential mediators. More pertinently, moderated mediation analyses revealed significant between-treatment differences. Whereas improvement in ICT was mainly mediated by reductions in avoidance and self-focused attention, improvement in CBGT was mediated by changes in self-focused attention and in anticipatory and post-event processing. These results support the importance of the putative mediators, but suggest that their relative weights are moderated by treatment type.     

A preliminary investigation of impulsivity in generalized anxiety disorder

Few studies have examined the association between impulsivity and generalized anxiety disorder (GAD). This study examined whether individuals with probable GAD display impulsivity in a particular way, and the extent to which impulsivity uniquely predicts GAD severity and GAD status, over and above intolerance of uncertainty (IU), a key cognitive factor in GAD. Individuals with (n = 63) and without (n = 77) probable GAD completed self-report measures of impulsivity and IU. Results revealed that elevations in the severity of GAD symptoms and in IU were associated with impulsive actions in the face of negative affect (i.e., negative urgency), but also greater premeditation and lower “functional” impulsivity (i.e., the ability to take quick action when it is advantageous to do so). Impulsivity led to an increment in the prediction of GAD symptoms and GAD status, over and above IU. Negative urgency and lower functional impulsivity were significant unique predictors of GAD severity or GAD status. The findings highlight a need to consider impulsivity in theories that implicate intolerance of negative affect and uncertainty in excessive and uncontrollable worry.