Blushing and physiological arousability in social phobia

Blushing is the most prominent symptom of social phobia, and fear perception of visible anxiety symptoms is an important component of cognitive behavioral models of social phobia. However, it is not clear how physiological and psychological aspects of blushing and other somatic symptoms are linked in this disorder. The authors tested whether social situations trigger different facial blood volume changes (blushing) between social phobic persons with and without primary complaint of blushing and control participants. Thirty social phobic persons. 15 of whom were especially concerned about blushing, and 14 control participants were assessed while watching an embarrassing videotape, holding a conversation, and giving a talk. Only when watching the video did the social phobic persons blush more than controls blushed. Social phobic persons who complained of blushing did not blush more intensely than did social phobic persons without blushing complaints but had higher heart rates, possibly reflecting higher arousability of this subgroup.     

Recurrent images and early memories in social phobia

A recent model [Clark, D. M. & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D. A. Hope & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment and treatment (pp. 69-93). New York: Guildford Press] suggests that a distorted image of one's public self lies at the heart of social phobia. A previous study of spontaneous imagery [Hackmann, A., Surawy, C. & Clark, D. M. (1998) Seeing yourself through others' eyes: a study of spontaneously occurring images in social phobia. Behavioural and Cognitive Psychotherapy, 26, 3-12] confirmed that patients with social phobia frequently report experiencing negative, distorted, observer-perspective images when in anxiety provoking social situations. In the present study, 22 patients with social phobia were given a semistructured interview which aimed to further explore the nature of social phobic imagery. All participants were able to identify negative spontaneous images that were recurrent in the sense that their content appeared to be relatively stable over time and across different feared social situations. Most recurrent images involved several sensory modalities. Most recurrent images were linked to memories of adverse social events that clustered in time around the onset of the disorder. Taken together, the results suggest that in patients with social phobia, early unpleasant experiences may lead to the development of excessively negative images of their social selves that are repeatedly activated in subsequent social situations and fail to update in the light of subsequent, more favourable experiences. Implications of the findings for the understanding and treatment of social phobia are discussed.     

Social phobia in youth: the diagnostic utility of feared social situations

The present study evaluated the utility of parent- and child-reported social fears for reaching a diagnosis of social phobia in youth. The diagnostic utility of (a) the number of fears and (b) specific feared social situations was examined. The sample included 140 youth and their parents: youth diagnosed with social phobia (n=50), youth diagnosed with generalized anxiety disorder or separation anxiety disorder but not social phobia (n=49), and youth without an anxiety disorder (n=41). Youth and their parents were interviewed separately using the Anxiety Disorders Interview Schedule for Children and Parents. Analyses indicate that a cut score of 4 parent-endorsed social fears optimally distinguished youth with and without social phobia. Analyses of child-reported fears did not identify a meaningful cut score. Conditional probability and odds ratio analyses indicated that several specific social fears have high diagnostic efficiency, and others were found to have limited diagnostic efficiency. Results are discussed with regard to informing diagnostic interviews and diagnostic systems for social phobia in youth.     

Frequency and comorbidity of social phobia and social fears in adolescents.

This report presents findings on the frequency, comorbidity and psychosocial impairment of social phobia and social fears among 1035 adolescents, aged 12-17 years. The adolescents were randomly selected from 36 schools in the province of Bremen, Germany. Social phobia and other psychiatric disorders were coded based on DSM-IV criteria using the computerized Munich version of the Composite International Diagnostic Interview. Seventeen (1.6%) of the adolescents met the DSM-IV criteria for social phobia sometimes in their life. More girls than boys received the diagnosis of social phobia and the frequency of the disorder increased with age. The lifetime frequency of social fears were much higher than that of social phobia. The most common types of feared social situations were fear of doing something in front of other people, followed by public speaking. Social phobia comorbid highly with depressive disorders, somatoform disorders and substance use disorders. Despite the high level of psychosocial impairment experienced by cases with social phobia and those with any social fears, only a small portion of them did receive professional help.     

Shyness: relationship to social phobia and other psychiatric disorders

The relationship between shyness, social phobia and other psychiatric disorders was examined. The prevalence of social phobia was significantly higher among shy persons (18%) compared with non-shy persons (3%). However, the majority of shy individuals (82%) were not socially phobic. A significant and positive correlation was found between the severity of shyness and the presence of social phobia, but the data suggest that social phobia is not merely severe shyness. Social phobia was also positively and moderately correlated with introversion and neuroticism. Thus, shy persons with social phobia were shyer, more introverted, and more neurotic than other shy people, but none of these factors was sufficient to distinguish shy persons with social phobia from those without social phobia. The proportion of the shy group with psychiatric diagnoses other than social phobia was significantly higher than among the non-shy group, indicating that various diagnostic categories are prominent among the shy. The results are discussed in terms of the overlap in shyness and social phobia and the relationship of shyness to other psychiatric diagnoses and personality dimensions.     

Social phobic interoception: effects of bodily information on anxiety, beliefs and self-processing

It has been suggested that body-state information influences self-perception and negative thinking in social phobia [Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment and treatment (pp. 69-93). New York: Guilford Press.]. This study explored the effects of body-state information on anxiety and cognition in patients with generalised social phobia during a feared social interaction. It was hypothesised that information concerning an increase in pulse rate would lead to increments in anxiety, negative beliefs and self-processing whilst information concerning a decrease in pulse rate would have the opposite effect. The results of this study were generally consistent with the hypotheses. These findings are important as they may help to account for fluctuations in anxiety, negative beliefs and self-processing in social situations that do not present objective social threat. In particular, social anxiety appears to be modulated by body-state information. The implications of the present findings for cognitive therapy of social phobia are briefly discussed.     

Virtual reality therapy versus cognitive behavior therapy for social phobia: a preliminary controlled study.

Social phobia is one of the most frequent mental disorders and is accessible to two forms of scientifically validated treatments: anti-depressant drugs and cognitive behavior therapies (CBT). In this last case, graded exposure to feared social situations is one of the fundamental therapeutic ingredients. Virtual reality technologies are an interesting alternative to the standard exposure in social phobia, especially since studies have shown its usefulness for the fear of public speaking. This paper reports a preliminary study in which a virtual reality therapy (VRT), based on exposure to virtual environments, was used to treat social phobia. The sample consisted of 36 participants diagnosed with social phobia assigned to either VRT or a group-CBT (control condition). The virtual environments used in the treatment recreate four situations dealing with social anxiety: performance, intimacy, scrutiny, and assertiveness. With the help of the therapist, the patient learns adapted cognitions and behaviors in order to reduce anxiety in the corresponding real situations. Both treatments lasted 12 weeks, and sessions were delivered according to a treatment manual. Results showed statistically and clinically significant improvement in both conditions. The effect-sizes comparing the efficacy of VRT to the control traditional group-CBT revealed that the differences between the two treatments are trivial.     

Patterns of anxious arousal during exposure to feared situations in individuals with social phobia

Behavioral assessment tests (BATs) are commonly used in studies of social phobia (SP). While previous studies have examined subjective anxiety during BATs, they have usually reported only mean or peak ratings. The current study examined whether there are different patterns of anxious arousal in anticipation of, and during exposure to, feared situations among individuals seeking treatment for SP (N = 153). A four cluster solution was judged to best describe the data, and the four clusters were labeled 'high anxiety,' 'increasing/high anxiety', 'moderate anxiety' and 'mild anxiety'. Before treatment, the cluster groups did not differ on person characteristics, subtype of social phobia, or levels of depressive symptoms. However, they did differ in terms of the severity of social phobia symptoms and the emotional valence of thoughts reported at the conclusion of the BAT. While members of all clusters benefited from cognitive-behavioral group therapy for social phobia, the clusters showed some differential response in amount of symptom reduction and likelihood of continuing to meet diagnostic criteria following treatment. The different emotional experiences of clients in the various clusters are explored and implications for cognitive-behavioral therapy are proposed. Finally, limitations of this study and future directions are discussed.     

Phenomenal characteristics of autobiographical memories for social and non-social events in social phobia

Previous studies failed to show clear differences between people with social phobia and non-anxious individuals regarding the specificity and affective intensity of their autobiographical memories for social events. However, these studies did not assess the subjective experience associated with remembering. In this study, people with social phobia and non-anxious control participants recalled social and non-social events, and rated the phenomenal characteristics of their memories. The memories of people with social phobia for social events contained fewer sensorial details but more self-referential information than controls' memories. In addition, people with social phobia remembered social situations from an observer perspective, viewing themselves as if from outside, to a greater extent than controls. By contrast, the two groups did not differ concerning their memories for non-social events. These findings are discussed in relation to cognitive models of social phobia.     

The effects of dropping in‐situation safety behaviors in the treatment of social phobia

Over the past years, important advances in the cognitive–behavioral treatment of social phobia have taken place. There is wide evidence that demonstrates exposure is an effective treatment for social phobia. However, some research has noticed that exposure has limitations in treating this disorder. In clinical practice we find patients who do not achieve marked reductions in anxiety using this technique. One of the mechanisms that can be involved is the use of in‐situation safety behaviors, which patients use to prevent the feared consequences in social situations. The aim of this study is to present a single case study where we compare the improvement achieved using exposure alone versus exposure dropping in‐situation safety behaviors. The social phobic patient improved significantly when exposure was combined with the drop of in‐situation safety behaviors. Copyright © 2003 John Wiley & Sons, Ltd.     

A New Model to Facilitate Individualized Case Conceptualization and Treatment of Social Phobia: An Examination and Reaction to Moscovitch's Model

Moscovitch's (2009) model of social phobia is put forth as an integration and extension of previous cognitive-behavioral models. The author asserts that his approach overcomes a number of shortcomings of previous models and will serve to better guide case conceptualization, treatment planning, and intervention implementation for clients with social phobia. Here I respond to these claims and examine the new and not-so-new aspects of Moscovitch's model. Moscovitch provides creative ways of thinking about feared stimuli and maladaptive methods for anxiety management used by clients with social phobia, and these notions may indeed expand our horizons, linking cognitive-behavioral thought to literatures on emotional suppression and emotion regulation. Other aspects of Moscovitch's thesis do provide heuristic and useful approaches to the assessment and treatment of social phobia which may be of great utility to the cognitive-behavioral clinician, but they do not provide a truly new approach to understanding the psychopathology or treatment of social phobia.     

Relations Among Symptoms of Social Phobia Subtypes, Avoidant Personality Disorder, Panic, and Depression

This study's primary goal was to examine relations between symptoms of specific social phobia (SSP), generalized social phobia (GSP), avoidant personality disorder (APD), and panic and depression. Past research has suggested a single social phobia continuum in which SSP displays less symptom severity than GSP or APD. We found SSP symptoms correlated less strongly with depression but more strongly with panic relative to both GSP and APD symptoms. These findings challenge a unidimensional model of social phobia, suggesting a multidimensional model may be more appropriate. These findings also inform current research aimed at classifying mood and anxiety disorders more broadly by identifying that the different factors of fear versus distress appear to underlie different subtypes of social phobia.     

Negative self‐imagery in social anxiety contaminates social interactions

Patients with social phobia report experiencing negative images of themselves performing poorly when in feared social situations. The present study investigates whether such negative self‐imagery (based on memory of past social situations) contaminates social interactions. High socially anxious volunteers participated in two conversations with another volunteer (conversational partner). During one conversation, the socially anxious volunteers held in mind a negative self‐image, and during the other they held in mind a less negative (control) self‐image. As predicted, when holding the negative image the socially anxious volunteers felt more anxious, reported using more safety behaviours, believed that they performed more poorly, and showed greater overestimation of how poorly they came across (relative to ratings by the conversational partner). Conversational partners rated the socially anxious volunteers' performance as poorer in the negative image condition. Furthermore, the conversation was contaminated since both groups of participants rated its quality as poorer in the negative image condition.     

Negative self-imagery in social anxiety contaminates social interactions

Patients with social phobia report experiencing negative images of themselves performing poorly when in feared social situations. The present study investigates whether such negative self-imagery (based on memory of past social situations) contaminates social interactions. High socially anxious volunteers participated in two conversations with another volunteer (conversational partner). During one conversation, the socially anxious volunteers held in mind a negative self-image, and during the other they held in mind a less negative (control) self-image. As predicted, when holding the negative image the socially anxious volunteers felt more anxious, reported using more safety behaviours, believed that they performed more poorly, and showed greater overestimation of how poorly they came across (relative to ratings by the conversational partner). Conversational partners rated the socially anxious volunteers' performance as poorer in the negative image condition. Furthermore, the conversation was contaminated since both groups of participants rated its quality as poorer in the negative image condition.     

Impaired positive inferential bias in social phobia

People with social phobia report anticipatory and retrospective judgments about social situations that appear consistent with a negative interpretative bias. However, it is not at all clear that biased interpretative inferences are made "on-line;" that is, at the time that ambiguous information is first encountered. In a previous study, volunteers who were anxious about interviews were found to lack the positive on-line inferential bias that was characteristic of nonanxious controls but also failed to show a bias favoring threatening inferences (C. R. Hirsch & A. Mathews, 1997). This finding was confirmed in the present study, in which social phobic patients showed no evidence of making on-line emotional inferences, in contrast with socially nonanxious controls who were again clearly biased in favor of positive inferences. The authors concluded that nonanxious individuals are characterized by a benign on-line inferential bias, but that this is impaired in people with social phobia.     

Role of social skills training in adolescents with social anxiety disorder

Background/Objective: Social skills training (SST) is frequently included in the treatment of social anxiety disorder (SAD) in both children and adolescents, although there is no empirical evidence to support it. Consequently, our objective is to study the role and effects of SST in the treatment of a sample of adolescents with SAD. Method: A total of 108 adolescents diagnosed with generalized social phobia were randomly assigned to two treatment conditions (with and without SST) and a control group waiting list (WLCG). The evaluation included self-report measures, observational tests and blind evaluators. Results: Both interventions significantly reduced the number of social situations feared/avoided with respect to the WLCG, which worsened. Likewise, both interventions were effective but the group with SST obtained better results in the post-test and follow-ups, as well as a lower dropout rate (6:1). Conclusions: The use of SST reduces the dropout rate of treated adolescents and increases the effectiveness of the Intervention Program for Adolescents with Social Phobia.     

Social Phobia and the Experience of Shame: Childhood Origins and Pastoral Implications

While social phobia is typically diagnosed in adolescence, the roots of social phobia are found in childhood experiences of shame. When shame occurs because of a failure to meet a child’s need this creates a fundamental uncertainty which can become internalized in the form of self-contempt. Emotions such as sadness are sometimes forbidden by caregivers, and the expression of natural sexual drives are sometimes prohibited. Such experiences create shame and may keep the person from feeling emotions and drives because shame has displaced the real emotion. The fractures in early relationships can be restored through the healing presence of another. The pastor has access to persons with social phobia who may not be willing to seek psychiatric care and is in a unique position to bring the resources of the church to bear in the lives of persons with social phobia. To do so, she moves away from the extroverted frame of reference within which the church frequently operates.Philip Browning Helsel, a graduate of Princeton Theological Seminary, serves as a Chaplain Resident in the Clinical Pastoral Education program at Yuma Regional Medical Center in, Yuma, AZ