Social rank and affiliation in social anxiety disorder

The present study examined the interpersonal lives of individuals with social anxiety disorder (SAD). According to evolutionary and interpersonal theories, we construed the interpersonal world using the social rank and the affiliation psychological systems. Two studies assessed measures of social rank, affiliation, social anxiety and depression among a population of treatment-seeking individuals with SAD. In study 1, individuals with SAD without major depressive disorder (MDD; n=42) were compared to healthy controls (n=47). In study 2, individuals with SAD and MDD (n=45) were compared to individuals with other anxiety disorders and MDD (n=31). Results indicated that SAD was related to perceiving oneself as having low social rank, being inferior, and behaving submissively, as well as to low perceived intimacy and closeness among peer relations, friendships and romantic relations. SAD was distinctly associated with these perceptions above and beyond the symptomatic (study 1) and the syndrome-level (study 2) effects of depression. These findings were further supported by a path analysis of the SAD participants from both studies. Our findings highlight the need to address both social rank and affiliation issues in the assessment and treatment of SAD.     

Cognitive Behavioral Therapy for Social Anxiety Disorder: Predictors of Treatment Outcome in a Quasi-Naturalistic Setting

We examined the outcomes of individual cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) in a sample of 93 adults seeking treatment in a university outpatient clinic specializing in CBT for SAD. Treatment followed the structure of a manual, but number of sessions varied according to client needs. After approximately 20 weeks of therapy, patients’ social anxiety had decreased and their quality of life had increased. Patients with more severe SAD or comorbid major depressive disorder (MDD) at pretreatment demonstrated higher levels of social anxiety averaged across pre- and posttreatment. However, clinician-rated severity of SAD, comorbid MDD, or comorbid generalized anxiety disorder did not predict treatment outcome. Higher pretreatment scores on measures of safety behaviors and cognitive distortions were associated with higher social anxiety averaged across pre- and posttreatment and predicted greater decreases from pre- to posttreatment on multiple social anxiety outcome measures. We found no predictors of change in quality of life. Those with high levels of safety behaviors and distorted cognitions may benefit more from CBT, perhaps due to its emphasis on targeting avoidance through exposure and changing distorted thinking patterns through cognitive restructuring methods. Our study lends support to the body of research suggesting that manualized CBT interventions can be applied flexibly in clinical settings with promising outcomes for patients over a relatively short course of therapy.     

Cognitive Factors that Maintain Social Anxiety Disorder: a Comprehensive Model and its Treatment Implications

Social anxiety disorder (SAD) is a common, distressing and persistent mental illness. Recent studies have identified a number of psychological factors that could explain the maintenance of the disorder. These factors are presented here as part of a comprehensive psychological maintenance model of SAD. This model assumes that social apprehension is associated with unrealistic social standards and a deficiency in selecting attainable social goals. When confronted with challenging social situations, individuals with SAD shift their attention toward their anxiety, view themselves negatively as a social object, overestimate the negative consequences of a social encounter, believe that they have little control over their emotional response, and view their social skills as inadequate to effectively cope with the social situation. In order to avoid social mishaps, individuals with SAD revert to maladaptive coping strategies, including avoidance and safety behaviors, followed by post‐event rumination, which leads to further social apprehension in the future. Possible disorder‐specific intervention strategies are discussed.     

Motives and Consequences of Alcohol Use in People With Social Anxiety Disorder: A Daily Diary Study

People with social anxiety disorder (SAD) are at increased risk for alcohol-related problems. Most research exploring social anxiety and alcohol use has examined negative drinking consequences, with less consideration of positive consequences—namely positive social experiences—that may reinforce alcohol use. In this daily diary study, we examined how adults diagnosed with SAD (N = 26) and a psychologically healthy control group (N = 28) experienced positive drinking consequences in naturally occurring drinking episodes during the study period. For 14 consecutive days, participants answered questions about alcohol use, motives for drinking, and positive consequences of drinking. On days when participants drank, those with SAD were more likely than healthy controls to perceive a reduction in anxiety, but the two groups did not differ in their likelihood of experiencing positive social drinking consequences. For both groups, on days when they were more motivated to drink to enhance social experiences (affiliation motives) or cope with distress (coping motives), they were more likely to obtain positive consequences from drinking. Compared to controls, participants with SAD endorsed stronger trait and daily coping motives (anxiety-coping, social anxiety-coping, and depression-coping). Results are discussed in the context of reinforcement mechanisms that may maintain social anxiety and alcohol use.     

Daily emotional dynamics in depressed youth: a cell phone ecological momentary assessment study

This study used a new cell phone ecological momentary assessment approach to investigate daily emotional dynamics in 47 youths with major depressive disorder (MDD) and 32 no-psychopathology controls (CON) (ages 7-17 years). Information about emotional experience in the natural environment was obtained using answer-only cell phones, while MDD youths received an 8-week course of cognitive behavioral therapy and/or psychopharmacological treatment. Compared with CON youths, MDD youths reported more intense and labile global negative affect; greater sadness, anger, and nervousness; and a lower ratio of positive to negative affect. These differences increased with pubertal maturation. MDD youths spent more time alone and less time with their families than CON youths. Although differences in emotional experiences were found across social contexts, MDD youths were more negative than CON youths in all contexts examined. As the MDD participants progressed through treatment, diagnostic group differences in the intensity and lability of negative affect decreased, but there were no changes in the ratio of positive to negative affect or in measures of social context. We discuss methodological innovations and advantages of this approach, including improved ecological validity and access to information about variability in emotions, change in emotions over time, the balance of positive and negative emotions, and the social context of emotional experience.     

Emotion Differentiation as a Protective Factor Against the Behavioral Consequences of Rumination: A Conceptual Replication and Extension in the Context of Social Anxiety

Rumination is thought to play a central role in affective disorders such as social anxiety disorder (SAD). Past research indicates that rumination tends to exacerbate negative emotions and increase the risk of engaging in maladaptive coping behaviors (e.g., avoiding social activities). However, little is known on how to effectively protect against the negative outcomes of rumination. Previously, Zaki, Coifman, Rafaeli, Berenson, and Downey (2013) found that negative emotion differentiation (NED) protected against rumination and nonsuicidal self-injury in borderline personality disorder. Nevertheless, it is unclear whether this protective effect would extend to other populations and behaviors. Therefore, the present investigation sought to replicate and extend Zaki et al.’s (2013) findings in the context of SAD. In two studies, we examined if NED would moderate the positive association between rumination and frequency of social avoidance. Study 1 involved 29 individuals who met criteria for SAD with or without co-occurring major depressive episode, while Study 2 involved a nonclinical sample of 190 college students. All participants completed a measure of rumination and an experience-sampling diary which provided indices of NED and social avoidance. The results from both studies were unanimous: NED significantly moderated the relationship between rumination and social avoidance such that the positive association between rumination and social avoidance was significant for low but not moderate to high NED. Overall, the findings provide a conceptual replication of Zaki et al. (2013) and further evidence for the protective effects of NED against the maladaptive behavioral consequences of rumination across populations.     

Social Anxiety Disorder and Social Support Behavior in Friendships

Relationship quality is a strong predictor of health outcomes, and individuals with social anxiety disorder (SAD) report increased interpersonal impairment. However, there are few studies testing the effect of SAD on friendships and it is thus unclear whether there are behavioral differences that distinguish friendships in which a target individual has SAD from friendships in which the target individual does not have SAD. We tested for differences in the provision and receipt of support behaviors as a function of having a SAD diagnosis and accounting for comorbid depressive symptoms. Participants with SAD (n = 90) and their friends engaged in support conversations that were coded using the Social Support Interaction Coding System. Structural equation modeling revealed some differences between participants and friends when accounting for depression. Specifically, friends of participants with SAD and comorbid depression engaged in fewer positive helper behaviors than the friends of participants who did not have SAD or comorbid depression. Additionally, dyads in which the primary participant had SAD engaged in more off-task behaviors. Results suggest that SAD does not result in global interpersonal impairment, but that receipt of positive support behaviors from friends may differ as a function of SAD and comorbid depression. Interpersonal interventions aimed at increasing adaptive friendships and aspects of CBT that target subtle avoidance (e.g., safety behaviors) may be useful in facilitating more satisfactory relationships for these individuals.     

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.     

Safety Behaviors in Adults With Social Anxiety: Review and Future Directions

Safety behaviors are considered an important factor in the maintenance of social anxiety disorder (SAD). Safety behaviors are typically employed by socially anxious individuals to reduce anxiety in feared social situations. However, by preventing individuals with social anxiety from gathering evidence that would disconfirm their maladaptive beliefs about social situations, the use of safety behaviors ultimately maintains social anxiety over time. Twenty years ago, Wells and colleagues (1995) demonstrated that use of safety behaviors diminishes the efficacy of exposure treatment for SAD, suggesting that reduction in the use of safety behaviors during exposure can enhance treatment response. Research on safety behaviors has expanded considerably since Wells et al.’s seminal publication, and our understanding of the role safety behaviors may play in the maintenance of social anxiety has grown in breadth and depth. In this paper, we present a detailed review of the published research on safety behaviors relevant to social anxiety and social-anxiety-related processes. Finally, we evaluate the impact of safety behaviors on the outcome of treatment for SAD, and we look to the literature on safety behaviors in other anxiety disorders to inform our understanding of use of safety behaviors during exposure and to facilitate future research in SAD.     

Psychometric Evaluation of a Controlled Social Affiliation Paradigm: Findings From Anxiety,Depressive Disorder,and Healthy Samples

Social impairments are common across many psychiatric conditions. Standardized dyadic assessments intended to elicit social affiliation between unacquainted partners are used to elucidate mechanisms that disrupt relationship formation and inform possible treatment targets; however, the psychometric properties of such paradigms remain poorly understood. This study evaluated the psychometric properties of a controlled social affiliation paradigm intended to induce connectedness between a target participant and trained confederate. Individuals with an anxiety or depressive disorder diagnosis (clinical group; n = 132) and those without (control group; n = 35) interacted face-to-face with a trained confederate; partners took turns answering a series of increasingly intimate questions about themselves. Social connectedness, affect, and affiliative behavior measures were collected during the interaction. Participant symptom and social functioning measures were collected to examine validity. The paradigm elicited escalating social connectedness throughout the task for both participants and confederates. Parallel forms (i.e., different question sets) elicited similar affiliation outcomes. Self-reported (but not behavioral) affiliation differed across some demographic variables (e.g., participant gender, Hispanic ethnicity). Within-task affiliation measures were associated with one another and with global social connectedness and social anxiety symptom measures, but not with somatic anxiety measures. Clinical participants reported lower social affiliation and positive affect reactivity and higher negative affect reactivity than healthy participants. These findings provide initial psychometric support for a standardized and controlled dyadic affiliation paradigm that could be used to reliably probe social disconnection mechanisms across psychopathology.     

To see ourselves as others see us: an experimental integration of the intra and interpersonal consequences of self-protection in social anxiety disorder

The current study investigated the mechanism through which safety behaviors perpetuate perceived and actual negative social outcomes hypothesized to maintain social anxiety disorder (SAD). Eighty individuals diagnosed with generalized SAD took part in a "getting acquainted" conversation with a trained experimental confederate. Participants were then randomly assigned to either a safety behavior reduction plus exposure condition (SB + EXP) or a graduated exposure (EXP) control condition and completed a 2nd conversation with the same interaction partner. Mediation analyses revealed that participants instructed to reduce their idiosyncratic safety behaviors displayed significantly greater increases in both perceived and actual positive interpersonal outcomes relative to the EXP group. However, whereas the safety behavior manipulation influenced participants' appraisals of their partner's reaction to them through reducing self-judgments about the visibility of anxiety-related behaviors, in reality, the SB + EXP group elicited more positive partner reactions because they displayed a greater increase in social approach behavior. Thus, although both parties recognized positive changes in the social exchange following the safety behavior manipulation, different sources of social information accounted for participant versus partner interpersonal judgments. The current findings point to the potential value of considering both the intra and interpersonal consequences of safety behaviors in SAD.     

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.     

Theory of Mind Impairments in Social Anxiety Disorder

Social anxiety disorder (SAD) is a common psychiatric disorder characterized by a persistent, excessive fear and avoidance of social and performance situations. Research on cognitive biases indicates individuals with SAD may lack an accurate view of how they are perceived by others, especially in social situations when they allocate important attentional resources to monitoring their own actions as well as external threat. In the present study, we explored whether socially anxious individuals also have impairments in theory of mind (ToM), or the ability to comprehend others’ mental states, including emotions, beliefs, and intentions. Forty socially anxious and 40 non-socially-anxious comparison participants completed two ToM tasks: the Reading the Mind in the Eyes and the Movie for the Assessment of Social Cognition. Participants with SAD performed worse on ToM tasks than did non-socially-anxious participants. Relative to comparison participants, those with SAD were more likely to attribute more intense emotions and greater meaning to what others were thinking and feeling. These group differences were not due to interpretation bias. The ToM impairments in people with SAD are in the opposite direction of those in people with autism spectrum conditions whose inferences about the mental states of other people are absent or very limited. This association between SAD and ToM may have important implications for our understanding of both the maintenance and treatment of social anxiety disorder.     

Self-focused attention and safety behaviors across group therapies for social anxiety disorder

Background: Self-focused attention (SFA) and safety behaviors are two variables implicated in the maintenance of social anxiety disorder (SAD).

Design: The present study examined SFA and safety behaviors across two therapies for SAD, cognitive behavioral group therapy (CBGT) and mindfulness and acceptance-based group therapy (MAGT).

Method: Participants with symptoms meeting criteria for SAD (N?=?137) were randomly assigned to the 12-week-treatment groups (n?=?53 for each condition) or a waitlist control (n?=?31). Variables were assessed at baseline, midtreatment, posttreatment, and a 3-month follow-up.

Results: Both treatment conditions reported significantly lower SFA and safety behaviors compared to control, but did not differ from one another at posttreatment. Mediation analyses supported the following models: (1) safety behaviors mediating the relationship between SFA and social anxiety, and (2) SFA mediating the relationship between safety behaviors and social anxiety. These models were supported for both treatment groups.

Conclusions: Both treatments may have the potential to reduce the SFA and safety behaviors that serve to maintain SAD.     

Look at me, I'm happy and creative: The effect of impression management on behavior in social presence

The present research tested competing approaches to individual differences in impression management (as measured with social desirability scales) and their implication for behavior in social contexts. A defensiveness approach argues that impression management is a source of defensive self-presentation, which causes performance impairment in public social settings. The competing adjustment approach argues that impression management measures friendliness and self-control, which should bring about performance facilitation in public social settings. To decide between these approaches, two experiments utilized a social facilitation paradigm, whereby task performance was compared between an alone and a public condition. The results supported the predictions of the adjustment approach. Across different tasks, a high impression management score was associated with performance facilitation in social presence, expressed in greater creativity, positive implicit affect, and high self-control. The results reveal previously unnoticed constructive effects of impression management, supporting the reframing of the trait as reflecting interpersonally oriented self-control.     

Linguistic correlates of social anxiety disorder

The goal of this study was to examine the linguistic correlates of social anxiety disorder (SAD). Twenty-four individuals with SAD (8 of them with a generalised subtype) and 21 non-anxious controls were asked to give speeches in front of an audience. The transcribed speeches were examined for the frequency of negations, I-statements, we-statements, negative emotion words, and positive emotion words. During their speech, individuals with either SAD subtype used positive emotion words more often than controls. No significant differences were observed in the other linguistic categories. These results are discussed in the context of evolutionary and cognitive perspectives of SAD.     

Effect of affect on social cost bias in social anxiety disorder

Abstract

The cognitive model of social anxiety disorder (SAD) assumes that cognitive biases are important maintaining factors of the disorder. Research and theory have highlighted the impact of cognitive self-regulatory processes on affect, but have not sufficiently focused on the influence of affect on self-regulatory cognitions. The present study examined the influence of affect on cognitive self-regulatory mechanisms in SAD by focusing on one critical cognitive bias, estimated social cost. Individuals with SAD (N=48) and non-anxious controls (N=48) were randomly assigned to one of three experimental, affect induction conditions (negative, positive, or neutral) before giving a 10-minute impromptu, videotaped speech. As expected, the affect manipulation resulted in changes in estimated social cost. However, this effect was not specific to individuals with SAD. Participants in the positive affect condition in both groups had the highest social cost estimates post-speech challenge. These results suggest that social cost bias is dependent on the affective state in both individuals with SAD and controls.     

Randomized controlled trial of false safety behavior elimination therapy: a unified cognitive behavioral treatment for anxiety psychopathology

We tested the efficacy of a unified cognitive-behavioral therapy protocol for anxiety disorders. This group treatment protocol, termed false safety behavior elimination therapy (F-SET), is a cognitive-behavioral approach designed for use across various anxiety disorders such as panic disorder (PD), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). F-SET simplifies, as well as broadens, key therapeutic elements of empirically validated treatments for anxiety disorders to allow for easier delivery to heterogeneous groups of patients with anxiety psychopathology. Patients with a primary anxiety disorder diagnosis (N=96) were randomly assigned to F-SET or a wait-list control. Data indicate that F-SET shows good efficacy and durability when delivered to mixed groups of patients with anxieties (i.e., PD, SAD, GAD) by relatively inexperienced clinicians. Findings are discussed in the context of balancing treatment efficacy and clinical utility.     

Cognitive factors that maintain social anxiety disorder: a comprehensive model and its treatment implications

Social anxiety disorder (SAD) is a common, distressing and persistent mental illness. Recent studies have identified a number of psychological factors that could explain the maintenance of the disorder. These factors are presented here as part of a comprehensive psychological maintenance model of SAD. This model assumes that social apprehension is associated with unrealistic social standards and a deficiency in selecting attainable social goals. When confronted with challenging social situations, individuals with SAD shift their attention toward their anxiety, view themselves negatively as a social object, overestimate the negative consequences of a social encounter, believe that they have little control over their emotional response, and view their social skills as inadequate to effectively cope with the social situation. In order to avoid social mishaps, individuals with SAD revert to maladaptive coping strategies, including avoidance and safety behaviors, followed by post-event rumination, which leads to further social apprehension in the future. Possible disorder-specific intervention strategies are discussed.