Implicit associations in social anxiety disorder: The effects of comorbid depression

Implicit associations of the self to concepts like “calm” have been shown to be weaker in persons with social anxiety than in non-anxious healthy controls. However, other implicit self associations, such as those to acceptance or rejection, have been less studied in social anxiety, and none of this work has been conducted with clinical samples. Furthermore, the importance of depression in these relationships has not been well investigated. We addressed these issues by administering two Implicit Association Tests (IATs; Greenwald, McGhee, & Schwartz, 1998), one examining the implicit association of self/other to anxiety/calmness and the other examining the association of self/other to rejection/acceptance, to individuals with generalized social anxiety disorder (SAD, n = 85), individuals with generalized SAD and a current or past diagnosis of major depressive disorder or current dysthymic disorder (n = 47), and non-anxious, non-depressed healthy controls (n = 44). The SAD and SAD-depression groups showed weaker implicit self-calmness associations than healthy controls, with the comorbid group showing the weakest self-calmness associations. The SAD-depression group showed the weakest implicit self-acceptance associations; no difference was found between non-depressed individuals with SAD and healthy controls. Post hoc analyses revealed that differences appeared to be driven by those with current depression. The SAD-only and SAD-depression groups did not differ in self-reported (explicit) social anxiety. The implications of these findings for the understanding of SAD-depression comorbidity and for the treatment of SAD are considered.     

Reduction of depersonalization during social stress through cognitive therapy for social anxiety disorder: A randomized controlled trial

Symptoms of depersonalization during feared social situations are commonly experienced by individuals with social anxiety disorder (SAD). Despite its clinical relevance, it is not addressed in standard treatment manuals and it remains unclear if depersonalization is reduced by well-established treatments. This study investigated whether cognitive therapy (CT) for SAD effectively reduces depersonalization and whether pre-treatment severity of depersonalization predicts or mediates treatment outcome.In a randomized controlled trial, patients underwent the standardized Trier Social Stress Test before and after CT (n = 20) or a waitlist period (n = 20) and were compared to healthy controls (n = 21). Self-reported depersonalization was measured immediately after each stress test.Depersonalization significantly decreased following CT, especially in treatment responders (η_p² = 0.32). Pre-treatment depersonalization did neither predict nor mediate post-treatment severity of social anxiety.Further prospective studies are needed for a better scientific understanding of this effect. It should be scrutinized whether SAD-patients suffering from depersonalization would benefit from a more specific therapy.     

Psychometric evaluation of the Concerns of Social Reprisal Scale: Further explicating the roots of fear of positive evaluation

Fear of positive evaluation (FPE) has been proposed to be an important feature of social anxiety disorder (SAD) and to be rooted, at least partly, in concerns of social reprisal due to positive impressions. In order to formally test this hypothesis, the Concerns of Social Reprisal Scale (CSRS) was developed. The purpose of the present series of studies was to examine the psychometric profile of the CSRS across several independent samples including: a large (n = 981) undergraduate sample; a clinical sample of individuals diagnosed with social anxiety disorder (n = 27), and a demographically-matched subsample of healthy control participants (n = 24). The factorial validity, internal consistency, and construct validity of the CSRS were examined. Results across both studies provided support for the psychometric profile of the CSRS. The implications of concerns of social reprisal for the assessment of social anxiety symptoms, theoretical models of fear of evaluation and SAD, and their potential clinical utility with regard to treating SAD are discussed.     

Fearful responding to interoceptive exposure in social anxiety disorder

There is accumulating evidence suggesting that anxiety sensitivity (AS) may play a role in social anxiety disorder (SAD; e.g., Ball, Otto, Pollack, Uccello, & Rosenbaum, 1995). Precedent research has demonstrated the role of AS in panic disorder and posttraumatic stress disorder, and subsequently, treatment techniques aimed at reducing AS (i.e., interoceptive exposure (IE)) have been studied in these populations (Schmidt and Trakowski, 2004, Wald and Taylor, 2008). The purpose of this study was to examine the types of responses elicited during IE exercises among individuals with SAD. This study describes the responses of individuals with SAD (n = 37) and nonclinical control participants (n = 28) to six IE exercises. Significant differences in responses to the IE exercises were found between participants with SAD and nonclinical controls. However, there were no significant differences in responses to the exercises among persons with SAD, depending on whether the exercises were completed in private versus group settings. Similarity to symptoms during naturally occurring anxiety significantly predicted fearful responding across all exercises in persons with SAD. Implications and directions for future research are discussed.     

Perception matters for clinical perfectionism and social anxiety

Despite research documenting a relationship between social anxiety and perfectionism, very little research has examined the relationship between social anxiety and clinical perfectionism, defined as the combination of high personal standards and high maladaptive perfectionistic evaluative concern. In the current studies we examined whether clinical perfectionism predicted social anxiety in a large sample of undergraduates (N = 602), in a clinical sample of participants diagnosed with social anxiety disorder (SAD; N = 180), and by using a variance decomposition model of self- and informant-report of perfectionism (N = 134). Using self-report, we found that an interaction of personal standards and evaluative concern predicted both social interaction anxiety and fear of scrutiny, but not in the theorized direction. Specifically, we found that self-report of low standards and high evaluative concern was associated with the highest levels of social anxiety, suggesting that when individuals with SAD hold low expectations for themselves combined with high concerns about evaluation, social anxiety symptoms may increase. Alternatively, when an informants’ perspective was considered, and more consistent with the original theory, we found that the interaction of informant-only report of personal standards and shared-report (between both primary participant and informant) of concern over mistakes was associated with self-reported social anxiety, such that high concern over mistakes and high personal standards predicted the highest levels of social anxiety. Theoretical, clinical, and measurement implications for clinical perfectionism are discussed.     

Relative effects of cognitive and behavioral therapies on generalized anxiety disorder,social anxiety disorder and panic disorder: A meta-analysis

Although cognitive and behavioral therapies are effective in the treatment of anxiety disorders, it is not clear what the relative effects of these treatments are. We conducted a meta-analysis of trials comparing cognitive and behavioral therapies with a control condition, in patients with social anxiety disorder (SAD), generalized anxiety disorder (GAD) and panic disorder. We included 42 studies in which generic measures of anxiety were used (BAI, HAMA, STAI-State and Trait). Only the effects of treatment for panic disorder as measured on the BAI (13.33 points; 95% CI: 10.58–16.07) were significantly (p = 0.001) larger than the effect sizes on GAD (6.06 points; 95% CI: 3.96–8.16) and SAD (5.92 points; 95% CI: 4.64–7.20). The effects remained significant after adjusting for baseline severity and other major characteristics of the trials. The results should be considered with caution because of the small number of studies in many subgroups and the high risk of bias in most studies.     

Meta-analysis of technology-assisted interventions for social anxiety disorder

This meta-analysis investigated the efficacy of technology-assisted interventions for individuals with social anxiety disorder (SAD). A systematic literature search in the databases Medline, PsychInfo, and Web of Science revealed 37 randomized controlled trials (2991 participants) that were grouped into internet delivered cognitive behavior therapy (ICBT; 21 trials), virtual reality exposure therapy (VRET; 3 trials), and cognitive bias modification (CBM; 13 trials). Patients undergoing ICBT and VRET showed significantly less SAD symptoms at postassessment than passive control conditions (g = 0.84 and 0.82, respectively). Compared to active control conditions, ICBT had a small advantage (g = 0.38) and VRET showed comparable effects (p > 0.05). CBM was not more effective than passive control conditions, except when delivered in the laboratory (g = 0.35). While the efficacy of CBM was limited, substantial evidence for ICBT and preliminary evidence for VRET suggests that both can effectively reduce SAD symptoms indicating the potential of technology-assisted interventions for SAD.     

Anxiety trajectories in response to a speech task in social anxiety disorder: Evidence from a randomized controlled trial of CBT

The subjective experience of anxiety plays a central role in cognitive behavioral models of social anxiety disorder (SAD). However, much remains to be learned about the temporal dynamics of anxiety elicited by feared social situations. The aims of the current study were: (1) to compare anxiety trajectories during a speech task in individuals with SAD (n = 135) versus healthy controls (HCs; n = 47), and (2) to compare the effects of CBT on anxiety trajectories with a waitlist control condition. SAD was associated with higher levels of anxiety and greater increases in anticipatory anxiety compared to HCs, but not differential change in anxiety from pre- to post-speech. CBT was associated with decreases in anxiety from pre- to post-speech but not with changes in absolute levels of anticipatory anxiety or rates of change in anxiety during anticipation. The findings suggest that anticipatory experiences should be further incorporated into exposures.     

Developmental pathways of social avoidance across adolescence: The role of social anxiety and negative cognition

It is argued that the adolescent onset of social anxiety disorder (SAD) may be partly attributable to an increase in avoidance of social situations across this period. The current cohort-sequential study investigated developmental pathways of social avoidance in adolescence and examined the explanatory role of social anxiety and negative cognitive processes. A community sample of youth (9–21 years, N = 331) participated in a four-wave study. Trajectory analyses revealed two pathways: an increased avoidance pathway and a low avoidance pathway. The pathways were hardly distinguishable at age 9 and they steadily diverged across adolescence. Logistic regression analyses showed that social anxiety and post-event rumination were significantly related to the increased avoidance pathway; anticipatory processing and self-focused attention were not. The findings suggest that adolescence is a key developmental period for the progression of social avoidance among youth who show relatively high levels of social anxiety and post-event rumination.     

Social anxiety disorder and quality of life: How fears of negative and positive evaluation relate to specific domains of life satisfaction

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.     

The link between social anxiety disorder,treatment outcome,and sleep difficulties among patients receiving cognitive behavioral group therapy

ObjectiveThe aim of our study was to examine the association between sleep disturbances and social anxiety disorder (SAD). Another aim was to explore the impact of cognitive behavioral group therapy (CBGT) for SAD on co-occurring sleep difficulties.MethodsData were obtained retrospectively from patient files receiving CBGT for SAD. The sample included 63 patients with SAD (mean age, 30.42 years [standard deviation, 6.92 years]). There were 41 men and 22 women, of whom 41 participants completed the treatment protocol. Before treatment onset participants completed the Liebowitz Social Anxiety Scale (LSAS), the Beck Depression Inventory (BDI), the Pittsburgh Sleep Quality Index, and several sociodemographic questions. On completion of the treatment protocol, the same measures were completed, with the addition of the Sheehan Disabilities Scale (SDS).ResultsThe results of our study suggest that: (1) subjective insomnia is associated with SAD severity even after controlling for depression severity and additional variables; (2) participants with SAD with co-occurring clinical levels of subjective insomnia present a more severe clinical picture both at treatment onset and termination; and (3) although CBGT lead to reduction in SAD and depression symptoms severity, it had no significant impact on co-occurring sleep difficulties.ConclusionsSleep difficulties predict SAD severity regardless of depressive symptoms and may be linked to a more severe clinical picture. Clinicians should be aware of these sleep difficulties co-occurring with SAD and consider implementing specific sleep interventions. Future studies should incorporate larger samples sizes from clinical populations outside of Israel.     

The SPAI-18, a brief version of the Social Phobia and Anxiety Inventory: Reliability and validity in clinically referred and non-referred samples

We developed a new version of the Social Phobia and Anxiety Inventory (SPAI) in order to have a brief instrument for measuring social anxiety and social anxiety disorder (SAD) with a strong conceptual foundation. In the construction phase, a set of items representing 5 core aspects of social anxiety was selected by a panel of social anxiety experts. The selected item pool was validated using factor analysis, reliability analysis, and diagnostic analysis in a sample of healthy participants (N = 188) and a sample of clinically referred participants diagnosed with SAD (N = 98). This procedure resulted in an abbreviated version of the Social Phobia Subscale of the SPAI consisting of 18 items (i.e. the SPAI-18), which correlated strongly with the Social Phobia Subscale of the original SPAI (both groups r = .98). Internal consistency and diagnostic characteristics using a clinical cut-off score > 48 were good to excellent (Cronbach's alpha healthy group = .93; patient group = .91; sensitivity: .94; specificity: .88). The SPAI-18 was further validated in a community sample of parents-to-be without SAD (N = 237) and with SAD (N = 65). Internal consistency was again excellent (both groups Cronbach's alpha = .93) and a screening cut-off of >36 proved to result in good sensitivity and specificity. The SPAI-18 also correlated strongly with other social anxiety instruments, supporting convergent validity. In sum, the SPAI-18 is a psychometrically sound instrument with good screening capacity for social anxiety disorder in clinical as well as community samples.     

Guided and unguided Acceptance and Commitment Therapy for social anxiety disorder and/or panic disorder provided via the Internet and a smartphone application: A randomized controlled trial

Acceptance and Commitment Therapy (ACT) can be effective in treating anxiety disorders, yet there has been no study on Internet-delivered ACT for social anxiety disorder (SAD) and panic disorder (PD), nor any study investigating whether therapist guidance is superior to unguided self-help when supplemented with a smartphone application. In the current trial, n = 152 participants diagnosed with SAD and/or PD were randomized to therapist-guided or unguided treatment, or a waiting-list control group. Both treatment groups used an Internet-delivered ACT-based treatment program and a smartphone application. Outcome measures were self-rated general and social anxiety and panic symptoms. Treatment groups saw reduced general (d = 0.39) and social anxiety (d = 0.70), but not panic symptoms (d = 0.05) compared to the waiting-list group, yet no differences in outcomes were observed between guided and unguided interventions. We conclude that Internet-delivered ACT is appropriate for treating SAD and potentially PD. Smartphone applications may partially compensate for lack of therapist support.     

Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for Social Anxiety Disorder and comorbid disorders: A randomized controlled trial

Disorder-specific (DS-CBT) and transdiagnostic (TD-CBT) cognitive behaviour therapy have both been used to treat social anxiety disorder (SAD). This study compared internet-delivered DS-CBT and TD-CBT for SAD across clinician-guided (CG-CBT) and self-guided (SG-CBT) formats. Participants with SAD (n = 233) were randomly allocated to receive internet-delivered TD-CBT or DS-CBT and CG-CBT or SG-CBT. Large reductions in symptoms of SAD (Cohen’s d ≥ 1.01; avg. reduction ≥ 30%) and moderate-to-large reductions in symptoms of comorbid depression (Cohen’s d ≥ 1.25; avg. reduction ≥ 39%), generalised anxiety disorder (Cohen’s d ≥ 0.86; avg. reduction ≥ 36%) and panic disorder (Cohen’s d ≥ 0.53; avg. reduction ≥ 25%) were found immediately post-treatment and were maintained or further improved to 24-month follow-up. No marked differences were observed between TD-CBT and DS-CBT or CG-CBT and SG-CBT highlighting the potential of each for the treatment of SAD and comorbid disorders.     

Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized-controlled trials

Group psychotherapy for social anxiety disorder (SAD) is an established treatment supported by findings from primary studies and earlier meta-analyses. However, a comprehensive summary of the recent evidence is still pending. This meta-analysis investigates the efficacy of group psychotherapy for adult patients with SAD. A literature search identified 36 randomized-controlled trials examining 2171 patients. Available studies used mainly cognitive-behavioral group therapies (CBGT); therefore, quantitative analyses were done for CBGT. Medium to large positive effects emerged for wait list-controlled trials for specific symptomatology: g = 0.84, 95% CI [0.72; 0.97] and general psychopathology: g = 0.62, 95% CI [0.36; 0.89]. Group psychotherapy was also superior to common factor control conditions in alleviating symptoms of SAD, but not in improving general psychopathology. No differences appeared for direct comparisons of group psychotherapy and individual psychotherapy or pharmacotherapy. Hence, group psychotherapy for SAD is an efficacious treatment, equivalent to other treatment formats.     

Effect of quetiapine vs. placebo on response to two virtual public speaking exposures in individuals with social phobia

ObjectiveClinical practice and open-label studies suggest that quetiapine (an atypical anti-psychotic) might improve symptoms for individuals with social anxiety disorder (SAD). The purpose of this study was to provide a rigorous test of the acute impact of a single dose of quetiapine (25 mg) on SAD symptoms.MethodIndividuals with SAD (N = 20) were exposed to a 4-min virtual reality (VR) public speaking challenge after having received quetiapine or placebo (double-blind) 1 h earlier. A parallel VR challenge occurred 1 week later using a counter-balanced cross-over (within subject) design for the medication-placebo order between the two sessions.ResultThere was no significant drug effect for quetiapine on the primary outcome measures. However, quetiapine was associated with significantly elevated heart rate and sleepiness compared with placebo.ConclusionStudy findings suggest that a single dose of 25 mg quetiapine is not effective in alleviating SAD symptoms in individuals with fears of public speaking.     

Why not the best? Social anxiety symptoms and perfectionism among Israeli Jews and Arabs: a comparative Study

BackgroundSocial Anxiety Disorder (SAD) has been repeatedly shown to be very prevalent in the Western society and is characterized by low self-esteem, pessimism, procrastination and also perfectionism. Very few studies on SAD have been done in the Middle East or in Arab countries, and no study tackled the relationship between social anxiety symptoms and perfectionism in non-Western samples.MethodsWe examined social anxiety symptoms and perfectionism in a group of 132 Israeli Jewish (IJ) and Israeli Arab (IA) students. Subjects completed the Liebowitz Social Anxiety Scale (LSAS), the Multidimensional Perfectionism Scale (MPS), the Negative Automatic Thoughts Questionnaire (ATQ-N), the Positive Automatic Thoughts Questionnaire (ATQ-P) and a socio-demographic questionnaire.ResultsThe rate of SAD in our sample according to a LSAS score of 60 or more was 17.2% (IJ = 13.8%, IA = 19%, ns). The correlation between perfectionism and the LSAS was high in both groups, and in particular in the IJ group. The IA group had higher scores of social avoidance, of ATQ-P and of two of the MPS subscales: parental expectations and parental criticism. Concern over mistakes and negative automatic thoughts positively predicted social fear in the IJ group, whereas in the IA group being female, religious and less educated positively predicted social fear. Negative automatic thoughts and age positively predicted social avoidance in the IJ group. In general, the IJ and IA subjects showed higher social anxiety, higher ATQ-N scores and lower parental expectations as compared with non-clinical US samples.ConclusionsSocial anxiety symptoms and perfectionism are prevalent in Arab and Jewish students in Israel and seem to be closely related. Further studies among non-western minority groups may detect cultural influences on social anxiety and might add to the growing body of knowledge on this intriguing condition.     

Unique relations among anxiety sensitivity factors and anxiety,depression, and suicidal ideation

Anxiety sensitivity (AS) is composed of three lower-order dimensions, cognitive concerns, physical concerns, and social concerns. We examined the relations between AS dimensions using a more adequate assessment of subscales (ASI-3) than has previously been used, and measures of anxiety and mood disorders as well as suicidal ideation in a sample of 256 (M age = 37.10 years, SD = 16.40) treatment-seeking individuals using structural equation modeling. AS cognitive concerns was uniquely associated with generalized anxiety disorder (GAD), obsessive–compulsive disorder (OCD), major depressive disorder (MDD), post-traumatic stress disorder (PTSD), and suicidal ideation. AS physical concerns was uniquely associated with OCD, social anxiety disorder (SAD), panic disorder (PD), and specific phobia. AS social concerns was uniquely associated with SAD, GAD, OCD, and MDD. These results highlight the importance of considering the lower-order AS dimensions when examining the relations between AS and psychopathology.