Information processing in social phobia: a critical review

Attention bias modification for anxiety and phobias: current status and future directions

Attention bias modification (ABM) was introduced over a decade ago as a computerized method of manipulating attentional bias and has been followed by intense interest in applying ABM for clinical purposes. While meta-analyses support ABM as a method of modifying attentional biases and reducing anxiety symptoms, there have been notable discrepancies in findings published within the last several years. In this review, we comment on recent research that may help explain some of the inconsistencies across ABM studies. More relevant to the future of ABM research, we highlight areas in which continuing research is needed. We suggest that ABM appears to be a promising treatment for anxiety disorders, but relative to other interventions, ABM is in its infancy. Thus, research is needed in order to improve ABM as a clinical treatment and advance the psychological science of ABM.

Threat processing in generalized social phobia: an investigation of interpretation biases in ambiguous facial affect

Facial affect is one of the most important information sources during the course of social interactions, but it is susceptible to distortion due to the complex and dynamic nature. Socially anxious individuals have been shown to exhibit alterations in the processing of social information, such as an attentional and interpretative bias toward threatening information. This may be one of the key factors contributing to the development and maintenance of anxious psychopathology. The aim of the current study was to investigate whether a threat-related interpretation bias is evident for ambiguous facial stimuli in a population of individuals with a generalized Social Anxiety Disorder (gSAD) as compared to healthy controls. Participants judged ambiguous happy/fearful, angry/fearful and angry/happy blends varying in intensity and rated the predominant affective expression. The results obtained in this study do not indicate that gSAD is associated with a biased interpretation of ambiguous facial affect.

Effects of standard and explicit cognitive bias modification and computer-administered cognitive-behaviour therapy on cognitive biases and social anxiety

BACKGROUND AND OBJECTIVES

This study examines the effects of a single session of Cognitive Bias Modification to induce positive Interpretative bias (CBM-I) using standard or explicit instructions and an analogue of computer-administered CBT (c-CBT) program on modifying cognitive biases and social anxiety.

METHODS

A sample of 76 volunteers with social anxiety attended a research site. At both pre- and post-test, participants completed two computer-administered tests of interpretative and attentional biases and a self-report measure of social anxiety. Participants in the training conditions completed a single session of either standard or explicit CBM-I positive training and a c-CBT program. Participants in the Control (no training) condition completed a CBM-I neutral task matched the active CBM-I intervention in format and duration but did not encourage positive disambiguation of socially ambiguous or threatening scenarios.

RESULTS

Participants in both CBM-I programs (either standard or explicit instructions) and the c-CBT condition exhibited more positive interpretations of ambiguous social scenarios at post-test and one-week follow-up as compared to the Control condition. Moreover, the results showed that CBM-I and c-CBT, to some extent, changed negative attention biases in a positive direction. Furthermore, the results showed that both CBM-I training conditions and c-CBT reduced social anxiety symptoms at one-week follow-up.

LIMITATIONS

This study used a single session of CBM-I training, however multi-sessions intervention might result in more endurable positive CBM-I changes.

CONCLUSIONS

A computerised single session of CBM-I and an analogue of c-CBT program reduced negative interpretative biases and social anxiety.

Hypervigilance and avoidance in visual attention in children with social phobia

BACKGROUND AND OBJECTIVES

Attentional bias towards threat in socially anxious adults is well documented; however, research on this bias in children with social phobia is rather scarce. The present study investigates whether the hypervigilance-avoidance hypothesis also applies to children with social phobia.

METHODS

Thirty children (aged 8-12) with social phobia and 43 control children participated in an eye-tracking experiment while their attentional distribution was recorded. Social anxiety was induced in half of the children before the eye-tracking task. Stimuli were presented for 3000 ms, and bias scores for initial fixations and the time span of attention were assessed.

RESULTS

Results indicated initial vigilance towards angry faces for all children independent of anxiety induction, while hypervigilance (but not avoidance) was only established in children with social phobia for angry-neutral face pairs and with social fears induced. Self-report measures of anxiety correlated with bias towards threat with more pronounced associations occurring in the anxiety induction condition.

LIMITATIONS

We did not record reaction times simultaneously which limits the opportunity to compare our results to some previous studies which focused on this variable as an indicator of attention.

CONCLUSIONS

Cognitive biases in elementary school children (between 8 and 12 years) relate to hypervigilant rather than to avoidant information processing. Attentional distribution varies over time. Differences between clinical anxious and healthy children seem to be modified by anxiety induction, symptom severity and contextual stimuli, such as the emotional valence of a face and the context in which the threat stimulus appears.

Altered emotion processing circuits during the anticipation of emotional stimuli in women with borderline personality disorder

Borderline personality disorder (BPD) is associated with disturbed emotion processing, typically encompassing intense and fast emotional reactions toward affective stimuli. In this study, we were interested in whether emotional dysregulation in BPD occurs not only during the perception of emotional stimuli, but also during the anticipation of upcoming emotional pictures in the absence of concrete stimuli. Eighteen female patients with a diagnosis of BPD and 18 healthy control subjects anticipated cued visual stimuli with prior known emotional valence or prior unknown emotional content during functional magnetic resonance imaging. Brain activity during the anticipation of emotional stimuli was compared between both groups. When anticipating negative pictures, BPD patients demonstrated less signal change in the left dorsal anterior cingulate cortex (dACC) and left middle cingulate cortex (MCC), and enhanced activations in the left pregenual ACC, left posterior cingulate cortex (PCC) as well as in left visual cortical areas including the lingual gyrus. During the anticipation of ambiguously announced stimuli, brain activity in BPD was also reduced in the left MCC extending into the medial and bilateral dorsolateral prefrontal cortex. Results point out that deficient recruitment of brain areas related to cognitive-emotional interaction already during the anticipation phase may add to emotional dysregulation in BPD. Stronger activation of the PCC could correspond to an increased autobiographical reference in BPD. Moreover, increased preparatory visual activity during negative anticipation may contribute to hypersensitivity toward emotional cues in this disorder.

Body image in social anxiety disorder, obsessive-compulsive disorder, and panic disorder

Body dysmorphic disorder falls under the category of obsessive-compulsive and related disorders, yet research has suggested it may also be highly associated with social anxiety disorder. The current study examined body image variables among 68 outpatients with primary obsessive-compulsive disorder (OCD; n=22), social anxiety disorder (SAD; n=25), and panic disorder (PD; n=21). Participants filled out self-report measures of body image disturbance, attitudes toward one's appearance, and anxiety. Body image disturbance and attitudes toward appearance did not significantly differ between the groups. However, SAD symptoms predicted body image disturbance, Appearance Evaluation and Body Areas Satisfaction, and OCD symptoms predicted Appearance Orientation. These findings suggest that SAD and OCD may be associated with different facets of body image. Implications for the treatment of anxiety disorders and for future research are discussed.

The Effects of Approach-Avoidance Modification on Social Anxiety Disorder: A Pilot Study

Cognitive bias modification has recently been discussed as a possible intervention for mental disorders. A specific form of this novel treatment approach is approach-avoidance modification. In order to examine the efficacy of approach-avoidance modification for positive stimuli associated with social anxiety, we recruited 43 individuals with social anxiety disorder and randomly assigned them to a training (implicit training to approach smiling faces) or a control (equal approach and avoidance of smiling faces) condition in three sessions over the course of a one-week period. Dependent measures included clinician ratings, self-report measures of social anxiety, and overt behavior during behavioral approach tasks. No group differences in any of the outcome measures were observed after training. In addition, while individuals in the training group showed increased approach tendency in one of the sessions, this effect was inconsistent across the three sessions and did not result in long-term changes in implicit approach tendencies between the groups over the course of the entire study. These results suggest that approach-avoidance modification might result in short-lasting effects on implicit approach tendencies towards feared positive stimuli, but this modification may not result in meaningful behavioral change or symptom reduction in individuals with social anxiety disorder.

Social anxiety is associated with general but not specific biases in emotion recognition

Misreading facial expressions as signals of social disapproval, such as anger and disgust, may maintain social anxiety. If so, manipulating face processing could be therapeutic. It remains unclear, however, whether socially anxious individuals are in fact more sensitive to disapproving emotions. We assessed decoding of, and cost attributions to, emotional expressions in high and low socially anxious females (n=102) using five emotions (anger, disgust, fear, happiness, and sadness) expressed at 15 intensities (9-65%), providing 75 stimuli (see Supplementary Material). The decoding task briefly presented the stimuli and participants identified the emotion. The cost attribution task asked individuals to rate each stimulus for how costly it would be for them to interact with the person. Random effects regression indicated that social anxiety was not associated with overall decoding accuracy but was associated with a response bias. High socially anxious individuals had a lower threshold for decoding emotions but also more frequently classified low intensity emotions incorrectly. These effects were not emotion-specific. Socially anxious individuals also attributed excessive social cost to expressions of negative valence. Our results provide a novel conceptual framework for understanding emotion decoding in social anxiety, indicating the importance of considering both accuracy and response bias.

Cognitive processes as mediators of the relation between mindfulness and change in social anxiety symptoms following cognitive behavioral treatment

The present study examined whether pretreatment mindfulness exerts an indirect effect on outcomes following cognitive-behavioral therapy (CBT). Cognitive processes of probability and cost bias (i.e., overestimations of the likelihood that negative social events will occur, and that these events will have negative consequences when they do occur) were explored as potential mediators of the relation between mindfulness and social anxiety symptom change. People with higher levels of mindfulness may be better able to benefit from treatments that reduce biases because mindfulness may aid in regulation of attention. Sixty-seven individuals with a primary diagnosis of social phobia identifying public speaking as their greatest fear received eight sessions of one of two types of exposure-based CBT delivered according to treatment manuals. Participants completed self-report measures of mindfulness, probability bias, cost bias, and social anxiety symptoms. Mediation hypotheses were assessed by a bootstrapped regression using treatment outcome data. Pretreatment mindfulness was not related to change in social anxiety symptoms from pre- to posttreatment. However, mindfulness had an indirect effect on treatment outcome via its association with probability bias, but not cost bias, at midtreatment. These findings were consistent across three metrics of social anxiety symptoms. Mindfulness may play a role in response to CBT among individuals with social phobia through its relation with probability bias--even when the treatment does not target mindfulness.

Maladaptive cognitive appraisals in children with high-functioning autism: associations with fear, anxiety and theory of mind

Despite the well-documented success of cognitive restructuring techniques in the treatment of anxiety disorders, there is still little clarity on which cognitions underpin fear and anxiety in children with high-functioning autism spectrum disorder. This study examined whether certain cognitive appraisals, known to be associated with fear and anxiety in typically developing groups, may help explain these emotions in children with high-functioning autism spectrum disorder. It also investigated relations between these cognitive appraisals and theory of mind. Appraisals, fear and anxiety were assessed using a vignette approach in 22 children with high-functioning autism spectrum disorders and 22 typically developing children. The two groups differed significantly on all four appraisal types. Anxiety was negatively correlated with future expectancy and positively with problem-focused coping potential in the high-functioning autism spectrum disorder group but was not correlated with appraisals in the typically developing group. The two appraisals associated with fear were emotion-focused coping potential (in the high-functioning autism spectrum disorder group only) and self-accountability (in the typically developing group only). Linear regression analysis found that appraisals of emotion-focused coping potential, problem-focused coping potential and future expectancy were significant predictors of theory-of-mind ability in the high-functioning autism spectrum disorders group. These findings indicate that specific, problematic patterns of appraisal may characterise children with high-functioning autism spectrum disorders.

Attentional bias and emotional reactivity as predictors and moderators of behavioral treatment for social phobia

Cognitive behavioral therapy (CBT) is a well-established treatment for anxiety disorders, and evidence is accruing for the effectiveness of acceptance and commitment therapy (ACT). Little is known about factors that relate to treatment outcome overall (predictors), or who will thrive in each treatment (moderators). The goal of the current project was to test attentional bias and negative emotional reactivity as moderators and predictors of treatment outcome in a randomized controlled trial comparing CBT and ACT for social phobia. Forty-six patients received 12 sessions of CBT or ACT and were assessed for self-reported and clinician-rated symptoms at baseline, post treatment, 6, and 12 months. Attentional bias significantly moderated the relationship between treatment group and outcome with patients slow to disengage from threatening stimuli showing greater clinician-rated symptom reduction in CBT than in ACT. Negative emotional reactivity, but not positive emotional reactivity, was a significant overall predictor with patients high in negative emotional reactivity showing the greatest self-reported symptom reduction.

Relationship between social anxiety and perceived trustworthiness

Four different patterns of biased ratings of facial expressions of emotions have been found in socially anxious participants: higher negative ratings of (1) negative, (2) neutral, and (3) positive facial expressions than nonanxious controls. As a fourth pattern, some studies have found no group differences in ratings of facial expressions of emotion. However, these studies usually employed valence and arousal ratings that arguably may be less able to reflect processing of social information. We examined the relationship between social anxiety and face ratings for perceived trustworthiness given that trustworthiness is an inherently socially relevant construct. Improving on earlier analytical strategies, we evaluated the four previously found result patterns using a Bayesian approach. Ninety-eight undergraduates rated 198 face stimuli on perceived trustworthiness. Subsequently, participants completed social anxiety questionnaires to assess the severity of social fears. Bayesian modeling indicated that the probability that social anxiety did not influence judgments of trustworthiness had at least three times more empirical support in our sample than assuming any kind of negative interpretation bias in social anxiety. We concluded that the deviant interpretation of facial trustworthiness is not a relevant aspect in social anxiety.

Self-referential and anxiety-relevant information processing in subclinical social anxiety: an fMRI study

The fear of negative evaluation is one of the hallmark features of social anxiety. Behavioral evidence thus far largely supports cognitive models which postulate that information processing biases in the face of socially relevant information are a key factor underlying this widespread phobia. So far only one neuroimaging study has explicitly focused on the fear of negative evaluation in social anxiety where the brain responses of social phobics were compared to healthy participants during the processing of self-referential relative to other-referential criticism, praise or neutral information. Only self-referential criticism led to stronger activations in emotion-relevant regions of the brain, such as the amygdala and medial prefrontal cortices (mPFC), in the social phobics. The objective of the current study was to determine whether these findings could be extended to subclinical social anxiety. In doing so, the specificity of this self-referential bias was also examined by including both social and non-social (physical illness-related) threat information as well as a highly health anxious control group in the experimental paradigm. The fMRI findings indicated that the processing of emotional stimuli was accompanied by activations in the amygdala and the ventral mPFC, while self-referential processing was associated with activity in regions such as the mPFC, posterior cingulate and temporal poles. Despite the validation of the paradigm, the results revealed that the previously reported behavioral and brain biases associated with social phobia could not be unequivocally extended to subclinical social anxiety. The divergence between the findings is explored in detail with reference to paradigm differences and conceptual issues.

Automatic neural processing of disorder-related stimuli in social anxiety disorder: faces and more

It has been proposed that social anxiety disorder (SAD) is associated with automatic information processing biases resulting in hypersensitivity to signals of social threat such as negative facial expressions. However, the nature and extent of automatic processes in SAD on the behavioral and neural level is not entirely clear yet. The present review summarizes neuroscientific findings on automatic processing of facial threat but also other disorder-related stimuli such as emotional prosody or negative words in SAD. We review initial evidence for automatic activation of the amygdala, insula, and sensory cortices as well as for automatic early electrophysiological components. However, findings vary depending on tasks, stimuli, and neuroscientific methods. Only few studies set out to examine automatic neural processes directly and systematic attempts are as yet lacking. We suggest that future studies should: (1) use different stimulus modalities, (2) examine different emotional expressions, (3) compare findings in SAD with other anxiety disorders, (4) use more sophisticated experimental designs to investigate features of automaticity systematically, and (5) combine different neuroscientific methods (such as functional neuroimaging and electrophysiology). Finally, the understanding of neural automatic processes could also provide hints for therapeutic approaches.

Are Positive Beliefs about Post-Event Processing Related to Social Anxiety?

Although positive metacognitive beliefs have been found to be associated with symptoms of depression and generalised anxiety disorder, surprisingly few studies have focused on the degree to which positive metacognitive beliefs are associated to social phobia symptoms. In response to this limitation, the primary goal of the current study was the development and validation of the Positive Beliefs about Post-Event Processing Questionnaire (PB-PEPQ). It was anticipated that the PB-PEPQ would exhibit adequate psychometric properties. Based on a non-referred sample of 300 undergraduate students, the PB-PEPQ was found to be positively associated with measures of post-event processing and social anxiety symptoms. Further, support was found for the incremental validity of the PB-PEPQ, as the measure predicted variance in social phobia symptoms after controlling for other metacognitive variables, including positive beliefs about worry and positive beliefs about rumination. Overall, the findings may have implications for cognitive models of social phobia. Further, the current findings have possible treatment implications, as individuals with social phobia may benefit from interventions focused on the identification and modification of positive metacognitive beliefs.

Efficacy of attention bias modification using threat and appetitive stimuli: a meta-analytic review

Attention bias modification (ABM) protocols aim to modify attentional biases underlying many forms of pathology. Our objective was to conduct an effect size analysis of ABM across a wide range of samples and psychological problems. We conducted a literature search using PubMed, PsycInfo, and author searches to identify randomized studies that examined the effects of ABM on attention and subjective experiences. We identified 37 studies (41 experiments) totaling 2,135 participants who were randomized to training toward neutral, positive, threat, or appetitive stimuli or to a control condition. The effect size estimate for changes in attentional bias was large for the neutral versus threat comparisons (g=1.06), neutral versus appetitive (g=1.41), and neutral versus control comparisons (g=0.80), and small for positive versus control (g=0.24). The effects of ABM on attention bias were moderated by stimulus type (words vs. pictures) and sample characteristics (healthy vs. high symptomatology). Effect sizes of ABM on subjective experiences ranged from 0.03 to 0.60 for postchallenge outcomes, -0.31 to 0.51 for posttreatment, and were moderated by number of training sessions, stimulus type, and stimulus orientation (top/bottom vs. left/right). Fail-safe N calculations suggested that the effect size estimates were robust for the training effects on attentional biases, but not for the effect on subjective experiences. ABM studies using threat stimuli produced significant effects on attention bias across comparison conditions, whereas appetitive stimuli produced changes in attention only when comparing appetitive versus neutral conditions. ABM has a moderate and robust effect on attention bias when using threat stimuli. Further studies are needed to determine whether these effects are also robust when using appetitive stimuli and for affecting subjective experiences.

Processing mode during repetitive thinking in socially anxious individuals: evidence for a maladaptive experiential mode

BACKGROUND AND OBJECTIVES

Evidence from the depression literature suggests that an analytical processing mode adopted during repetitive thinking leads to maladaptive outcomes relative to an experiential processing mode. To date, in socially anxious individuals, the impact of processing mode during repetitive thinking related to an actual social-evaluative situation has not been investigated. We thus tested whether an analytical processing mode would be maladaptive relative to an experiential processing mode during anticipatory processing and post-event rumination.

METHODS

High and low socially anxious participants were induced to engage in either an analytical or experiential processing mode during: (a) anticipatory processing before performing a speech (Experiment 1; N = 94), or (b) post-event rumination after performing a speech (Experiment 2; N = 74). Mood, cognition, and behavioural measures were employed to examine the effects of processing mode.

RESULTS

For high socially anxious participants, the modes had a similar effect on self-reported anxiety during both anticipatory processing and post-event rumination. Unexpectedly, relative to the analytical mode, the experiential mode led to stronger high standard and conditional beliefs during anticipatory processing, and stronger unconditional beliefs during post-event rumination.

LIMITATIONS

These experiments are the first to investigate processing mode during anticipatory processing and post-event rumination. Hence, these results are novel and will need to be replicated.

CONCLUSIONS

These findings suggest that an experiential processing mode is maladaptive relative to an analytical processing mode during repetitive thinking characteristic of socially anxious individuals.

Oxytocin selectively moderates negative cognitive appraisals in high trait anxious males

The mammalian neuropeptide oxytocin has well-characterized effects in facilitating prosocial and affiliative behavior. Additionally, oxytocin decreases physiological and behavioral responses to social stress. In the present study we investigated the effects of oxytocin on cognitive appraisals after a naturalistic social stress task in healthy male students. In a randomized, double-blind, placebo-controlled trial, 48 participants self-administered either an oxytocin or placebo nasal spray and, following a wait period, completed an impromptu speech task. Eye gaze to a pre-recorded video of an audience displayed during the task was simultaneously collected. After the speech, participants completed questionnaires assessing negative cognitive beliefs about speech performance. Whilst there was no overall effect of oxytocin compared to placebo on either eye gaze or questionnaire measures, there were significant positive correlations between trait levels of anxiety and negative self-appraisals following the speech. Exploratory analyses revealed that whilst higher trait anxiety was associated with increasingly poorer perceptions of speech performance in the placebo group, this relationship was not found in participants administered oxytocin. These results provide preliminary evidence to suggest that oxytocin may reduce negative cognitive self-appraisals in high trait anxious males. It adds to a growing body of evidence that oxytocin seems to attenuate negative cognitive responses to stress in anxious individuals.

Internet-delivered attention bias modification training in individuals with social anxiety disorder--a double blind randomized controlled trial

BACKGROUND

Computerized cognitive bias modification for social anxiety disorder has in several well conducted trials shown great promise with as many as 72% no longer fulfilling diagnostic criteria after a 4 week training program. To test if the same program can be transferred from a clinical setting to an internet delivered home based treatment the authors conducted a randomized, double-blind placebo-controlled trial.

METHODS

After a diagnostic interview 79 participants were randomized to one of two attention training programs using a probe detection task. In the active condition the participant was trained to direct attention away from threat, whereas in the placebo condition the probe appeared with equal frequency in the position of the threatening and neutral faces.

RESULTS

Results were analyzed on an intention-to-treat basis, including all randomized participants. Immediate and 4-month follow-up results revealed a significant time effect on all measured dimensions (social anxiety scales, general anxiety and depression levels, quality of life). However, there were no time x group interactions. The lack of differences in the two groups was also mirrored by the infinitesimal between group effect size both at post test and at 4-month follow-up.

CONCLUSION

We conclude that computerized attention bias modification may need to be altered before dissemination for the Internet.

TRIAL REGISTRATION

ISRCTN01715124.

Social anxiety and social cognition: the influence of sex

Current theoretical models predict a negative relationship between social anxiety and performance on measures of social cognition, yet there appears to be relatively little research that directly examines this relationship and the potential interaction of sex. Two samples of undergraduates self-reporting either a high (n=27; 59% female) or low (n=29; 62% female) level of social anxiety on the abbreviated Social Phobia and Anxiety Inventory completed two social cognition measures: the Reading the Mind in the Eyes Test (Eyes Test) and The Awareness of Social Inference Test-Parts 2 and 3). A multivariate analysis of variance revealed a significant group by sex interaction on overall social cognition performance. Follow-up analyses indicated that males with high and low levels of social anxiety did not differ on any of the social cognition measures. In contrast, females with high social anxiety performed significantly better on the Eyes Test and the TASIT-Part 3 than females with low social anxiety. Contrary to expectations, results of this study suggest that females with high social anxiety may exhibit better-developed social cognition abilities than those with low social anxiety. These preliminary results have clinical implications in the treatment of individuals with social phobia.

Affective engagement for facial expressions and emotional scenes: the influence of social anxiety

Pictures of emotional facial expressions or natural scenes are often used as cues in emotion research. We examined the extent to which these different stimuli engage emotion and attention, and whether the presence of social anxiety symptoms influences responding to facial cues. Sixty participants reporting high or low social anxiety viewed pictures of angry, neutral, and happy faces, as well as violent, neutral, and erotic scenes, while skin conductance and event-related potentials were recorded. Acoustic startle probes were presented throughout picture viewing, and blink magnitude, probe P3 and reaction time to the startle probe also were measured. Results indicated that viewing emotional scenes prompted strong reactions in autonomic, central, and reflex measures, whereas pictures of faces were generally weak elicitors of measurable emotional response. However, higher social anxiety was associated with modest electrodermal changes when viewing angry faces and mild startle potentiation when viewing either angry or smiling faces, compared to neutral. Taken together, pictures of facial expressions do not strongly engage fundamental affective reactions, but these cues appeared to be effective in distinguishing between high and low social anxiety participants, supporting their use in anxiety research.

A pilot study of attention bias subtypes: examining their relation to cognitive bias and their change following cognitive behavioral therapy

OBJECTIVE

The present investigation examined (a) whether a clinical sample of individuals with social anxiety disorder (SAD) comprises two distinct groups based on attention bias for social threat (vigilant, avoidant), (b) the relation between attention bias and cognitive bias, specifically estimates of the probability that negative social events will occur (probability bias), and (c) specific changes in attention bias following cognitive behavioral therapy for social anxiety.

METHOD

Participants were 24 individuals (nfemale = 7, nmale = 17; mage = 41) who met diagnostic criteria for SAD and sought treatment for fear of public speaking. Hypotheses were tested using t tests, linear regression analyses, and a mixed design analysis of variance.

RESULTS

Results yielded evidence of 2 pretreatment groups (vigilant and avoidant). There was a significant positive correlation between vigilance for (but not avoidance of) threat and probability bias (R = .561, p < .05). After 8 weeks of treatment, the direction of change in attention bias differed between groups, such that the vigilant group became less vigilant and the avoidant group became less avoidant, with the avoidant group showing a significant change in attention bias from pretreatment to posttreatment.

CONCLUSIONS

These findings provide very preliminary support for the idea that individuals with SAD may differ according to type attention bias, avoidant or vigilant, as these biases changed in different ways following cognitive-behavioral therapy for SAD. Further research is needed to replicate and extend these findings in order to evaluate whether SAD comprises subgroups of attentional biases.

Mood regulation and quality of life in social anxiety disorder: an examination of generalized expectancies for negative mood regulation

The present study examined negative mood regulation expectancies, anxiety symptom severity, and quality of life in a sample of 167 patients with social anxiety disorder (SAD) and 165 healthy controls with no DSM-IV Axis I disorders. Participants completed the Generalized Expectancies for Negative Mood Regulation Scale (NMR), the Beck Anxiety Inventory, and the Quality of Life Enjoyment and Satisfaction Questionnaire. SAD symptom severity was assessed using the Liebowitz Social Anxiety Scale. Individuals with SAD scored significantly lower than controls on the NMR. Among SAD participants, NMR scores were negatively correlated with anxiety symptoms and SAD severity, and positively correlated with quality of life. NMR expectancies positively predicted quality of life even after controlling for demographic variables, comorbid diagnoses, anxiety symptoms, and SAD severity. Individuals with SAD may be less likely to engage in emotion regulating strategies due to negative beliefs regarding their effectiveness, thereby contributing to poorer quality of life.

Images of the self and self-esteem: do positive self-images improve self-esteem in social anxiety?

Negative self-images play an important role in maintaining social anxiety disorder. We propose that these images represent the working self in a Self-Memory System that regulates retrieval of self-relevant information in particular situations. Self-esteem, one aspect of the working self, comprises explicit (conscious) and implicit (automatic) components. Implicit self-esteem reflects an automatic evaluative bias towards the self that is normally positive, but is reduced in socially anxious individuals. Forty-four high and 44 low socially anxious participants generated either a positive or a negative self-image and then completed measures of implicit and explicit self-esteem. Participants who held a negative self-image in mind reported lower implicit and explicit positive self-esteem, and higher explicit negative self-esteem than participants holding a positive image in mind, irrespective of social anxiety group. We then tested whether positive self-images protected high and low socially anxious individuals equally well against the threat to explicit self-esteem posed by social exclusion in a virtual ball toss game (Cyberball). We failed to find a predicted interaction between social anxiety and image condition. Instead, all participants holding positive self-images reported higher levels of explicit self-esteem after Cyberball than those holding negative self-images. Deliberate retrieval of positive self-images appears to facilitate access to a healthy positive implicit bias, as well as improving explicit self-esteem, whereas deliberate retrieval of negative self-images does the opposite. This is consistent with the idea that negative self-images may have a causal, as well as a maintaining, role in social anxiety disorder.

The association between social phobia, social anxiety cognitions and paranoid symptoms

OBJECTIVE

Previous research suggests high levels of comorbidity between social phobia and paranoid symptoms, although the nature of this association remains unclear.

METHOD

Data were derived from the Early Developmental Stages of Psychopathology study, a 10-year longitudinal study in a representative German community sample of 3021 participants aged 14-24 years at baseline. The Munich-Composite International Diagnostic Interview was used to assess social phobia and paranoid symptoms, along with data on social phobia features. Cross-sectional and longitudinal analyses were conducted. Differential associations with environmental risk factors and temperamental traits were investigated.

RESULTS

Lifetime social phobia and paranoid symptoms were associated with each other cross-sectionally (OR = 1.80, 95% CI = 1.31-2.47). Lifetime paranoid symptoms were associated specifically with social anxiety cognitions. Lifetime cognitions of negative evaluation predicted later onset of paranoid symptoms, whereas onset of social phobia was predicted by cognitions of loss of control and fear/avoidance of social situations. Lifetime social phobia and paranoid symptoms shared temperamental traits of behavioural inhibition, but differed in environmental risks.

CONCLUSIONS

The present study showed that paranoid symptoms and social phobia share similarities in cognitive profile and inhibited temperament. Avoidance appears to be important in the development of social phobia, whereas cannabis use and traumatic experiences may drive paranoid thinking in vulnerable individuals.

Culturally Competent CBT

A 21-year-old Korean, single, and immigrant male presented to therapy with significant symptoms of social anxiety disorder (SAD) for treatment at a university training clinic. At the time of intake, he was experiencing intense distress and remarkable adaptations in his life to accommodate rather chronic physiological symptoms related to social interactions. He immigrated to the United States 5 years prior to treatment from Seoul, Korea. He endured social anxiety for 6 years preceding treatment. The case was conceptualized and treated from a cognitive-behavioral framework. Treatment gains were measured using behavioral markers and a reliable change index using standardized outcome measures. This case illustrates the ability to adhere to a cognitive-behavioral treatment model for SAD while considering pertinent cultural factors. Furthermore, it highlights the generalizability of a specific treatment model when working with Korean immigrants. The authors discuss the need for future research, and treatment implications of this case are described.

Interpretation of ambiguous social scenarios in social phobia and depression: evidence from event-related brain potentials

In the current study, event-related potentials (ERPs) and behavioral responses were measured in individuals meeting diagnostic criteria for social phobia, depression, their combination, or neither in order to examine the unique and combined effects of social phobia and depression on the interpretation of ambiguous social scenarios. ERPs revealed a lack of positive interpretation bias and some suggestion of a negative bias in the semantic expectancy N4 component across all clinical groups. Furthermore, socially phobic and comorbid individuals showed reductions in baseline attention allocation to the task, as indexed by P6 amplitude. RT and accuracy likewise revealed a lack of positive interpretation bias across disordered groups. When considered on a continuum across all samples, social phobia and depression symptoms were related to the N4 interpretation bias effect whereas P6 amplitude reduction and RT interpretation bias appeared uniquely associated with social phobia.

Social cognition in bulimia nervosa: a systematic review

OBJECTIVE

Clinical accounts and previous evidence suggest that socio-emotional impairments may be present in people with bulimia nervosa (BN). The aim of this paper was to systematically review studies of social cognition, and to evaluate whether social cognitive deficits exist in BN.

METHOD

Keywords were identified using an existing model of social cognition (Green et al., 2007) [16], and used to search for relevant papers in three online databases. Records were then screened according to a priori inclusion/exclusion criteria.

RESULTS

Five papers reporting seven social cognition tasks were identified as pertinent to the review. All involved either theory of mind ability or emotional processing skills. Participants with BN had impaired performance on the Levels of Emotional Awareness Scale and showed greater attentional bias than controls on an emotional Stroop task. There were no overall group differences for any other tasks, although there were small differences for some specific test items.

CONCLUSIONS

Basic social cognition does not appear to be impaired in people with BN. Future research should make use of more complex, ecologically valid measures, and consider the relationship between task performance and everyday social functioning.

Face value: eye movements and the evaluation of facial crowds in social anxiety

Scientific evidence is equivocal on whether Social Anxiety Disorder (SAD) is characterized by a biased negative evaluation of (grouped) facial expressions, even though it is assumed that such a bias plays a crucial role in the maintenance of the disorder. To shed light on the underlying mechanisms of face evaluation in social anxiety, the eye movements of 22 highly socially anxious (SAs) and 21 non-anxious controls (NACs) were recorded while they rated the degree of friendliness of neutral-angry and smiling-angry face combinations. While the Crowd Rating Task data showed no significant differences between SAs and NACs, the resultant eye-movement patterns revealed that SAs, compared to NACs, looked away faster when the face first fixated was angry. Additionally, in SAs the proportion of fixated angry faces was significantly higher than for other expressions. Independent of social anxiety, these fixated angry faces were the best predictor of subsequent affect ratings for either group. Angry faces influence attentional processes such as eye movements in SAs and by doing so reflect biased evaluations. As these processes do not correlate with explicit ratings of faces, however, it remains unclear at what point implicit attentional behaviors lead to anxiety-prone behaviors and the maintenance of SAD. The relevance of these findings is discussed in the light of the current theories.

Social identity-based motivation modulates attention bias toward negative information: an event-related brain potential study

Research has demonstrated that people readily pay more attention to negative than to positive and/or neutral stimuli. However, evidence from recent studies indicated that such an attention bias to negative information is not obligatory but sensitive to various factors. Two experiments using intergroup evaluative tasks (Study 1: a gender-related groups evaluative task and Study 2: a minimal-related groups evaluative task) was conducted to determine whether motivation to strive for a positive social identity – a part of one’s self-concept – drives attention toward affective stimuli. Using the P1 component of event-related brain potentials (ERPs) as a neural index of attention, we confirmed that attention bias toward negative stimuli is not mandatory but it can depend on a motivational focus on affective outcomes. Results showed that social identity-based motivation is likely to bias attention toward affectively incongruent information. Thereby, early onset processes – reflected by the P1 component – appeared susceptible to top-down attentional influences induced by the individual’s motivation to strive for a positive social identity.

Differences in the nature of body image disturbances between female obese individuals with versus without a comorbid binge eating disorder: an exploratory study including static and dynamic aspects of body image

Various components of body image were measured to assess body image disturbances in patients with obesity. To overcome limitations of previous studies, a photo distortion technique and a biological motion distortion device were included to assess static and dynamic aspects of body image. Questionnaires assessed cognitive-affective aspects, bodily attitudes, and eating behavior. Patients with obesity and a binge eating disorder (OBE, n = 15) were compared with patients with obesity only (ONB; n = 15), to determine the nature of any differences in body image disturbances. Both groups had high levels of body image disturbances with cognitive-affective deficits. Binge eating disorder (BED) participants also had perceptual difficulties (static only). Both groups reported high importance of weight and shape for self-esteem. There were some significant differences between the groups suggesting that a comorbid BED causes further aggravation. Body image interventions in obesity treatment may be warranted.

Cognitive-evaluative features of childhood social anxiety in a performance task

Using an experimental design, we analysed differences in the occurrence of cognitive-evaluative distortions and performance deficits across children with social anxiety disorder, with subclinical anxiety and without any anxiety symptoms. Twenty-one children with full syndrome social phobia, 18 children with partial syndrome social phobia and 20 children without any symptoms of social phobia were compared with respect to their degree of anxiety, negative thinking and task performance during two social-evaluative tasks. In addition, self-ratings of task performance, performance estimations for other children and objective behavioural ratings by two independent observers were obtained. Children with social anxiety disorder and subclinical social anxiety showed higher degrees of experienced anxiety and negative thinking than healthy control children. There was no group difference in respect to actual task performance. Findings are discussed with regard to the continuum assumption of childhood social anxiety disorder and the need of well-adapted early interventions.