The etiology of social anxiety disorder: An evidence-based model

Cortical activity during social acceptance and rejection task in social anxiety disorder: A controlled functional near infrared spectroscopy study

BACKGROUND

The cognitive and emotional vulnerability of individuals with social anxiety disorder (SAD) and their response to repeated experiences of social rejection and social acceptance are important factors for the emergence and maintenance of symptoms of the disorder. Functional neuroimaging studies of SAD reveal hyperactivity in regions involved in the fear circuit such as amygdala, insula, anterior cingulate, and prefrontal cortices (PFC) in response to human faces with negative emotions. Observation of brain activity, however, involving studies of responses to standardized human interaction of social acceptance and social rejection have been lacking.

METHODS

We compared a group of index subjects with SAD (N = 22, mean age:26.3 ± 5.4, female/male: 7/15) (SADG) with a group of healthy controls (CG) (N = 21, mean age:28.7 ± 4.5, female/male: 14/7) in measures of cortical activity during standardized experiences of human interaction involving social acceptance (SA) and social rejection (SR) video-simulated handshaking tasks performed by real actors. In a third, control condition (CC), the subjects were expected to press a switch button in an equivalent space. Subjects with a concurrent mood episode were excluded and the severity of subclinical depressive symptoms was controlled. 52-channel functional near-infrared spectroscopy (fNIRS) was used to measure cortical activity.

RESULTS

Activity was higher in the SAD subjects compared to healthy controls, in particular in channels that project to middle and superior temporal gyri (STG), frontal eye fields (FEF) and dorsolateral prefrontal cortex (DLPFC) in terms of both SA and SR conditions. Cortical activity during the CC was not different between the groups. Only in the SAD-group, activity in the pre-motor and supplementary motor cortices, inferior and middle temporal gyri and fronto-polar area was higher during the rejection condition than the other two conditions. Anxiety scores were correlated with activity in STG, DLPFC, FEF and premotor cortex, while avoidance scores were correlated with activity in STG and FEF.

CONCLUSIONS

SA and SR are represented differently in terms of cortical activity in SAD subjects compared to healthy controls. Higher activity in both social conditions in SAD subjects compared to controls may imply biological sensitivity to these experiences and may underscore the importance of increased cortical activity during social interaction experiences as a putative mediator of vulnerability to SAD. Higher cortical activity in the SADG may possibly indicate stronger need for inhibitory control mechanisms and higher recruitment of theory of mind functions during social stress. Higher activity during the SR compared to the SA condition in the SAD subjects may also suggest distinct processing of social cues, whether they involve acceptance or rejection.

Academic Stress in the Final Years of School: A Systematic Literature Review

Heightened academic stress in the final years of schooling is a common concern, yet little is known about how stress changes over time and what individual, school and family factors are associated with distress. We conducted a systematic review to examine the nature of distress in students in their final two years of secondary school. Sixty studies were eligible for inclusion. The main findings indicated severity of distress differed across the 17 countries sampled and measures used. There was some consistencies suggesting about 1 in 6 students experienced excessive distress. Female gender and anxiety proneness were consistently associated with increased distress, and freedom from negative cognitions with reduced distress. There was some evidence that individual characteristics (perfectionism, avoidance, coping, self-efficacy, resilience), lifestyle (sleep, homework), school, family and peer connectedness were associated with distress. Overall at-risk students can be predicted by theoretical models of anxiety and distress targeted with psychological interventions.

Disentangling the effects of attentional difficulties on fears of social evaluation and social anxiety symptoms: Unique interactions with sluggish cognitive tempo

Although fears of negative and positive social evaluation are hallmark cognitive features of social anxiety, attentional difficulties may exacerbate the relation between fears of social evaluation and social anxiety. Thus, the goal of the current study was to test whether two different types of self-reported attentional difficulties, specifically sluggish cognitive tempo (SCT) and attention-deficit/hyperactivity disorder (ADHD) inattention symptoms, moderate the relation between fears of social evaluation and social anxiety. Participants (N = 4756; Mage = 19.28 years; 72.7% female) enrolled in five universities across the United States completed self-report measures of fears of negative and positive evaluation and psychopathology symptoms. Results indicated a significant two-way interaction of fear of negative evaluation and SCT in relation to social anxiety symptoms, as well as a significant two-way interaction of fear of positive evaluation and SCT in relation to social anxiety symptoms. In both instances, the associations between fears of negative and positive evaluation in relation to social anxiety became increasingly stronger at higher levels of SCT. Conversely, the interactions between fears of negative and positive evaluation with ADHD inattentive symptoms were non-significant. These results are the first to report that self-reported SCT, but not ADHD inattentive symptoms, exacerbate the relation between fears of social evaluation and social anxiety, and suggest that attentional difficulties characteristic of SCT may prolong engagement in fears.

Investigating microstructure of white matter tracts as candidate endophenotypes of Social Anxiety Disorder - Findings from the Leiden Family Lab study on Social Anxiety Disorder (LFLSAD)

BACKGROUND

Social anxiety disorder (SAD) is a mental illness with a complex, partially genetic background. Differences in characteristics of white matter (WM) microstructure have been reported in patients with SAD compared to healthy controls. Also, WM characteristics are moderately to highly heritable. Endophenotypes are measurable characteristics on the road from genotype to phenotype, putatively reflective of genetically based disease mechanisms. In search of candidate endophenotypes of SAD we used a unique sample of SAD patients and their family members of two generations to explore microstructure of WM tracts as candidate endophenotypes. We focused on two endophenotype criteria: co-segregation with social anxiety within the families, and heritability.

METHODS

Participants (n = 94 from 8 families genetically vulnerable for SAD) took part in the Leiden Family Lab Study on Social Anxiety Disorder (LFLSAD). We employed tract-based spatial statistics to examine structural WM characteristics, being fractional anisotropy (FA), axial diffusivity (AD), mean diffusivity (MD) and radial diffusivity (RD), in three a-priori defined tracts of interest: uncinate fasciculus (UF), superior longitudinal fasciculus (SLF) and inferior longitudinal fasciculus (ILF). Associations with social anxiety symptoms and heritability were estimated.

RESULTS

Increased FA in the left and right SLF co-segregated with symptoms of social anxiety. These findings were coupled with decreased RD and MD. All characteristics of WM microstructure were estimated to be at least moderately heritable.

CONCLUSION

These findings suggest that alterations in WM microstructure in the SLF could be candidate endophenotypes of SAD, as they co-segregated within families genetically vulnerable for SAD and are heritable. These findings further elucidate the genetic susceptibility to SAD and improve our understanding of the overall etiology.

The role of loneliness as a mediator between autism features and mental health among autistic young adults

LAY ABSTRACT

Autistic adults commonly experience mental health concerns including social anxiety and depression, which can have negative effects on their quality of life. It is not completely clear, however, why rates of mental health concerns are so high. Some evidence suggests that social connectedness might play a key role. The goal of this study was to explore links between loneliness, mental health concerns, autism features, and social contact among autistic adults and test whether the links between mental health with autism features and social contact can be explained by loneliness. Researchers in this study collected data using questionnaires completed by 69 autistic young adults. Autistic adults who reported more autism features also reported more social and family loneliness, higher levels of social anxiety and depression, and fewer initiated social contacts. In addition, adults with more social contact initiations were likely to report lower levels of social and family loneliness and social anxiety but not depression. Results showed that the link from social engagement and autism features to social anxiety and depression symptoms could be mostly explained by loneliness. The results of this study expand previous findings by illustrating one factor (loneliness) that might be responsible for the high rates of mental health concerns among adults on the autism spectrum. These findings highlight the importance of studying factors related to mental health concerns among autistic adults and ways to best support social connectedness for the mental well-being of autistic young adults.

How Passion for Playing World of Warcraft Predicts In-Game Social Capital, Loneliness, and Wellbeing

Playing digital games can nurture wellbeing by helping players recover from daily stressors, cope with life's challenges, practice emotion regulation, and engage in meaningful social interaction; however, this same leisure activity can also result in problematic gaming (i.e., harmful play at the expense of healthy behaviors), and social isolation that damages wellbeing. Research consistently demonstrates that the value or harm of gaming on wellbeing cannot be determined solely from whether and how much people play, but rather depends on contingent factors related to the player, the game, and the gaming context. In this paper, we aim to model contingent factors that differentiate between beneficial and harmful outcomes within players of the same massively multiplayer online role playing game (MMORPG). We model how passion for gaming—defined as a strong desire to engage in a beloved activity that is enjoyed and valued, in which time and energy is invested, and that ultimately integrates into a person's identity—affects loneliness and wellbeing. We employ the dualistic model that divides passion into harmonious passion (HP)—characterized by a balanced and authentic relationship with the beloved activity, and obsessive passion (OP)—characterized by preoccupation and inflexible persistence toward the loved activity. We sampled 300 frequent World of Warcraft (WoW) players, recruited from online forums, and used structural equation modeling (SEM) to investigate the effects of their passion for playing WoW on in-game social capital, loneliness, and wellbeing. We demonstrate that HP for playing WoW facilitates in-game social capital (both bridging and bonding), combats loneliness, and increases wellbeing, whereas OP also builds social capital, but these social ties do not combat loneliness, and OP is directly associated with increased loneliness. Further, the positive effect of HP on wellbeing is mediated through an increase in bonding social capital and a resulting decrease in loneliness. Our findings highlight that passion orientation is important for characterizing the relationship between gaming and wellbeing. We contribute to the conversation on combating problematic gaming, while also promoting digital gaming as an appealing leisure activity that provides enjoyment, recovery, and meaningful social interaction for the millions of gamers who benefit from its captivation.

Protocol for a systematic review and network meta-analysis of randomised controlled trials examining the effectiveness of early parenting interventions in preventing internalising problems in children and adolescents

BACKGROUND

Internalising problems, such as depression and anxiety, are common and represent an important economical and societal burden. The effectiveness of parenting interventions in reducing the risk of internalising problems in children and adolescents has not yet been summarised. The aims of this review are to assess the effectiveness of parenting interventions in the primary, secondary and tertiary prevention of internalising problems in children and adolescents and to determine which intervention components and which intervention aspects are most effective for reducing the risk of internalising problems in children and adolescents.

METHODS

Electronic searches in OVID SP versions of MEDLINE, EMBASE and PsycINFO; Cochrane Central Register of Controlled Trials; EBSCO version of ERIC and ClinicalTrials.gov have been performed to identify randomised controlled trials or quasi-randomised controlled trials of parenting interventions. At least two independent researchers will assess studies for inclusion and extract data from each paper. The risk of bias assessment will be conducted independently by two reviewers using the Cochrane Collaboration's Risk of Bias Assessment Tool. Statistical heterogeneity is anticipated given potential variation in participant characteristics, intervention type and mode of delivery, and outcome measures. Random effects models, assuming a common between-study variability, will be used to account for statistical heterogeneity. Results will be analysed using a network meta-analysis (NMA). If appropriate, we will also conduct a component-level NMA, where the 'active ingredients' of interventions are modelled using a network meta-regression approach.

DISCUSSION

Preventing and reducing internalising problems could have major beneficial effects at the economic and societal level. Informing policy makers on the effectiveness of parenting interventions and on which intervention's component is driving the effect is important for the development of treatment strategies.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register for Systematic Reviews (PROSPERO) number CRD42020172251.

Determinants of anxiety levels among young males in a threat of experiencing military conflict-Applying a machine-learning algorithm in a psychosociological study

Background

Anxiety could be felt even in objectively peaceful situations, but a vision of conflict could result in increased stress levels. In this article, we aimed to identify hidden patterns of mental conditions and create male profiles to illustrate the different subgroups as well as determinants of anxiety levels among them in accordance with proximity to a possibility of direct exposure to military action.

Methods

A sample of Ukrainian males, in duty as conscripts to military service (n = 392, M±SD = 22.1±5.3) participated in a survey. We used the 36-Item Short Form Health Survey, and State-Trait Anxiety Inventory. In addition to psychological indices, social-demographic data were collected. To discover the number of clusters, the k-means algorithm was used, the optimal number of clusters was found by the elbow algorithm. For validation of the model and its use for further prediction, the random forest machine-learning algorithm, was used.

Results

By performing k-means cluster analyses, 3 subgroups were identified. High values of psychological indices dominated in Subgroup 2, while lowest values dominated in Subgroup 3. Subgroup 1 showed a more even distribution among the indices. The strength of the relevance and main determinants of the prediction of the presented model mostly consisted of mental qualities, while socio-demographic data were slightly significant.

Conclusions

There is no clear relevance between proximity or even the experience of military actions and anxiety levels. Other factors, mostly subjective feelings about mental conditions, are crucial determinants of feeling anxiety.

Associations between adolescent social phobia, sickness absence and unemployment: a prospective study of twins in Sweden

BACKGROUND

Little is known about adolescent mental health problems, including social phobia, as risk factors for future work incapacity. The aim of this study was to investigate the association between social phobia in adolescence and unemployment and sickness absence (SA) in early adulthood, also evaluating the role of familial factors (genetics and shared environment).

METHODS

A sample of 2845 Swedish twins born in 1985-86 in Sweden was followed longitudinally in the population-based and prospective Twin study of CHild and Adolescent Development. Information on twins' social phobia was collected at ages 13-4, 16-7 and 19-20 years. Logistic regression providing odds ratios (OR) with 95% confidence intervals (95% CI) was used to analyze the associations between social phobia, unemployment and SA during the follow-up 2006-12. The influence of familial factors was evaluated by conditional logistic regression.

RESULTS

Presence of social phobia during adolescence was associated with increased odds for unemployment and SA in young adulthood. For unemployment, the highest OR was at the age of 13-4 years (1.58 [95% CI: 1.22-2.06]), and the associations became null after adjusting for familial factors. For SA, the highest OR was at the age of 19-20 years (1.73 [95% CI: 1.13-2.65]), and the estimates changed slightly after adjusting for familial factors.

CONCLUSIONS

: Results suggest that social phobia experienced in adolescence contribute to early adulthood unemployment and SA. Familial factors seemed to explain the association between social phobia and unemployment.

Extrahypothalamic oxytocin neurons drive stress-induced social vigilance and avoidance

Oxytocin increases the salience of both positive and negative social contexts and it is thought that these diverse actions on behavior are mediated in part through circuit-specific action. This hypothesis is based primarily on manipulations of oxytocin receptor function, leaving open the question of whether different populations of oxytocin neurons mediate different effects on behavior. Here we inhibited oxytocin synthesis in a stress-sensitive population of oxytocin neurons specifically within the medioventral bed nucleus of the stria terminalis (BNSTmv). Oxytocin knockdown prevented social stress-induced increases in social vigilance and decreases in social approach. Viral tracing of BNSTmv oxytocin neurons revealed fibers in regions controlling defensive behaviors, including lateral hypothalamus, anterior hypothalamus, and anteromedial BNST (BNSTam). Oxytocin infusion into BNSTam in stress naïve mice increased social vigilance and reduced social approach. These results show that a population of extrahypothalamic oxytocin neurons plays a key role in controlling stress-induced social anxiety behaviors.

Parenting Interacts with Oxytocin Polymorphisms to Predict Adolescent Social Anxiety Symptom Development: A Novel Polygenic Approach

Guided by a developmental psychopathology framework, research has increasingly focused on the interplay of genetics and environment as a predictor of different forms of psychopathology, including social anxiety. In these efforts, the polygenic nature of complex phenotypes such as social anxiety is increasingly recognized, but studies applying polygenic approaches are still scarce. In this study, we applied Principal Covariates Regression as a novel approach to creating polygenic components for the oxytocin system, which has recently been put forward as particularly relevant to social anxiety. Participants were 978 adolescents (49.4% girls; M_age T₁ = 13.8 years). Across 3 years, questionnaires were used to assess adolescent social anxiety symptoms and multi-informant reports of parental psychological control and autonomy support. All adolescents were genotyped for 223 oxytocin single nucleotide polymorphisms (SNPs) in 14 genes. Using Principal Covariates Regression, these SNPs could be reduced to five polygenic components. Four components reflected the underlying linkage disequilibrium and ancestry structure, whereas the fifth component, which consisted of small contributions of many SNPs across multiple genes, was strongly positively associated with adolescent social anxiety symptoms, pointing to an index of genetic risk. Moreover, significant interactions were found with this polygenic component and the environmental variables of interest. Specifically, adolescents who scored high on this polygenic component and experienced less adequate parenting (i.e., high psychological control or low autonomy support) showed the highest levels of social anxiety. Implications of these findings are discussed in the context of individual-by-environment models.

New Developments in Emotion-Focused Therapy for Social Anxiety Disorder

Social anxiety disorder (SAD) is a highly complex, chronic, disabling and costly anxiety disorder. Although cognitive-behavioral therapy (CBT) is effective for many patients, many others do not respond to CBT or remain considerably symptomatic at the end of treatment. Pharmacological effects are also modest. More empirically-supported treatment options are needed in order to increase patient access to effective treatment. Emotion-focused therapy (EFT) shows great promise in treating SAD effectively and is particularly suitable for treating SAD because pervasive emotional avoidance, difficulties with emotional differentiation, and high levels of self-criticism, which are central psychopathological processes in SAD, are also primary therapeutic targets in EFT. EFT is based on the assumption that the most efficient way to change a maladaptive emotion is not through reason or skill learning, but through the activation of other, more adaptive emotions. EFT aims to access shame-based emotional memories that underlie SAD, and transform them by exposing them to new adaptive emotional experiences, such as empowering assertive anger, grief, and self-compassion. In this paper, the core features of EFT for SAD are presented, as well as the EFT view of dysfunction in SAD and EFT change processes. Research findings regarding the effectiveness of EFT for SAD are presented together with initial findings regarding mechanisms of change occurring during treatment.

Measuring associations between social anxiety and use of different types of social media using the Swedish Social Anxiety Scale for Social Media Users: A psychometric evaluation and cross-sectional study

Research on the association between social anxiety and social media usage remains inconclusive: despite the preference for computer-mediated communication there is currently no clear empirical support for social anxiety being associated with longer duration of social media use. Self-report measures for social anxiety that are adapted for the context of social media could facilitate further research. The current study aimed to develop a Swedish version of the recently developed Social Anxiety Scale for Social Media Users (SAS-SMU), evaluate its psychometric properties, and explore associations between different uses of social media and social anxiety. Three factors were retained for SAS-SMU with excellent internal consistency. SAS-SMU evidenced convergent validity with measures of social anxiety, negative convergent validity with satisfaction with life, and divergent validity with measures of obsessive-compulsive disorder, depression and generalized anxiety disorder. Results indicated that higher levels of social anxiety were associated with passive and active use as well as longer duration of social media use in general, which is at odds with a previous study where passive use remained the only significant predictor for social anxiety.

Practitioner Review: Anxiety disorders in children and young people - assessment and treatment

Despite significant advancements in our knowledge of anxiety disorders in children and adolescents, they continue to be underrecognised and undertreated. It is critical that these disorders are taken seriously in children and young people as they are highly prevalent, have a negative impact on educational, social and health functioning, create a risk of ongoing anxiety and other mental health disorders across the life span and are associated with substantial economic burden. Yet very few children with anxiety disorders access evidence-based treatments, and there is an urgent need for widespread implementation of effective interventions. This review aimed to provide an overview of recent research developments that will be relevant to clinicians and policymakers, particularly focusing on the development and maintenance of child anxiety disorders and considerations for assessment and treatment. Given the critical need to increase access to effective support, we hope this review will contribute to driving forward a step change in treatment delivery for children and young people with anxiety disorders and their families.

Social anxiety and perceptions of likeability by peers in children

The current study aimed to investigate the discrepancy between self-reported and peer-reported likeability among children, and the relation with social anxiety, depression, and social support. In total, 532 children between 7 and 12 years completed questionnaires about social anxiety symptoms, depressive symptoms, and social support, estimated their own likeability, and indicated how much they liked their classmates. Children with higher levels of social anxiety or depression overestimated their likeability less or even underestimated their likeability. Social anxiety symptoms, but not depressive symptoms, were significant predictors of the discrepancy. Social support was positively related to likeability and negatively related to social anxiety, but did not moderate the association between social anxiety symptoms and perception accuracy of likeability. These results are in line with cognitive theories of childhood social anxiety, and they stress the importance of using multi-informant measures when studying the relation between social anxiety and social functioning in children.

Experience Versus Report: Where Are Changes Seen After Exposure-Based Cognitive-Behavioral Therapy? A Randomized Controlled Group Treatment of Childhood Social Anxiety Disorder

A considerable number of children and adolescents with social anxiety disorder (SAD) do not benefit from treatment as much as expected. However, treatment success should not be measured with social anxiety reports alone; the cognitive, behavioral, and physiological components of social stress should also be assessed. The authors examined an exposure-based SAD-specific group cognitive behavioral therapy (CBT) in a randomized controlled trial (N = 67, age 9-13 years, blind randomized allocation to treatment [CBT; n = 31] and waitlist control [WLC; n = 36] groups). Success was operationalized as a clinically significant reduction of symptoms measured with SAD-specific questionnaires, structured interviews, and changes in response to the Trier Social Stress Test (TSST). In the CBT group, there was a trend toward a significant increase in positive cognitions in the TSST after treatment (d = 0.37), whereas these positive cognitions decreased in the WLC group (d = 0.40). No significant results involving group appeared for negative cognitions, behavior and physiology. Children in the CBT group, but not parents, further reported less social anxiety in one questionnaire from pre- to post-treatment (d = 0.89). A structured interview confirmed a decrease in severity of SAD in the CBT group. While the gold standard of a blind interview showed efficacy of treatment, not all trait and state measures demonstrated similar success patterns.Trial registration Eligibility criteria and some of the dependent variables (cognitions, physiology) for treatment success were registered with the German Research Foundation (TU 78/5-2, HE 3342/4-2) prior to recruitment. Clinical assessment of diagnosis and behavioral data were not a priori planned as outcome measures for this trial and therefore analyzed in a post-hoc approach.

Effectiveness of a culturally adapted cognitive behavioural therapy-based guided self-help (CACBT-GSH) intervention to reduce social anxiety and enhance self-esteem in adolescents: a randomized controlled trial from Pakistan

BACKGROUND

Social anxiety is common among adolescents in Pakistan and is associated with low self-esteem. Among the recommended treatments, cognitive behavioural therapy (CBT) is effective, and self-help approaches are encouraged.

AIM

To determine the effectiveness of culturally adapted CBT-based guided self-help (CACBT-GSH) intervention, using a manual 'Khushi aur Khatoon', for treating social anxiety when added to treatment as usual (TAU) compared with TAU only.

METHOD

A total of 76 adolescents with social anxiety aged 13-16 years from six schools in Multan, Pakistan were recruited into this randomized controlled trial. Participants were divided into intervention and control groups in a 1:1 ratio. Social anxiety, self-esteem and fear of negative evaluation were assessed through the Liebowtiz Social Anxiety Scale for children and adolescents, the Rosenberg Self-Esteem Scale and the Brief Fear of Negative Evaluation, respectively, at baseline and at the end of the study. Guided self-help using culturally adapted CBT (CACBT)-based self-help manual (eight sessions, one session per week) was provided to the intervention group. The effect of the CACBT-GSH intervention was analysed with ANCOVA.

RESULTS

There was a statistically significant difference between the intervention and the control groups in favour of intervention. Participants in the intervention group showed reduced symptoms of social anxiety (p < .001), fear of negative evaluation (p < .001) and enhanced self-esteem (p < .001).

CONCLUSION

The study demonstrated the effectiveness of CACBT-based guided self-help intervention in treating social anxiety and addressing the symptoms associated with it.

Transactional Links Between Social Anxiety Symptoms and Parenting Across Adolescence: Between- and Within-Person Associations

This 4-year longitudinal multi-informant study examined between- and within-person associations between adolescent social anxiety symptoms and parenting (parental psychological control and autonomy support). A community sample of 819 adolescents (46.1% girls; Mage T1  = 13.4 years) reported annually on social anxiety symptoms and both adolescents and mothers reported on parenting. Between-person associations suggested that adolescent social anxiety symptoms were associated with higher adolescent- and mother-reported psychological control and lower mother-reported autonomy support. At the within-person level, however, mothers reported lower psychological control and higher autonomy support after periods with higher adolescent social anxiety symptoms. Our findings illustrate the importance of distinguishing among between-person and within-person associations and including perceptions of both dyad members in longitudinal research concerning parenting and adolescent mental health.

Can words be worse than stones? Understanding distressing social events and their relationship with social anxiety

Research on the relationship between distressing social events and social anxiety has focused on antagonistic social events (i.e., peer victimization, cyberbullying) in adolescent samples. There is little research examining such relationships in adults, and less examining the relationship between non-antagonistic distressing social events (i.e., accidental embarrassing events) and social anxiety. The current investigation utilized a retrospective design to examine how different distressing social events may be associated with posttraumatic stress-like reactions, which may relate to social anxiety in early adulthood. Characteristics of distressing social events (i.e., betrayal, presence of an antagonist) were explored as possible influences on the severity of stress responses. Community participants (n = 271; ages 18-25) completed online questionnaires measuring social anxiety and reactions to distressing social events. Antagonistic and non-antagonistic distressing social events were both related to social anxiety. Relationships between the frequencies of any distressing social events and social anxiety were mediated by reactions akin to posttraumatic stress. Responses to distressing social events were not influenced by the presence of an antagonist or betrayal. The results suggest that non-antagonistic distressing social events can be as distressing as antagonistic distressing social events and contribute to expanding evidence that reactions to distressing social events may resemble reactions to life-threatening events.

Higher- and lower-order personality traits and cluster subtypes in social anxiety disorder

Social anxiety disorder (SAD) can come in different forms, presenting problems for diagnostic classification. Here, we examined personality traits in a large sample of patients (N = 265) diagnosed with SAD in comparison to healthy controls (N = 164) by use of the Revised NEO Personality Inventory (NEO-PI-R) and Karolinska Scales of Personality (KSP). In addition, we identified subtypes of SAD based on cluster analysis of the NEO-PI-R Big Five personality dimensions. Significant group differences in personality traits between patients and controls were noted on all Big Five dimensions except agreeableness. Group differences were further noted on most lower-order facets of NEO-PI-R, and nearly all KSP variables. A logistic regression analysis showed, however, that only neuroticism and extraversion remained significant independent predictors of patient/control group when controlling for the effects of the other Big Five dimensions. Also, only neuroticism and extraversion yielded large effect sizes when SAD patients were compared to Swedish normative data for the NEO-PI-R. A two-step cluster analysis resulted in three separate clusters labelled Prototypical (33%), Introvert-Conscientious (29%), and Instable-Open (38%) SAD. Individuals in the Prototypical cluster deviated most on the Big Five dimensions and they were at the most severe end in profile analyses of social anxiety, self-rated fear during public speaking, trait anxiety, and anxiety-related KSP variables. While additional studies are needed to determine if personality subtypes in SAD differ in etiological and treatment-related factors, the present results demonstrate considerable personality heterogeneity in socially anxious individuals, further underscoring that SAD is a multidimensional disorder.

Fear of positive evaluation and social anxiety: A systematic review of trait-based findings

BACKGROUND

Although fear of negative evaluation (FNE) has long been recognized as a core cognitive bias in social anxiety, fear of positive evaluation (FPE) has received considerable attention over the past several years. The literature would benefit from a synthesis of the current state of the research in order to contribute to our understanding of FPE.

METHODS

A systematic review of the literature was conducted in order to address several questions: (a) Is self-reported FPE distinct from self-reported FNE? (b) Is self-reported FPE related to social anxiety symptomatology? and (c) Is self-reported FPE uniquely related to social anxiety symptomatology when accounting for self-reported FNE? Inclusion criteria included studies published in English, testing FPE and FNE with trait-based measures, and testing social anxiety with either self-report or diagnostic interviews.

RESULTS

There were 33 studies identified in this review that provided convincing empirical support for each of these questions across community and clinical samples of adolescents, undergraduates, and adults.

LIMITATIONS

The systematic review did not have access to null results, present meta-analytic results, or include studies that evaluated FPE or social anxiety with experimental designs.

CONCLUSIONS

The findings from the systematic review support updated theoritical models of social anxiety and highlight the importance of assessing and treating FPE in clinical interventions.

A systematic review of visual avoidance of faces in socially anxious individuals: Influence of severity, type of social situation, and development

Although visual avoidance of faces is a hallmark feature of social anxiety disorder (SAD) on clinical and theoretical grounds, empirical support is equivocal. This review aims to clarify under which conditions socially anxious individuals display visual avoidance of faces. Through a systematic search in Web of Science and PubMed up to March 2019 we identified 61 publications that met the inclusion criteria. We discuss the influence of three factors on the extent to which socially anxious individuals avoid looking at faces: (a) severity of social anxiety symptoms (diagnosed SAD versus High Social Anxiety levels in community samples [HSA] or related characteristics [Shyness, Fear of Negative Evaluation]), (b) three types of social situation (computer facial-viewing tasks, speaking tasks, social interactions), and (c) development (age-group). Adults with SAD exhibit visual avoidance across all three types of social situations, whereas adults with HSA exhibit visual avoidance in speaking and interaction tasks but not in facial-viewing tasks. The relatively few studies with children and adolescents suggest that visual avoidance emerges during adolescence. The findings are discussed in the context of cognitive-behavioral and skills-deficit models. Suggestions for future research include the need for developmental studies and more fine-grained analyses of specific areas of the face.

Social anxiety disorder among children and adolescents: A nationwide survey of prevalence, socio-demographic characteristics, risk factors and co-morbidities

BACKGROUND

Social anxiety disorder is a frequent psychiatric disorder. We aimed to estimate the life-time prevalence, socio-demographic characteristics, risk factors and co-morbidities of this condition among children and adolescents.

METHODS

This was a cross sectional national survey conducted in Iranian individuals aged 6 to 18 years. Face-to-face household interviews were performed by trained clinical psychologists. The Farsi version of the kiddie schedule for affective disorders and schizophrenia for school-age children/present and lifetime version (K-SADS-PL) was administered to estimate the SAD prevalence. Parental personality traits and their psychopathologies were also obtained using Millon clinical multiaxial inventory, third edition (MCMI-III) to find the possible risk factors.

RESULTS

From 29,878 participants, 585 individuals were diagnosed with SAD and weighted lifetime prevalence of 1.8% was observed. The odds of this condition was significantly higher among older adolescents (odds ratio (OR):1.47; 95% confidence interval(CI): 1.11-1.95) and individuals with paternal history of psychiatric hospitalization (OR: 2.96; 95%CI: 1.29-6.79). Higher means of persistent depression disorder (OR: 1.009; 95%CI: 1.000-1.018) and melancholic personality trait (OR: 1.007; 95%CI: 1.001-1.014) in mothers as well as schizophrenia spectrum (OR: 1.014; 95%CI: 1.001-1.027) and anxiety (OR: 1.010; 95%CI: 1.010-1.021) in fathers were statistically associated with higher odds of SAD in their children. Other anxiety disorders and behavioral disorders were the most prevalent co-morbidities.

LIMITATIONS

The cross-sectional analysis does not enable analyses of possible causal associations. Lacking control group and follow-up periods were other major limitations that should be resolved in future studies.

CONCLUSION

Clinicians and researchers need to continue studying this condition at all levels and in all developmental periods.

Not intended, still embarrassed: Social anxiety is related to increased levels of embarrassment in response to unintentional social norm violations

Background:

Social anxiety disorder (SAD) is associated with altered social norm (SN) processing: SAD-patients rate stories on SN violations as more inappropriate and more embarrassing than healthy participants, with the most prominent effect for stories on unintentional SN violations (i.e. committing a blunder). Until now it’s unknown how levels of social anxiety (SA) are related to ratings of SN violations in the general population, in which SA-symptoms are present at a continuum. More insight in this relationship could improve our understanding of the symptom profile of SAD. Therefore, we investigated the relation between ratings of SN violations and SA-levels in the general population.

Methods:

Adults and adolescents (n = 87) performed the revised Social Norm Processing Task (SNPT-R) and completed self-report questionnaires on social anxiety. Repeated-measures ANCOVAs were used to investigate the effect of SA on the ratings of inappropriateness and embarrassment.

Results:

As hypothesized, participants with higher SA-levels rated SN violations as more inappropriate and more embarrassing. Whereas participants with low-to-intermediate SA-levels rated unintentional SN violations as less embarrassing than intentional SN violations, participants with high SA-levels (z-score SA ≥ 1.6) rated unintentional SN violations as equally embarrassing as intentional SN violations.

Conclusion:

These findings indicate that increased embarrassment for unintentional SN violations is an important characteristic of social anxiety. These high levels of embarrassment are likely related to the debilitating concern of socially-anxious people that their skills and behavior do not meet expectations of others, and to their fear of blundering. This concern might be an important target for future therapeutic interventions.

Child maltreatment, peer victimization, and social anxiety in adulthood: a cross-sectional study in a treatment-seeking sample

BACKGROUND

Childhood adversities, especially emotional abuse, emotional neglect, and peer victimization are considered to be crucial risk factors for social anxiety disorder (SAD). We investigated whether particular forms of retrospectively recalled childhood adversities are specifically associated with SAD in adulthood or whether we find similar links in other anxiety or depressive disorders.

METHODS

Prevalences of adversities assessed with the Childhood Trauma Questionnaire (CTQ) and a questionnaire of stressful social experiences (FBS) were determined in N = 1091 outpatients. Adversity severities among patients with SAD only (n = 25), specific phobia only (n = 18), and generalized anxiety disorder only (n = 19) were compared. Differences between patients with anxiety disorders only (n = 62) and depressive disorders only (n = 239) as well as between SAD with comorbid depressive disorders (n = 143) and SAD only were tested.

RESULTS

None of the adversity types were found to be specifically associated with SAD and severities did not differ among anxiety disorders but patients with depressive disorders reported more severe emotional abuse, physical abuse, and sexual abuse than patients with anxiety disorders. SAD patients with a comorbid depressive disorder also reported more severe adversities across all types compared to SAD only.

CONCLUSION

Findings indicate that particular forms of recalled childhood adversities are not specifically associated with SAD in adulthood. Previously established links with SAD may be better explained by comorbid depressive symptoms.

A disorder-specific group cognitive behavior therapy for social anxiety disorder in adolescents: study protocol for a randomized controlled study

Background

Social anxiety disorder (SAD) is a common disorder in adolescence associated with extensive distress and long-term impairment. Generic cognitive behavior therapy (CBT) programs for anxiety disorders have shown poorer outcomes for adolescents with SAD than for other anxiety disorders.

Aim

The aim of the present study is to investigate the efficacy of a disorder-specific group cognitive behavior therapy (G-CBT) program for youth SAD, the Cool Kids Anxiety Program - Social Enhanced (CK-E), developed at Macquarie University, Sidney, Australia.

Methods

The study is a randomized controlled trial comparing CK-E to a generic G-CBT program for anxiety disorders. Approximately 96 adolescents aged 12 to 17 years are included with data points at pre- and post-treatment, and at 3 months and 1 year follow-ups.

Discussion

The current study will provide more information about the efficacy of diagnosis-specific G-CBT treatment for youth SAD.

Trial registration

ClinicalTrials.gov, NCT03986827. Registered on 14 June 2019.

Visual attention to emotional faces in adolescents with social anxiety disorder receiving cognitive behavioral therapy

Social anxiety disorder (SAD) is a psychiatric condition that often onsets in childhood. Cognitive models underline the role of attention in the maintenance of SAD, but studies on youth populations are few, particularly those using eye tracking to measure attention. Cognitive behavioral therapy (CBT) for SAD includes interventions targeting attention, like exposure to eye contact, but the link between CBT and attention bias is largely unexplored. This study investigated attention bias in youth with SAD and the association with outcome from CBT. Latency to attend to pictures of faces with different emotions (vigilance) and latency to disengage from social stimuli (avoidance) was examined in N = 25 adolescents (aged 13–17) with SAD in relation to treatment outcome. Vigilance was operationalized as the time it took to relocate the gaze from a central position to a peripherally appearing social stimulus. The latency to disengage from a centrally located social stimulus, when a non-social stimulus appeared in the periphery, was used as a proxy for avoidance. Attention characteristics in the SAD group were compared to non-anxious (NA) controls (N = 22). Visual attention was measured using eye tracking. Participants in both the SAD and NA groups were vigilant towards angry faces, compared to neutral and happy faces. Similarly, both groups disengaged attention faster from angry faces. Adolescents with SAD who disengaged faster from social stimuli had less social anxiety after CBT. The results indicate that anxious youth display a vigilant-avoidant attention pattern to threat. However, partly inconsistent with previous research, the same pattern was observed in the NA group.

Examining the Relation Between Adolescent Social Anxiety and Positive Affect Regulation: Self-Report vs. Observation

Social anxiety symptomatology is associated with disruptions in positive affect, though no study has examined deficits in responses to positive affect related to adolescent social anxiety symptoms. The present study tested whether adolescents' self-reported and observed social anxiety symptoms were uniquely associated with specific responses to positive affect. Moreover, we examined whether adolescent gender moderated these relations. Ninety adolescents (ages 11 to 18, M_age = 14.26, SD = 2.03; girls = 62%; white = 79%) completed self-report measures, participated in a social stressor task, and engaged in two positively-valenced interaction tasks with their female caregivers. Adolescent self-reported social anxiety symptoms were not uniquely associated with responses to positive affect. However, observed social anxiety symptoms were uniquely related to greater self-reported inhibiting positive affect responses and fewer observed positive affect maximizing behaviors. These findings highlight the need to examine self-reported and observed social anxiety symptoms in understanding associated disruptions in positive affect regulation.

Therapeutic strategies for social anxiety disorder: where are we now?

Introduction: Classical well-established treatments of social anxiety disorder (SAD) are now complemented by more recent therapeutic strategies. This review aims to summarize available therapies for SAD and discuss recent evidence-based findings on the management of this disorder.Areas covered: Recent guidelines recommend psychotherapy, particularly cognitive-behavioral therapy (CBT), and pharmacotherapy, as first-line treatments of patients with SAD, without a clear superiority of one option over the other. CBT includes classical approaches such as in vivo exposure to social situations and cognitive therapy, but new modalities and techniques have been recently developed: third-wave approaches, internet-delivered therapy, virtual reality exposure, and cognitive bias modification. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors have been also extensively studied and shown to be effective in SAD. Two alternative strategies have been developed to treat SAD with disappointing results: cognitive bias modification, and pharmacological augmentation of psychotherapy using D-cycloserine during exposure sessions.Expert opinion: Personalized treatments for SAD patients are now available. Innovative strategies such as online psychotherapy and virtual reality exposure are useful alternatives to CBT and SSRIs. Future developments and optimization of attention bias modification and of pharmacological augmentation of psychotherapy can be promising.

Disaggregating the predictive effects of impaired psychosocial functioning on future DSM-5 eating disorder onset in high-risk female adolescents

OBJECTIVE

Impaired psychosocial functioning previously emerged as the only risk factor to predict future onset of each of the four Diagnostic and Statistical Manual of Mental Disorder (5th ed.) (DSM-5) eating disorders. The goal of this follow-up report was to refine understanding of this newly identified risk factor.

METHOD

Combining data from women at risk for eating disorders because of body image concerns (N = 1,153, mean age = 18.5 years, SD = 4.2), we investigated which subdomain(s) and individual item(s) of psychosocial functioning (friends, family, school, and work) at baseline predicted onset of any eating disorder, using Cox regression (CRA) and classification tree analysis (CTA).

RESULTS

Psychosocial impairment with friends, family, and at school, but not at work, significantly increased risk for disorder onset over 3-year follow-up in univariate models. A one-unit increase in each domain raw score was associated with a 107, 22, and 43% increased hazard of eating disorder onset, respectively. Multivariate CRA found friends functioning, with a 92% increased hazard of disorder onset, contributed the strongest unique effect. CTA suggested that loneliness was the most potent risk factor with a threefold increased onset risk (eating disorder incidence for high vs. low scorers was 27 and 8%). Three friends functioning items and one school functioning item produced additional CTA branches.

DISCUSSION

Results refine understanding of the relation of psychosocial impairment to future onset of eating disorders, suggesting that peer functioning is the most critical. Data imply it would be useful to target young women with impaired psychosocial functioning in prevention programs.

Tuned to voices and faces: Cerebral responses linked to social anxiety

Voices and faces are the most common sources of threat in social anxiety (SA) where the fear of negative evaluation and social exclusion is the central element. SA itself is spectrally distributed among the general population and its clinical manifestation, termed social anxiety disorder, is one of the most common anxiety disorders. While heightened cerebral responses to angry or contemptuous facial or vocal expressions are well documented, it remains unclear if the brain of socially anxious individuals is generally more sensitive to voices and faces. Using functional magnetic resonance imaging, we investigated how SA affects the cerebral processing of voices and faces as compared to various other stimulus types in a study population with greatly varying SA (N = 50, 26 female). While cerebral voice-sensitivity correlated positively with SA in the left temporal voice area (TVA) and the left amygdala, an association of face-sensitivity and SA was observed in the right fusiform face area (FFA) and the face processing area of the right posterior superior temporal sulcus (pSTSFA). These results demonstrate that the increase of cerebral responses associated with social anxiety is not limited to facial or vocal expressions of social threat but that the respective sensory and emotion processing structures are also generally tuned to voices and faces.

Are children with social anxiety disorder more likely than children with other anxiety disorders to anticipate poor social performance and reflect negatively on their performance?

BACKGROUND

The cognitive theory of social anxiety disorder (SAD) suggests that adults with SAD have a tendency to anticipate poor social performance and reflect negatively on their performance following a social event. While a number of studies with socially anxious adults have supported the role of poor performance anticipation and post-event rumination in SAD, to date, only a few studies have addressed whether this also applies to children with SAD.

METHODS

Children (7-12 years) diagnosed with SAD (n = 40), other anxious children (n = 40) and non-anxious children (n = 34) were exposed to a social stressor speech task and their pre- and post-performance appraisals assessed, taking into account objective performance ratings.

RESULTS

Although observers rated some aspects of performance as significantly worse among children with SAD than children with other anxiety disorders, children with SAD were not more likely than their anxious or non-anxious peers to show a general bias in pre- or post-performance appraisals. Furthermore, children with SAD were just as likely as their anxious and non-anxious peers to recognize good performance but were more critical of themselves when their performance was poor.

LIMITATIONS

The speech task did not involve a same-age peer. Participants were relatively affluent group of predominantly non-minority status. Specificity for SAD in relation to other anxiety disorders remains unclear.

CONCLUSIONS

Focusing on counteracting pre- and post-event social performance appraisals may potentially be inappropriate for childhood SAD. Children with SAD might benefit from interventions that focus on helping them to become less critical of themselves after social interactions have not gone well.

Navigating the social world: The role of social competence, peer victimisation and friendship quality in the development of social anxiety in childhood

Social and communication (SC) difficulties predict increased social anxiety (SA) symptoms in childhood. Peer victimisation and friendship quality are commonly associated with both SC difficulties and SA. Based on this, we tested for a cascade effect of early SC difficulties, peer victimisation and friendship quality on SA in late childhood, using a population-based sample of 8028 children from the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort. Parent-reported data were collected on SC difficulties at age 7 and SA at age 7, 10 and 13. Child-reported data on peer victimisation and friendship quality were collected at age 8. Our results revealed that SC difficulties predict increased negative friendship qualities and peer victimisation. Relational victimisation predicted increased SA symptoms at 13 years old. Neither overt nor relational victimisation mediated the developmental relationship between SC difficulties and SA. Furthermore, friendship quality did not moderate the developmental relationship between SC difficulties and SA. In addition, no sex differences were observed. The evidence demonstrates that peer victimisation and friendship quality do not explain why some children with SC difficulties go on to develop SA. Future research clarifying the complex etiological pathways contributing towards the development of SA in childhood and adolescence is warranted.

Cognitive-Behavioral and Psychodynamic Therapy in Adolescents with Social Anxiety Disorder: A Multicenter Randomized Controlled Trial

BACKGROUND

Although social anxiety disorder (SAD) has an early onset and is frequently found in adolescence, evidence for psychotherapeutic treatments of SAD in adolescents is rather scarce. Within the Social Phobia Psychotherapy Research Network (SOPHO-NET), we examined the efficacy of cognitive-behavioral (CBT) and psychodynamic therapy (PDT) compared to a waiting list (WL) in these patients.

METHODS

In a multicenter randomized controlled superiority trial, 107 patients, aged 14-20 years, were randomized to CBT (n = 34), PDT (n = 34), or WL (n = 39). Assessments were made at baseline, at the end of treatment, and 6 and 12 months after termination. The Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA) applied by raters masked to the treatment condition was used as the primary outcome. As secondary outcomes, rates of response and remission and the Social Phobia Anxiety Inventory (SPAI) were used.

RESULTS

Both treatments were superior to WL in the LSAS-CA (CBT: p = 0.0112, d = 0.61, 95% CI 0.14-1.08; PDT: p = 0.0261, d = 0.53, 95% CI 0.06-1.00). At the end of treatment, response rates were 66, 54, and 20% for CBT, PDT, and WL. The corresponding remission rates were 47, 34, and 6%, respectively. CBT and PDT were significantly superior to WL regarding remission (CBT: p = 0.0009, h = 1.0; PDT: p = 0.0135, h = 0.74), response (CBT: p = 0.0004, h = 0.97; PDT: p = 0.0056, h = 0.72), and the SPAI (CBT: p = 0.0021, d = 0.75, 95% CI 0.27-1.22; PDT: p = 0.0060, d = 0.66, 95% CI 0.19-1.13). Treatment effects were stable at 6- and 12-month follow-ups.

CONCLUSIONS

These results are comparable to the large SOPHO-NET trial in adults (n = 495). Early treatments for social anxiety are needed in order to prevent chronic manifestation of SAD.

Social anxiety disorder: looking back and moving forward

Fifty years have passed since social anxiety disorder (SAD) was first differentiated from other phobias. In the years since research has largely aligned with the zeitgeist of categorical classificatory frameworks, and has spanned identifying causes, maintenance factors and innovative interventions. Despite significant advances in the field, the capacity to conceptualise SAD as an independent entity is limited given the heterogeneity and dimensionality of diagnostic criteria, high rates of comorbidity, and non-specificity of aetiological mechanisms, maintaining factors and approaches to treatment. The Research Domain Criteria (RDoC) initiative was developed in an effort to overcome the inherent limitations posed by descriptive diagnostic systems - particularly in terms of reliability and validity - and in doing so seeks to facilitate research into underlying pathophysiological and behavioural mechanisms that cut across traditional diagnostic boundaries. The RDoC framework is furnished with a 'matrix', which in essence corresponds to a set of research principles that attempt to reconcile neuroscience and psychopathology. This review outlines a rationale for integrating SAD research with the RDoC approach, and offers examples of how future studies may wish to frame hypotheses and design experiments as the field moves towards classifying dimensions of psychopathology through a mechanistic understanding of underlying neurobiological and behavioural processes.