Understanding Social Anxiety Disorder in Adolescents and Improving Treatment Outcomes: Applying the Cognitive Model of Clark and Wells (1995)

Psychotherapies for social anxiety disorder in adults: A systematic review and Bayesian network meta-analysis

Psychotherapies for social anxiety disorder (SAD) encompass various protocols and delivery formats; consequently, an investigation into the relative efficacy of different treatments is needed. This study aimed to compare the efficacy of different common psychotherapies for SAD and identify the most effective psychotherapies for SAD. Using a Bayesian network meta-analysis, we compared the relative efficacy of six common psychotherapies: cognitive behavioral therapy (CBT), cognitive restructuring (CR), exposure therapy (ET), psychodynamic therapy (PDT), interpersonal therapy (IPT), and mindfulness-based interventions (MBI). Sensitivity analyses were conducted to test the robustness of the results. This network meta-analysis included 92 studies up to June 2024, covering 90 randomized controlled trials. The findings suggested that, compared with the waitlist control group, all included psychotherapies showed varying degrees of efficacy in reducing SAD symptoms severity. Specifically, CBT was generally the most effective psychotherapy. The Clark and Wells CBT protocol showed the highest efficacy (SMD: 1.42, 95 % CrI: [1.14, 1.70]), while Andersson and Carlbring's Internet-based CBT ranked highly (SMD: 1.15, 95 % CrI: [0.87, 1.42]). PDT was the most effective non-CBT treatment (SMD: 0.98, 95 % CrI: [0.61, 1.36]). Guided therapies appeared more effective than unguided ones, and Internet-based treatments were comparable to face-to-face therapies. This study can aid clinicians in optimizing treatment choices and selecting appropriate formats when treating patients with SAD.

Post-event rumination as a mediator in the relationship between self-focused attention and social anxiety in Chinese adolescents

Cognitive models of social anxiety disorder have conveyed the implication that self-focused attention (SFA) and post-event rumination (PER) are significant predictors in maintaining the symptoms of social anxiety (SA); however, their relationships have been scarcely studied in adolescents, including Chinese samples. The primary purpose of the current study was to examine the role of PER as a potential mediator between SFA and SA among Chinese adolescents; moreover, the moderation effect of gender was investigated. A total of 2,755 Chinese adolescents ranging in age from 11 to 19 years old with an average age of 14.18 were recruited from six urban public schools. Participants were asked to complete questionnaires measuring SFA, PER, SA, and depression. Structural equation modeling results showed that PER displayed as a plausible mediator in the relationship between SFA and SA, even after controlling for depression. In addition, gender was revealed to be a significant moderator, with a stronger relationship between PER and SA for girls than for boys. The current study provided evidence for Clark and Wells' proposition about the associations among SFA, PER, and SA, contributing to the field of adolescents' mental health and supporting the cultural applicability of the model.

The mechanism of body appreciation influencing social anxiety in college students: A moderated mediation model

This study examines the impact of body appreciation on social anxiety among college students, focusing on the mediating role of social suspiciousness and the moderating role of self-congruency in the relationship between body appreciation and social suspiciousness. An analysis of data from 1161 questionnaires reveals that body appreciation is a significant negative predictor of social anxiety among college students. Furthermore, body appreciation indirectly influences social anxiety through social suspiciousness. Additionally, self-congruency significantly moderates the relationship between body appreciation and social suspiciousness. Specifically, a positive perception of one's body-appreciating its uniqueness and functionality, and positively processing and protecting body-related evaluative information-can directly reduce social anxiety. It can also indirectly reduce social anxiety by lowering social suspiciousness in interpersonal settings. Moreover, self-congruency plays a moderating role in the pathway from body appreciation to social suspiciousness. The findings of this study offer new insights into the relationship between body appreciation and social anxiety among college students. By enhancing self-congruency, the negative impact of low body appreciation on social anxiety can be lessened, providing important practical implications for developing effective interventions to address social anxiety in college students.

Effects of a 12-week dance intervention on left-behind children with co-occurring social anxiety and low self-concept

Objective

This study aimed to investigate the effects of a 12-week dance intervention on left-behind children (LBC) suffering from social anxiety and low self-concept, and to explore the relationship between social anxiety and self-concept.

Methods

Sixty LBC who met the criteria were selected from a school in Shaoyang City, Hunan Province, and were randomly divided into an Interventional group (n = 30) and a Control group (n = 30). The Interventional group received a 45-min dance intervention five times a week for 12 weeks, while the Control group maintained their original lifestyle. Social anxiety and self-concept were measured three times using the Social Anxiety Scale for Children and the Piers-Harris Child Self-concept Scale: at baseline (T0), post-intervention (12 weeks, T1), and follow-up (14 weeks after baseline, T2).

Results

(i) After the dance intervention, social anxiety and self-concept were significantly improved (p < 0.05). (ii) There was a significant negative correlation between the change scores (T1 minus T0) of social anxiety and self-concept (p < 0.05).

Conclusion

Dance intervention is an acceptable, practical and effective intervention that we can incorporate into a health programme to improve social anxiety and low self-concept in LBC.

Examining the Latent Dimensions of Social Anxiety Disorder

While the body of literature has investigated the latent dimensions of Social Anxiety Disorder (SAD), only few have directly anchored in the DSM-5 SAD symptoms. Similarly, a continuing issue on measuring mental health disorders pertains to whether a symptom's frequency, intensity, or both, are appropriate and sufficient indicators of severity. To address this gap, the present study developed and validated a DSM-5-based measurement tool, the Social Anxiety Symptom Severity Inventory (SASSI), which assesses both the intensity (intensity of disturbance) and frequency (frequency of occurrence) of SAD symptoms. In study 1 (n = 6458, college students), the results revealed a two-factor structure using exploratory structural equation modeling. In study 2 (n = 425, left-behind emerging adults), confirmatory factor analysis, measurement invariance testing, and latent class analysis were used. Findings demonstrated the importance of using both frequency and intensity of symptoms in assessing SAD severity. Moreover, a five-class solution best fitted the sample. Studies 1 and 2 demonstrated the good psychometric properties of SASSI and filled an important gap among available measures in assessing SAD severity through symptom frequency and intensity.

Social stress task with parental support or self-instruction decreases negative cognitions in children with social anxiety disorder

Social anxiety disorder (SAD) is highly prevalent in childhood, yet research on cognitive processes in children with SAD is limited. This study examined anticipatory rumination (AR), self-focused attention (SFA), and post-event processing (PEP) in children with SAD and healthy controls (HC), and the impact of possible influencing factors (two conditions: parental support, self-instruction). Based on adult cognitive models, we hypothesized that children with SAD would report more negative and similar positive AR, more internal SFA, similar external focus, more negative and similar positive PEP compared to HCs. We predicted that both conditions would reduce negative AR, internal SFA, and negative PEP, with stronger effects in HCs. Participants (ages 9-14; SAD: n = 43, HC: n = 48) completed two speech tasks (T1, T2) in front of a peer audience. Children with SAD reported more negative AR, internal SFA, and negative PEP than HCs in both sessions. All children reported more negative AR, internal SFA, and negative PEP in T1 than T2. Surprisingly, these effects were equally strong in both groups. Condition effects were comparable across groups, with reduced negative cognitive processes in T2. These findings highlight cognitive biases in childhood SAD and the need for further research on their modifiability.

Changes and persistence in heart rate variability before and during social stress: A comparison of individuals with and without social anxiety disorder

Individuals with social anxiety disorder (SAD) experience significant and persistent fear of social situations as they anticipate rejection, scrutiny, and embarrassment. Given that physiological reactions to social situations may shape emotional experience in SAD, understanding psychophysiological changes operating in SAD may be important to address this potentially key perpetuating factor. This study compared the patterns of change (via contrasts of estimated marginal means) and persistence (via autoregressive models) of two indices of heart rate variability (HRV; Root Mean Square of Successive Differences between normal heartbeats, and High-Frequency absolute units) as physiological measures of emotion regulation, between individuals with SAD (n = 94) and without (n = 59) using the Trier Social Stress Test phases (TSST). Results revealed that the SAD group increased their need to regulate their emotions (peak HRV) during the preparation (i.e., anticipation) phase, particularly among women, whereas HRV peaked for the non-SAD group during the social-evaluative context. The SAD group's increase in HRV in the preparation phase, relative to non-SAD group, was the opposite of the hypothesised effect. The non-SAD group demonstrated no significant persistence of HRV between some TSST phases, whereas the SAD group showed significant persistence across all phases, however no between-group differences were found. These findings provide novel evidence of similarities and differences in HRV between individuals with and without SAD while anticipating and encountering social-evaluative contexts.

Examining two of the ingredients of Cognitive therapy for adolescent social anxiety disorder: Back-translation from a treatment trial

BACKGROUND

Cognitive Therapy for Social Anxiety Disorder (CT-SAD) based on the Clark & Wells model is a complex intervention comprised of a series of therapeutic elements. Two of the key ingredients are the self-focused attention and safety behaviour experiment and video feedback. The present study examined the effects of these two therapeutic procedures in adolescents with SAD, as well as common themes of the young people's social fears and negative self-images.

METHOD

35 participants with a diagnosis of SAD completed internet-delivered CT-SAD as part of a randomised controlled trial. We conducted a series of paired samples t-tests to evaluate the effects of the self-focused attention and safety behaviour experiment and video feedback. We applied Latent Dirichlet Allocation to identify latent topics based on participants' description of their social fears and negative self-images that were elicited during the course of these therapy procedures.

RESULTS

Participants reported lower anxiety and more positive self-appraisals when focusing externally and dropping safety behaviours, compared to when focusing internally and using safety behaviours (ps < 0.0025). After they watched the videos compared to before, they reported more positive appraisals of their appearance and performance (ps < 0.0025). The differences in these outcomes were significantly larger when they focused internally and used safety behaviours, compared to focusing externally and dropping safety behaviours (ps < 0.0025). Topic modelling identified six social fear topics and five negative self-image topics.

CONCLUSIONS

Self-focused attention, safety behaviours, and negative self-imagery are modifiable with the 'self-focused attention and safety behaviour experiment' and 'video feedback' as part of internet delivered CT-SAD.

The risks versus the benefits of pharmacological intervention in social anxiety disorder in children

INTRODUCTION

Many children are affected by social anxiety disorder (SAD). Pharmacotherapy, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), may be indicated, but a clear understanding of the risks and benefits associated with these pharmacological treatments is needed.

AREAS COVERED

This expert review explores the risks and benefits of pharmacotherapy for treating SAD in children.

EXPERT OPINION

Pharmacotherapy may be considered as a treatment when symptoms are complex or severe or when effective psychotherapy, such as cognitive behavioral therapy (CBT), is not accessible. We recommend that clinicians collaborate closely with parents, pediatricians, and psychiatrists in the treatment planning process, while monitoring the effects of pharmacotherapy. Future research should prioritize the personalization of treatments.

Supporting a Young Adult with Social Anxiety Disorder and Improving Engagement in Cancer Care: A Case Report

Adolescent and young adult (AYA) patients with cancer often demonstrate suboptimal engagement in cancer care due to a host of logistical, developmental, and psychological factors. This clinical case study of a young adult (YA) with cancer highlights the multiple ways in which social anxiety disorder (SAD) impacted a YA's engagement in cancer care. The case study also details the use of an evidence-based treatment for SAD to support behavioral change. Identification and receipt of timely evidence-based psychological intervention for SAD have the potential to improve AYA well-being and enhance cancer care engagement.

The Effectiveness of Mindfulness-based Interventions versus Cognitive Behavioral Therapy on Social Anxiety of Adolescents: A Systematic Review and Meta-analysis

Background and Objective

Mindfulness-based interventions (MBI), a novel treatment, and cognitive behavioral therapy (CBT), the standard treatment, are both effective in treating anxiety in adolescents. This study determined the effectiveness of mindfulness-based interventions versus cognitive behavioral therapy in reducing symptoms of anxiety among adolescents experiencing social anxiety through a systematic review and meta-analysis.

Methods

A systematic approach was used to identify eligible studies. Electronic databases, reference lists of relevant articles, and gray literature were searched. Data was analyzed using RevMan to calculate standard mean differences with 95% confidence intervals and subgroups. Heterogeneity was measured using visual assessment, the I2 statistic, and chi-square test.

Results

Randomized controlled trials comparing MBI to CBT for adolescents diagnosed with social anxiety or social phobia disorder were analyzed, with non-randomized studies being excluded. Structured searches in electronic databases, reference lists, and gray literature were conducted by four independent reviewers who initially identified potential articles through title and abstract screening. After a comprehensive review of full-text articles and a consensus-building process, the selection of included articles was finalized. Data was analyzed using RevMan to calculate standard mean differences with 95% confidence intervals and to examine subgroups, with heterogeneity being assessed through visual evaluation, the I2 statistic, and chi-square tests. Total number of participants was 255; 101 were male and 158 were women. Mean age was 27.5 years old, and diagnosed with Social Anxiety Disorder, Social Phobia, or DSM-IV-Defined-Anxiety-Disorder. They were divided into two groups: 125 participated in 8- to 12-week MBI sessions lasting 2 hours each, while 130 underwent 2-hour CBT sessions spanning 8, 12, or 14 weeks. There is moderate quality of evidence reporting non-significant difference on MBI vs CBT's effectiveness in alleviating symptoms of social anxiety [mean (95% CI) = -0.04 (-0.58, 0.51)].

Conclusion

Study found that there were no significant differences between Mindfulness-Based Interventions and Cognitive Behavioral Therapy in reducing social anxiety in adolescents. Mindfulness interventions have advantages in terms of cost-effectiveness for reducing symptoms of anxiety. Future research should include larger sample sizes and longer follow-up periods to further assess long-term effects of these interventions.

Worry and Depressive Symptoms in Adolescents with Neurodevelopmental Disorders

Although worry is a normal cognitive process experienced by adolescents, for a significant number, it can reach intense and uncontrollable levels. If left untreated, these worries can lead to significant mental health problems that are maintained into adulthood. Adolescents with neurodevelopmental disorders (NDDs) may be more prone to cognitive biases (that precede worry) and therefore highly vulnerable to worry. Limited research has examined worry in adolescents with NDDs; however, most studies have focused on measuring anxiety. The present research administered an instrument specifically developed to measure worry to 404 10 to 16-year-old mainstream school-aged adolescents, 204 (123 males, 81 females) of whom had a formally diagnosed NDD. A measure of depressive symptoms was also administered. Confirmatory factor analysis revealed a satisfactory fitting model for worry. Multivariate analysis of variance revealed no interaction effects or main effect for worry according to NDD/non-NDD status. There were, however, main effects for sex, with females scoring significantly higher than males on worry about academic success and the future; worry about peer relationships; combined worry score; and depressive symptoms. The findings of this study offer psychologists and educators a brief validated measure of worry that is suited to mainstream school adolescents with or without NDDs. The wider implications of the findings in the context of education and intervention for students with NDDs are discussed.

Sleep-wake patterns of fencing athletes: a long-term wearable device study

Objective

Sleep is the most efficient means of recovery for athletes, guaranteeing optimal athletic performance. However, many athletes frequently experience sleep problems. Our study aims to describe the sleep-wake patterns of fencing athletes and determine whether factors, such as sex, competitive level and training schedules, could affect the sleep-wake rhythm.

Methods

Sleep data from 23 fencing athletes were collected using the Huawei Band 6, monitoring key sleep parameters such as bedtime, wake time, duration of deep and light sleep, wake periods, REM sleep duration, and nap duration. During this period, athletes were required to wear the band continuously for 24 hours daily, except bathing, charging, and competition times.

Results

Athletes averaged 7.97 hours of sleep per night, with significant differences observed in wake time (p = 0.015) and midpoint of sleep (p = 0.048) between high-level and low-level athletes, as well as a higher frequency of naps among high-level (χ2 = 11.97, p = 0.001) and female (χ2 = 3.88, p = 0.049) athletes. Nap duration was negatively correlated with night sleep duration (r =  - 0.270, p < 0.001). Athletes were observed for changes in sleep-wake patterns from Monday to Sunday. On Mondays, Wednesdays, and Fridays, when there was no morning training, the athletes' wake-up time and the midpoint of sleep were shifted significantly backward, and there were significant differences in sleep parameters between training days and rest days.

Conclusion

The sleep patterns of athletes differ according to level and gender. The sleep-wake patterns of athletes are influenced by training schedules, indicating the presence of sleep rhythm disruption.

Interrelations Among Adolescents' Family Connections, Solitude Preferences, Theory of Mind and Perceptions of Academic and Work Competence

This study explored the links among family connections, solitude preferences, perceptions of work (academic and job) competence, and Theory of Mind (ToM) in 73 Canadian adolescents aged 11-18 (M age = 13.1). Previous studies show significant connections among these factors, although little is known about how such associations may relate to one another, especially the role of young people's perceptions. To address these gaps in the literature, this study focused on adolescents' experiences and perceptions of their family relationships, solitude preferences, and competence in the school context and workplace. Participants completed a series of self-report measures, advanced ToM tasks and written explanation for perceived family emotional connections. Results revealed that adolescents with more positive family connections reported higher levels of self-perceived academic and job competence, embraced solitude positively, yet felt less desire to be alone. Girls showed a higher affinity for solitude than boys, and the presence of more siblings reduced the desire for solitude. Those youth who were proficient in ToM skills reported positive family connections and high levels of academic competence. Findings hold implications for future research and education in adolescent's social cognition and social and academic outcomes.

Social anxiety in adolescence and the first timing of parental home leaving and living with a partner: a longitudinal population-based Young-HUNT3 study in Norway

Background

Social anxiety can make significant life transitions from adolescence to young adulthood particularly stressful. Despite the potential impact, few population-based longitudinal studies have examined the relationship between social anxiety and the timing of key markers of the transition to adulthood. This study investigated the association between social anxiety and the timing of two critical life events: first leaving the parental home and first living with a partner.

Methods

Data were drawn from 8,199 adolescents aged 13-19 who participated in the Young-HUNT3 survey (2006-2008) in Norway, linked with event registration data from Statistics Norway through 2020. Social anxiety was assessed via the Short Form of the Social Phobia and Anxiety Inventory for Children, with scores ranging from 1 to 5. Accelerated failure time (AFT) regression analyses with a Weibull distribution were conducted to evaluate the relationship between social anxiety and the timing of first leaving the parental home and first living with a partner.

Results

The final analytic sample size was 8,045. The median age for first leaving the parental home was 21, whereas the median age for first starting to live with a partner was 24. Higher levels of social anxiety were modestly associated with delays in both life transitions. Specifically, a one-unit increase in the social anxiety score was associated with an approximate one-month delay in leaving the parental home (T = 1.005; p < 0.05) and a two-month delay in first living with a partner (T = 1.010; p < 0.001). The predicted mean indicates a difference of 4 months for leaving the parental home and 8 months for first living with a partner, comparing adolescents with the lowest (score of 1) to the highest (score of 5) within the social anxiety spectrum.

Conclusion

This study highlights the association between social anxiety and delays in key life transitions from adolescence to early adulthood. Despite these delays, socially anxious adolescents in Norway appear to reach these milestones-leaving the parental home and living with a partner-in their early twenties, similar to their peers. Although the findings are modest, practically, this information may still hold significant value in informing care providers and policymakers to focus on adolescents as a potential period for implementing evidence-based programs aimed at social anxiety. Future research should explore other stress-inducing life events and examine the long-term socioeconomic and health outcomes of adolescents with social anxiety.

Understanding Mechanisms that Maintain Social Anxiety Disorder in Autistic Individuals Through the Clark and Wells (1995) Model and Beyond: A Systematic Review

Given the high co-occurrence of social anxiety in autism, no reviews to date have explored how cognitive and behavioural mechanisms identified to maintain social anxiety in non-autistic individuals may operate in autistic individuals. This systematic review evaluated: (1) empirical evidence underlying the Clark and Wells (1995) Cognitive Model of Social Anxiety in autistic individuals; (2) how vulnerability factors identified from autism literature (beyond core autistic traits) may be associated with social anxiety beyond the cognitive model. Published peer-reviewed English articles until 27th November 2023 were retrieved from PubMed, EMBASE, Ovid MEDLINE and PsycINFO. Quality appraisal and risk of bias were assessed using The Standard Quality Assessment Criteria for Evaluating Primary Research papers from a Variety of Fields tool. 47 articles met full inclusion criteria and included autistic individuals (with clinical diagnosis), a measure of social anxiety, and a mechanism outlined by either (or both) research questions. The majority of the 3340 participants across studies were male without intellectual disability, White/Caucasian, with 7 studies reporting an average age above 30 years old. Most studies used only self-report measures that may have inflated associations observed between social anxiety and mechanisms. All studies employed cross-sectional design, and no causality inferences could be drawn. Methodological issues around potential construct overlaps between social anxiety and autistic traits are highlighted. Overall, there is evidence in support of the as reported by Clark and Well (in: Heimberg (eds), A cognitive model of social phobia, The Guilford Press, 1995) model, as greater fear of negative evaluation from others, use of safety behaviours and somatic symptoms, and peer victimisation were associated with greater social anxiety. The review contributes evidence in support of autism specific contextual, predisposing/antecedent and maintenance factors of social anxiety beyond the original Clark and Well (in: Heimberg (eds), A cognitive model of social phobia, The Guilford Press, 1995) model. Given the potential for considerable heterogeneity for each highlighted process at an individual level across autistic individuals, clinicians can broaden formulation conversations with autistic clients to understand how autism related factors may influence the development and maintenance of social anxiety symptoms when applying and adapting the Clark and Well (in: Heimberg (eds), A cognitive model of social phobia, The Guilford Press, 1995) model.

Association between childhood trauma and social anxiety in adolescents: The mediating role of self-compassion and loneliness

BACKGROUND

Previous studies have shown a correlation between childhood trauma and social anxiety. However, the underlying mechanism of this association is not well understood.

OBJECTIVE

The aim of this study was to examine the relationship between childhood trauma and social anxiety in adolescents, and to explore the mediating role of self-compassion and loneliness.

PARTICIPANTS AND SETTING

In total 1309 adolescents (531 of whom were female) were recruited, and their mean age was 15.4 ± 2.30 years.

METHODS

Participants completed the Adolescent Social Anxiety Scale, Childhood Trauma Questionnaire Short Form, Self-Compassion Scale, and University of California, Los Angeles Loneliness Scale. Pearson correlation analysis was conducted to investigate the relationships among childhood trauma, self-compassion, loneliness, and social anxiety. The PROCESS Macro Model 80 was used for regression analysis to explore the mediating effects of self-compassion and loneliness on the relationship between childhood trauma and social anxiety.

RESULTS

After controlling for the influence of gender and parental marital status, self-compassion mediated the association between childhood trauma and social anxiety, in which positive self-compassion alleviated the relationship between childhood trauma and social anxiety, while negative self-compassion aggravated the relationship between childhood trauma and social anxiety. Furthermore, self-compassion and loneliness chain-mediated the relationship between childhood trauma and social anxiety.

CONCLUSION

These results offer theoretical support for the research and intervention of adolescents' social anxiety, and are crucial for developing adolescents' mental health education and promoting interpersonal communication.

The Relation Between Social Anxiety and Perceptions of Likeability and Friendship in Adolescents

Background

This study investigated how different social anxiety symptoms (i.e., worrying about negative evaluation versus avoidance tendencies) in adolescents are related to the perception accuracy of likeability by peers and friendships with peers.

Method

A community sample of 263 adolescents between 12 and 15 years old reported on their social anxiety symptoms. In addition, they estimated how much their peers liked them, indicated how much they liked their peers, and who their friends were in their classroom.

Results

Results showed that socially anxious adolescents who mainly worried about negative evaluations, underestimated their likeability by peers. Adolescents with strong social avoidance tendencies had a more accurate perception of their likeability and friendships; they were less liked by their peers and had fewer friends.

Conclusion

The results emphasize the importance of treating avoidance behavior in social anxiety since avoidance tendencies may not only maintain the social anxiety symptoms but are also related to a more negative judgment by others.

Testing theoretical processes that maintain paediatric social anxiety: A comparison between children and adolescents with social anxiety disorder, other mental disorders, and non-clinical controls

BACKGROUND

Paediatric social anxiety disorder (SoAD) responds poorly to treatment. Improved understanding of potential psychological maintaining processes may indicate fruitful directions to improve treatment outcomes. The current study compared self-reported psychological processes and state anxiety in response to two social tasks experienced by children and adolescents with SoAD against comparison samples.

METHODS

641 children and adolescents aged 6-17 years (Mage = 9.45 yr; 47.6% girls) engaged in a brief, impromptu speech and a social discussion with a confederate. Participants included 307 with SoAD, 285 with other mental disorders, and 49 non-clinical controls. Participants who completed each task self-reported their anticipated probability and cost of negative evaluation, self-focused attention, personal evaluation of social performance, and engagement in post-event rumination (assessed 1 h later). Independent raters also scored their social performance. Relationships between the variables were tested through path analysis.

RESULTS

Participants with SoAD were more likely to avoid and reported significantly greater state anxiety than both comparison groups. They also reported higher levels of each of the putative maintaining processes than either comparison group. In contrast, independent observers did not discriminate between groups on their overt social performance. Path analyses demonstrated good fit of a priori models to the data for both social tasks.

CONCLUSIONS

Paediatric SoAD is associated with strong expectation of the probability and cost of negative evaluation, excess self-focused attention, and more negative evaluation of one's own social performance. In turn, these putative processes are strong predictors of state anxiety and post-event processing in response to both a speech and social interaction.

Effectiveness cognitive emotion regulation strategies to reduce social anxiety and improve social self-efficacy

BACKGROUND

This study aimed to investigate the effectiveness of a training program based on cognitive emotion regulation strategies to reduce social anxiety and improve social self-efficacy among Hashemite University students.

MATERIALS AND METHOD

The study sample comprised 57 students randomly divided into two groups: The experimental group consisted of 28 students, and the control group consisted of 29 students. The experimental group was exposed to the training program consisting of 18 sessions, while the control group did not receive any experimental treatment. The students in both experimental and control groups completed the social anxiety scale and social self-efficacy scales before and after the training program.

RESULTS

The study found differences in the mean score of the experimental group on the post-test of the social anxiety level in favor of the experimental group and in the mean score of the experimental group on the post-test of the social self-efficacy scale in favor of the experimental group.

CONCLUSION

The training program based on cognitive emotion regulation strategies is very effective in reducing the social anxiety and improving social self-efficacy.

Associations Between Family Functioning and Social Avoidance and Distress in Patients with Strabismus: A Chain Mediation Model

Purpose

Exploring the mechanisms of fear of negative evaluation (FNE) and self-esteem between family functioning and social avoidance and distress (SAD) to inform the promotion of social functioning in people with strabismus.

Patients and Methods

Convenience sampling was used to select 249 strabismus patients attending a tertiary-level ophthalmology hospital in Wenzhou City from July 2023 to February 2024. The Social Avoidance and Distress Scale, Rosenberg Self-Esteem Scale, Brief Fear of Negative Evaluation Scale, and Family APGAR Index Questionnaire were utilized to assess levels of social avoidance and distress, self-esteem, fear of negative evaluation, and family functioning. Structural equation modeling (SEM) was employed to explore the sequential mediating role of FNE and self-esteem in the relationship between family functioning and SAD.

Results

Family functioning negatively predicted SAD directly (β=-0.14, P<0.01). Additionally, family functioning predicted FNE (β=-0.19, P<0.01) and self-esteem (β=0.41, P<0.01). FNE positively predicted SAD (β=-0.38, P<0.01) and negatively predicted self-esteem (β=-0.22, P<0.01). Moreover, self-esteem negatively predicted SAD (β=-0.33, P<0.01). FNE and self-esteem mediated the relationship between family functioning and SAD, with a combined mediating effect of -0.249, explaining 63.52% of the total variance.

Conclusion

This study examined how FNE and self-esteem affect the link between family functioning and SAD in patients with strabismus. These findings complement our understanding of SAD mechanisms in strabismus patients, encompassing familial, cognitive, and emotional perspectives, and offer theoretical insights for enhancing social functioning in this population.

Psychological interventions for social anxiety disorder in children and adolescents: A systematic review and network meta-analysis

BACKGROUND

Social anxiety disorder (SAD) is a high-prevalence mental disorder among children and adolescents. The aim of this study is to compare and rank the effectiveness of several psychotherapies for SAD among children and adolescents.

METHODS

Only randomized controlled trials (RCTs) were utilized by searching PubMed, Embase, Cochrane Library, and Web of Science. We used network meta-analysis in the Bayesian framework to analyze the data. This study is registered with PROSPERO, number CRD42023476829.

RESULTS

In total, 30 RCTs with 1547 individuals were included, and nine psychotherapies with three control conditions were compared and ranked in this study. The findings revealed that internet-delivered cognitive behavioural therapy (surface under the cumulative ranking curve [SUCRA: 71.2 %]), group cognitive behavioural therapy (SUCRA: 68.4 %), and individual cognitive behavioural therapy (SUCRA: 66.0 %) significantly reduced social anxiety symptoms; internet-delivered cognitive behavioural therapy also significantly decreased depression symptoms in these patients (SUCRA: 92.2 %). In addition, group cognitive behavioural therapy can enhance functioning in these patients (SUCRA: 89.6 %).

CONCLUSION

These results suggest that internet-delivered cognitive behavioural therapy is the optimal type of psychotherapy for reducing social anxiety and depression symptoms in children and adolescents with SAD, internet-delivered parent-child interaction therapy and cognitive bias modification of interpretation have relatively poor treatment effects on social anxiety symptoms in children than other psychological interventions, and group cognitive behavioural therapy has better benefits in enhancing the functioning among children and adolescents with SAD. Further studies are needed to ascertain these results due to the limited number of included studies.

Virtual Reality Exposure Therapy for Reducing School Anxiety in Adolescents: Pilot Study

BACKGROUND

Virtual reality exposure therapy (VRET) is a promising treatment approach for anxiety disorders. However, while its efficacy has been demonstrated in adults, research on the efficacy of VRET in the treatment of adolescents with anxiety disorders is largely lacking.

OBJECTIVE

A pilot study was carried out to test whether exposure to a virtual reality (VR) school environment elicits state anxiety and autonomic arousal in adolescents with school anxiety (diagnoses covering social anxiety disorder or specific phobia involving school contexts). In addition, we examined whether repeated VR exposure led to a reduction in this fear response, trait school anxiety, and social anxiety symptoms. Moreover, the relationship of presence, the subjective sense of "being there," during VR exposure with anxiety measures and treatment response was examined.

METHODS

In a pilot study, 10 adolescents with school anxiety (age range 14 to 17 years) participated in five VRET sessions. Self-reported state anxiety, heart rate, and presence during exposure, as well as trait school anxiety and social anxiety before and after treatment, were measured.

RESULTS

The VR scenario induced state anxiety and autonomic arousal. After VRET, a significant reduction in state anxiety (η2=0.74) and social anxiety symptoms (d=0.82) as well as a trend toward a decrease in trait school anxiety were observed, while autonomic arousal did not change. In addition, presence during VR exposure was associated with state anxiety and treatment response.

CONCLUSIONS

Our findings indicate the feasibility and potential effectiveness of VRET as a treatment method for symptoms of school and social anxiety in adolescents.

Social anxiety and bullying victimization: A three-level meta-analysis of cross-sectional and longitudinal studies

BACKGROUND

Numerous studies have explored the association between social anxiety and bullying victimization. However, inconsistency are found regarding the strength and the direction of this relationship. Moreover, it remains unclear how different subtypes of bullying victimization associate with social anxiety.

OBJECTIVE

The purpose of this study was to conduct a meta-analysis to systematically investigate the cross-sectional and longitudinal relationships between social anxiety and bullying victimization.

PARTICIPANTS AND SETTING

Individuals experiencing social anxiety and bullying victimization.

METHODS

The present study employed three-level random effects model to combine the correlation coefficients r to indicate the strength of the cross-sectional association between social anxiety and bullying victimization. Cross-lagged regressions were utilized to examine the prospective relationship between both variables.

RESULTS

A total of 133 cross-sectional studies reporting 220 effect sizes were included in the meta-analysis, and the results showed a significant moderate association between social anxiety and bullying victimization (r = 0.268, 95 % CI [0.244, 0.292]). Nineteen longitudinal studies were also identified, revealing that social anxiety at Time 1 significantly predicted bullying victimization at Time 2 (β = 0.067, 95 % CI [0.038, 0.096]). However, bullying victimization did not significantly predict subsequent social anxiety (β = 0.012, 95 % CI [-0.026, 0.049]). Subgroup analyses revealed that social anxiety had the strongest association with relational victimization (r = 0.382, 95 % CI [0.335, 0.430]), followed by reputational victimization (r = 0.254, 95 % CI [-0.171, 0.337]), physical victimization (r = 0.226, 95 % CI [0.144, 0.308]) and overt victimization (r = 0.202, 95 % CI [0.146, 0.257]). Social anxiety was significantly more associated with traditional bullying victimization (r = 0.281, 95 % CI [0.233, 0.328]) than cyberbullying victimization (r = 0.177, 95 % CI [0.137, 0.218]; p < 0.001).

CONCLUSIONS

Social anxiety was found to be moderately associated with and prospectively predict bullying victimization. Future research and interventions could focus on reducing social anxiety to prevent bullying victimization.

Research hot topics and frontiers in social anxiety over the past decade: a CiteSpace bibliometric analysis based on Web of Science database from 2013 to 2023

Objective

To understand the current study of social anxiety (SA) over the past decade, and to analyze the research hot topics and frontiers in this field.

Methods

CiteSpace 6.2.R3 was used to analyze the literature on SA collected in the Web of Science Core Collection database from 2013 to 2023.

Results

A total of 9940 literature were included after the screening, and the annual publication volume showed a steady increase. The results emphasize that Zvolensky MJ, Pine DS, and Heimberg RG are important authors in the field of SA. The United States has the highest number of publications, with the University of California System contributing the most. Research hotspots include cognitive impairment, risk factors, complications, neuroimaging, and intervention strategies. SA related to the "theory of mind", "bullying victimization", "mobile phone", "network analysis", "technology", and "satisfaction" are emerging research foci.

Conclusion

This study identifies the current situation and trends of SA research, and provides a reference for future research topics and directions.

Cognitive behavioral group therapy for social anxiety disorder - A critical review of methodological designs

Social anxiety disorder (SAD) is highly prevalent with significant lifetime impacts, especially when left untreated. Cognitive behavioral therapy is the current gold standard treatment with successful patient outcomes. Cognitive behavioral group therapy (CBGT) is one form that provides unique benefits to participants including normalization of symptoms and social support, as well as providing increased access to treatment at a lower per-session cost. Research on this mode of treatment has been ongoing for over 20 years, but we still have much to learn about its overall efficacy. The goals of this critical review were to summarize and evaluate the most current research, including an analysis of the overall methodological design quality, and provide recommendations for the enhancement of future studies based on best practices. Recent studies included some best practice design elements used in measuring efficacy such as the use of comparison groups, masking procedures, fidelity assessments, and consideration of clinical significance in outcomes. However, many gaps exist such as a lack of consensus around measures and therapy manuals, as well as baseline competencies of facilitators. Future studies should consider incorporating additional best practice elements aligning with study goals to strengthen designs and provide the field with even more confidence in this mode of treatment.

Social Anxiety in Autistic People: Does the Clark and Wells Model fit?

PURPOSE

Cognitive behaviour therapy based on the Clark and Wells (1995) model is a first-line treatment for neurotypical people seeking support for social anxiety. While autistic people frequently report high social anxiety, it is unclear how appropriate the model is for this population.

METHODS

Over 300 autistic and non-autistic adults completed an online survey measuring key variables of the Clark and Wells model (socially-related negative thoughts, safety behaviours, self-focused attention). Using multiple regression and structural equation modelling, we assessed whether these variables accounted for the link between autism and social fears.

RESULTS

In multiple regression, autistic people experienced greater social fears than expected based on Clark and Wells variables, and safety behaviours were less predictive of social fears in autistic people. In structural equation modelling, Clark and Wells variables only mediated half the link between autistic traits and social fears. In exploratory analysis, we found that distress relating to uncertainty was an additional variable that needed to be taken into consideration in the relationship between autistic traits and social fears.

CONCLUSION

The Clark and Wells variables were relevant in autism, but did not fully explain elevated social fears in autistic people, which suggests that other factors are also important in accounting for social anxiety in autistic people. This means that therapy informed by the model may not be optimal for autistic people. We recommend further research developing adapted therapy for social anxiety in autistic people.

Self-concealment scale (SCS) in middle-aged people: psychometric features and cross-age equivalence test

BACKGROUND

Individuals' concealment of negative information and privacy may lead to impaired social interactions and threatened health conditions. This study aimed to investigate the effectiveness of the Self-Concealment Scale (SCS) in the middle-aged Chinese population and to examine the equivalence of the SCS among different age groups.

METHODS

The current research adopted the SCS, Distress Disclosure Index (DDI), Revised Cheek and Buss Shyness Scale (RCBS), Social Interaction Anxiety Scale (SIAS), Social Phobia Scale (SPS), UCLA Loneliness Scale (ULS-8), and Kessler Psychological Distress Scale (K10) to survey 1124 middle-aged people. To explore the factor structure of the SCS, the study employed exploratory factor analysis and confirmatory factor analysis. The reliability of the SCS was measured based on Cronbach's α coefficients, McDonald's Omega coefficients, and split-half reliability. Correlation analysis was applied to examine the relationship between SCS and RCBS, SIAS, SPS, ULS-8, and K10. Moreover, this study recruited 1458 emerging adults and 1104 older adults to identify the cross-age invariance of the SCS.

RESULTS

Exploratory factor analysis of the middle aged adults' data supported a single factor model. The factor loadings of SCS items ranged from 0.62 to 0.73, the commonality ranged from 0.39 to 0.53, and the single-factor model fitted well. The scale showed a Cronbach's α coefficient value of 0.895, McDonald's Omega coefficient of 0.893, and a split-half reliability coefficient value of 0.861. In addition, the SCS demonstrated invariance in emerging adults, middle-aged adults, and older adults. Further analysis showed that the scores of the SCS (F = 3.55, p = 0.029) among emerging adults (M = 26.43, SD = 7.96) were significantly higher than among middle-aged (M = 25.77, SD = 7.79), and older cohort (M = 25.69, SD = 7.91).

CONCLUSION

The SCS revealed favorable psychometric characteristics among the middle-aged Chinese population. The degree of self-concealment among emerging adults was higher than that of middle-aged and older people.

Behavioral Inhibition and Social Anxiety Disorder as Predictors of Long-Term Outcomes of Cognitive Behavioral Therapy for Youth Anxiety Disorders

The temperamental trait behavioral inhibition (BI) is related to the development and maintenance of anxiety, particularly much so to social anxiety disorder. We investigated if BI and social anxiety disorder predicted cognitive behavioral therapy (CBT) outcomes for youth anxiety. Youth (N = 179; Mage = 11.6 years) were assessed 4 years following a randomized controlled CBT effectiveness trial. BI was measured by the parent-reported Behavioral Inhibition Questionnaire at baseline. The outcomes were diagnostic recovery, youth- and parent-reported anxiety symptoms, and clinical severity at post-treatment, 1-year, and 4-year follow-up. Having social anxiety disorder negatively predicted diagnostic recovery and predicted higher clinical severity at all assessment points and was the only significant predictor of outcomes at 4-year follow-up. Higher BI negatively predicted diagnostic recovery and predicted higher clinical severity and parent-reported symptom levels at post-treatment and 1-year follow-up, and predicted higher youth-reported anxiety levels at 1-year follow-up. Higher BI was the only predictor of youth- and parent-reported anxiety symptoms. BI and social anxiety disorder seem to be unique predictors of CBT outcomes among youth with anxiety disorders. CBT adaptations may be indicated for youth with high BI and social anxiety disorder.

Estimation of the Global Disease Burden of Depression and Anxiety between 1990 and 2044: An Analysis of the Global Burden of Disease Study 2019

(1) Background: Depression and anxiety are the most common and severe mental disorders. This research estimated the prevalence and disease burden of depression and anxiety from 1990 to 2044. (2) Methods: Data on disease burden, population, and risk factors were identified and gathered from the Global Health Data Exchange database. The time trends, sex and age differences, key factors, and regional variations in and predictions of depression and anxiety were analyzed based on the age-standardized incidence rate, prevalence rate, and DALY rate. (3) Results: Our findings revealed that the burden of depression and anxiety was heavy. Specifically, the age-standardized DALY rate of depression started to decrease compared with trends related to anxiety disorders. Meanwhile, females bear a heavier burden for both depression and anxiety. Seniors and the middle-aged population carry the highest burden regarding mental disorders. Both high- and low-socio-demographic-index countries were found to be high-risk regions for depressive disorders. The disease burden attributed to childhood sexual abuse, bullying victimization, and intimate partner violence has increased since 1990. Finally, projections regarding depression and anxiety revealed geographic and age variations. (4) Conclusions: Public health researchers, officers, and organizations should take effective age-, sex-, and location-oriented measures.

Bullying victimization and bullying perpetration, social anxiety, and social withdrawal in Portuguese adolescents: A reciprocal association model

Further research is needed to clarify the association of the different forms of bullying with social anxiety and social withdrawal over time in adolescents. This two-wave panel study with a 1-year time lag (October 2021-October 2022) examined the cross-lagged relationships between bullying victimization and bullying perpetration, social anxiety (i.e., fear or distress in social situations), and social withdrawal (i.e., consistent, and deliberate social solitude). Participants were 485 middle school students (234 girls) attending the seventh or eighth grade at Time 1 (T1) (Mage = 12.67 years, SD = 1.14 years). Social anxiety and social withdrawal were assessed using subscales of the Social and Emotional Competencies Evaluation Questionnaire. Bullying perpetration and bullying victimization were assessed using the Bullying and Cyberbullying Behavior Questionnaire-Short Form. The within-wave associations between the study variables were similar at T1 and Time 2 (T2), with the exception that the association between bullying perpetration and social anxiety was much weaker at T1 than at T2. The results of the path analysis showed that T1 bullying perpetration predicted T2 social anxiety, and that T1 bullying victimization predicted T2 social withdrawal. We also found a reciprocal relationship between social anxiety and social withdrawal. These findings highlight the importance of preventive and remediation interventions to reduce social anxiety in adolescents who engage in and experience bullying behavior.

Impact of vortioxetine on psychosocial functioning moderated by symptoms of fatigue in post-COVID-19 condition: a secondary analysis

INTRODUCTION

Fatigue is a prominent symptom in post-COVID condition (PCC) sequelae, termed "long COVID." Herein, we aim to ascertain the effect of fatigue on psychosocial function in persons living with PCC.

METHODS

This post hoc analysis evaluated the effects of vortioxetine on measures of fatigue as assessed by the Fatigue Severity Scale (FSS) in psychosocial function as measured by the Sheehan Disability Scale (SDS) in persons with PCC. We also evaluated the change in FSS on psychosocial functioning as measured by the Sheehan Disability Scale (SDS). This post hoc analysis obtained data from a recently published placebo-controlled study evaluating vortioxetine's effect on objective cognitive functions in persons living with PCC.

RESULTS

One hundred forty-four participants meeting World Health Organization (WHO) criteria for PCC were included in this analysis. At the end of 8 weeks of vortioxetine treatment, significant improvement of all domains was observed for psychosocial functioning. There was a significant between-group difference at treatment endpoint in the family, social, and work SDS subcategories (p < 0.001). There was a statistically significant interaction effect between the treatment condition time point and FSS effect on the SDS social (χ2 = 10.640, p = 0.014) and work (χ2 = 9.342, p = 0.025) categories but a statistically insignificant effect on the family categories ((χ2 = 5.201, p = 0.158)).

DISCUSSION

This post hoc analysis suggests that vortioxetine treatment significantly improves psychosocial function in persons with PCC. Our results also indicate that the improvement in psychosocial function was significantly mediated by improvement in measures of fatigue. Our results provide empirical support for recommendations to identify therapeutics for fatigue in persons living with PCC with a broader aim to improve psychosocial function in this common and severely impaired population.

Comparison of the Effectiveness of Cognitive-Behavioral Therapy and Acceptance and Commitment-Based Therapy on Anxiety Sensitivity in Adolescents with Social Anxiety Disorder

The Article Abstract is not available.  

The impact of long-term online learning on social anxiety and problematic smartphone use symptoms among secondary school students with different levels of fear of missing out: Evidence from a symptom network and longitudinal panel network analysis

Background

The advancement of communication technology and the impact of the COVID-19 pandemic have led to an increased reliance on online education. However, the effects of the long-term use of smart devices for online learning on students' social anxiety and problematic smartphone use (PSU) and the role of fear of missing out (FoMO) in this process have yet to be fully explored.

Methods

This study analysed longitudinal data from 2,356 high school students (female = 1,137 (48.26%), mean age = 13.84, SD age = 1.37) in China, divided into high- and low-FoMO groups based on their scores on the FoMO scale, to examine the impact of four months of online learning on social anxiety and PSU. The Social Anxiety Scale (SAS) and Mobile Phone Addiction Index (MPAI) were used to assess social anxiety and PSU symptoms.

Results

The undirected symptom networks revealed more bridge symptoms among the students in the high-FoMO group, although their overall symptom scores decreased. The results of the directed cross-lagged panel networks showed that "productivity loss" predicted other symptoms in the low-FoMO group but that "afraid of negative evaluation" was the predictor in the high-FoMO group. Meanwhile, "withdrawal/escape" and "productivity loss" were the symptoms that were most affected by other symptoms in the high-FoMO and low-FoMO groups, respectively.

Conclusions

The current study therefore sheds light on the changes in social anxiety and PSU symptoms among secondary school students during long-term online learning, as well as the moderating role of FoMO.

Understanding the relationship between social camouflaging in autism and safety behaviours in social anxiety in autistic and non-autistic adolescents

BACKGROUND

Social camouflaging (hereafter camouflaging) in autism includes factors such as masking and compensating for one's neurodevelopmental differences, and to assimilate or 'fit in' with non-autistic peers. Efforts to hide one's authentic self and autism traits (masking) resemble impression management (IM) in safety behaviours identified in Clark and Wells' (1995) cognitive model of social anxiety (SA). This study explores the relationship between camouflaging in autism and safety behaviours in SA among autistic and non-autistic adolescents.

METHODS

One hundred fifteen adolescents (14-19 years) with (n = 61; 36 female) and without (n = 54; 37 female) a clinical diagnosis of autism matched on age and SA symptom severity were recruited from clinics, schools and online. Adolescents completed online measures including autism traits, SA symptoms, camouflaging behaviours, SA-related safety behaviours and SA-related negative cognitions. Partial and bivariate Pearson's correlations and structural equation modelling were used to understand the relationship between camouflaging, safety behaviours, autism traits and SA in both groups. Exploratory factor analysis assessed item-level factor cross-loadings between camouflaging and safety behaviours.

RESULTS

Across both groups, masking and IM were significantly associated with SA symptom severity, not autism traits, via SA-related social cognitions. Exploratory factor analysis indicated construct overlap across masking, assimilation, IM and avoidance behaviours and identified factors analogous to self-focused attention, social avoidance and mental rehearsal identified in the Clark and Wells' (1995) model of SA.

CONCLUSIONS

This is the first study using group-matched design to identify that masking (factor in social camouflaging) and IM both relate to SA in autistic and non-autistic adolescents. Assessment and formulation of construct overlap between masking and IM may inform psychoeducation and adaptation of SA treatment for autistic adolescents.

Effectiveness and User Experience of Virtual Reality for Social Anxiety Disorder: Systematic Review

BACKGROUND

Social anxiety disorder (SAD) is a debilitating psychiatric disorder that affects occupational and social functioning. Virtual reality (VR) therapies can provide effective treatment for people with SAD. However, with rapid innovations in immersive VR technology, more contemporary research is required to examine the effectiveness and concomitant user experience outcomes (ie, safety, usability, acceptability, and attrition) of emerging VR interventions for SAD.

OBJECTIVE

The aim of this systematic review was to examine the effectiveness and user experience of contemporary VR interventions among people with SAD.

METHODS

The Cochrane Library, Emcare, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science databases were searched between January 1, 2012, and April 26, 2022. Deduplicated search results were screened based on title and abstract information. Full-text examination was conducted on 71 articles. Studies of all designs and comparator groups were included if they appraised the effectiveness and user experience outcomes of any immersive VR intervention among people with SAD. A standardized coding sheet was used to extract data on key participant, intervention, comparator, outcome, and study design items.

RESULTS

The findings were tabulated and discussed using a narrative synthesis. A total of 18 studies met the inclusion criteria.

CONCLUSIONS

The findings showed that VR exposure therapy-based interventions can generally provide effective, safe, usable, and acceptable treatments for adults with SAD. The average attrition rate from VR treatment was low (11.36%) despite some reported user experience difficulties, including potential simulator sickness, exposure-based emotional distress, and problems with managing treatment delivered in a synchronous group setting. This review also revealed several research gaps, including a lack of VR treatment studies on children and adolescents with SAD as well as a paucity of standardized assessments of VR user experience interactions. More studies are required to address these issues.

TRIAL REGISTRATION

PROSPERO CRD42022353891; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=353891.

Associations between humiliation, shame, self-harm and suicidality among adolescents and young adults: A systematic review

BACKGROUND

Suicide is the second leading cause of death among young people worldwide. Research indicates that negative social contexts involving familial and peer relationships have far-reaching influences on levels of suicidality in later life. While previous systematic reviews have focused on evaluating associations between negative life events such as abuse and bullying in childhood and subsequent suicidality, this systematic review examines the prevalence of, and association between the processes of humiliation and shame in later self-harm, suicidal ideation, and suicide among adolescents and young adults.

METHODS

A systematic literature search of databases including MEDLINE, Web of Science Core Collection, CINAHL, PsycINFO, and Embase was conducted to identify potential studies. ProQuest was searched to identify relevant grey literature research. A combination of MESH terms and keywords was used. All original quantitative studies published in English that examined the prevalence, or association between humiliation or shame and suicidal behaviours and/or death by suicide were included. Studies were assessed for methodological quality using Joanna Briggs Institute critical appraisal tools. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) [CRD42022289843].

RESULTS

Narrative synthesis was performed. A total of 33 studies reporting the prevalence of, or association between humiliation (n = 10) or shame (n = 23) and suicidal thoughts/behaviours were included. The prevalence of humiliation among those with any suicidality ranged from 18% to 28.1%, excluding an outlier (67.1%), with two studies presenting a significant association between humiliation and self-harm in their fully adjusted analyses. The studies that outlined humiliation and suicidal thinking (intent/suicide plan) had no association after adjustment for confounders. For shame, half of the studies found an association in adjusted models (n = 10), and this was evident for both suicidal ideation and self-harm.

CONCLUSION

To our knowledge, this is the first study to attempt a systematic review on this topic. The dearth of research in this field of enquiry is reflective of unique challenges associated with assessments of humiliation and shame in various clinical settings amongst adolescent and young adult populations. Nonetheless, given the importance and relevance of the psychological imprint of humiliation in youth morbidity and mortality in the field of mental health, it is timely to attempt such a systematic review. In light of the associated role of humiliation and shame in self-harm and suicidality among young people, we recommend that these processes need to be explored further via prospective studies and assessed as part of a comprehensive bio-psycho-social assessment when focusing on life stressors for adolescent and young adults presenting with suicidality to emergency departments and mental health services.

The role of developmental caregiving programming in modulating our affiliation tendency and the vulnerability to social anxiety and eating disorders

Attachment is the evolutionarily-established process through which humans create bonds with others to receive care from them. The phenomenon is as essential to our physical survival as it is to our psychological development. An increasing number of studies demonstrates that in sensitive periods during the early years of life, our brain circuitry is programmed in the interactions with our caregivers, with the imprinting of information over multiple attachment dimensions. Adopting a basic brain-computer analogy, we can think of this knowledge as the psycho-social firmware of our mind. According to a recently proposed extension of the classical three-dimensional view, one attachment dimension - somaticity - concerns the caregiver's task of reflecting and confirming the child's (internal) states - such as sensations, emotions, and representations - to support the child's ability to identify and define those entities autonomously. Relying on multidisciplinary evidence - from neuroscientific, developmental, evolutionary, and clinical sources - we suggest that somaticity (H1) has the adaptive function to modulate our tendency to comply and affiliate with a reference group but also (H2) increases the vulnerability to developing Social Anxiety (SA) and Eating Disorders (EDs). We evaluate H1-H2, (1) indicating the evolutionary role of somaticity in modulating our affiliation tendency to optimize the ancestral threat-opportunity balance coming from infectious diseases and (2) showing the deep connection between SA-EDs and the features most closely related to somaticity - interoception and parenting style. Finally, we discuss three relevant implications of H1-H2: (A) Bringing into research focus the adaptive role of our firmware knowledge system versus the hardware (neural substrate) and software (higher cognition) ones. (B) Complementing the well-grounded Objectification and Allocentric Lock Theories, allowing us to integrate multiple levels of explanation on the etiology of psychopathology. (C) Suggesting the design of new psychological treatments. While not aiming to prove H1-H2, our analysis supports them and encourages their direct testing.

The role of interpretation biases and safety behaviours in social anxiety: an intensive longitudinal study

BACKGROUND

Interpretation bias and safety behaviours (Safe-B) have been proposed as factors perpetuating social anxiety (SA). However, longitudinal research on how they contribute to SA in everyday life is scarce.

AIM

The aim was to examine whether interpretation bias predicts daily Safe-B and SA. A mediated moderation was hypothesized, where the relationship between daily social stressors and Safe-B would be moderated by interpretation bias, and Safe-B, in turn, would mediate the association between stressors and SA levels. In addition, it was hypothesized that prior levels of SA would predict higher Safe-B use, especially in co-occurrence with stressors.

METHOD

An intensive longitudinal design was employed, with 138 vocational training students (51% men, mean age 20.15 years). They completed initial measures of SA and interpretation bias and 7-day diaries with measures of social stressors, Safe-B, and SA. They reported SA levels two months later.

RESULTS

Both stressors and interpretation bias in ambiguous situations predicted Safe-B, which in turn predicted daily SA levels. However, neither interpretation bias nor Safe-B predicted SA levels at the follow-up, and interpretation bias did not moderate the association between stressors and daily SA. In addition, the relationship between stressors and Safe-B was stronger in people with higher initial SA levels.

CONCLUSIONS

The results suggest that Safe-B are a mechanism through which earlier SA levels and interpretation bias contribute to higher SA levels in daily life.

Social anxiety disorder in Black American adolescents: Cultural considerations in conceptualization, assessment, and treatment

Social anxiety disorder (SAD) is characterized by significant distress and avoidance surrounding social and performance situations, with marked interpersonal and academic impairment. This review article highlights cultural considerations relevant to the conceptualization, identification, and treatment of SAD in Black youth. Research evaluating the utility of evidence-based measures to assess SAD suggests they are culturally relevant; however, gaps in knowledge regarding the psychometric properties of even the most widely used instruments are evident. In regard to intervention, cognitive behavioral therapy (CBT) approaches hold promise, yet there is a lack of research on the use of CBT with Black adolescents. Recommendations to incorporate cultural factors into CBT are provided, and future work investigating culturally adapted interventions is needed. Finally, given significant disparities in access and utilization of mental health services among Black youth, strategies to increase treatment engagement, such as school-based services, are important to consider.

The Course of Anxiety-Specific Cognitive Bias Following Daycare/Inpatient Treatment in Youths with Social Phobia and School Absenteeism

Social phobia (SP) is a common mental disorder in youth often accompanied by absence from school, which may require daycare or inpatient intervention (DC/IN). Objective: The present explorative study investigates changes in anxiety-specific implicit assumptions and interpretation bias following DC/IN. Methods: The study included 16 youths with SP (M age = 15.8 [SD = 1.24], females: 62.5 %) participating in DC/IN. We assessed the main outcomes using the Implicit Association Test and Affective Misattribution Procedure. Results: A large effect was shown for reducing implicit assumptions of feeling anxious (p = .142; η2p = .171) and for reducing the implicit interpretation bias (p = .137; η2p = .162). No change was indicated by effect size in implicit assumptions of feeling socially rejected (p = .649; η2p = .016). Social phobia symptoms initially correlated with changes in implicit assumptions of feeling anxious (r = .45). Conclusion: Effect sizes indicate that implicit anxiety-specific assumptions and interpretation bias descriptively improved following DC/IN. Thus, DC/IN may lead to meaningful improvements of anxiety-specific cognition in some individuals with high SP symptoms, emphasizing the relevance of cognitive behavioral approaches in the treatment of SP. Several limitations are discussed.

Social interpretation inflexibility moderates emotional reactions to social situations in children and adolescents

Interpretation biases and inflexibility (i.e., difficulties revising interpretations) have been linked to increased internalizing symptoms. Although adolescence is a developmental period characterized by novel social situations and increased vulnerability to internalizing disorders, no studies have examined interpretation inflexibility in adolescents. Additionally, no studies (on adolescents or adults) have examined interpretation flexibility as a protective factor against adverse outcomes of interpersonal events. Using a novel task and a 28-day diary we examined relations among interpretation bias and inflexibility, internalizing symptoms, and negative interpersonal events in a sample of children and adolescents (N = 159, ages 9-18). At baseline, negative interpretation bias was positively correlated with social anxiety symptoms, and positive interpretation bias negatively correlated with social anxiety and depressive symptoms. Inflexible positive interpretations were correlated with higher social anxiety and depressive symptoms, while inflexible negative interpretations were correlated with higher social anxiety. Finally, interpretation inflexibility moderated daily associations between negative interpersonal events and depressive symptoms in daily life, such that higher inflexibility was associated with stronger associations between interpersonal events and subsequent depressive symptoms, potentially increasing depressive symptom instability. These results suggest that interpretation biases and inflexibility may act as both risk and protective factors for adolescent anxiety and depression.

A brain model of altered self-appraisal in social anxiety disorder

The brain's default mode network has a central role in the processing of information concerning oneself. Dysfunction in this self-referential processing represents a key component of multiple mental health conditions, particularly social anxiety disorder (SAD). This case-control study aimed to clarify alterations to network dynamics present during self-appraisal in SAD participants. A total of 38 adolescents and young adults with SAD and 72 healthy control participants underwent a self-referential processing fMRI task. The task involved two primary conditions of interest: direct self-appraisal (thinking about oneself) and reflected self-appraisal (thinking about how others might think about oneself). Dynamic causal modeling and parametric empirical Bayes were then used to explore differences in the effective connectivity of the default mode network between groups. We observed connectivity differences between SAD and healthy control participants in the reflected self-appraisal but not the direct self-appraisal condition. Specifically, SAD participants exhibited greater excitatory connectivity from the posterior cingulate cortex (PCC) to medial prefrontal cortex (MPFC) and greater inhibitory connectivity from the inferior parietal lobule (IPL) to MPFC. In contrast, SAD participants exhibited reduced intrinsic connectivity in the absence of task modulation. This was illustrated by reduced excitatory connectivity from the PCC to MPFC and reduced inhibitory connectivity from the IPL to MPFC. As such, participants with SAD showed changes to afferent connections to the MPFC which occurred during both reflected self-appraisal as well as intrinsically. The presence of connectivity differences in reflected and not direct self-appraisal is consistent with the characteristic fear of negative social evaluation that is experienced by people with SAD.

Cognitive and behavioural processes in adolescents with social anxiety disorder

BACKGROUND

A better understanding of the processes that maintain social anxiety disorder (SAD) in adolescents could improve treatment outcomes. This study aimed to establish whether cognitive and behavioural processes known to be important in the maintenance of adult SAD are observed in adolescent populations and whether they are specific to SAD.

METHODS

We recruited three groups of adolescents (12-18y): (1) 90 adolescents with a SAD diagnosis, (2) 58 adolescents with an anxiety disorder that was not SAD, and (3) 45 community-based adolescents. Participants completed measures of negative social cognitions, social attitudes, safety behaviours, self-focused attention, and social anxiety, anxiety, and depression symptoms.

RESULTS

The clinical SAD sample endorsed higher levels of negative social cognitions, attitudes, and safety behaviours compared to both control groups. Self-focused attention was higher in the clinical SAD sample compared to the anxiety clinical control group but not compared to the community control group.

CONCLUSIONS

This study provided evidence of SAD-specific mechanisms including negative social cognitions, attitudes and safety behaviours in adolescents. The study did not provide evidence of disorder-specific mechanisms of self-focused attention but this may have been due to methodological limitations. These findings indicate avenues for further research and point to the potential value of Cognitive Therapy for the treatment of adolescent SAD.

Anxiety disorders in children and adolescents: A summary and overview of the literature

Considerable work has advanced understanding of the nature, causes, management, and prevention of anxiety disorders in children and adolescents over the past 30 years. Prior to this time the primary focus was on school refusal and specific phobias. It is now recognised that children and adolescents experience the full gamut of anxiety disorders in very similar ways to adults and that anxiety disorders in the paediatric years can predict a lifelong mental-health struggle. Given the vast array of specific studies in this field, the current review summarises current knowledge about these high prevalence disorders, points to overarching limitations, and suggests potentially important future directions. Following a brief historical overview, the review summarises knowledge about demographic and epidemiological characteristics, distal and proximal risk factors, current treatment directions, and prevention. There is still a great deal to learn about the causes and treatments of child and adolescent anxiety disorders. By amalgamating our current knowledge, this review provides a window to the research directions that are likely to lead to future advances.

Prevention and Treatment of Social Anxiety Disorder in Adolescents: Protocol for a Randomized Controlled Trial of the Online Guided Self-Help Intervention SOPHIE

BACKGROUND

Social anxiety symptoms are highly prevalent among adolescents and are associated with poor quality of life and low psychosocial functioning. If untreated, social anxiety often persists into adulthood and increases the risk for comorbid disorders. Therefore, early interventions for social anxiety to prevent negative long-term consequences are critical. However, adolescents rarely seek help and often avoid face-to-face psychotherapeutic interventions due to the perceived lack of autonomy and anonymity. Thus, online interventions represent a promising opportunity to reach adolescents who have social anxiety but do not seek help yet.

OBJECTIVE

This study aims to evaluate the efficacy, moderators, and mediators of an online intervention developed to reduce social anxiety in adolescents.

METHODS

A total of 222 adolescents aged 11-17 years with subclinical social anxiety (N=166) or with a diagnosis of social anxiety disorder (N=56) are randomly assigned to the online intervention or a care-as-usual control group. The 8-week guided online intervention is based on the Cognitive Model of Social Phobia and evidence-based online interventions for social anxiety adapted to the specific needs of adolescents. The care-as-usual group will be given access to the online intervention after the follow-up assessment. Participants are assessed at baseline, at 4 and 8 weeks post intervention, and at 3-month follow-up assessment on the primary outcome, that is, social anxiety, on secondary outcomes (eg, level of functioning, fear and avoidance, general anxiety, depression, quality of life, self-esteem, and negative effects of the intervention), on potential moderators (eg, therapy motivation, therapy expectancy, and satisfaction with the intervention), and potential mediators (eg, therapeutic alliance and adherence to the intervention). Data will be analyzed based on an intention-to-treat approach and both groups (intervention and care-as-usual) will be compared at each assessment time point. Furthermore, potential mechanisms of change and generalization of intervention effects on daily life are assessed using an ecological momentary assessment procedure that includes items on maintaining mechanisms of social anxiety, social context, and affect. Participants are prompted 3 times a day during the first 8 weeks of the study and again for 2 weeks following the follow-up assessment.

RESULTS

Recruitment is ongoing; initial results are expected in 2024.

CONCLUSIONS

Results are discussed considering the potential of online interventions as a low-threshold prevention and treatment option for adolescents with social anxiety and in light of current advances in dynamic modeling of change processes and mechanisms in early intervention and psychotherapy in adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04782102; https://clinicaltrials.gov/ct2/show/NCT04782102.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44346.

Cognitive Variables in Social Anxiety Disorder in Children and Adolescents: A Network Analysis

Clark and Wells' prominent model of social anxiety disorder (SAD) assumes that cognitive variables such as negative expectations or dysfunctional cognitions play a central role in the symptomatology of SAD. In contrast to adults, it is less clear how well the cognitive model can be applied to children and adolescents. A network analysis with seven nodes was conducted to explore the importance of cognitive variables and their interaction with symptoms of SAD based on N = 205 children and adolescents (8-18 years, M = 11.54 years). Cognitive variables had a high but differential impact within the positively connected network of SAD. Dysfunctional cognitions were most strongly connected within the network. Dysfunctional cognitions, as predicted by Clark and Wells' model, seem to act as a hub affecting several symptoms. The association between negative expectations and avoidance indicates that negative expectations may particularly contribute to the maintenance of SAD.

Saudi Arabian Perceptions of Childhood Anxiety, Parental Communication, and Parenting Style

Parenting communication and parenting style, including expressions of fear, worry, and threat, may contribute to children's anxiety and apprehension. This study examined the degree to which perceptions of parental communication (both verbal and nonverbal) and parenting style are linked with childhood anxiety. This is among the first studies to investigate these relationships in a Saudi Arabian context. We employed a sample of 121 Saudi adults who completed questionnaires measuring perceptions of 2 parenting styles (authoritative and authoritarian), parental anxiety, and childhood anxiety. Parental communication elements such as shouting, criticism, facial expression, and body expressions were included among assessments of perceived parental anxiety, authoritative style, and authoritarian style. The results indicated that perceptions of childhood anxiety were positively associated with parental anxiety but not consistently associated with other assessed variables. This research addressed perceptions of parental communication and parenting style in the development of childhood anxiety, extending upon previous research on Western samples to a Middle Eastern sample residing in Saudi Arabia.

Social Anxiety and Suicidality in Youth: A Systematic Review and Meta-analysis

Suicide is a leading cause of death among young people every year. Identifying risk factors provides opportunities to intervene, and social anxiety may represent one such factor. This systematic review and meta-analysis aimed to review the evidence of associations between social anxiety and suicidality in youth (10-25 years). Embase, PsycInfo, and Medline were searched to identify relevant articles. Meta-analysis was conducted to examine the mean effect sizes of concurrent and prospective associations between social anxiety and three indices of suicidality in adolescents aged 10-25 years. Meta-analyses of 16 studies showed that social anxiety was associated cross-sectionally with suicide attempt (r = 0.10, 95% CI: 0.04, 0.15), suicidal ideation (r = 0.22, 95% CI: 0.02, 0.41), and suicide risk (r = 0.24, 95% CI: 0.05, 0.41), and prospectively at trend level with suicidal ideation (r = 0.62, 95% CI: -0.03, 0.90). An examination of the prospective associations with suicide attempt and risk was not possible due to a lack of studies. Several studies suggested that results could not be solely attributed to depressive symptoms. A high level of heterogeneity was observed in each meta-analysis. Moderation analysis was possible for gender and publication year only; neither was significant. Findings provide further evidence of a link between social anxiety and suicidal thoughts and behaviors in youth but are limited by the small number of studies of mixed quality. This review supports future research into social anxiety symptoms as potential risk factors and treatment targets for suicidal youth.

Implicit assumptions and interpretation bias in youth with severe, chronic social phobia

Interpretation bias and dysfunctional social assumptions are proposed to play a pivotal role in the development and maintenance of social phobia (SP), especially in youth. In this study, we aimed to investigate disorder-specific implicit assumptions of rejection and implicit interpretation bias in youth with severe, chronic SP and healthy controls (CG). Twenty-seven youth with SP in inpatient/day-care treatment (M age = 15.6 years, 74% female) and 24 healthy controls (M age = 15.7 years, 54% female) were included. The Implicit Association Test (IAT) and the Affect Misattribution Procedure (AMP) were completed to assess implicit assumptions and interpretation bias related to the processing of social and affective stimuli. No group differences were observed for the IAT controlling for depressive symptoms in the analyses. However, group differences were found regarding interpretation bias (p = .017, η²_p = .137). Correlations between implicit scores and explicit questionnaire results were medium to large in the SP group (r =|.28| to |.54|, p_all ≤ .05), but lower in the control group (r =|.04| to |.46|, p_all ≤ .05). Our results confirm the finding of an interpretation bias in youth SP, especially regarding the implicit processing of faces, whereas implicit dysfunctional social assumptions of being rejected do not seem to be specific for SP. Future research should investigate the causal relationship of assumptions/interpretation bias and SP.