Social Anxiety and Gaze Avoidance: Averting Gaze but not Anxiety

Vulnerabilities in social anxiety: Integrating intra- and interpersonal perspectives

What are the major vulnerabilities in people with social anxiety? What are the most promising directions for translational research pertaining to this condition? The present paper provides an integrative summary of basic and applied translational research on social anxiety, emphasizing vulnerability factors. It is divided into two subsections: intrapersonal and interpersonal. The intrapersonal section synthesizes research relating to (a) self-representations and self-referential processes; (b) emotions and their regulation; and (c) cognitive biases: attention, interpretation and judgment, and memory. The interpersonal section summarizes findings regarding the systems of (a) approach and avoidance, (b) affiliation and social rank, and their implications for interpersonal impairments. Our review suggests that the science of social anxiety and, more generally, psychopathology may be advanced by examining processes and their underlying content within broad psychological systems. Increased interaction between basic and applied researchers to diversify and elaborate different perspectives on social anxiety is necessary for progress.

Bidirectional relationships between interpretation biases, safety behaviors, and social anxiety

Theoretical models of social anxiety (SA) propose bidirectional relationships between SA, interpretation biases, and safety behaviors (Safe-B). However, longitudinal studies evaluating these bidirectional relationships are scarce. The main objective of this study was to analyze the bidirectional relationships between interpretation biases (from ambiguous situations and ambiguous faces), Safe-B, and SA. A two-time longitudinal study was carried out with the participation of 575 vocational training students (M = 19.49, SD = 2.41). Both the interpretation biases measured through ambiguous situations and ambiguous faces and the Safe-B predicted higher levels of SA in the second time. In turn, a bidirectional relationship was found between SA and Safe-B. However, no bidirectional relationships were found between interpretation biases and Safe-B and between biases and SA. Among others, the limitations of the study include the high attrition rate (30.4%) and the high proportion of male students (62.1%). The findings highlight the role of interpretation bias and Safe-B in SA. In turn, as a new initiative, the study supports the bidirectional relationship between Safe-B and SA. Implications are discussed throughout the manuscript.

Building Closer Friendships in social anxiety disorder: A randomized control trial of an internet-based intervention

BACKGROUND AND OBJECTIVES

Loneliness is an important factor in mental and physical health. People with social anxiety disorder (SAD) often report high levels of loneliness, which may be maintained by difficulties with intimacy. Building Closer Friendships (BCF) is a technology-based intervention we developed to reduce loneliness through reducing fear of intimacy in individuals with SAD.

METHODS

A sample of individuals with current SAD (N = 55), were randomized to BCF or waitlist control conditions and completed self-report assessments of loneliness, fear of intimacy, social anxiety and other outcomes throughout the study. An in vivo conversation task was also administered at post-treatment to assess distress and perceived disclosure, warmth, and friendliness of participants when interacting with a stranger.

RESULTS

In the intent-to-treat analyses, the BCF group reported lower fear of intimacy at post-treatment compared to the control group. Among completers, BCF led to lower fear of intimacy at post-treatment and follow-up, and lower loneliness and depression at follow-up compared to the waitlist control. No treatment effects were found in the conversation task or for other symptom outcomes, including social anxiety. Analyses of treatment components revealed that the frequency of emotional check-ins with friends was associated with reductions in loneliness and depression.

LIMITATIONS

The study was limited by the sample of primarily undergraduate college students, and use of self-report measures.

CONCLUSIONS

This preliminary study found modest support for BCF as a computerized intervention to reduce fear of intimacy and loneliness in individuals with SAD.

The impact of particular safety behaviours on perceived likeability and authenticity during interpersonal interactions in social anxiety disorder

BACKGROUND

Safety behaviours are hypothesized to play a vital role in maintaining social anxiety disorder (SAD), in part by orienting socially anxious individuals to adopt an avoidance-based mindset focused on self-protection and self-concealment. Evidence suggests an association between safety behaviour use and negative social outcomes for individuals with SAD. However, research has largely focused on the broad group of safety behaviours, whereas specific subtypes have received less attention.

AIM

The present study aimed to further our understanding of the negative interpersonal consequences of specific types of safety behaviours for individuals with SAD by examining whether active, inhibiting/restricting, or physical symptom management safety behaviour use affects perceived likeability and authenticity during a conversation with a stranger.

METHOD

Individuals with SAD (n = 29; mean age 35.5 years) and healthy control (non-SAD) participants (n = 40; mean age 18.6 years) engaged in a semi-structured social interaction with trained confederates.

RESULTS

Participants with SAD were perceived as significantly less likeable and authentic by the confederates, and rated themselves as significantly less authentic compared with those without SAD. The association between group status and likeability was mediated by the use of inhibiting/restricting safety behaviours and the association between group status and participant-rated authenticity was mediated by the use of both inhibiting/restricting and active safety behaviours, but not physical symptom management strategies.

CONCLUSIONS

These results contribute to a growing literature suggesting that some, but not all, safety behaviours may play an important role in creating the negative social outcomes that individuals with SAD experience.

Exploring patient participation during video consultations: A qualitative study

Objective

Video consultations enable a digital point of contact between the general practitioner and patient. With their medium-specific characteristics, video consultations may create novel conditions for the enactment of patient participation during consultations. Although numerous studies have explored patients' experiences of video consultations, research explicitly investigating patient participation within this new consultation setting remains sparse. This qualitative study explores how patients participate during interactions with their general practitioner by drawing on the affordances of video consultations.

Methods

The data corpus comprises eight recorded video consultations (59 minutes and 19 seconds in total) between patients and their general practitioner, all subjected to reflexive thematic analysis yielding three themes illustrating concrete participatory use cases.

Results

We find that video consultations provide an accessible format for patients otherwise unable to attend a physical consultation due to physical and mental barriers. Moreover, patients participate by drawing on resources situated in their spatial setting to settle health-related questions of doubt arising during the consultation. Lastly, we posit that patients enact participation by visually communicating their impromptu engagement in decision-making and reporting to their general practitioner by making use of the qualities of their smartphone during their consultation.

Conclusions

Our findings illustrate how video consultations provide a communicative context in which patients may enact distinct forms of participation by drawing on its technologically contingent affordances during interactions with their general practitioner. More research is needed to explore the participatory opportunities of video consultations in telemedical healthcare services for different patient groups.

Frozen with Fear? Attentional Mechanisms in Children with Selective Mutism

Background

Children with selective mutism (SM) are consistently unable to speak in certain social situations. Due to an overlap between SM and social anxiety disorder (SAD) in children, similar mechanisms could apply to both disorders. Especially biased attentional processing of threat and fear-induced reduced visual exploration (referred to as attentive freezing) appear promising in SM.

Methods

A total of N = 84 children (8–12 years, SM: n = 28, SAD: n = 28, typical development (TD): n = 28) participated in an eye-tracking paradigm with videos of a social counterpart expressing a question, a social evaluation or a neutral statement. We investigated gaze behavior towards the social counterpart’s eye-region and the extent of visual exploration (length of scanpath), across conditions.

Results

There were no group differences regarding gaze behavior on the eye region. Neither gaze behavior with respect to the eye region nor visual exploration were dependent on the video condition. Compared to children with TD, children with SM generally showed less visual exploration, however children with SAD did not.

Conclusion

Reduced visual exploration might be due to the mechanism of attentive freezing, which could be part of an extensive fear response in SM that might also affect speech-production. Interventions that counteract the state of freezing could be promising for the therapy of SM.

Attentional processes during emotional face perception in social anxiety disorder: A systematic review and meta-analysis of eye-tracking findings

Background In recent years, a growing body of eye-tracking research has investigated gaze behavior in individuals with social anxiety during the visual perception of emotional stimuli. The aim of this article was to review and synthesize studies examining attention orientation in patients with clinical social anxiety by means of eye-tracking methodology. Methods Through a systematic search, 30 articles were identified, including 11 studies in which single emotional faces were used as stimuli and seven eligible studies in which threatening faces were paired with neutral stimuli. Meta-analyses were conducted to compare prolonged eye-contact behavior and early attentional biases to threats in individuals with social anxiety disorder (SAD) and healthy controls. Results Moderate group differences were revealed for single face viewing studies, with SAD patients showing significantly reduced eye contact with negative (Hedges' g = -0.67) and positive emotional faces (g = -0.49) compared to that of healthy participants. Type of task and duration of stimulus presentation were (marginally) significant moderators of between-study variance in effect size. Small but significant group differences were found for early attentional biases toward angry faces versus neutral stimuli (g = 0.21) but not toward happy faces versus neutral stimuli (g = 0.05). Preliminary evidence for a hyperscanning strategy in SAD patients relative to healthy controls emerged (g = 0.42). Limitations The number of included studies with face pairings was low, and two studies were excluded due to unavailable data. Conclusions Our results suggest that eye contact avoidance with emotional faces is a prominent feature in SAD patients. Patients might benefit from guidance to learn to make adequate eye contact during therapeutic interventions, such as exposure therapy. SAD patients demonstrated slightly heightened attention allocation toward angry faces relative to that of healthy participants during early processing stages. Threat biases can be potential targets for attention modification training as an adjuvant to other treatments. Future research on early attentional processes may benefit from improved arrangements of paired stimuli to increase the psychometric properties of initial attention indices.

Communication Apprehension and Eye Contact Anxiety in Video Conferences Involving Teleoperated Robot Avatars: A Subjective Evaluation Study

Communication apprehension (CA), defined as anxiety in oral communication, and anxiety in eye contact (AEC), defined as the discomfort felt in communication while being stared at by others, limit communication effectiveness. In this study, we examined whether using a teleoperated robot avatar in a video teleconference provides communication support to people with CA and AEC. We propose a robotic telecommunication system in which a user has two options to produce utterance for own responses in online interaction with interviewer i.e., either by a robot avatar that faces the interviewer, or by self. Two imagination-based experiments were conducted, in which a total of 400 participants were asked to watch videos for interview scenes with or without the proposed system; 200 participants for each experiment. The participants then evaluated their impressions by imagining that they were the interviewee. In the first experiment, a video conference with the proposed system was compared with an ordinary video conference, where the interviewer and interviewee faced each other. In the second experiment, it was compared with an ordinary video conference where the interviewer’s attentional focus was directed away from the interviewee. A significant decrease in the expected CA and AEC of participants with the proposed system was observed in both experiments, whereas a significant increase in the expected sense of being attended (SoBA) was observed in the second experiment. This study contributes to the literature in terms of examining the expected impact of using a teleoperated robot avatar for better video conferences, especially for supporting individuals with CA and AEC.

The Medium is the Message: Effects of Mediums of Communication on Perceptions and Emotions in Social Anxiety Disorder

We examined the use of voice/text and visual mediums and their effects on perceptions and emotions in social anxiety disorder (SAD). Our sample included 88 individuals: 44 individuals with SAD and 44 non-socially-anxious (NSA) individuals. We used an experience sampling methodology (ESM) in which participants received daily links to online measures at random times during the day, for 21 days and reported on social interactions, emotions and perceptions. Results indicated that individuals with SAD used voice/text mediums to a greater extent and used visual mediums to a lesser extent compared to NSA individuals. However, despite preferring voice/text mediums, use of visual mediums resulted in immediate increases in positive perceptions and emotions for individuals with SAD. These findings were above and beyond the effect of depressive symptoms and remained when social anxiety was represented as a continuum of severity. This has important implications for exposure interventions in the treatment of SAD.

Social Distancing During A COVID-19 Lockdown Contributes to The Maintenance of Social Anxiety: A Natural Experiment

Background

The COVID-19 pandemic has led to extensive social distancing measures. For those suffering from social anxiety, social distancing coincides with a tendency to avoid social interactions. We used this natural experiment imposed by a COVID-19 lockdown to examine how mandated low social exposure influenced socially anxious university students, and compared their anxiety to that of socially anxious students in preceding academic years with no social distancing.

Methods

Ninety-nine socially anxious students were assessed for social anxiety symptoms at the beginning of the fall and spring semesters. Students from the 2019–2020 academic year (which included a lockdown followed by social distancing measures at the end of the fall semester) were compared to students from preceding years (2016–2019) on social anxiety levels.

Results

Whereas social anxiety decreased in socially anxious students from the fall to the spring semester in the years preceding the pandemic, during the 2019–2020 academic year social anxiety levels remained high and unchanged. These results held when controlling for depressive symptoms and when analyzing social anxiety items that cannot be confounded with COVID-19-related anxiety.

Conclusions

The current results suggest that reduced exposure to social situations may play a role in the maintenance of social anxiety. Alternative explanations are discussed.

Gaze behavior is associated with the cortisol response to acute psychosocial stress in the virtual TSST

BACKGROUND

The Trier Social Stress Test (TSST) is a reliable tool for psychobiological stress induction. Because of its socio-evaluative nature, it has been useful for investigating gaze behavior. It has been shown that healthy people avoid looking toward faces when under stress, a finding that corroborates studies demonstrating avoidance of eye contact in social anxiety disorder. Yet, little is known about the relationship between gaze behavior and the biological stress response.

METHODS

In a final sample of 74 healthy males, a virtual reality version of the Trier Social Stress Test (TSST-VR) with an integrated eye tracker was implemented to investigate gaze behavior during acute stress induction. Stress response measures were collected via saliva samples and subjective stress ratings. Additional questionnaires were administered for examining the influence of social anxiety traits.

RESULTS

The TSST-VR elicited a significant psychobiological stress response. Overall, higher gaze times on judges compared to surroundings were found in the speech task while this pattern was reversed in the arithmetic task. Critically, there was a significant negative association between gaze time on judges and cortisol output in cortisol responders.

CONCLUSIONS

In a non-clinical sample, avoidance of gaze is associated with a stronger cortisol response to acute stress. This study demonstrates the potential of eye tracking to disentangle the effects of acute stress on social interaction, warranting further investigation in clinical populations characterized by high levels of anxiety in social situations, such as social anxiety and autism spectrum disorder.

The role of cognitive load in modulating social looking: a mobile eye tracking study

The effect of cognitive load on social attention was examined across three experiments in a live pedestrian passing scenario (Experiments 1 and 2) and with the same scenario presented as a video (Experiment 3). In all three experiments, the load was manipulated using an auditory 2-back task. While the participant was wearing a mobile eye-tracker, the participant's fixation behavior toward a confederate was recorded and analyzed based on temporal proximity from the confederate (near or far) and the specific regions of the confederate being observed (i.e., head or body). In Experiment 1 we demonstrated an effect of cognitive load such that there was a lower proportion of fixations and time spent fixating toward the confederate in the load condition. A similar pattern of results was found in Experiment 2 when a within-subject design was used. In Experiment 3, which employed a less authentic social situation (i.e., video), a similar effect of cognitive load was observed. Collectively, these results suggest attentional resources play a central role in social attentional behaviors in both authentic (real-world) and less authentic (video recorded) situations.

The Measurement of Eye Contact in Human Interactions: A Scoping Review

Eye contact is a fundamental aspect of nonverbal communication and therefore important for understanding human interaction. Eye contact has been the subject of research in many disciplines, including communication sciences, social psychology, and psychiatry, and a variety of techniques have been used to measure it. The choice of measurement method has consequences for research outcomes and their interpretation. To ensure that research findings align with study aims and populations, it is essential that methodological choices are well substantiated. Therefore, to enhance the effective examination of eye contact, we performed a literature review of the methods used to study eye contact. We searched Medline, PsycINFO and Web of Science for empirical peer-reviewed articles published in English that described quantitative studies on human eye contact and included a methodological description. The identified studies (N = 109) used two approaches to assess eye contact: direct, i.e., assessing eye contact while it is occurring, and indirect, i.e., assessing eye contact retrospectively (e.g., from video recordings). Within these categories, eight specific techniques were distinguished. Variation was found regarding the reciprocity of eye contact between two individuals, the involvement of an assessor and the behavior of participants while being studied. Measures not involving the interactors in assessment of eye contact and have a higher spatial and temporal resolution, such as eye tracking, have gained popularity. Our results show wide methodological diversity regarding the measurement of eye contact. Although studies often define eye contact as gaze towards an exact location, this may not do justice to the subjective character of eye contact. The various methodologies have hardly ever been compared, limiting the ability to compare findings between studies. Future studies should take notice of the controversy surrounding eye contact measures.

Psychometric Properties of the Safety Maneuver Scale for Adolescents (SMS-A) and Relationship to Outcomes of a Transdiagnostic Treatment

Safety behaviors are common in anxiety and have been thought to reduce the efficacy of exposure therapy, although some investigations have indicated that safety behaviors may have a non-significant or beneficial impact on exposure efficacy. There have been few investigations of the characteristics and impact of safety behavior use in youth compared to adults, and no known validated, transdiagnostic youth measure of safety behaviors exists. In Study 1, we investigated the psychometric properties of a transdiagnostic measure of adolescent safety behavior use. In Study 2, we examined the relationship between safety behavior use and treatment outcome in 51 anxious and depressed adolescents. Results of Study 1 supported the measure's psychometric properties, while results of Study 2 revealed that decreased safety behavior use is associated with better treatment outcomes. This investigation supports the importance of safety behavior reduction and provides a tool for further investigating adolescent safety behavior use.

Symptom network connectivity in adolescents with comorbid major depressive disorder and social phobia

PURPOSE

Major depressive disorder (MDD) and social phobia (SP) are both common and highly co-occurring psychiatric disorders. This study used symptom network analysis approach to examine comorbidity structure and the complex symptom dynamics which may play a role in the co-occurrence of MDD and SP.

METHOD

Data comes from the National Comorbidity Survey - Adolescent Supplement, a nationally representative survey of adolescents ages 13 to 18 years. This study examined data of adolescents with a lifetime diagnosis of MDD (n = 597), SP (n = 708), and adolescents with comorbid MDD and SP (n = 189). Networks were estimated by means of 26 symptoms from both disorders.

RESULTS

All MDD and SP symptoms were involved in the network of both pure disorders (MDD; SP) and comorbid condition (MDD + SP). Network structure was different between the pure disorders (p = 0.014), but not when comparing each of these disorders that have comorbid condition. Depressive symptoms of poor self-esteem and suicidal symptoms were central (i.e., showed a higher influence) in the symptom network for the pure disorders and for the comorbid condition. Other key symptoms in the comorbid condition network were two depressive symptoms: feelings of worthlessness and anhedonia. SP and MDD networks showed two common key SP symptoms: feeling uncomfortable when meeting new people and feeling uncomfortable talking to people do not know well.

CONCLUSION

The study of symptom dynamics will provide useful targets for preventing the development of comorbid disorders as well as new lines of intervention to deal with key symptoms of psychiatric disorders.

Impact of Social Anxiety on Behavioral Mimicry During a Social Interaction With a Confederate

Behavioral mimicry, the unintentional alteration of one's behavior to match that of an interaction partner, leads to many positive outcomes such as increased rapport. The current study examined the influence of social anxiety on mimicry behavior during a social interaction. Participants (N = 84), pre-screened for low and high social anxiety, participated in a face-to-face interaction with a confederate. Individuals with high social anxiety were less likely to mimic the movements of the confederate than individuals with low social anxiety. However, reduced mimicry behavior was only found during the portion of the experiment in which the confederate's movements were not planned, and not during the portion of the experiment in which the confederate made planned movements. Further, individuals with increased self-focused attention were also less likely to mimic during the portion of the experiment where the confederate's movements were not planned. Overall, results provide partial evidence to support the notion of reduced mimicry among individuals with high social anxiety. Future research can further evaluate the contexts in which those with high levels of social anxiety may mimic less, as well as factors that may play a role (e.g., self-focused attention), to enhance the probability of a positive interpersonal interaction for these individuals.

The aetiology and maintenance of social anxiety disorder: A synthesis of complimentary theoretical models and formulation of a new integrated model

BACKGROUND

Within maintenance models of social anxiety disorder (SAD), a number of cognitive and behavioural factors that drive the persistence of SAD have been proposed. However, these maintenance models do not address how SAD develops, or the origins of the proposed maintaining factors. There are also models of the development of SAD that have been proposed independently from maintenance models. These models highlight multiple factors that contribute risk to the onset of SAD, but do not address how these aetiological factors may lead to the development of the maintaining factors associated with SAD.

METHODS

A systematic review of the literature was conducted to identify aetiological and maintenance models of SAD. We then united key factors identified in these models and formulated an integrated aetiological and maintenance (IAM) model of SAD. A systematic review of the literature was then conducted on the components of the IAM model.

RESULTS

A number of aetiological and maintaining factors were identified in models of SAD. These factors could be drawn together into the IAM model. On balance, there is empirical evidence for the association of each of the factors in the IAM model with social anxiety or SAD, providing preliminary support for the model.

LIMITATIONS

There are relationships between components of the IAM model that require empirical attention. Future research will need to continue to test the IAM model.

CONCLUSIONS

The IAM model provides a framework for future investigations into the development and persistence of SAD.

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

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