Sub-types of safety behaviours and their effects on social anxiety disorder

Bivalent fears of evaluation: A developmentally-informed, multi-informant, and multi-modal examination of associations with safety behaviors

Fears of negative (FNE) and positive (FPE) evaluation and safety behaviors feature prominently in cognitive-behavioral models of social anxiety. However, we have a poor understanding of their associations, particularly given evidence that they both vary in form and function. This study aimed to identify the factor structure of safety behaviors and explore their differential associations with FNE and FPE. We addressed these aims across samples that varied in developmental stage, informant, and assessment modality. We collected self-reported data from college students (n = 349; Mage = 19.42) and adolescent-parent dyads (n = 134; Mage_adolescents = 14.49, Mage_parents = 45.01); parents also completed an ecologically-valid evaluation task. We confirmed a two-factor structure of safety behaviors (i.e., avoidance and impression management) that fit the data well for college students, adolescents, and parents' self-report, but not for parents' report about adolescents. Associations between avoidance and impression management and FNE/FPE were significant within-informants but not between-informants. For parents, in-the-moment arousal following receipt of negative, but not positive, feedback was associated with avoidance and impression management. Findings have implications for integrated measurement of FNE, FPE, and safety behaviors, as well as treatments that target social anxiety through each of these domains.

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.

Brief scales for the measurement of target variables and processes of change in cognitive behaviour therapy for major depression, panic disorder and social anxiety disorder

BACKGROUND

The measurement of process variables derived from cognitive behavioural theory can aid treatment development and support the clinician in following treatment progress. Self-report process measures are ideally brief, which reduces the burden on patients and facilitates the implementation of repeated measurements.

AIMS

To develop 13 brief versions (3-6 items) of existing cognitive behavioural process scales for three common mental disorders: major depression, panic disorder, and social anxiety disorder.

METHOD

Using data from a real-world teaching clinic offering internet-delivered cognitive behavior therapy (n=370), we drafted brief process scales and then validated these scales in later cohorts (n=293).

RESULTS

In the validation data, change in the brief process scales significantly mediated change in the corresponding domain outcomes, with standardized coefficient point estimates in the range of -0.53 to -0.21. Correlations with the original process scales were substantial (r=.83-.96), internal consistency was mostly adequate (α=0.65-0.86), and change scores were moderate to large (|d|=0.51-1.18). For depression, the brief Behavioral Activation for Depression Scale-Activation subscale was especially promising. For panic disorder, the brief Agoraphobic Cognitions Questionnaire-Physical Consequences subscale was especially promising. For social anxiety disorder, the Social Cognitions Questionnaire, the Social Probability and Cost Questionnaire, and the Social Behavior Questionnaire-Avoidance and Impression Management subscales were all promising.

CONCLUSIONS

Several brief process scales showed promise as measures of treatment processes in cognitive behaviour therapy. There is a need for replication and further evaluation using experimental designs, in other clinical settings, and preferably in larger samples.

Social anxiety is related to reduced face gaze during a naturalistic social interaction

BACKGROUND

Social anxiety has long been related to reduced eye contact, and this feature is seen as a causal and a maintaining factor of social anxiety disorder. The present research adds to the literature by investigating the relationship between social anxiety and visual avoidance of faces in a reciprocal face-to-face conversation, while taking into account two aspects of conversations as potential moderating factors: conversational role and level of intimacy.

METHOD

Eighty-five female students (17-25 years) completed the Leibowitz Social Anxiety Scale and had a face-to-face getting-acquainted conversation with a female confederate. We alternated conversational role (talking versus listening) and manipulated intimacy of the topics (low versus high). Participants' gaze behavior was registered with Tobii eye-tracking glasses. Three dependent measures were extracted regarding fixations on the face of the confederate: total duration, proportion of fixations, and mean duration.

RESULTS

The results revealed that higher levels of social anxiety were associated with reduced face gaze on all three measures. The relation with total fixation duration was stronger for low intimate topics. The relation with mean fixation duration was stronger during listening than during speaking.

CONCLUSION

The results highlight the importance of studying gaze behavior in a naturalistic social interaction.

Examining Safety Behavior Subtypes Across Distinct Social Contexts in Social Anxiety Disorder and Major Depression

People with social anxiety disorder (SAD) use different types of safety behaviors that have been classified as avoidance vs. impression management. The current study investigated differences in safety behavior subtype use in 132 individuals with principal diagnoses of social anxiety disorder (SAD, n = 69), major depressive disorder (MDD, n = 30), and nonpatient controls (n = 33) across two social contexts: an interpersonal relationship-building task (social affiliation) and a speech task (social performance). We examined whether diagnostic groups differed in safety behavior subtype use and whether group differences varied by social context. We also explored relationships between avoidance and impression management safety behaviors, respectively, and positive and negative valence affective and behavioral outcomes within the social affiliation and social performance contexts. Safety behavior use varied by diagnosis (SAD > MDD > nonpatient controls). The effect of diagnosis on impression management safety behavior use depended on social context: use was comparable for the principal SAD and MDD groups in the social performance context, whereas the SAD group used more impression management safety behaviors than the MDD group in the social affiliation context. Greater use of avoidance safety behaviors related to higher negative affect and anxious behaviors, and lower positive affect and approach behaviors across contexts. Impression management safety behaviors were most strongly associated with higher positive affect and approach behaviors within the social performance context. These findings underscore the potential value of assessing safety behavior subtypes across different contexts and within major depression, in addition to SAD.

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.

In the moment social experiences and perceptions of children with social anxiety disorder: A qualitative study

OBJECTIVES

Childhood social anxiety disorder (SAD) is a common and disabling condition. General forms of cognitive behavioural treatments have demonstrated poorer efficacy for childhood SAD when compared to other childhood anxiety disorders and further understanding of the psychological factors that contribute to the maintenance of childhood SAD is warranted. Examining the social experiences of children with SAD may help to identify relevant psychological factors and increase our understanding of what keeps childhood SAD going.

METHODS

The current study used reflexive thematic analysis to analyse the transcripts of interviews with 12 children aged 8-12 years with SAD who had been interviewed about their 'in the moment' social experiences during a social stress induction task. The interview topic guide included factors hypothesized to maintain SAD in adult cognitive models of the disorder.

RESULTS

The interviews revealed both variety and commonalities in the experiences and interpretations of social events in children with SAD, captured in three related main themes: (i) Discomfort being the centre of attention, (ii) (Lack of) awareness of cognitions and (iii) Managing social fears. Findings indicated likely developmental influences on which maintenance mechanisms apply at which point in time.

CONCLUSIONS

There is variation in the psychological mechanisms that children with SAD endorse and developmental factors are likely to influence when specific mechanisms are relevant. We now need further studies that take a developmentally informed approach to understand the nature of the association between the factors identified in this study and social anxiety in childhood to inform the development of more effective interventions for childhood 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.

Abnormal hubs in global network as potential neuroimaging marker in generalized anxiety disorder at rest

Background

Mounting studies have reported altered neuroimaging features in generalized anxiety disorder (GAD). However, little is known about changes in degree centrality (DC) as an effective diagnostic method for GAD. Therefore, we aimed to explore the abnormality of DCs and whether these features can be used in the diagnosis of GAD.

Methods

Forty-one GAD patients and 45 healthy controls participated in the study. Imaging data were analyzed using DC and receiver operating characteristic (ROC) methods.

Results

Compared with the control group, increased DC values in bilateral cerebellum and left middle temporal gyrus (MTG), and decreased DC values in the left medial frontal orbital gyrus (MFOG), fusiform gyrus (FG), and bilateral posterior cingulate cortex (PCC). The ROC results showed that the DC value of the left MTG could serve as a potential neuroimaging marker with high sensitivity and specificity for distinguishing patients from healthy controls.

Conclusion

Our findings demonstrate that abnormal DCs in the left MTG can be observed in GAD, highlighting the importance of GAD pathophysiology.

The relationship between three subtypes of safety behaviors and social anxiety: Serial mediating effects of state and trait post-event processing

The cognitive model for social anxiety disorder (SAD) highlights the role of safety behaviors and post-event processing (PEP). We identify the serial mediating effect of state and trait PEP between three types of safety behaviors (impression management, avoidance behavior, and anxiety-symptom control) and social anxiety. Given that the associations between the three subtypes of safety behaviors and two perspectives of PEP have not yet been examined, we aimed to investigate these relationships according to the level of social anxiety. A total of 487 participants participated in an online survey. Participants were classified into two groups, high and low, based on their social anxiety scores. We used Social Behavior Questionnaire to distinguish three types of safety behaviors and the State and Trait versions of the Post-Event Processing Inventory to identify two perspectives of PEP. We used descriptive statistics and an independent t-test to compare the high and low social anxiety groups. Mediation effects were examined using mediation analysis and bootstrapping with 5,000 replications. The results showed that the three safety behaviors had different effects on social anxiety via PEP. In the high social anxiety group, avoidance behavior and anxiety-symptom control predicted social anxiety positively, whereas impression management did not. However, with state PEP and trait PEP as mediators, impression management and avoidance behavior positively predicted social anxiety but not anxiety-symptom control. In the low social anxiety group, only avoidance behavior was significantly related to social anxiety, but when the state and trait PEP were mediated, the effect disappeared. These results indicated that impression management could affect social anxiety only when mediated by PEP in people with high social anxiety. A better understanding of the content and processes underpinning safety behavior and PEPs might have important implications for the prevention and treatment of social anxiety disorder.

Technology-Mediated Sexual Interactions, Social Anxiety, and Sexual Wellbeing: A Scoping Review

Technology-mediated sexual interactions (TMSI) are interpersonal exchanges via technology of self-created sexual material, including photos, videos, and auditory or text messages. There is little research on the factors that predict both TMSI experiences and their sexual wellbeing outcomes. Social anxiety is anxiety experienced in response to social or performance situations. From a cognitive–behavioural perspective, people higher in social anxiety may avoid TMSI, preventing positive or negative consequences. They also may use TMSI to avoid the anxiety caused by in-person sexual interactions, benefiting from access to sexual interactions while perpetuating anxiety about them. The purpose of this scoping review was to explore the role of social anxiety in TMSI and its sexual wellbeing outcomes. We executed a comprehensive search strategy across eight academic databases and searched reference lists of included articles. We included 19 articles written in English or French that had a human sample and were published between 1991 and 2021 and evaluated connections between social anxiety constructs (e.g., shyness, anxiety) and TMSI-related experiences (e.g., sexting, internet sex addiction). The pattern of results suggested that social anxiety constructs may predict some but not all forms of TMSI. Future research from a cognitive–behavioural perspective will expand knowledge on social anxiety, TMSI, and its sexual wellbeing outcomes.

Safety behaviours in social anxiety: An examination across adolescence

BACKGROUND

Safety behaviours have been shown to be a key maintaining factor in Social Anxiety Disorder (SAD). In adults, a two-factor structure of safety behaviours reflecting 'avoidance' and 'impression-management' types has been identified. This has not yet been investigated in adolescents.

AIMS

We set out to investigate the factor structure of safety behaviours in relation to adolescent social anxiety symptoms and SAD, the extent to which this varies by age, and then to examine the association between the derived factor scores and other social anxiety related phenomena.

METHOD

Questionnaire measures of social anxiety symptoms, cognitions and safety behaviours, peer relationship outcomes, general anxiety and depression were collected from a community sample of 584 younger (11-14 years) and 208 older (16-18 years) adolescents, and a clinical sample of 80 adolescents (11-18 years) with a primary diagnosis of SAD. Four hypotheses were investigated using exploratory and confirmatory factor analyses, regressions, correlations and path analyses.

RESULTS

A two-factor structure reflecting 'avoidance' and 'impression-management' safety behaviours was supported in the community and clinical sample. Older adolescents were found to use 'impression-management' behaviours more than younger adolescents after controlling for overall safety behaviour score. Both types of safety behaviour were significantly positively associated with social anxiety symptoms and cognitions. Path analyses revealed an indirect effect of social anxiety symptoms on peer victimisation, social satisfaction and friendship quality via 'avoidance', but not 'impression-management' safety behaviours.

CONCLUSIONS

Both 'avoidance' and 'impression-management' safety behaviours are associated with social anxiety symptoms and cognitions in youth, with age-related differences in their frequency. 'Avoidance' behaviours are specifically associated with negative outcomes for quality of peer relationships.

Reconnecting in the Face of Exclusion: Individuals with High Social Anxiety May Feel the Push of Social Pain, but not the Pull of Social Rewards

Background

Previous research has shown that high levels of trait social anxiety (SA) disrupt the social repair processes following a painful social exclusion, but the cognitive mechanisms involved in these processes and how trait SA may disrupt them remain unknown.

Methods

We conducted a preregistered study on Prolific participants (N = 452) who were assigned to experience either social exclusion or inclusion and were then exposed to follow-up opportunities for social reconnection.

Results

Moderated mediation analyses revealed that irrespective of levels of SA, participants responded to social pain with heightened approach motivation and greater downstream positive affect. Exploratory analyses revealed that heightened desire to affiliate was driven by increased curiosity and attention to social rewards. Moreover, higher SA was associated with lower overall desire to affiliate and this relationship between SA and affiliation was mediated by diminished reward responsiveness.

Conclusions

Findings highlight the roles of goal pursuit and social reward responsiveness in social repair and how high levels of trait SA may disrupt these processes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-021-10263-z.

Self-reported camouflaging behaviours used by autistic adults during everyday social interactions

Autistic people may camouflage their innate autistic social behaviours to adapt to, cope within and/or influence the predominately neurotypical social landscape. This study describes behaviours exhibited, altered or avoided by autistic adults whilst camouflaging (i.e. camouflaging behaviours). Using Interpersonal Process Recall methodology, 17 autistic adults (8 women, 6 men and 3 agender/gender neutral individuals) participated in a brief social task designed to replicate a common day-to-day social situation. Participants then watched a video of their interaction with a researcher, actively identifying and describing camouflaging behaviours. Using qualitative content analysis, descriptions of 38 camouflaging behaviours described by participants were clustered into four main categories and seven subcategories: (1) masking, (2) innocuous engagement (subcategories: passive encouragement, centring social partner, deferential engagement and reducing social risk), (3) modelling neurotypical communication and (4) active self-presentation (subcategories: reciprocal social behaviours, risky social behaviours, and comfortable and familiar social behaviours). The novel use of Interpersonal Process Recall methodology addressed limitations in existing camouflaging research and facilitated the identification of previously unreported camouflaging behaviours. These camouflaging behaviours are discussed with reference to literature concerning interpersonal research and theory within and outside the field of autism.

Effects of mask-wearing on social anxiety: an exploratory review

BACKGROUND

A unique feature of the global coronavirus pandemic has been the widespread adoption of mask-wearing as a public health measure to minimize the risk of contagion. Little is known about the effects of increased mask-wearing on social interactions, social anxiety, or overall mental health.

OBJECTIVES

Explore the potential effects of mask-wearing on social anxiety.

DESIGN

We review existing literatures to highlight three preselected sets of factors that may be important in shaping the effects of mask-wearing on social anxiety. These are: (a) people's perceptions of the social norms associated with wearing masks; (b) people's experiences of the degree to which masks prevent accurate interpretation of social and emotional cues; and (c) people's use of masks as a type of safety behavior that enables self-concealment.

METHODS

APA PsycNet and PubMed were searched principally between September and November 2020 for articles describing the relationship between social anxiety, intolerance of uncertainty, ambiguous feedback, and safety behavior use and for research on the relationship between mask-wearing and social norms and social interactions. Information identified as relevant from articles of interest was extracted and included in our review.

RESULTS & CONCLUSIONS

The effects of mask-wearing on social anxiety are likely to be substantial and clinically relevant.

Fears of receiving compassion from others predict safety behaviour use in social anxiety disorder over and above fears of negative self-portrayal

Why do people with social anxiety disorder (SAD) engage in the use of safety behaviours? While past research has established that fears of negative self-portrayal are strongly associated with safety behaviour use in SAD, no research to date has investigated the potential role of fears of receiving compassion. Both types of fears could motivate those with SAD to engage in safety behaviours in order to keep others at a distance. In the present study, 150 participants with a clinical diagnosis of SAD completed measures of fears of negative self-portrayal, fears of receiving compassion, and safety behaviour use. Multiple regression analyses revealed that when controlling for self-portrayal fears, fears of receiving compassion significantly predicted increased use of safety behaviours overall, as well as the use of avoidance and impression management subtypes. Furthermore, there was a significant interaction effect in which greater fears of receiving compassion predicted greater use of impression management at lower levels of self-portrayal fears. We discuss the implications of our findings for addressing safety behaviours in the treatment of SAD.

Cognitive predictors of adolescent social anxiety

Background

Identifying psychological processes that maintain social anxiety holds promise for improving treatment outcomes for young people. Experimental and prospective studies in adults suggest negative social cognitions, safety behaviours, self-focused attention, and pre- and post-event processing are all implicated in the maintenance of social anxiety. Despite social anxiety typically starting in adolescence, prospective studies examining these cognitive processes in youth are lacking. The current study examined prospective associations between these five cognitive processes and social anxiety in a sample of 614 participants (53% girls; aged 11–14 years).

Methods

Psychological processes, social anxiety symptoms, and depressive symptoms were assessed using self-report questionnaires at two time points.

Results

Negative social cognitions, safety behaviours, self-focused attention, and post-event processing predicted prospective levels of social anxiety over and above the effect of baseline levels of social anxiety. When these process variables were entered together in a regression model, three of them were independently associated with prospective social anxiety. Neither pre- nor post-event processing independently predicted later social anxiety over and above the effects of other psychological process variables.

Conclusions

The findings indicate that these psychological processes are promising targets for treatment in adolescent social anxiety.

•

The applicability of the cognitive model of Clark & Wells was tested in a sample of 614 adolescents.

•

Negative social cognitions independently predicted increases in social anxiety.

•

Safety behaviours independently predicted increases in social anxiety.

•

Self-focused attention independently predicted increases in social anxiety.

•

Unexpectedly, neither pre- or post-event processing was an independent predictor of social anxiety.

Interpretation Bias in Online and Offline Social Environments and Associations with Social Anxiety, Peer Victimization, and Avoidance Behavior

Background

In face-to-face (offline) social situations a tendency, or bias, to negatively interpret ambiguous situations is consistently related to social anxiety. Although social interactions increasingly occur over the Internet (online), our understanding of cognitive processes in online social situations and how they relate to social anxiety, social experiences, and behavior, is limited.

Methods

In a sample of 324 young people (18–25 years), the current study addressed this gap in two ways: by simultaneously investigating online and offline interpretation bias in relation to social anxiety; and examining the extent to which online interpretation bias predicts peer victimization and avoidance.

Results

In line with hypotheses, online and offline interpretation bias each correlated positively with social anxiety; the offline interpretation bias-social anxiety association was stronger. Regression analyses revealed unique associations between online interpretation bias and online peer victimization and avoidance, after controlling for social anxiety and offline interpretation bias.

Discussion

Findings suggest that cognitive behavioral interventions for social anxiety could be optimized through eliciting and testing negative social beliefs related to online social settings.

Conclusions

The current study’s results indicate the importance of studying online interpretation bias to further understand social anxiety in online social environments.