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.

Just do something: An experimental investigation of brief interventions for reducing the negative impact of post-event processing in social anxiety disorder.

Post-Event Processing (PEP) is prevalent and problematic in Social Anxiety Disorder (SAD) but is typically not a direct target in evidence-based treatments such as cognitive behavioural therapy (CBT) for SAD. The primary aim of the current study was to examine the impact of several theoretically and empirically derived interventions for PEP in SAD, including concrete thinking, abstract thinking, and distraction in comparison to a control (i.e., do nothing) condition. Based on prior research, we hypothesized that the concrete and distract conditions would be associated with positive benefits, including reductions in PEP and improvements in self-perception, whereas the abstract and control conditions would not. The second aim of the study was to identify baseline variables that predict the trajectory of change in PEP over time. Participants (N=92) with a principal diagnosis of SAD completed a social stress task and were randomly assigned to one of four conditions. Participants completed measures at baseline, post-intervention/control, and at 1-week, and 1-month follow-up. Contrary to hypotheses, all three active conditions were similarly effective at reducing PEP and improving self-perceptions relative to the control condition. In the absence of an intervention, engagement in PEP remained high up to a month following the social stress task. Higher levels of baseline state anxiety, intolerance of uncertainty, and use of safety behaviours predicted greater PEP, even in the presence of an intervention. These results highlight the benefits of relatively brief interventions that disrupt the course of PEP for people with SAD. Such interventions can be easily incorporated into CBT protocols for SAD to enhance their effects.

Neurocognitive Model of Schema-Congruent and -Incongruent Learning in Clinical Disorders: Application to Social Anxiety and Beyond.

Negative schemas lie at the core of many common and debilitating mental disorders. Thus, intervention scientists and clinicians have long recognized the importance of designing effective interventions that target schema change. Here, we suggest that the optimal development and administration of such interventions can benefit from a framework outlining how schema change occurs in the brain. Guided by basic neuroscientific findings, we provide a memory-based neurocognitive framework for conceptualizing how schemas emerge and change over time and how they can be modified during psychological treatment of clinical disorders. We highlight the critical roles of the hippocampus, ventromedial prefrontal cortex, amygdala, and posterior neocortex in directing schema-congruent and -incongruent learning (SCIL) in the interactive neural network that comprises the autobiographical memory system. We then use this framework, which we call the SCIL model, to derive new insights about the optimal design features of clinical interventions that aim to strengthen or weaken schema-based knowledge through the core processes of episodic mental simulation and prediction error. Finally, we examine clinical applications of the SCIL model to schema-change interventions in psychotherapy and provide cognitive-behavior therapy for social anxiety disorder as an illustrative example.

Social anxiety inhibits needs repair following exclusion in both relational and non-relational reward contexts: The mediating role of positive affect.

The pain of social exclusion can motivate people to capitalize on opportunities to reconnect with others and repair their self-esteem and feelings of belongingness. This effect is often diminished for those with high social anxiety (HSA). Prior research suggests this may be due to their diminished capacity for recognizing and emotionally responding to relational reward cues. We investigated whether non-relational success experiences in the aftermath of exclusion may be an alternative means of repairing threatened self-esteem and belongingness in HSA individuals. In a preregistered, online study, we threatened belongingness and self-esteem in 422 participants by excluding them in a Cyberball game and then assigned them to one of three conditions: Relational Repair, Non-Relational Repair, or a No-Repair control condition. Results showed that both repair contexts facilitated needs repair relative to the no-repair control condition, and mediation analyses suggested this effect was driven by increased positive affect (PA). HSA individuals were less likely to restore needs regardless of condition and this effect appeared to be driven by low PA. Findings emphasize the critical role of PA for restoring threatened needs in the aftermath of exclusion and suggest that HSA inhibits needs repair processes across both relational and non-relational reward contexts.

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.

Positive emotional reactivity to pleasant social and nonsocial stimuli in social anxiety disorder.

Prior research has shown that Social Anxiety Disorder (SAD) is associated with significantly diminished positive affect (PA). Few studies have examined PA reactivity to pleasant experimental stimuli in individuals with SAD and whether emotional responses might be moderated by social context. Here, we investigated repeated measures of PA reactivity among individuals with SAD (n = 46) and healthy controls (HC; n = 39) in response to standardized neutral images, pleasant music, and social versus nonsocial guided imagery. Primary analyses revealed that SAD and HC participants did not differ in their PA reactivity when PA was conceptualized as a unitary construct. Exploratory analyses examining discrete subfacets of PA revealed potential deficits for SAD participants in relaxed and content PA, but not activated PA. Although participants with SAD reported relatively lower levels of relaxed and content PA overall compared with controls, they exhibited normal increases in all PA subfacets in response to pleasant music as well as pleasant social and nonsocial stimuli. These findings support a more nuanced conclusion about PA deficits in SAD than is described in the extant literature, suggesting that detecting PA deficits in SAD may depend upon how PA is conceptualized, evoked, and measured. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Impacts of imagery-enhanced versus verbally-based cognitive behavioral group therapy on psychophysiological parameters in social anxiety disorder: Results from a randomized-controlled trial.

Social anxiety disorder (SAD) is associated with marked physiological reactivity in social-evaluative situations. However, objective measurement of biomarkers is rarely evaluated in treatment trials, despite potential utility in clarifying disorder-specific physiological correlates. This randomized controlled trial sought to examine the differential impact of imagery-enhanced vs. verbal-based cognitive behavioral group therapy (IE-CBGT, n = 53; VB-CBGT, n = 54) on biomarkers of emotion regulation and arousal during social stress in people with SAD (pre- and post-treatment differences in heart rate variability (HRV) and skin conductance). We acquired psychophysiological data from randomized participants across four social stress test phases (baseline, speech preparation, speech, interaction) at pre-treatment, and 1- and 6-months post-treatment. Analyses revealed that IE-CBGT selectively attenuated heart rate as indexed by increases in median heart rate interval (median-RR) compared to VB-CBGT at post-treatment, whereas one HRV index showed a larger increase in the VB-CBGT condition before but not after controlling for median-RR. Other psychophysiological indices did not differ between conditions. Lower sympathetic arousal in the IE-CBGT condition may have obviated the need for parasympathetic downregulation, whereas the opposite was true for VB-CBGT. These findings provide preliminary insights into the impact of imagery-enhanced and verbally-based psychotherapy for SAD on emotion regulation biomarkers.

Imagery-enhanced v. verbally-based group cognitive behavior therapy for social anxiety disorder: a randomized clinical trial.

BACKGROUND: Cognitive behavior therapy (CBT) is effective for most patients with a social anxiety disorder (SAD) but a substantial proportion fails to remit. Experimental and clinical research suggests that enhancing CBT using imagery-based techniques could improve outcomes. It was hypothesized that imagery-enhanced CBT (IE-CBT) would be superior to verbally-based CBT (VB-CBT) on pre-registered outcomes. METHODS: A randomized controlled trial of IE-CBT v. VB-CBT for social anxiety was completed in a community mental health clinic setting. Participants were randomized to IE (n = 53) or VB (n = 54) CBT, with 1-month (primary end point) and 6-month follow-up assessments. Participants completed 12, 2-hour, weekly sessions of IE-CBT or VB-CBT plus 1-month follow-up. RESULTS: Intention to treat analyses showed very large within-treatment effect sizes on the social interaction anxiety at all time points (ds = 2.09-2.62), with no between-treatment differences on this outcome or clinician-rated severity [1-month OR = 1.45 (0.45, 4.62), p = 0.53; 6-month OR = 1.31 (0.42, 4.08), p = 0.65], SAD remission (1-month: IE = 61.04%, VB = 55.09%, p = 0.59); 6-month: IE = 58.73%, VB = 61.89%, p = 0.77), or secondary outcomes. Three adverse events were noted (substance abuse, n = 1 in IE-CBT; temporary increase in suicide risk, n = 1 in each condition, with one being withdrawn at 1-month follow-up). CONCLUSIONS: Group IE-CBT and VB-CBT were safe and there were no significant differences in outcomes. Both treatments were associated with very large within-group effect sizes and the majority of patients remitted following treatment.

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.

The moderating effects of reported pre-pandemic social anxiety, symptom impairment, and current stressors on mental health and affiliative adjustment during the first wave of the COVID-19 pandemic.

BACKGROUND AND OBJECTIVES: Individuals with social anxiety (SA) have well-established fears of being negatively evaluated and exposing self-perceived flaws to others. However, the unique impacts of pre-existing SA on well-being and interpersonal outcomes within the stressful context of the pandemic are currently unknown. DESIGN: In a study that took place in May 2020, we surveyed 488 North American community participants online. METHODS: We used multiple linear regression to analyze whether retrospective reports of pre-pandemic SA symptoms predicted current coronavirus anxiety, loneliness, fears of negative evaluation, use of preventive measures, and affiliative outcomes, and whether pre-pandemic functional impairment and recent COVID-related stressors moderated these relations. RESULTS: Results highlighted the negative effects of pre-pandemic SA on current mental health functioning, especially for participants with higher pre-pandemic functional impairment and greater exposure to COVID-related stressors. Although participants with higher pre-pandemic SA reported currently feeling lonelier and more fearful of negative evaluation, they also endorsed greater efforts to affiliate with others. CONCLUSIONS: High SA individuals may have heightened desire for social support within the isolating context of the pandemic, in which COVID-related social restrictions enable greater avoidance of social evaluation but may also mask the enduring impairment associated with pre-pandemic SA.

Social Anxiety and the Generation of Positivity During Dyadic Interaction: Curiosity and Authenticity Are the Keys to Success.

What drives positive affective and interpersonal experiences during social interaction? Undergraduates with high (n = 63) or low (n = 56) trait social anxiety (SA) were paired with unfamiliar low SA partners in a 45-minute conversation task. Throughout the task, participants and their conversation partners completed measures of affiliative goals, affect, curiosity, authenticity, and attentional focus. Both affective and interpersonal outcomes were assessed. Dyadic analyses revealed that participants' affiliative goals during the social interaction predicted positive outcomes for both themselves and their partners, although the link between affiliative goals and positive affect was weaker for participants with high SA. Mediation analyses demonstrated that adopting affiliative goals may promote more positive outcomes by increasing participants' curiosity and felt authenticity. Taken together, results illuminate the pathways through which people with varying levels of trait SA may derive interpersonally generated positive affect and positive social outcomes, with implications for clinical theory and practice.

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.

The effects of positive interpretation bias on cognitive reappraisal and social performance: Implications for social anxiety disorder.

People with social anxiety disorder (SAD) lack non-socially anxious individuals' tendency to interpret ambiguous social information in a positively biased manner. To gain a better understanding of the specific in-vivo social consequences of positive interpretation bias, we recruited 38 individuals with SAD and 31 healthy controls (HC) to participate in an in-vivo social task. We tested whether a positive interpretation bias, measured using a sentence completion task, might confer benefits for the adaptive emotion regulation strategy of cognitive reappraisal, and whether such benefits depended on participants' emotional states. We also examined whether positive interpretation bias might confer additional benefits such as improved self-perceived and observer-rated social performance. In support of prior research, HC participants exhibited a positive interpretation bias on the sentence completion task, whereas participants with SAD did not. Regression analyses revealed that positive interpretation bias predicted greater cognitive reappraisal during social stress, particularly when state positive affect was low. Moreover, positive interpretation bias predicted more positive self-perception of social performance and reduced underestimations of performance relative to observer ratings. These results suggest that positive interpretations of ambiguous social information may be related to increased use of cognitive reappraisal and more positive self-perceptions of social performance.

Coping with social wounds: How social pain and social anxiety influence access to social rewards.

BACKGROUND AND OBJECTIVES: Prior studies have shown that people display signs of increased social approach motivation and affiliative behaviour in response to social exclusion. This response is considered an adaptive strategy that serves to repair damage to social networks and increase access to mood-enhancing social rewards. However, heightened trait social anxiety (SA) has been linked to decreased approach motivation and responsiveness to social rewards. In the current preliminary experimental study, we tested whether trait SA inhibits the expected increase in social approach following the pain of exclusion. We then tested whether diminished social approach is associated with reduced positive affect. METHODS: Participants played a game of Cyberball and were randomly assigned to receive significantly fewer passes (exclusion condition) or an equal number of passes (control condition) as other players. Subsequently, participants were given the opportunity to engage in an online social interaction activity with avatars they believed were other participants. RESULTS: Analyses revealed that the exclusion condition led to greater social pain than the control condition. Across conditions, greater social pain was associated with higher levels of approach motivation in anticipation of the social interaction activity, but only for individuals with lower levels of trait SA. Finally, when controlling for levels of trait SA, social pain was associated with positive affect following the social interaction activity, but only for individuals with higher levels of approach motivation. LIMITATIONS: Participants consisted predominantly of female undergraduates, limiting generalizability of these data. As well, hypotheses were supported for the measure of approach motivation but not the measure of approach behaviour. Finally, this study was not powered to enable moderated mediation analyses, which would have provided the most direct test of the hypothesized model. CONCLUSIONS: Heightened approach motivation in the face of social pain may facilitate increased positive affect. However, higher levels of trait SA dampen approach motivation. Future well-powered studies should use moderated mediation analyses to test the hypothesized model more parsimoniously.

Social anxiety is associated with impaired memory for imagined social events with positive outcomes.

Cognitive models of social anxiety disorder suggest that memory biases for negative social information contribute to symptoms of social anxiety (SA). However, it remains unclear whether memory biases in SA are related to social information, specifically, and if so, whether the valence of such information would moderate memory performance. In the present study, 197 community participants were randomised to imagine themselves as the central character in either 10 social or 10 non-social scenarios. In both conditions, half of the scenarios ended with objectively positive outcomes and half ended with objectively negative outcomes. Results demonstrated that higher trait SA was related to memory performance for social scenarios only, and in particular to poorer memory for social scenarios that ended positively. Thus, the impact of SA on memory performance depended on how social information was framed, with higher SA related to poorer memory for positive social experiences. These context-specific effects contribute to the growing literature on positivity deficits in SA.

The effects of imagery rescripting on memory outcomes in social anxiety disorder.

Imagery rescripting (IR) is an effective intervention for social anxiety disorder (SAD) that targets negative autobiographical memories. IR has been theorized to work through various memory mechanisms, including modifying the content of negative memory representations, changing memory appraisals, and improving negative schema or core beliefs about self and others. However, no prior studies have investigated the unique effects of rescripting itself relative to other IR intervention components on these proposed mechanisms. In this preliminary study, 33 individuals with SAD were randomized to receive a single session of IR, imaginal exposure (IE), or supportive counselling (SC). Memory outcomes were assessed at 1- and 2-weeks post-intervention and at 3-months follow-up. Results demonstrated that the content of participants' autobiographical memory representations changed in distinct ways across the three conditions. Whereas IR facilitated increases only in positive/neutral memory details, IE facilitated increases in both positive/neutral and negative memory details and SC facilitated no changes in memory details. Although memory appraisals did not differ across conditions, participants who received IR were more likely to update their negative memory-derived core beliefs. These unique effects of rescripting on memory representations and core beliefs enhance our understanding of the memory-based mechanisms of IR within the context of exposure-based learning for people with SAD.

Social problem solving in social anxiety disorder.

Successful social problem solving requires both an adaptive orientation toward the problem and the necessary skills to generate relevant and effective solutions. Surprisingly few studies have examined social problem solving in the context of social anxiety. We examined social problem solving in 38 participants with social anxiety disorder (SAD) in comparison to 30 healthy control (HC) participants with no history of anxiety problems. Participants rated their problem solving attitudes and abilities (i.e., problem orientation) and then generated solutions to hypothetical interpersonal problems from both their own perspective and that of an objective other. These solutions were coded for effectiveness and relevance, as well as the degree to which the solution was active versus passive. Participants with SAD exhibited a more negative problem orientation than HC participants. Furthermore, although SAD and HC participants demonstrated no overall differences in generating relevant and effective solutions to interpersonal problems, utilizing a personal perspective facilitated the generation of more active solutions for HC participants, but less active solutions for those with SAD. Findings illuminate new research directions regarding social problem solving in social anxiety, with potential implications for applied intervention.

Autobiographical memory retrieval and appraisal in social anxiety disorder.

Individuals with social anxiety disorder (SADs; n = 41) and healthy controls (HCs; n = 40) were administered the Waterloo Images and Memories Interview, in which they described mental images that they tend to experience in both anxiety-provoking and non-anxiety-provoking social situations. Participants then recalled, in as much detail as possible, specific autobiographical memories of salient aversive and non-aversive social experiences that they believed led to the formation of these images. Audio-recorded memory narratives were transcribed and coded based on the procedure of the Autobiographical Interview, which provides a precise measure of the degree of episodic detail contained within each memory. Participants also rated the subjective properties of their recalled memories. Results revealed that participants across the two groups retrieved equivalent rates of both aversive and non-aversive social memories. However, SAD participants' memories of aversive events contained significantly more episodic detail than those of HCs, suggesting that they may be more highly accessible. Moreover, participants with SAD appraised their memories of aversive experiences as more distressing and intrusive than HCs, and perceived them as having a significantly greater influence on their self-perception. In contrast, no group differences were observed for memories of non-aversive events. Findings have the potential to shed new light on autobiographical memory in SAD, with implications for psychotherapeutic intervention.

Theory of mind ability in high socially anxious individuals.

BACKGROUND/OBJECTIVES: Research has demonstrated an association between social anxiety and impaired Theory of Mind (ToM). We assess whether ToM deficits occur even at a subclinical level of social anxiety and whether group differences in ToM performance are consistent with interpretation bias. We also explore potential reasons as to why socially anxious individuals may perform differently on ToM tasks. METHODS/DESIGN: Undergraduate participants high (HSA; n = 78) and low (LSA; n = 35) in social anxiety completed a task of ToM decoding, the Reading the Mind in the Eyes (MIE), a task of ToM reasoning, the Movie for the Assessment of Social Cognition (MASC), and a post-task questionnaire about their experience completing the MASC. RESULTS: HSAs performed marginally worse than LSAs on the MIE on neutrally valenced trials, and their pattern of errors may be consistent with a negative interpretation bias. HSAs and LSAs did not differ overall in performance on the MASC, though HSAs reported experiencing more confusion and distress than LSAs during the task, and this distress was associated with more MASC errors for HSA participants only. These results provide insight into the nature of ToM ability in socially anxious individuals and highlight important avenues for future research.