Do your troubles today seem further away than yesterday? On sleep's role in mitigating the blushing response to a reactivated embarrassing episode.

The "sleep to forget and sleep to remember hypothesis" proposes that sleep weakens the emotional tone of an experience while preserving or even enhancing its content. Prior experimental research however shows contradictory findings on how emotional reactivity changes after a period of sleep, likely explained by methodological variations. By addressing these inconsistencies, we investigated the mitigating effect of overnight sleep on emotional reactivity triggered by memory reactivation. Using a karaoke paradigm, we recorded participants' singing of two songs, followed by exposing them to one of the recordings (rec1) to induce an embarrassing episode. After a 12-hr period of either day-time wakefulness (N = 20) or including nighttime sleep (N = 20), we assessed emotional reactivity to the previously exposed recording (rec1) and the newly exposed recording (rec2). Emotional reactivity was assessed with a physiological measure of facial blushing as the main outcome and subjective ratings of embarrassment and valence. Sleep and wake were monitored with diaries and actigraphy. The embarrassing episode was successfully induced as indicated by objective and subjective measures. After controlling for an order effect in stimulus presentation, we found a reduction in blushing response to the reactivated recording (rec1) from pre- to post-sleep compared to wakefulness. However, emotional reactivity to the reactivated recording (rec1) and the new recording (rec2) did not differ after sleep and wakefulness. This study shows that facial blushing was reduced following overnight sleep, while subjective ratings were unaffected. Whether the beneficial effect of sleep is due to changes in memory representation or rather emotion regulation remains elusive.

Niacin biological challenge: A paradigm to evaluate social concerns.

BACKGROUND AND OBJECTIVES: Anxiety sensitivity (AS) social concerns, the fear of observable anxiety symptoms is posited as a risk factor for social anxiety by increasing fear reactivity in social situations when observable anxiety symptoms are present. Experimental evaluation of AS social concerns is limited. The current study utilized several manipulations designed to be relevant to AS social concerns or fear of negative evaluation (FNE), a distinct social anxiety risk factor. The effects of these manipulations on fear reactivity to a speech were examined. METHODS: Participants (N = 124 students; M age = 19.44, SD = 2.45; 64.5% female) were randomized to one of four conditions in a 2 (100 mg niacin vs 100 mg sugar pill) X 2 (instructional set) design. For the instructional set manipulation, participants were told their speech performance would be evaluated by a judge based on their performance (i.e., FNE-relevant) or their observable anxiety symptoms (i.e., AS social concerns-relevant). RESULTS: There was a main effect for vitamin condition with participants in the niacin condition reporting higher panic symptoms post-speech relative to those in the placebo condition. There was no main effect for speech instructions. As hypothesized, these effects were qualified by an interaction indicating that AS social concerns significantly predicted panic symptoms for those receiving niacin. LIMITATIONS: Limitations include the reliance on self-reports of outcome variables and the use of an undergraduate student sample. CONCLUSIONS: These findings highlight a distinct role of AS social concerns in fear responding to socially evaluative situations in the context of physically observable arousal.

Are Socially Anxious Children Poor or Advanced Mindreaders?

Why are some children more socially anxious than others? One theory holds that socially anxious children are poor mindreaders, which hampers their social interactions; another that socially anxious children are advanced mindreaders leading to heightened self-consciousness in social situations. To test these theories simultaneously, this study (N = 105, ages 8-12) assessed children's mindreading (accuracy in detecting mental states from the eye region), self-consciousness (indexed as physiological blushing during public performance), and social anxiety levels. Results support both theories, showing a quadratic relation between mindreading and social anxiety. Low mindreading was related to clinical levels of social anxiety. High mindreading was related to subclinical levels of social anxiety through blushing. Our findings suggest two social-cognitive pathways to heightened social anxiety.

When gushing leads to blushing: Inflated praise leads socially anxious children to blush.

Blushing is an involuntary reddening of the face that typically occurs when people are concerned about making negative impressions on others. Although people typically blush for their mishaps or misdeeds, Darwin observed that some people, and especially children, also blush when they are lavished with praise. We theorize that socially anxious children blush when praised in inflated ways because they believe they do not match the inflated image others hold of them. Such praise-induced blushing might be particularly common in late childhood, when children's worries about their social image escalate. In this randomized experiment, 105 children (ages 8-12, 85% Caucasian) sang in front of an audience. Afterwards, children received inflated praise ("You sang incredibly well!"), noninflated praise ("You sang well!"), or no praise. Children's physiological blushing was assessed through photoplethysmography and a temperature sensor. As predicted, inflated praise-but not non-inflated praise-increased blushing in socially anxious children. This emerged for blood pulse amplitude changes (AC reactivity) and self-reported blushing, not for blood volume (DC reactivity) and temperature changes. Socially anxious children may blush to "apologize" in advance for not being as incredible as others think they are. Thus, blushing may be elicited in situations that seem benign but actually evoke the fear of being evaluated negatively.

Role of surgical thoracic sympathetic interruption in treatment of facial blushing: a systematic review.

OBJECTIVES: This paper aims to review the evidence to support the effectiveness of sympathectomy as a treatment for facial blushing in terms of relief of facial blushing, patient satisfaction, recurrence of blushing, patients regretting treatment and its associated complications. METHODS: A systematic search strategy was performed in Ovid-Medline, Embase, Cochrane library and NICE. Studies reporting outcomes of sympathetic interruption in the treatment of facial blushing were retrieved. RESULTS: Nine studies met the inclusion criteria with 1369 patients included in the final analysis. The age range of patients was 8 to 74 years (from 7 studies) with 56% females. Mean follow up was 21 months in 8 studies (range 6 to 30 months). The pooled proportion of patients who had good relief of facial blushing was 78.30% (95% C.I. 58.20% - 98.39%). Complete satisfaction was reported in 84.02% (95% C.I. 71.71% - 96.33%). Compensatory sweating and gustatory sweating were the commonest complications occurring in 74.18% (95% C.I. 58.10% - 90.26%) and 24.42% (95% C.I. 12.22% - 36.61%) respectively. The estimated proportion of patients regretting surgery was 6.79% (C.I 2.08% 11.50%). CONCLUSION: Sympathetic interruption at T2 or T2-3 ganglia appears to be an effective treatment for facial blushing. However, lack of randomized trials comparing sympathetic interruption with non-surgical methods of treatment and heterogeneity of included studies with respect to assessment of outcome measures preclude strong evidence and definitive recommendations.

Facial Blushing: Patient Selection and Long-Term Results.

Facial blushing, associated with social phobia, may have severe negative impact on the quality of daily life. The first line of treatment should be psychological and/or pharmacologic. In severe cases not responding to nonsurgical treatment, surgical sympathetic denervation is an option. A thorough disclosure of effects, complications, and side effects is mandatory and patient selection is crucial to obtain high patient satisfaction from surgical treatment.

Social blushing: a neuropsychiatric disorder? / El sonrojo social: ¿un trastorno neuropsiquiátrico?

Until recently, social blushing was rarely discussed in the medical literature. It was usually considered only a normal and occasional physiological reaction associated with emotions such as embarrassment brought on by social situations. This has changed in recent years with attention increasingly being paid to blushing, either in the context of social anxiety disorder or in its own right. Some argue that blushing has adaptive value, so it may not make sense to treat people for blushing, a view we do not agree with since the blushing experience is not the same for everyone and those who seek medical help do so because their blushing impairs their quality of life. Furthermore, the fact that a symptom is adaptive does not place it beyond the scope of medical treatment. Quite the contrary: physicians treat many symptoms that cause discomfort, e.g. pain and vomiting, which may be regarded as adaptive, yet few doubt the value of treating such problems. The same is true for blushing. Recognizing its potential adaptive value does not mean that it should not be treated. The distress of those who blush easily and seek help justifies attempts to find ways to help them. This article underlines the need to distinguish between normal social blushing and pathological social blushing and, at the same time, reviews current available treatments for individuals who seek help for this condition.

Hasta hace poco tiempo, rara vez se debatía sobre el sonrojo social en la literatura médica. Se le consideraba solo una reacción fisiológica normal y ocasional, provocada por situaciones sociales. Esto ha cambiado en años recientes pues se le presta cada vez mayor atención, ya sea en el contexto del trastorno de ansiedad social o por derecho propio. Algunos argumentan que sonrojarse tiene valor adaptativo y que por lo tanto no tiene sentido tratar a las personas que se sonrojan, visión que no compartimos porque la experiencia de ruborizarse no es igual en todos los individuos y porque los que consultan lo hacen debido a que las sucesivas experiencias de rubor van minando su calidad de vida. Más aún, el que un síntoma sea adaptativo no lo pone fuera del ámbito de la medicina. Al contrario: hay numerosos síntomas que tratamos los médicos, desagradables para el individuo -el dolor y los vómitos son buenos ejemplos-, los cuales pueden considerarse adaptativos y sin embargo pocos podrían en duda la legitimidad de tratarlos. Lo mismo es válido para el sonrojo. Reconocer su potencial valor adaptativo no hace ilegítimo su tratamiento. El sufrimiento de aquellos que se sonrojan fácilmente y buscan ayuda por ello, justifica los intentos de encontrar modos de ayudarlos. Este texto subraya la necesidad de distinguir entre el sonrojo social normal y el sonrojo social patológico y, a la vez, revisa los tratamientos actualmente disponibles para las personas que consultan por esta condición.

Autonomic arousal in children of parents with and without social anxiety disorder: a high-risk study.

OBJECTIVE: Autonomic hyperarousal in social situations is considered a genetic vulnerability factor for social anxiety disorder (SAD), but so far it is unstudied in children at risk for developing SAD. We examined autonomic activity during socially stressful tasks in children of mothers and fathers with and without lifetime SAD to reveal possible biological mechanisms of intergenerational transmission of SAD. METHODS: One hundred ten children aged 4.5 years were asked to sing a song in front of an audience and watch back their performance in the presence of that audience. Heart rate (HR), heart rate variability (HRV), electrodermal activity (EDA), and blushing (cheek blood flow and temperature) were measured in anticipation of, during, and after the tasks. Both parents' lifetime SAD status was assessed, and both parents reported about their own and their child's social anxiety symptoms. RESULTS: Children of parents with lifetime SAD blushed more during the socially challenging tasks than children of parents without SAD. Moreover, children of parents with more social anxiety symptoms showed increased EDA throughout the tasks. Finally, more blushing, increased EDA, and reduced HRV were associated with greater child social anxiety. CONCLUSIONS: This study adds to the current knowledge on the intergenerational transmission of SAD by providing evidence that children at risk for SAD are characterized by excessive blushing in socially challenging situations. The findings also demonstrate that heightened autonomic activity is a characteristic of social anxiety already during early childhood. Hence, autonomic hyperarousal, and blushing in particular, is likely to play an etiological role in the development of SAD.

Blushing in early childhood: Feeling coy or socially anxious?

Blushing has adaptive social functions. However, blushing is also assumed to be a hallmark of social anxiety and shyness. For the first time, blushing and its relation to the expressions of shyness and social anxiety was examined in early childhood. Four-and-a-half-year-old children (N = 102) were asked to perform (singing in front of an audience) and watched back their performance in the presence of that audience. Physiological blushing (blood volume pulse, blood volume, and cheek temperature) was measured, and positive (gaze and/or head aversion with smiling) and negative expressions of shyness (gaze and/or head aversion with negative facial expressions) were observed. In addition, both parents reported their child's social anxiety level. A higher level of blushing response was related to greater social anxiety in children who displayed few positive shy expressions, but not in children who displayed many positive shy expressions during the performance. Moreover, children who expressed many negative shy expressions were highly socially anxious, no matter their blushing. Our findings suggest that blushing appears to be an early indicator of social anxiety in children who are not able to successfully cope with fearful social situations. In contrast, blushing, in combination with positive shy behaviors, appears to be an adaptive social mechanism that may protect from heightened social anxiety. (PsycINFO Database Record

Thoracoscopic sympathectomy increases efferent cardiac vagal activity and baroreceptor sensitivity.

OBJECTIVES: Thoracoscopic sympathectomy at levels T2 or T2-T3 is a treatment for focal hyperhidrosis and facial blushing. These levels of the sympathetic trunk innervate the heart, and consequently, the procedure is reported to change the heart rate variability due to changes in efferent cardiac autonomic activity. Our objective was to investigate the effects of thoracoscopic sympathectomy on global autonomic control, including baroreceptor sensitivity. METHODS: Eight patients (6 F, median age 28 years [range 20-58 years]) were exposed to the tilt-table test and cardiopulmonary exercise test before, and 3 months after, thoracoscopic sympathectomy. Eight healthy age-, gender- and BMI-matched controls were used as controls and underwent the same tests once. During tilt-table testing electrocardiogram, blood pressure, impedance cardiography and respiration were measured continuously, and efferent cardiac autonomic balance was estimated. RESULTS: The heart rate measured during orthostatic stress test was lowered after thoracoscopic sympathectomy (between-group; P = 0.01) due to a change in autonomic tone, with increased vagal (high-frequency power n.u.; P = 0.001), and reduced sympathetic efferent cardiac activity (low-frequency power n.u.; P < 0.001). Baroreceptor sensitivity measured during rest was increased (26 ± 13 vs 44 ± 19 ms/mmHg; P = 0.01), and diastolic blood pressure reduced after surgery (P = 0.01). The increases in systolic blood pressure and the sympathetic marker CCV-LF in response to orthostatic stress were higher before sympathectomy, with almost no increases post-surgically (condition × group interaction; P = 0.01 and P = 0.001, respectively). We found no change in post-procedure exercise capacity, although patients had a lower peak VO2 and maximal cardiac index than controls. CONCLUSIONS: Thoracoscopic sympathectomy changes the autonomic tone towards increased vagal activity; this is potentially cardioprotective. To our knowledge, this is the first study to show increased baroreceptor sensitivity after thoracoscopic sympathectomy.

Increased autonomic activation in vicarious embarrassment.

We studied the somatovisceral response pattern of vicarious embarrassment for someone else's inappropriate condition. Participants (N=54) were confronted with hand-drawn sketches depicting public situations and were instructed to rate the intensity of their vicarious embarrassment. The inappropriate condition varied according to the attribution of intentionality (absent/present) and awareness (absent/present). Irrespective of these attributions, participants reported stronger vicarious embarrassment in comparison to neutral situations. Across a set of eleven somatovisceral variables vicarious embarrassment elicited a pattern of increased autonomic activation which was modulated by the awareness of the protagonist about the ongoing norm violation. The somatovisceral response pattern matches previous findings for the first-person experience of embarrassment. Together, these results support the hypothesis that processes of perspective taking also mediate the vicarious experience of embarrassment.

The effect of facial blood flow on ratings of blushing and negative affect during an embarrassing task: preliminary findings.

Expecting to blush is a common source of social anxiety, and is associated with heightened perceptions of blushing and embarrassment. To assess whether sensory cues associated with heightened facial blood flow are an additional source of anxiety, the vasodilator niacin (100mg) or placebo was administered double-blind to 33 participants, and facial blood flow was investigated when they sang a children's song. Vasodilatation during singing was greater in the niacin than placebo condition, and niacin-evoked flushing and increases in pulse rate were greater in participants with high than low fear of negative evaluation. Nevertheless, ratings of embarrassment, anxiety, blushing and facial heat were similar in both drug conditions. This dissociation implies that cognitive appraisals or negative affect overrode more subtle physiological cues of blushing during embarrassment. Clarifying how judgments about blushing are made could be crucial for correcting faulty assumptions about blushing in people who are frightened of this response.

Blushing in rosacea sufferers.

OBJECTIVE: Rosacea is characterized by extremely sensitive skin and persistent facial flushing, perhaps initiated or exacerbated by frequent or intense blushing. To investigate this, blushing was assessed in rosacea sufferers and controls during embarrassing laboratory tasks. METHODS: Changes in forehead blood flow were monitored with laser Doppler fluxmetry in 31 rosacea sufferers (12 with severe symptoms and 19 with mild symptoms) and 86 controls while singing, giving an impromptu speech, and listening to recordings of these activities. RESULTS: Changes in forehead blood flow were similar in rosacea sufferers and controls, and were similar in subgroups with mild and severe rosacea. Even so, rosacea sufferers thought that that they blushed more intensely and were more embarrassed than controls during most of the tasks. Likewise, changes in forehead blood flow were similar in participants with mild and severe rosacea. Nevertheless, ratings of embarrassment and blushing were greater in those with severe than mild symptoms. Within the rosacea group, increases in blood flow while singing were greatest in participants with the highest blushing ratings, whereas increases in blood flow while listening to the speech were greatest in the most embarrassed participants. CONCLUSIONS: These findings do not support the hypothesis that blushing is abnormal in rosacea but, nevertheless, suggest that rosacea sufferers are more aware of and embarrassed by blushing than controls. This might contribute to social anxiety in rosacea sufferers.

The effect of niacin on facial blood flow in people with an elevated fear of negative evaluation.

The vasodilator niacin may provoke greater facial flushing and other symptoms of anxiety in patients with social anxiety disorder than in non-anxious controls. To determine whether this also applies in non-clinical samples, niacin (100mg) or placebo was administered double-blind to 33 young adults and flushing was investigated in relation to fear of negative evaluation (a cardinal feature of social anxiety). Increases in facial blood flow were greater in people with high than low fear of negative evaluation in the niacin condition, but were similar in both groups in the placebo condition. However, changes in pulse rate and ratings of embarrassment, anxiety, blushing and facial heat were similar in both groups in both drug conditions. These findings suggest that the facial vessels of people with a heightened fear of negative evaluation are particularly responsive to niacin under conditions of low anxiety and embarrassment.

The relationship between blushing propensity, social anxiety and facial blood flow during embarrassment.

To investigate blushing in relation to blushing propensity scores and core elements of social anxiety, facial blood flow was monitored in 86 normal volunteers during an embarrassing task (singing a children's song). Increases in facial blood flow were greater in women than men, as were scores on the Blushing Propensity and Fear of Negative Evaluation scales. In addition, high scores on the Blushing Propensity and Social Interaction Anxiety scales were associated with large increases in facial blood flow during singing. However, this appeared to be due primarily to social anxiety because the association between blushing propensity scores and changes in facial blood flow disappeared when social interaction anxiety scores were taken into account. These findings suggest that people generally base their beliefs about blushing on cues other than changes in facial blood flow. Social anxiety may augment increases in facial blood flow during embarrassment, independently of expected or perceived blushing.

Is there a place for fear of blushing in social anxiety spectrum?

BACKGROUND: Fear of blushing (FB) in front of other people is a frequent and potentially incapacitating problem, but is not yet described as a specific diagnosis in psychiatric classifications. This can be explained by a lack of comparative studies with other forms of social anxiety disorder (SAD). Our aim was thus to explore the specificity of FB in patients with SAD. METHODS: SAD patients with FB but without other social threat (n = 142), the majority of whom were referred by a department of surgery after an initial request of sympathetic block for facial blushing, were compared to SAD patients with FB and other associated social fears (n = 97), and to SAD patients without FB (n = 190). They were assessed and compared with a structured diagnostic interview for DSM-IV and various scales measuring social anxiety, other anxiety and depressive symptoms, impairment and personality traits. RESULTS: The group with pure FB showed specific profiles when compared with the two other groups: later age of onset, less comorbidity, lower behavioral and temperamental inhibition, and higher self-esteem. However, their levels of social anxiety and impairment were high. No important differences appeared between the two other groups. CONCLUSION: The specificity of FB should be considered in the social anxiety spectrum, and could be viewed either as a SAD subtype or as SAD form secondary to facial blushing. Further epidemiological and therapeutic studies on this disorder are necessary.

Late results of endoscopic thoracic sympathectomy for hyperhidrosis and facial blushing.

BACKGROUND: The purpose of this study was to clarify the long-term effects, side-effects and overall satisfaction rates of endoscopic thoracic sympathectomy (ETS) used in the treatment of hyperhidrosis and facial blushing. METHODS: Some 3015 patients had bilateral ETS from 1989 to 1998. A questionnaire follow-up was used. Some of the patients had participated in a previous follow-up study, and the answers in both surveys were compared. RESULTS: A total of 1700 patients responded (56·4 per cent); mean(s.d.) follow-up was 14·6(2·4) years. The best result was achieved for palmar hyperhidrosis (95·6 per cent) compared with axillary hyperhidrosis (68·9 per cent), facial hyperhidrosis (83 per cent) and facial blushing (72·8 per cent) (P < 0·001). Compensatory sweating, the main side-effect, was present in 80·0 per cent. Some 6·5 per cent were dissatisfied and 13·5 per cent regretted having the procedure. Patients with palmar hyperhidrosis were more satisfied (86·6 per cent) than those with axillary hyperhidrosis (66·0 per cent), facial hyperhidrosis (74 per cent) or facial blushing (73·5 per cent) (P < 0·001). Women were more satisfied than men (85·4 versus 71·4 per cent; P < 0·001). The procedure regret rate rose from 7·8 per cent in the first survey to 13·5 per cent in the present one. CONCLUSION: ETS had an excellent and lasting effect on palmar hyperhidrosis. The effect on facial and axillary hyperhidrosis and facial blushing was less rewarding. The procedure regret rate increased over time.

Reading embodied consciousness in "Emma".

The language of Emma (1815) reflects Jane Austen's developing view of embodied consciousness and her particular interest in this novel in the physical manifestations of emotions, such as blushes and nervous responses. The discursive exploration of the inner life in Emma is the product of a cultural context that features emerging brain science and Austen's own conceptualization of the psychophysical nature of emotions. This article analyzes the language of mind and emotion in Emma, to contend that Austen grapples with the implications of the idea of embodied consciousness in a narrative that contrasts mind reading with interpreting the body.

Physiological blushing in social anxiety disorder patients with and without blushing complaints: two subtypes?

This study investigates whether social anxiety disorder (SAD) patients with blushing complaints show heightened physiological blushing and arousability in social situations than SAD patients without blushing complaints and healthy controls. SAD blushers (n=32), SAD non-blushers (n=34), and healthy controls (n=25) conducted two social tasks. The physiological responses cheek and forehead blood flow, cheek temperature, and skin conductance were recorded, as well as confederates-observed blushing. The SAD blushers showed more physiological blushing (cheek temperature and blood flow) than SAD non-blushers and observers detected this difference. This finding was also present in comparison to the controls, except for blood flow. For blood flow SAD blushers and controls did not differ but SAD non-blushers showed a 'suppressed response': a smaller cheek blood flow increase during the interaction and no recovery compared to the other groups. Furthermore, on skin conductance no differences between groups were observed. Discussed is to what extent SAD blushers and SAD non-blushers represent two qualitative distinct subgroups of SAD.