Targeting fear of positive evaluation in patients with social anxiety disorder via a brief cognitive behavioural therapy protocol: a proof-of-principle study.

BACKGROUND: Our aim was to develop a brief cognitive behavioural therapy (CBT) protocol to augment treatment for social anxiety disorder (SAD). This protocol focused specifically upon fear of positive evaluation (FPE). To our knowledge, this is the first protocol that has been designed to systematically target FPE. AIMS: To test the feasibility of a brief (two-session) CBT protocol for FPE and report proof-of-principle data in the form of effect sizes. METHOD: Seven patients with a principal diagnosis of SAD were recruited to participate. Following a pre-treatment assessment, patients were randomized to either (a) an immediate CBT condition (n = 3), or (b) a comparable wait-list (WL) period (2 weeks; n = 4). Two WL patients also completed the CBT protocol following the WL period (delayed CBT condition). Patients completed follow-up assessments 1 week after completing the protocol. RESULTS: A total of five patients completed the brief, FPE-specific CBT protocol (two of the seven patients were wait-listed only and did not complete delayed CBT). All five patients completed the protocol and provided 1-week follow-up data. CBT patients demonstrated large reductions in FPE-related concerns as well as overall social anxiety symptoms, whereas WL patients demonstrated an increase in FPE-related concerns. CONCLUSIONS: Our brief FPE-specific CBT protocol is feasible to use and was associated with large FPE-specific and social anxiety symptom reductions. To our knowledge, this is the first treatment report that has focused on systematic treatment of FPE in patients with SAD. Our protocol warrants further controlled evaluation.

Intolerance of uncertainty moderates the relations among religiosity and motives for religion, depression, and social evaluation fears.

OBJECTIVES: Intolerance of uncertainty (IU) underlies several psychological disorders, and religion may help some individuals cope with IU and/or protect against psychological symptoms. It was hypothesized that IU would moderate the relations between coping motives for being religious, as well as religiosity, and common psychological disorder symptoms: Depression and social evaluation fears. METHODS: Study 1 included 473 self-reporting community members (M age = 48, 48% female, 80% Protestant/Catholic). Study 2 included 412 self-reporting undergraduates ( M age = 19, 71% female, 76% Protestant/Catholic). RESULTS: For Study 1, coping-based motives related to greater depression for young adults with above-average IU and to lower depression for young adults with below-average IU. For Study 2, religiosity related to lower depression and fear of negative evaluation for individuals with above-average IU and to greater fear of positive evaluation for individuals with below-average IU. CONCLUSION: IU may be an important mechanism between aspects of religion and psychological disorder symptoms.

Social anxiety and eating disorder comorbidity and underlying vulnerabilities: Using network analysis to conceptualize comorbidity.

OBJECTIVE: Eating disorders (EDs) and social anxiety disorder (SAD) are highly co-occurring. This comorbidity is extremely relevant, given that individuals with comorbid ED-SAD are less likely to seek and/or benefit from ED treatment. METHOD: We used network analysis to conceptualize ED-SAD comorbidity in a sample of 2,215 participants with a primary diagnosis of ED, SAD, or no known diagnosis. We used novel network analyses methods to select symptoms for our models, identify potential illness pathways (i.e., bridge symptoms) between disorders and underlying vulnerabilities (e.g., perfectionism, social appearance anxiety), and to compare across sample types (e.g., clinical vs. nonclinical). We also tested several novel network analyses methods aimed at the following methodological concerns: (a) topological concerns (i.e., which items should be included in NA models), (b) how to use empirical indices to quantify bridge symptoms and (c) what differences in networks across samples mean. RESULTS: We found that difficulty with drinking beverages and eating in public were bridge symptoms between ED and SAD. We also found that feeling nervous about one's appearance was a bridge symptom. CONCLUSIONS: We identified public eating and drinking as bridge symptoms between EDs and SAD. Future research is needed to test if interventions focused on public eating and drinking might decrease symptoms of both EDs and SAD. Researchers can use this study (code provided) as an exemplar for how to use network analysis, as well as to use network analysis to conceptualize ED comorbidity and compare network structure and density across samples.

Convergent, incremental, and criterion-related validity of multi-informant assessments of adolescents' fears of negative and positive evaluation.

Adolescents who experience social anxiety tend to hold fears about negative evaluations (e.g., taunting) and may also hold fears about positive evaluations (e.g., praise from a teacher). The Brief Fear of Negative Evaluation (BFNE) scale and Fear of Positive Evaluation Scale (FPES) are 2 widely used measures of adults' evaluative concerns. Yet we know little about their psychometric properties when assessing adolescents. In a mixed clinical/community sample of 96 adolescents (66.7% female; M = 14.50 years, SD = 0.50; 63.3% African American), we examined both self-report and parent report versions of the BFNE and FPES. Adolescents and parents also provided reports about adolescents on survey measures of social anxiety and depressive symptoms. Adolescents participated in multiple social interactions in which they self-reported their state arousal before and during the tasks. Adolescent and parent BFNE and FPES reports distinguished adolescents who displayed elevated social anxiety from those who did not. Both informants' reports related to survey measures of adolescent social anxiety, when accounting for domains that commonly co-occur with social anxiety (i.e., depressive symptoms). Further, both the BFNE and FPES displayed incremental validity in relation to survey measures of adolescent social anxiety, relative to each other. However, only adolescents' BFNE and FPES reports predicted adolescents' self-reported arousal within social interactions, and only adolescents' FPES displayed incremental validity in predicting self-reported arousal, relative to their BFNE. Adolescent and parent BFNE and FPES reports display convergent validity and in some cases incremental and criterion-related validity. These findings have important implications for evidence-based assessments of adolescents' evaluative concerns.

Relations among Social Anxiety, Eye Contact Avoidance, State Anxiety, and Perception of Interaction Performance during a Live Conversation.

There is building evidence that highly socially anxious (HSA) individuals frequently avoid making eye contact, which may contribute to less meaningful social interactions and maintenance of social anxiety symptoms. However, research to date is lacking in ecological validity due to the usage of either static or pre-recorded facial stimuli or subjective coding of eye contact. The current study examined the relationships among trait social anxiety, eye contact avoidance, state anxiety, and participants' self-perceptions of interaction performance during a live, four-minute conversation with a confederate via webcam, and while being covertly eye-tracked. Participants included undergraduate women who conversed with same-sex confederates. Results indicated that trait social anxiety was inversely related to eye contact duration and frequency averaged across the four minutes, and positively related to state social anxiety and negative self-ratings. In addition, greater anticipatory state anxiety was associated with reduced eye contact throughout the first minute of the conversation. Eye contact was not related to post-task state anxiety or self-perception of poor performance; although, trends emerged in which these relations may be positive for HSA individuals. The current findings provide enhanced support for the notion that eye contact avoidance is an important feature of social anxiety.

Culture of honour theory and social anxiety: Cross-regional and sex differences in relationships among honour-concerns, social anxiety and reactive aggression.

Consistent with the "flight or fight" model of anxiety, social anxiety may incite withdrawal or attack; yet, it is unclear why some socially anxious individuals are vulnerable to aggress. It may be that culture impacts tendencies to "fight" or "flee" from social threat. Honour cultures, including the American South, permit or even promote aggression in response to honour-threats. Thus, social anxiety in the South may be more associated with aggression than in non-honour cultures. In the current sample, region moderated the relation between social anxiety and aggression; social anxiety related positively to reactive (but not proactive) aggression among Southerners (n = 285), but not Midwesterners (n = 258). Participant sex further moderated the relationship, such that it was significant only for Southern women. Also, for Southerners, prototypically masculine honour-concerns mediated the relationship between social anxiety and reactive aggression. Cultural factors may play key roles in aggressive behaviour among some socially anxious individuals.

Replication and extension of a hierarchical model of social anxiety and depression: fear of positive evaluation as a key unique factor in social anxiety.

Wang, Hsu, Chiu, and Liang (2012, Journal of Anxiety Disorders, 26, 215-224) recently proposed a hierarchical model of social interaction anxiety and depression to account for both the commonalities and distinctions between these conditions. In the present paper, this model was extended to more broadly encompass the symptoms of social anxiety disorder, and replicated in a large unselected, undergraduate sample (n = 585). Structural equation modeling (SEM) and hierarchical regression analyses were employed. Negative affect and positive affect were conceptualized as general factors shared by social anxiety and depression; fear of negative evaluation (FNE) and disqualification of positive social outcomes were operationalized as specific factors, and fear of positive evaluation (FPE) was operationalized as a factor unique to social anxiety. This extended hierarchical model explicates structural relationships among these factors, in which the higher-level, general factors (i.e., high negative affect and low positive affect) represent vulnerability markers of both social anxiety and depression, and the lower-level factors (i.e., FNE, disqualification of positive social outcomes, and FPE) are the dimensions of specific cognitive features. Results from SEM and hierarchical regression analyses converged in support of the extended model. FPE is further supported as a key symptom that differentiates social anxiety from depression.

Cognitive constructs and social anxiety disorder: beyond fearing negative evaluation.

Pioneering models of social anxiety disorder (SAD) underscored fear of negative evaluation (FNE) as central in the disorder's development. Additional cognitive predictors have since been identified, including fear of positive evaluation (FPE), anxiety sensitivity, and intolerance of uncertainty (IU), but rarely have these constructs been examined together. The present study concurrently examined the variance accounted for in SAD symptoms by these constructs. Participants meeting criteria for SAD (n = 197; 65% women) completed self-report measures online. FNE, FPE, anxiety sensitivity, and IU all accounted for unique variance in SAD symptoms. FPE accounted for variance comparable to FNE, and the cognitive dimension of anxiety sensitivity and the prospective dimension of IU accounted for comparable variance, though slightly less than that accounted for by FNE and FPE. The results support the theorized roles that these constructs play in the etiology of SAD and highlight both FNE and FPE as central foci in SAD treatment.

Social anxiety and the Big Five personality traits: the interactive relationship of trust and openness.

It is well established that social anxiety (SA) has a positive relationship with neuroticism and a negative relationship with extraversion. However, findings on the relationships between SA and agreeableness, conscientiousness, and openness to experience are mixed. In regard to facet-level personality traits, SA is negatively correlated with trust (a facet of agreeableness) and self-efficacy (a facet of conscientiousness). No research has examined interactions among the Big Five personality traits (e.g., extraversion) and facet levels of personality in relation to SA. In two studies using undergraduate samples (N = 502; N = 698), we examined the relationships between trust, self-efficacy, the Big Five, and SA. SA correlated positively with neuroticism, negatively with extraversion, and had weaker relationships with agreeableness, openness, and trust. In linear regression predicting SA, there was a significant interaction between trust and openness over and above gender. In addition to supporting previous research on SA and the Big Five, we found that openness is related to SA for individuals low in trust. Our results suggest that high openness may protect against the higher SA levels associated with low trust.

Psychometric properties of the gaze anxiety rating scale: convergent, discriminant, and factorial validity.

Fear and avoidance of gaze are two features thought to be associated with problematic social anxiety. Avoidance of eye contact has been linked with such undesirable traits as deceptiveness, insincerity, and lower self-esteem. The Gaze Anxiety Rating Scale (GARS) is a self-report measure designed to assess gaze anxiety and avoidance, but its psychometric properties have only been assessed in one preliminary study. We further investigated psychometric properties of the GARS by assessing convergent and factorial validity. We obtained a two-factor solution: gaze anxiety and avoidance across situations (1) in general (GARS-General) and (2) related to dominance communication (GARS-Dominance). The GARS-General factor related more strongly to social anxiety than the GARS-Dominance, and convergent validity of the factors was supported by expected relationships with personality and social anxiety variables. Our results indicate that the GARS subscales are psychometrically valid measures of gaze aversion, supporting their use in future study of the relationship between social anxiety and eye contact behavior.

Cross-cultural validation of the BFOE model: Best practices and future directions for psychometric evaluation of the Fear of positive evaluation scale - Insights from a Dutch translation.

The Bivalent Fear of Evaluation (BFOE) model suggests that Social Anxiety Disorder is not only characterized by fear of negative evaluation (FNE), but also fear of positive evaluation (FPE). While FNE has been firmly established, research of the latter is accumulating. To evaluate the role of the BFOE Model, and particularly FPE, validated measures such as the Fear of Positive Evaluation Scale (FPES) are pivotal. Yet, validation of psychometric properties is often at stake or neglected when translating a scale to other languages. This hampers cross-cultural evaluation of questionnaires and related concepts considerably, including the BFOE Model. To illustrate, a freely available, but not validated Dutch version of the FPES was completed, along with other measures by 354 community participants from the Netherlands and Belgium in an online study. The Dutch FPES showed excellent convergent and discriminant validity. In addition, it explained additional variance in social anxiety above and beyond FNE. These results as well as those from the factor analyses were highly comparable with those deriving from evaluations of the original English version. In conclusion, the Dutch FPES showed excellent psychometric properties and is fit for further exploring consistency or differences in the BFOE model across cultures. Based on this case, practice guidelines for international use and validation of measures are discussed, and recommendations are provided.

Re-assessing the assessment of fears of positive and negative evaluation: Scale development and psychometric evaluation of the Bivalent Fear of Evaluation Scale (BFOES).

The bivalent fear of evaluation (BFOE) model of social anxiety divides fear of evaluation into two distinct valences: fear of positive evaluation (FPE) and fear of negative evaluation (FNE). However, there is evidence that the two most widely utilized and psychometrically supported measures of FNE and FPE contain items which are ambiguous with regard to valence of evaluative fear. To formally address this, the BFOE Scale (BFOES) was developed, by merging items from measures of FNE and FPE into a single scale with an integrated response format. The present studies examined the psychometric profile of the BFOES across a large pooled archival dataset (N = 2216), which included approximately 10 % (n = 224) patients with social anxiety disorder (SAD). The factorial validity, internal consistency, and construct validity of the BFOES were examined. Additionally, item response theory analyses were employed for the purpose of merging items from self-report scales which utilized different Likert-type response formats. Results from both studies provided support for the psychometric profile of the BFOES. The implications of the BFOES for the assessment of social anxiety, and theoretical models of fear of evaluation and SAD, are discussed.

Mutual eye gaze and vocal pitch in relation to social anxiety and depression: A virtual interaction task.

BACKGROUND: Individuals with high social interaction anxiety (SIA) and depression often behave submissively in social settings. Few studies have simultaneously examined the associations between objectively assessed submissive behaviors and SIA or depression, despite their high comorbidity and unknown mechanisms regarding submissiveness. METHODS: A sample of 45 young adults self-reported trait SIA and depression, state positive/negative affect (PA/NA) before and after a virtual social interaction. Participants engaged in a four-minute conversation with a confederate who was trained to behave neutrally. Mutual eye gaze, via eye-tracking, and vocal pitch were assessed throughout the interaction. RESULTS: Depression and SIA were positively correlated with NA, poorer self-rated performance, and vocal pitch. Highly socially anxious women engaged in less mutual eye gaze than highly socially anxious men. Also, vocal pitch was inversely associated with mutual eye gaze and positively related to NA and (nonsignificantly) to self-ratings of poor performance. Finally, our data partially replicated past research on the use of vocal pitch during social stress to detect social anxiety disorder. LIMITATIONS: The current sample is relatively homogenous in educational attainment, age, and race. All research confederates were women. Future research should examine whether these archival data replicate with the latest telecommunication technologies. CONCLUSION: Our findings highlight nuanced relationships among SIA, depression, emotions, self-perceptions, and biobehavioral indicators of submissive behavior-in response to an ambiguously negative/positive social interaction. Sex/gender may interact with these effects, emphasizing considerations for research method designs.

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.

Gaze avoidance in social anxiety disorder.

BACKGROUND: The relationship between gaze avoidance and social anxiety has been examined previously using eye-tracking and static social images. Overall, findings to date highlight increased gaze avoidance as a behavioral marker of social anxiety. The purpose of the present study was to better elucidate the relationship between gaze avoidance and social anxiety disorder (SAD) symptoms via covert eye tracking of gaze tendencies in response to a dynamic computerized social interaction simulation. On the basis of the bivalent fear of evaluation (BFOE) model of social anxiety,([1]) it was expected that participants with SAD, compared to nonsocially anxious control (NSAC) participants, would exhibit gaze avoidance in response to both positive and negative social feedback. METHODS: Participants with SAD (n = 20), and a sample of demographically equivalent NSAC (n = 19), were administered clinical diagnostic interviews and a computerized social simulation task. The simulation task consisted of viewing 26 dynamic videos (13 positive and 13 negative), each 12 s in duration. All participants were covertly eye tracked during the simulation. RESULTS: SAD participants exhibited greater global gaze avoidance in response to both the positive and negative video clips in comparison to the controls. Moreover, the SAD group exhibited equivalent gaze avoidance in response to stimuli of both emotional valences. CONCLUSIONS: These results provide additional support for gaze avoidance as a behavioral marker of SAD, as well as additional support for the BFOE model. Implications for the assessment of SAD are discussed.

Social appearance anxiety, perfectionism, and fear of negative evaluation: distinct or shared risk factors for social anxiety and eating disorders?

Social anxiety and eating disorders are highly comorbid. Social appearance anxiety (i.e., fear of negative evaluation of one's appearance), general fear of negative evaluation, and perfectionism have each been proposed as risk factors for both social anxiety disorder and the eating disorders. However, no research to date has examined all three factors simultaneously. Using structural equation modeling in two diverse samples (N=236; N=136) we tested a model in which each of these risk factors were uniquely associated with social anxiety and eating disorder symptoms. We found support for social appearance anxiety as a shared risk factor between social anxiety and eating disorder symptoms, whereas fear of negative evaluation was a risk factor only for social anxiety symptoms. Despite significant zero-order relationships, two facets of perfectionism (high standards and maladaptive perfectionism) did not emerge as a risk factor for either disorder when all constructs were considered. These results were maintained when gender, body mass index, trait negative affect, and depression were included in the model. It is possible that treating negative appearance evaluation fears may reduce both eating disorder and social anxiety symptoms.

Linguistic correlates of social anxiety disorder.

The goal of this study was to examine the linguistic correlates of social anxiety disorder (SAD). Twenty-four individuals with SAD (8 of them with a generalised subtype) and 21 non-anxious controls were asked to give speeches in front of an audience. The transcribed speeches were examined for the frequency of negations, I-statements, we-statements, negative emotion words, and positive emotion words. During their speech, individuals with either SAD subtype used positive emotion words more often than controls. No significant differences were observed in the other linguistic categories. These results are discussed in the context of evolutionary and cognitive perspectives of SAD.

The bivalent fear of evaluation model of social anxiety: further integrating findings on fears of positive and negative evaluation.

Accumulating evidence supports the premise that fear of evaluation in general is important in social anxiety, including fear of positive evaluation (FPE) as well as fear of negative evaluation (FNE). This study tested various hypotheses pertaining to a novel, expanded conceptualization of social anxiety involving these two distinct fears: the bivalent fear of evaluation (BFOE) model. Responses from a large undergraduate sample (N = 585) were examined. In addition, responses from a subsample of participants qualifying for a probable diagnosis of social anxiety disorder (SAD; n = 133) were examined, via mediational analyses, for potential mechanisms underlying FPE within highly socially anxious individuals. FPE exhibited a unique and significantly stronger relationship with concerns of social reprisal due to making positive impressions than did FNE. FPE related uniquely and negatively to trait positive affect/automatic thoughts, whereas FNE, FPE, and social anxiety all related uniquely and positively to trait negative affect/automatic thoughts. FPE, FNE, and social anxiety all related uniquely and positively to disqualification of positive social outcomes (DPSO). However, FPE related most strongly to DPSO attributions at the level of the self, and these attributions mediated the relationship between FPE and negative automatic thoughts in an analog clinical sample. Concerns of social reprisal due to making positive impressions on others mediated the relationship between FPE and DPSO attributions to others in an analog clinical sample. The obtained findings replicate and extend support for the BFOE model of social anxiety. Implications for the theoretical conceptualization and treatment of SAD are discussed.

Psychometric properties of the Montreal Cognitive Assessment (MoCA) in inpatient liver transplant candidates.

Hepatic encephalopathy (HE) is a consequence of liver disease and often diagnosed via psychometric testing. With inpatients, the Montreal Cognitive Assessment (MoCA) may be used as part of cognitive screening for transplant candidacy. However, the MoCA was developed to detect mild cognitive impairment in aging populations and its psychometric properties in inpatients with liver disease have not been determined. Retrospective chart review identified inpatient liver transplant candidates who were administered a MoCA as part of their neuropsychological screening and had either no cognitive dysfunction or a diagnosis of HE made by a neuropsychologist (n = 57, mean age = 48.8 ± 12.6 years). Psychometric analyses were conducted and regression analysis was performed to determine the predictive value of different variables on total MoCA scores. Internal consistency of MoCA domain scores was good (α = 0.80). Significant inverse relationships were found with Trail Making Test, Parts A and B (r's = -0.43 and -0.71, respectively). A cutoff score of 24 or below had the best sensitivity (0.72) and specificity (0.77) for identifying those with a diagnosis of HE. Increasing age and the presence of altered mental status were the strongest predictors of lower MoCA scores (both p's < 0.05, ηp2 = 0.10-0.14). The MoCA is appropriate to use with inpatient liver transplant candidates, with a cutoff of 24 or below to detect abnormal cognition. In addition to the clinical interview and other neuropsychological tests (including, but not limited to, the Trail Making Test, Parts A and B), low MoCA scores can help determine the presence of HE.

The Fears of Evaluation About Performance (FEAP) Task: Inducing Anxiety-Related Responses to Direct Exposure to Negative and Positive Evaluations.

Fears of negative and positive evaluation (i.e., evaluative fears) manifest within performance-based situations (e.g., public speaking, group presentations), particularly among those experiencing social anxiety. Within these performance-based situations, individuals experiencing such evaluative fears frequently display a variety of impairments (e.g., avoidance, nervousness) that might manifest within and across various settings (e.g., employment, school). How do those who experience these fears react to in-the-moment feedback about their performance? We constructed the Fear of Evaluation About Performance (FEAP) task to examine ecologically valid experiences with anxiety when reacting to positive and negative feedback. During the task, participants gave a speech, and subsequent to this and in counterbalanced order, received positive and negative feedback about their speech, with continued assessment of anxiety-related arousal throughout the task. We tested the FEAP task among 127 adults, who provided self-reports of fears of positive and negative evaluation before completing the task. Fears of positive evaluation uniquely predicted arousal following receipt of positive feedback, whereas fears of negative evaluation uniquely predicted arousal following receipt of negative feedback. Relative to participants receiving positive feedback first, those receiving negative feedback first experienced elevated post-feedback arousal, followed by a steep decline in arousal post-positive feedback. Conversely, participants receiving positive feedback first experienced a buffer effect whereby arousal post-negative feedback remained low, relative to the arousal experienced post-negative feedback among those who received negative feedback first. We expect the FEAP task to inform basic science on fears of negative and positive evaluation, as well as treatment planning in applied clinical settings.