A model of the development and maintenance of generalized social phobia

Increased default mode network activity in socially anxious individuals during reward processing

Background

Social anxiety has been associated with potentiated negative affect and, more recently, with diminished positive affect. It is unclear how these alterations in negative and positive affect are represented neurally in socially anxious individuals and, further, whether they generalize to non-social stimuli. To explore this, we used a monetary incentive paradigm to explore the association between social anxiety and both the anticipation and consumption of non-social incentives. Eighty-four individuals from a longitudinal community sample underwent functional magnetic resonance imaging (fMRI) while participating in a monetary incentive delay (MID) task. The MID task consisted of alternating cues indicating the potential to win or prevent losing varying amounts of money based on the speed of the participant’s response. We examined whether self-reported levels of social anxiety, averaged across approximately 7 years of data, moderated brain activity when contrasting gain or loss cues with neutral cues during the anticipation and outcome phases of incentive processing. Whole brain analyses and analyses restricted to the ventral striatum for the anticipation phase and the medial prefrontal cortex for the outcome phase were conducted.

Results

Social anxiety did not associate with differences in hit rates or reaction times when responding to cues. Further, socially anxious individuals did not exhibit decreased ventral striatum activity during anticipation of gains or decreased MPFC activity during the outcome of gain trials, contrary to expectations based on literature indicating blunted positive affect in social anxiety. Instead, social anxiety showed positive associations with extensive regions implicated in default mode network activity (for example, precuneus, posterior cingulate cortex, and parietal lobe) during anticipation and receipt of monetary gain. Social anxiety was further linked with decreased activity in the ventral striatum during anticipation of monetary loss.

Conclusions

Socially anxious individuals may increase default mode network activity during reward processing, suggesting high self-focused attention even in relation to potentially rewarding stimuli lacking explicit social connotations. Additionally, social anxiety may relate to decreased ventral striatum reactivity when anticipating potential losses.

Comorbidity of anxiety and depression in children and adolescents: 20 years after

Brady and Kendall (1992) concluded that although anxiety and depression in youths are meaningfully linked, there are important distinctions, and additional research is needed. Since then, studies of anxiety-depression comorbidity in youths have increased exponentially. Following a discussion of comorbidity, we review existing conceptual models and propose a multiple pathways model to anxiety-depression comorbidity. Pathway 1 describes youths with a diathesis for anxiety, with subsequent comorbid depression resulting from anxiety-related impairment. Pathway 2 refers to youths with a shared diathesis for anxiety and depression, who may experience both disorders simultaneously. Pathway 3 describes youths with a diathesis for depression, with subsequent comorbid anxiety resulting from depression-related impairment. Additionally, shared and stratified risk factors contribute to the development of the comorbid disorder, either by interacting with disorder-related impairment or by predicting the simultaneous development of the disorders. Our review addresses descriptive and developmental factors, gender differences, suicidality, assessments, and treatment-outcome research as they relate to comorbid anxiety and depression and to our proposed pathways. Research since 1992 indicates that comorbidity varies depending on the specific anxiety disorder, with Pathway 1 describing youths with either social phobia or separation anxiety disorder and subsequent depression, Pathway 2 applying to youths with coprimary generalized anxiety disorder and depression, and Pathway 3 including depressed youths with subsequent social phobia. The need to test the proposed multiple pathways model and to examine (a) developmental change and (b) specific anxiety disorders is highlighted.

Escaping Threat

Individuals with a hypersensitivity to threatening stimuli in the environment may be more likely to experience a higher level of social anxiety. According to Reinforcement Sensitivity Theory (RST), there are two important aspects of threat stimuli that influence subsequent emotional and behavioral responses. Specifically, perceptions pertaining to defensive direction and distance are considered critical factors in understanding threat responses. This paper aimed to determine whether threat perceptions mediate the relationship between threat sensitivity and social anxiety. Self-report measures of sensitivity to threat, social anxiety, and a vignette designed to assess threat perceptions were administered to a sample of 218 participants (73% female; M age = 33.75, SD age = 11.52). Data indicated a mediational influence of perceived escapability on the relationship between sensitivity to threat and social anxiety. Overall, these findings highlight the role of perceived escapability of threat in understanding the relationship between threat sensitivity and social anxiety.

Examining the incremental contribution of behavioral inhibition to generalized anxiety disorder relative to other Axis I disorders and cognitive-emotional vulnerabilities

The goal of the present study was to investigate the incremental contribution of behavioral inhibition system (BIS) sensitivity to the presence of a current generalized anxiety disorder (GAD) diagnosis relative to other Axis I disorders (e.g., major depression, other anxiety disorders) and cognitive-emotional vulnerabilities (e.g., anxiety sensitivity, emotion dysregulation) previously found to be associated with GAD. Participants were 91 individuals recruited from the local community who completed a diagnostic interview and self-report questionnaires. Consistent with expectations, BIS sensitivity emerged as a significant predictor of current GAD status above and beyond major depression, anxiety disorder diagnoses, anxiety sensitivity, emotion dysregulation, and behavioral activation system sensitivity. However, emotion dysregulation also emerged as a significant predictor of GAD status in the final model. Findings speak to the importance of considering BIS sensitivity in models of the development and maintenance of GAD.

The Safety Bias: Risk-Avoidance and Social Anxiety Pathology

Background:The pervasive tendency to avoid perceived risks has been recently implicated in the maintenance of anxiety pathology, and more specifically, social phobia. Social anxiety symptoms are thus hypothesised to be associated with a global risk-avoidant decision-making bias.Aim:This study investigated: (1) the relationship between risk-avoidance and social anxiety symptoms using both self-report and behavioural measures of risk-taking; and (2) whether risk-avoidance mediates the relationship between a dispositional vulnerability to anxiety (Behavioural Inhibition System [BIS] sensitivity) and social anxiety symptoms.Method:Fifty-five undergraduate students completed self-report measures assessing for social anxiety symptoms, risk-taking across various domains, and BIS sensitivity. Risk-avoidance was also assessed using a behavioural computer task.Results:As hypothesised, risk-avoidance correlated significantly with both social anxiety and BIS. Multiple regression analyses revealed that risk-avoidance served as a partial mediator between BIS and social anxiety.Conclusion:These results confirm the hypothesised relationship between BIS, risk-avoidance, and social anxiety symptoms. Risk-avoidance is one possible mechanism by which personality characteristics may be linked to anxiety pathology.

Conceptual relations between anxiety disorder and fearful temperament

Fearful temperaments have been identified as a major risk factor for anxiety disorders. However, descriptions of fearful temperament and several forms of anxiety disorder show strong similarities. This raises the question whether these terms may simply refer to different aspects of the same underlying construct. The current review examines evidence for the overlap and distinction between these constructs. Although strong conclusions cannot be drawn from the extant literature, the bulk of the evidence appears to support a distinction between them.

Using a semi-structured interview to explore imagery experienced during social anxiety for clients with a diagnosis of psychosis: an exploratory study conducted within an early intervention for psychosis service

BACKGROUND

Social phobia frequently occurs as a comorbid condition, with high rates reported among people with psychosis. Little is known about the nature of social anxiety in this population or whether current psychological theories apply.

AIMS

This paper aims to develop and pilot a suitable measure to explore imagery experienced by participants with comorbid psychosis and social anxiety and to provide preliminary indications as to its nature.

METHOD

A semi-structured interview exploring imagery was used with seven participants (adapted from Hackmann, Surawy and Clark, 1998) and the results were analysed using qualitative template analysis.

RESULTS

Initial indications from this sample suggest that some participants experience typical social anxiety images, as identified by Hackmann et al. (1998). However, some experience images that appear more threatening, and may be related to residual psychotic paranoia. Image perspective was also explored: typical social anxiety images tended to be seen from an observer perspective, while those that may have been more related to psychosis tended to be seen from a field perspective.

CONCLUSIONS

This exploratory study has facilitated the careful adaptation and development of an imagery interview for use in this population and has suggested areas for further research and raised questions around clinical implications.

Social anxiety and its relationship to functional impairment in body dysmorphic disorder

Social anxiety appears to be a prominent characteristic of body dysmorphic disorder (BDD). However, few previous studies have examined social anxiety and its facets (i.e., physiological arousal, fear and avoidance of social situations) and their relationship to psychosocial functioning in BDD. The present study aimed to fill these gaps by examining (a) social anxiety and its facets in BDD, and b) cross-sectional and prospective relationships between social anxiety symptoms and functional impairment in BDD. Individuals with DSM-IV BDD without comorbid social phobia (N=108) completed measures of social anxiety and psychosocial functioning at study intake (T1). Psychosocial functioning was also assessed at a 12-month follow-up interview (T2). Severity of social anxiety (i.e., due to BDD or any other source) was rated with the Social Phobia Inventory (SPIN). In addition, participants were interviewed with the Duke Brief Social Phobia Scale (BSPS) to assess social anxiety independent of BDD. At T1, participants endorsed high levels of social anxiety on the SPIN and subclinical levels of social anxiety on the BSPS. Greater social anxiety was associated with poorer psychosocial functioning in cross-sectional and prospective analyses, particularly fear and avoidance of social situations. These results suggest that certain aspects of social anxiety, especially social fear and avoidance, may be significant contributing factors to functional impairment in individuals with BDD.

Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V?

The obsessive-compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive-compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or "chapter") in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM-V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM-V Research Planning Conference on Obsessive-Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC-spectrum grouping of disorders be included in DSM-V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of "Anxiety and Obsessive-Compulsive Spectrum Disorders." These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM-V.

An examination of the relationship between behavioral approach system (BAS) sensitivity and social interaction anxiety

BACKGROUND

Both behavioral inhibition system (BIS) and behavioral approach system (BAS) sensitivity have been proposed to play a role in social anxiety; however, findings concerning the relationship between BAS and social anxiety have been mixed. Moreover, recent evidence suggests that low levels of BAS may only be associated with the social interaction subdimension of social anxiety.

METHOD

Measures of BIS, BAS, social interaction anxiety, and social observation anxiety were administered to three large analogue samples.

RESULTS

As hypothesized, BAS was inversely related to social interaction anxiety, but was unrelated to social observation anxiety across all three samples. In addition, individuals with generalized social fears were found to report both higher levels of BIS and lower levels of BAS compared to individuals with few or specific social fears.

CONCLUSION

These findings suggest that a complete motivational account of generalized social anxiety should include both BIS and BAS.

The correlates and consequences of early appearing social anxiety in young children

Social anxiety is the fear of social situations and being negatively evaluated by others. Most previous studies of childhood social anxiety have employed clinical samples of children aged 10 years and older. The current study explored the correlates of social anxiety in an unselected sample of young children. Participants were n=178 elementary school children in grade 2 (aged 7-8 years). Children were individually administered the Social Anxiety Scale for Children-Revised (SASC-R), as well as measures of socio-emotional adjustment. Teachers completed measures of children's socio-emotional problems and school adjustment. Results indicated that social anxiety was positively associated with self-reported loneliness, school avoidance, and internalizing coping, and negatively related to school liking. However, social anxiety was mostly unrelated to teacher-rated outcomes. Findings are discussed in terms of use of the SASC-R for this type of population and reasons for the disparity between child and teacher reports of adjustment outcomes.

Social Anxiety Disorder: Recent Developments in Psychological Approaches to Conceptualization and Treatment

The aim of the present study was to identify and synthesize recent research findings in the aetiology and psychological treatment of social anxiety disorder and consider how these might improve outcome through more effective intervention. The electronic databases Medline, EMBASE and PsychInfo were searched for January 2000–December 2008. Publications of interest referred to in relevant articles were also reviewed. Case reports and publications not in English were excluded. The greatest variance in social anxiety disorder is accounted for by temperamental and personality factors and these may be associated with significant heritability. The environmental contribution is smaller and mainly due to non-shared factors, with a small contribution from shared environmental factors. Epidemiological research confirms that social anxiety disorder is chronic, and among the anxiety disorders has the lowest rates of treatment seeking, receipt of evidence-based treatments and recovery. Effective psychological treatments have been available for some time, and the research emphasis is on increasing the efficacy of treatments through innovations in programme content and delivery. Cognitive science research has contributed a better understanding of cognitive factors that maintain social anxiety disorder and informed enhancement of the cognitive elements of therapy. Internet-based programmes show promise as a novel way to deliver and improve access to effective therapy. Genetic, personality and temperamental factors contribute to the risk for social anxiety disorder. Given the associated comorbidity and disability, energy needs to be directed towards early recognition and treatment, and to increasing engagement and retention in effective therapy. Ongoing professional education is required to ensure that the disorder is recognized and evidence-based treatments received by patients who do seek help. Current cognitive behavioural treatments are being enhanced as the results of cognitive science research are being applied, and novel forms of treatment delivery show promise in increasing access.