Bridging the Gap between Aetiological and Maintaining Factors in Social Anxiety Disorder: The Impact of Socially Traumatic Experiences on Beliefs, Imagery and Symptomatology

Neural correlates of context-dependent extinction recall in social anxiety disorder: relevance of intrusions in response to aversive social experiences

BACKGROUND

There are phenomenological similarities between social anxiety disorder (SAD) and posttraumatic stress disorder, such as a provoking aversive event, posttraumatic stress symptoms (e.g. intrusions) in response to these events and deficient (context-dependent) fear conditioning processes. This study investigated the neural correlates of context-dependent extinction recall and fear renewal in SAD, specifically in patients with intrusions in response to an etiologically relevant aversive social event.

METHODS

During functional magnetic resonance imaging a two-day context-dependent fear conditioning paradigm was conducted in 54 patients with SAD and 54 healthy controls (HC). This included fear acquisition (context A) and extinction learning (context B) on one day, and extinction recall (context B) as well as fear renewal (contexts C and A) one day later. The main outcome measures were blood oxygen level-dependent responses in regions of interest and skin conductance responses.

RESULTS

Patients with SAD showed reduced differential conditioned amygdala activation during extinction recall in the safe extinction context and during fear renewal in the acquisition context compared to HC. Patients with clinically relevant intrusions moreover exhibited hypoactivation of the ventromedial prefrontal cortex (vmPFC) during extinction learning, extinction recall, and fear renewal in a novel context, while amygdala activation more strongly decreased during extinction learning and increased during fear renewal in the acquisition context compared with patients without intrusions.

CONCLUSIONS

Our study provides first evidence that intrusions in SAD are associated with similar deficits in context-dependent regulation of conditioned fear via the vmPFC as previously demonstrated in posttraumatic stress disorder.

Development and Validation of the Bullied Cognitions Inventory (BCI)

Background

Bullying increases risk of social anxiety and can produce symptoms of posttraumatic stress disorder (PTSD). According to cognitive models, these are maintained by unhelpful beliefs, which are therefore assessed and targeted in cognitive therapy. This paper describes psychometric validation of a new measure of beliefs related to bullying experiences.

Methods

In an online survey of 1879 young people before starting university or college in the UK, 1279 reported a history of bullying (N = 1279), and 854 rated their agreement with beliefs about self and others related to bullying experiences and completed symptom measures of social anxiety and PTSD related to bullying. An empirical structure for a Bullied Cognitions Inventory was established using exploratory and confirmatory factor analyses and assessed using model fit statistics and tests of reliability and validity.

Results

Fifteen items clustered into four themes: "degraded in the eyes of others", "negative interpretations of reactions to bullying", "recognisable as a bullying victim" and "social defeat". The measure has acceptable reliability and validity and, accounting for existing cognitive measures, explained additional variance in symptoms of PTSD but not social anxiety.

Conclusions

The Bullied Cognitions Inventory (BCI) is a valid and reliable tool for measuring cognitions related to bullying. It may be useful in therapy for identifying and monitoring unhelpful cognitions in those who were bullied.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-023-10412-6.

An exploratory investigation of schema modes in social anxiety disorder: Empirical findings and case conceptualization

BACKGROUND

Current "gold standard" treatments for social anxiety disorder (SAD) are limited by the limited emphasis of key etiological factors in conceptualization, and many individuals with SAD experience residual symptoms posttreatment. Hence, the novel application of the Schema Therapy Mode Model may provide a helpful framework for extending clinical understanding and treatment options for SAD. This exploratory study aimed to investigate the presence and pattern of schema modes among SAD individuals.

METHOD

Forty individuals with SAD completed questionnaire measures of symptomatology, social anxiety-relevant cognitions, schema modes, childhood trauma, and parental style.

RESULTS

Key maladaptive schema modes identified in SAD were Vulnerable Child, Punitive Critic, Demanding Critic, Compliant Surrender, and Detached Self-Soother.

CONCLUSION

Outcomes provide the basis for a proposed schema mode case conceptualization for SAD and are hoped to provide a rationale for testing the applicability of Schema Therapy as a novel treatment for SAD. Key limitations are discussed.

Memory representation of aversive social experiences in Social Anxiety Disorder

Aversive social experiences are proposed to be a risk factor for developing Social Anxiety Disorder (SAD). Many patients with SAD report associated daily life symptoms, such as intrusive re-experiencing (e.g., negatively distorted images of oneself), avoidance, alterations in cognitions and mood, as well as hyperarousal, resembling symptom dimensions of Posttraumatic Stress Disorder (PTSD). These PTSD-like symptoms may result from maladaptive processing and representation of the aversive social experiences in memory. Emotional hyperreactivity during memory retrieval of aversive social experiences is another feature of SAD which was found in previous studies. This study aimed to further investigate PTSD-like symptoms and emotional reactivity associated with etiologically relevant aversive social experiences and shed more light on a potential relationship between both. Eighty-five patients with SAD and 85 healthy controls (HC) participated in this cross-sectional study. It comprised an imagination task with self-report and physiological measures to assess emotional reactivity during the cued recall of the aversive social experience and clinical interviews to assess PTSD-like symptoms. We expected increased emotional reactivity and more severe PTSD-like symptoms in response to the aversive social experience in patients with SAD compared to HC, as well as a positive correlation between emotional reactivity and PTSD-like symptoms in patients with SAD. Indeed, patients with SAD showed emotional hyperreactivity (self-report, physiology) during the cued recall of the aversive social experiences, also when compared to two control memory conditions (neutral, negative non-social) and HC. Patients with SAD furthermore reported more severe PTSD-like symptoms compared to HC and intrusive re-experiencing symptoms were positively correlated with distress during imagery of the social aversive event in patients with SAD. These results might point toward a maladaptive representation of aversive social experiences in memory. Similar to PTSD, this maladaptive memory representation might promote the development of PTSD-like symptoms such as intrusive re-experiencing (e.g., in the form of intrusive self-images in patients with SAD), which might finally lead to and maintain symptoms of SAD.

Potential processes of change in MDMA-Assisted therapy for social anxiety disorder: Enhanced memory reconsolidation, self-transcendence, and therapeutic relationships

OBJECTIVE

Researchers have suggested that psychotherapy may be enhanced by the addition of 3,4-methylenedioxymethamphetamine (MDMA), particularly in the treatment of disorders wherein interpersonal dysfunction is central, such as social anxiety disorder. We review literature pertaining to three potential processes of change that may be instigated during sessions involving MDMA administration in the treatment of social anxiety disorder.

DESIGN

This is a narrative review that integrates research on the etiology and maintenance of social anxiety disorder and mechanisms of action of MDMA to examine how MDMA may enhance psychotherapy outcomes.

RESULTS

We first outline how MDMA may enhance memory reconsolidation in social anxiety disorder. We then discuss how MDMA may induce experiences of self-transcendence and self-transcendent emotions such as compassion, love, and awe; and how these experiences may be therapeutic in the context of social anxiety disorder. We subsequently discuss the possibility that MDMA may enhance the strength and effectiveness of the therapeutic relationship which is a robust predictor of outcomes across many disorders as well as a potential key ingredient in treating disorders where shame and social disconnection are central factors.

CONCLUSION

We discuss how processes of change may extend beyond the MDMA dosing sessions themselves.

Sexual Differences in Internet Gaming Disorder (IGD): From Psychological Features to Neuroanatomical Networks

Internet gaming disorder (IGD) has been included in the 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a condition in need of further study, and gaming disorder was recognized by the World Health Organization as a mental disorder in the International Classification of Disease (ICD-11) of 2018. IGD has different characteristics in the two sexes and is more prevalent in males than females. However, even if the female gamer population is constantly growing, the majority of available studies analyzed only males, or the data were not analyzed by sex. To better elucidate sex differences in IGD, we selectively reviewed research publications that evaluated IGD separately for males and females collected in approximately one hundred publications over the past 20 years. The available data in this narrative review indicate that IGD is strongly dimorphic by sex for both its psychological features and the involvement of different brain areas. Impulsivity, low self-control, anxiety, emotion dysregulation, and depression are some of the psychological features associated with IGD that show a sex dimorphism. At the same time, IGD and its psychological alterations are strongly correlated to dimorphic functional characteristics in relevant brain areas, as evidenced by fMRI. More research is needed to better understand sex differences in IGD. Animal models could help to elucidate the neurological basis of this disorder.

Social phobic beliefs mediate the relationship between post-event processing regarding the worst socially aversive experience and fear of negative evaluation

The experience of socially aversive events is proposed to be a critical etiological factor in the development of social anxiety symptoms even though the experience itself is also common among healthy individuals. Rather than the event itself, accompanying factors such as maladaptive processing might be associated with higher levels of social anxiety symptoms. One-hundred-seventy-four individuals participated in this online-survey comprising questionnaires regarding social anxiety symptoms and retrospective reports concerning maladaptive processing of the worst socially aversive event. Structural equation modelling was used to analyze the hypothesized mediation of maladaptive processing and fear of negative evaluation by intrusive re-experiencing and social phobic beliefs. The positive association between retrospectively evaluated maladaptive processing after the worst socially aversive event and fear of negative evaluation was mediated by social phobic beliefs but not by intrusive re-experiencing. These results point towards the relevance of further investigating processing strategies after socially aversive events as a potential influencing factor for SAD development. Trial registration. The trial was registered at the German Clinical Trial Register (DRKS00021502) on June 3rd, 2020.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12144-022-02805-9.

Imagery rescripting versus cognitive restructuring for social anxiety: Treatment effects and working mechanisms

Background

Negative mental images in social anxiety are often linked to memories of distressing social experiences. Imagery Rescripting (ImRs) has been found to be a promising intervention to target aversive memories, but mechanisms underlying ImRs are largely unknown. The present study aimed (a) to investigate the effects of ImRs compared to cognitive restructuring (CR) on social anxiety symptoms and (b) to extend previous research by examining whether ImRs works by fostering reappraisal of negative emotional self-beliefs.

Method

Highly socially anxious individuals (N = 77) were randomly allocated to ImRs, CR, or no intervention control (NIC). A speech task was performed at baseline and at 1-week follow-up.

Results

Only CR significantly reduced social anxiety symptoms from baseline to follow-up. Decreases in negative appraisals and emotional distress in response to the speech task did not differ between conditions. Regarding working mechanisms, ImRs led to stronger increases in positive emotions than CR and NIC. Both CR and ImRs yielded short-term reductions in emotionally anchored idiosyncratic self-beliefs, but CR was superior to ImRs at follow-up.

Conclusions

The present study provides evidence for the efficacy of a single-session of CR for social anxiety symptoms. As one specific version of ImRs was applied, it is conceivable that other or optimized versions of ImRs might be more effective.

CR was more effective than ImRs and no intervention to reduce social anxiety symptoms.

CR more effectively reduced dysfunctional beliefs.

ImRs led to strongest increase of positive emotions.

The hidden burden of social anxiety disorder in U.S. military veterans: Results from the National Health and Resilience in Veterans Study

BACKGROUND

Social anxiety disorder (SAD) is a chronic and disabling psychiatric disorder associated with low levels of help-seeking. To date, however, scarce research has examined the epidemiology of SAD in veterans. This study examined the prevalence, comorbidities and incremental burden of SAD in relation to suicidality and functioning in a representative sample of U.S. military veterans.

METHODS

A nationally representative sample of 3,157 U.S. veterans completed a web survey containing measures of SAD symptoms, trauma history, psychiatric history and functioning. Multivariable analyses were conducted to examine associations between SAD and psychiatric comorbidities, suicidality and functioning.

RESULTS

A total 9.5% (n = 272) of the sample screened positive for lifetime SAD. Veterans with SAD were more likely than those without SAD to be younger, female, single, racial/ethnic minorities and to have experienced childhood abuse. They also had substantially elevated rates of comorbid psychiatric disorders, particularly lifetime major depression (odds ratio [OR]=5.8) and posttraumatic stress disorder (OR=3.1), as well as current suicidal ideation (OR=3.3). Veterans with SAD scored lower on measures of functioning, particularly social, emotional and mental health functioning (d's=0.21-0.34).

LIMITATIONS

Data were collected cross-sectionally using self-report.

CONCLUSIONS

SAD in U.S. veterans is prevalent and associated with psychiatric comorbidities, functional impairment and a more than 3-fold greater risk for suicidal ideation . Given that SAD is associated with low treatment seeking and engagement, it may be undetected and undertreated relative to other psychiatric morbidities. These results underscore the importance of screening, monitoring and treating SAD in this population along with other prevalent mental disorders.

Familial Factors in the Development of Social Anxiety Disorder

The purpose of the current article is to explore familial factors that influence the development of social anxiety disorder (SAD) in children and adolescents, including parenting, sibling relationships, and family environment. A multitude of interrelated genetic and familial factors have been found to cause and maintain SAD in children and adolescents. There are many challenges in diagnosing and treating the disorder. Knowledge and awareness of familial factors provide insight on targeted treatments that prevent or ameliorate SAD. [Journal of Psychosocial Nursing and Mental Health Services, 59(7), 23-34.].

A Novel Application of the Schema Therapy Mode Model for Social Anxiety Disorder: A Naturalistic Case Study

Social Anxiety Disorder (SAD) is a condition defined by an excessive and persistent fear of negative evaluation in social or performance situations. Whilst Cognitive Behaviour Therapy (CBT) is the gold standard treatment, not all individuals with SAD respond to CBT. The Schema Therapy Mode Model is frequently applied to chronic and hard-to-treat conditions and therefore may be applicable for SAD individuals who are non-responders to CBT. This case study describes how the Mode Model was successfully used to treat a woman in her 20s who presented with excessive fears of negative evaluation and pervasive social avoidance. Experiential techniques, such as chair dialogues and imagery rescripting, resulted in cognitive modification of negative core beliefs, reduced experiential discomfort and increased engagement in social and relational activities. This case offers a preliminary indication that the Schema Therapy Mode Model may be an effective treatment for socially anxious individuals and that further theoretical and empirical study in this area is warranted.

Psychometric properties of the Self-Beliefs related to Social Anxiety (SBSA) scale in a sample of individuals with social anxiety disorder

The Self-Beliefs related to Social Anxiety (SBSA) scale assesses maladaptive social-evaluative beliefs, a key aspect in models of social anxiety disorder (SAD) that is frequently measured in research and clinical contexts. The SBSA has been evaluated psychometrically in student samples, but not in a large sample of individuals diagnosed with SAD. The current study tested the psychometric properties of the SBSA in a sample of individuals with SAD pooled from several studies (total N = 284). Results showed that the optimal factor structure for the SBSA was a correlated three-factor model (high standard beliefs factor, conditional beliefs factor, unconditional beliefs factor). The SBSA total and its subscales (formed based on the factors) exhibited good internal consistency. In terms of construct validity, the SBSA total, the high standard beliefs subscale, and conditional beliefs subscale had stronger associations with a measure of social anxiety than with a measure of depression, although the unconditional beliefs subscale was similarly related to both measures of social anxiety and depression. In terms of discriminative validity, the sample of individuals with SAD had higher SBSA total and subscale scores compared with a sample of individuals without SAD (N = 32). These findings provide a psychometric evidence base justifying the use of the SBSA for the assessment of maladaptive social-evaluative beliefs.

Differential Experiences of Mental Health among Trans/Gender Diverse Adults in Michigan

Transgender and gender diverse individuals experience high rates of health disparities, as compared with their cisgender (non-transgender) counterparts. One area in which these disparities is most grave is that of mental health, with some studies indicating transgender and gender diverse individuals as having a 40% rate of lifetime suicide attempts and similarly high rates of depression, anxiety, and suicidal ideation. These rates vary further within this population, with differential rates seen across sociodemographic factors, including race/ethnicity, gender, sexual orientation, disability status, education level, and income. This study explores mental health experiences across different social identities, using data from the 2018 Michigan Trans Health Survey (N = 659), a community-based participatory action research project collected in Michigan, United States, analyzed using chi-square tests of independence and logistic regressions. Findings indicate incredibly high rates of mental health concerns; 72.2% had been diagnosed with depression in their lifetime and 73.0% had been diagnosed with anxiety in their lifetime. In the past year, 49.9% had had non-suicidal self-injury (NSSI) thoughts, 45.4% had suicidal thoughts, 26.3% engaged in NSSI, and 7.7% had attempted suicide. Bivariate regressions showed some nuanced experiences of rates of mental health diagnoses and experiences, such as greater odds of experiencing all mental health disparities among those with disabilities, and differential odds across gender in regard to ever having a depression diagnosis, non-suicidal self-injury thoughts and engaging in non-suicidal self-injury behavior. This indicates a need for social workers, counselors, therapists, and other human services professionals to act more intentionally and with an intersectional lens when it comes to exploring the mental health of transgender and gender diverse persons.

Psychosocial factors mediating the relationship between childhood emotional trauma and internet gaming disorder: a pilot study

Internet gaming disorder (IGD) has been related to a wide range of detrimental psychological and health consequences. The purpose of the present pilot study was to test the direct and indirect relationships between IGD and emotional trauma, body image dissatisfaction, social anxiety, loneliness, depression, and self-esteem. A total of 242 online gamers completed a survey comprising a comprehensive battery of psychometric self-report scales concerning aforementioned variables. Results indicated that IGD was significantly correlated with all the variables except for body image dissatisfaction. Path analysis indicated an indirect relationship between childhood emotional trauma and IGD through depressive symptoms, while adjusting for gender, age, and number of hours gaming. The findings of the present study indicate that online gamers with a history of emotional abuse and/or neglect have higher levels of depressive symptoms, and that depressive symptoms are important risk factors of IGD.