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

Treatment Options for Fear of Blushing

PURPOSE OF REVIEW

To review mechanisms of blushing and fear of blushing from physiological, neuropharmacological and psychological viewpoints, and to evaluate current forms of treatment for blushing-related fear.

RECENT FINDINGS

Blushing appears to be driven primarily by sympathetic adrenomedullary and neural vasodilator discharge, possibly in association with secondary neurovascular inflammation. Psychological risk factors for fear of blushing include social anxiety, coupled with heightened self-focused attention and inflated beliefs about the likelihood and social costs of blushing. In addition, schemas of emotional inhibition, social isolation and alienation may underlie blushing-related fears. Established psychological treatments for fear of blushing include task concentration training, exposure, cognitive therapy, social skills training, psychoeducation and applied relaxation. More novel approaches include mindfulness and mindful self-compassion, video feedback and imagery rescripting. There are no established pharmacological treatments specifically for fear of blushing. However, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are effective treatments for social anxiety disorder and may thus help some patients manage their fear of blushing. A reactive sympathetic nervous system may interact with psychological predispositions to intensify fear of blushing. These physiological and psychological risk factors could be promising targets for treatment.

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.

Recent Insight Into the Subtypes of Social Anxiety Disorder

Systems for subtyping individuals with social anxiety disorder have been the focus of much research attention as a means to improve assessment and treatment of the disorder. This article highlights recent revisions to social anxiety disorder (SAD) subtypes from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to DSM-V, reviewing empirical evidence that served as the impetus for the revisions. Recent research examining the validity of the DSM-V system and alternative subtyping systems is reviewed. Overall, there appears to be greater empirical support for a dimensional subtyping system. Concerns therefore remain with the DSM-V system, which retained a categorical system but replaced the previous subtypes with a subtype of individuals fearing only performance situations. Recommendations for future research are discussed, as well as alternate options for capturing the variability in SAD presentations, including the possibility of eliminating subtyping altogether.

Intrapersonal and interpersonal concomitants of facial blushing during everyday social encounters

Facial blushing may usually be undesirable but may have an ameliorative function for some individuals under some circumstances. Researchers have studied the blush in laboratory settings, but not in daily life. In the present research, conducted with young adults, we employed for the first time an event-contingent recording method for assessing facial blushing during every-day social encounters. Blushing was associated with feeling embarrassed, ashamed, and exposed. These findings, though based on correlational analyses, are consistent with the idea that blushing is often unpleasant and can be maladaptive, and may contribute to the common belief that blushing is an undesirable response. Frequent blushers generally reported lower levels of dominant behavior, higher levels of submissive behavior, and perceived their social interaction partners as more powerful and less affiliative. This was independent of whether they blushed or not, suggesting that altered social behaviors and perceptions are associated with blushing-associated traits rather than with the blushing state. The experience of the blush varied as a function of the frequency with which a person blushed. Blushing was associated with higher levels of shame in frequent blushers than in infrequent blushers. In infrequent blushers, blushing was associated with higher levels of pleasant affect, suggesting that for infrequent blushers the blush may occur in positive social encounters.

Topical ibuprofen inhibits blushing during embarrassment and facial flushing during aerobic exercise in people with a fear of blushing

The flush that develops during whole-body heat stress depends partly on prostaglandins production in the skin. Variations in the strength of this local mechanism may contribute to individual differences in susceptibility to blushing and associated anxiety. To investigate this in the present study, the anti-inflammatory agent ibuprofen (which blocks prostaglandins formation) was applied topically to a small area of the cheek in 16 participants with a fear of blushing and in another 14 without this fear. Changes in skin blood flow were monitored at the ibuprofen-treated site and at a mirror image control site while participants sang (to induce embarrassment and blushing) and during aerobic exercise (to induce flushing). The topical ibuprofen treatment inhibited increases in cheek blood flow in both groups during both of these tasks. However, increases in cheek blood flow were greater in participants with high than low fear of blushing immediately after exercise. These findings suggest that prostaglandins contribute to dilatation of facial blood vessels both during emotional arousal (embarrassment) and aerobic exercise. Furthermore, fear of blushing may be associated with mechanisms that delay the resumption of normal vascular tone after a period of vasodilatation. Whether topical ibuprofen gel is suitable for intermittent or long-term use as an aid for blushing control requires further investigation.

Gaze behaviour in social blushers

Gaze aversion could be a central component of social phobia. Fear of blushing is a symptom of social anxiety disorder (SAD) but is not yet described as a specific diagnosis in psychiatric classifications. Our research consists of comparing gaze aversion in SAD participants with or without fear of blushing in front of pictures of different emotional faces using an eye tracker. Twenty-six participants with DSM-IV SAD and expressed fear of blushing (SAD+FB) were recruited in addition to twenty-five participants with social phobia and no fear of blushing (SAD-FB). Twenty-four healthy participants aged and sex matched constituted the control group. We studied the number of fixations and the dwell time in the eyes area on the pictures. The results showed gaze avoidance in the SAD-FB group when compared to controls and when compared to the SAD+FB group. However we found no significant difference between SAD+FB and controls. We also observed a correlation between the severity of the phobia and the degree of gaze avoidance across groups. These findings seem to support the claim that social phobia is a heterogeneous disorder. Further research is advised to decide whether fear of blushing can constitute a subtype with specific behavioral characteristics.