Understanding Social Anxiety Disorder in Adolescents and Improving Treatment Outcomes: Applying the Cognitive Model of Clark and Wells (1995)

Behavioral Inhibition and Social Anxiety Disorder as Predictors of Long-Term Outcomes of Cognitive Behavioral Therapy for Youth Anxiety Disorders

The temperamental trait behavioral inhibition (BI) is related to the development and maintenance of anxiety, particularly much so to social anxiety disorder. We investigated if BI and social anxiety disorder predicted cognitive behavioral therapy (CBT) outcomes for youth anxiety. Youth (N = 179; Mage = 11.6 years) were assessed 4 years following a randomized controlled CBT effectiveness trial. BI was measured by the parent-reported Behavioral Inhibition Questionnaire at baseline. The outcomes were diagnostic recovery, youth- and parent-reported anxiety symptoms, and clinical severity at post-treatment, 1-year, and 4-year follow-up. Having social anxiety disorder negatively predicted diagnostic recovery and predicted higher clinical severity at all assessment points and was the only significant predictor of outcomes at 4-year follow-up. Higher BI negatively predicted diagnostic recovery and predicted higher clinical severity and parent-reported symptom levels at post-treatment and 1-year follow-up, and predicted higher youth-reported anxiety levels at 1-year follow-up. Higher BI was the only predictor of youth- and parent-reported anxiety symptoms. BI and social anxiety disorder seem to be unique predictors of CBT outcomes among youth with anxiety disorders. CBT adaptations may be indicated for youth with high BI and social anxiety disorder.

Impact of vortioxetine on psychosocial functioning moderated by symptoms of fatigue in post-COVID-19 condition: a secondary analysis

INTRODUCTION

Fatigue is a prominent symptom in post-COVID condition (PCC) sequelae, termed "long COVID." Herein, we aim to ascertain the effect of fatigue on psychosocial function in persons living with PCC.

METHODS

This post hoc analysis evaluated the effects of vortioxetine on measures of fatigue as assessed by the Fatigue Severity Scale (FSS) in psychosocial function as measured by the Sheehan Disability Scale (SDS) in persons with PCC. We also evaluated the change in FSS on psychosocial functioning as measured by the Sheehan Disability Scale (SDS). This post hoc analysis obtained data from a recently published placebo-controlled study evaluating vortioxetine's effect on objective cognitive functions in persons living with PCC.

RESULTS

One hundred forty-four participants meeting World Health Organization (WHO) criteria for PCC were included in this analysis. At the end of 8 weeks of vortioxetine treatment, significant improvement of all domains was observed for psychosocial functioning. There was a significant between-group difference at treatment endpoint in the family, social, and work SDS subcategories (p < 0.001). There was a statistically significant interaction effect between the treatment condition time point and FSS effect on the SDS social (χ2 = 10.640, p = 0.014) and work (χ2 = 9.342, p = 0.025) categories but a statistically insignificant effect on the family categories ((χ2 = 5.201, p = 0.158)).

DISCUSSION

This post hoc analysis suggests that vortioxetine treatment significantly improves psychosocial function in persons with PCC. Our results also indicate that the improvement in psychosocial function was significantly mediated by improvement in measures of fatigue. Our results provide empirical support for recommendations to identify therapeutics for fatigue in persons living with PCC with a broader aim to improve psychosocial function in this common and severely impaired population.

The impact of long-term online learning on social anxiety and problematic smartphone use symptoms among secondary school students with different levels of fear of missing out: Evidence from a symptom network and longitudinal panel network analysis

Background

The advancement of communication technology and the impact of the COVID-19 pandemic have led to an increased reliance on online education. However, the effects of the long-term use of smart devices for online learning on students' social anxiety and problematic smartphone use (PSU) and the role of fear of missing out (FoMO) in this process have yet to be fully explored.

Methods

This study analysed longitudinal data from 2,356 high school students (female = 1,137 (48.26%), mean age = 13.84, SD age = 1.37) in China, divided into high- and low-FoMO groups based on their scores on the FoMO scale, to examine the impact of four months of online learning on social anxiety and PSU. The Social Anxiety Scale (SAS) and Mobile Phone Addiction Index (MPAI) were used to assess social anxiety and PSU symptoms.

Results

The undirected symptom networks revealed more bridge symptoms among the students in the high-FoMO group, although their overall symptom scores decreased. The results of the directed cross-lagged panel networks showed that "productivity loss" predicted other symptoms in the low-FoMO group but that "afraid of negative evaluation" was the predictor in the high-FoMO group. Meanwhile, "withdrawal/escape" and "productivity loss" were the symptoms that were most affected by other symptoms in the high-FoMO and low-FoMO groups, respectively.

Conclusions

The current study therefore sheds light on the changes in social anxiety and PSU symptoms among secondary school students during long-term online learning, as well as the moderating role of FoMO.

Understanding the relationship between social camouflaging in autism and safety behaviours in social anxiety in autistic and non-autistic adolescents

BACKGROUND

Social camouflaging (hereafter camouflaging) in autism includes factors such as masking and compensating for one's neurodevelopmental differences, and to assimilate or 'fit in' with non-autistic peers. Efforts to hide one's authentic self and autism traits (masking) resemble impression management (IM) in safety behaviours identified in Clark and Wells' (1995) cognitive model of social anxiety (SA). This study explores the relationship between camouflaging in autism and safety behaviours in SA among autistic and non-autistic adolescents.

METHODS

One hundred fifteen adolescents (14-19 years) with (n = 61; 36 female) and without (n = 54; 37 female) a clinical diagnosis of autism matched on age and SA symptom severity were recruited from clinics, schools and online. Adolescents completed online measures including autism traits, SA symptoms, camouflaging behaviours, SA-related safety behaviours and SA-related negative cognitions. Partial and bivariate Pearson's correlations and structural equation modelling were used to understand the relationship between camouflaging, safety behaviours, autism traits and SA in both groups. Exploratory factor analysis assessed item-level factor cross-loadings between camouflaging and safety behaviours.

RESULTS

Across both groups, masking and IM were significantly associated with SA symptom severity, not autism traits, via SA-related social cognitions. Exploratory factor analysis indicated construct overlap across masking, assimilation, IM and avoidance behaviours and identified factors analogous to self-focused attention, social avoidance and mental rehearsal identified in the Clark and Wells' (1995) model of SA.

CONCLUSIONS

This is the first study using group-matched design to identify that masking (factor in social camouflaging) and IM both relate to SA in autistic and non-autistic adolescents. Assessment and formulation of construct overlap between masking and IM may inform psychoeducation and adaptation of SA treatment for autistic adolescents.

Associations between humiliation, shame, self-harm and suicidality among adolescents and young adults: A systematic review

BACKGROUND

Suicide is the second leading cause of death among young people worldwide. Research indicates that negative social contexts involving familial and peer relationships have far-reaching influences on levels of suicidality in later life. While previous systematic reviews have focused on evaluating associations between negative life events such as abuse and bullying in childhood and subsequent suicidality, this systematic review examines the prevalence of, and association between the processes of humiliation and shame in later self-harm, suicidal ideation, and suicide among adolescents and young adults.

METHODS

A systematic literature search of databases including MEDLINE, Web of Science Core Collection, CINAHL, PsycINFO, and Embase was conducted to identify potential studies. ProQuest was searched to identify relevant grey literature research. A combination of MESH terms and keywords was used. All original quantitative studies published in English that examined the prevalence, or association between humiliation or shame and suicidal behaviours and/or death by suicide were included. Studies were assessed for methodological quality using Joanna Briggs Institute critical appraisal tools. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) [CRD42022289843].

RESULTS

Narrative synthesis was performed. A total of 33 studies reporting the prevalence of, or association between humiliation (n = 10) or shame (n = 23) and suicidal thoughts/behaviours were included. The prevalence of humiliation among those with any suicidality ranged from 18% to 28.1%, excluding an outlier (67.1%), with two studies presenting a significant association between humiliation and self-harm in their fully adjusted analyses. The studies that outlined humiliation and suicidal thinking (intent/suicide plan) had no association after adjustment for confounders. For shame, half of the studies found an association in adjusted models (n = 10), and this was evident for both suicidal ideation and self-harm.

CONCLUSION

To our knowledge, this is the first study to attempt a systematic review on this topic. The dearth of research in this field of enquiry is reflective of unique challenges associated with assessments of humiliation and shame in various clinical settings amongst adolescent and young adult populations. Nonetheless, given the importance and relevance of the psychological imprint of humiliation in youth morbidity and mortality in the field of mental health, it is timely to attempt such a systematic review. In light of the associated role of humiliation and shame in self-harm and suicidality among young people, we recommend that these processes need to be explored further via prospective studies and assessed as part of a comprehensive bio-psycho-social assessment when focusing on life stressors for adolescent and young adults presenting with suicidality to emergency departments and mental health services.

Effectiveness and User Experience of Virtual Reality for Social Anxiety Disorder: Systematic Review

BACKGROUND

Social anxiety disorder (SAD) is a debilitating psychiatric disorder that affects occupational and social functioning. Virtual reality (VR) therapies can provide effective treatment for people with SAD. However, with rapid innovations in immersive VR technology, more contemporary research is required to examine the effectiveness and concomitant user experience outcomes (ie, safety, usability, acceptability, and attrition) of emerging VR interventions for SAD.

OBJECTIVE

The aim of this systematic review was to examine the effectiveness and user experience of contemporary VR interventions among people with SAD.

METHODS

The Cochrane Library, Emcare, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science databases were searched between January 1, 2012, and April 26, 2022. Deduplicated search results were screened based on title and abstract information. Full-text examination was conducted on 71 articles. Studies of all designs and comparator groups were included if they appraised the effectiveness and user experience outcomes of any immersive VR intervention among people with SAD. A standardized coding sheet was used to extract data on key participant, intervention, comparator, outcome, and study design items.

RESULTS

The findings were tabulated and discussed using a narrative synthesis. A total of 18 studies met the inclusion criteria.

CONCLUSIONS

The findings showed that VR exposure therapy-based interventions can generally provide effective, safe, usable, and acceptable treatments for adults with SAD. The average attrition rate from VR treatment was low (11.36%) despite some reported user experience difficulties, including potential simulator sickness, exposure-based emotional distress, and problems with managing treatment delivered in a synchronous group setting. This review also revealed several research gaps, including a lack of VR treatment studies on children and adolescents with SAD as well as a paucity of standardized assessments of VR user experience interactions. More studies are required to address these issues.

TRIAL REGISTRATION

PROSPERO CRD42022353891; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=353891.

The role of developmental caregiving programming in modulating our affiliation tendency and the vulnerability to social anxiety and eating disorders

Attachment is the evolutionarily-established process through which humans create bonds with others to receive care from them. The phenomenon is as essential to our physical survival as it is to our psychological development. An increasing number of studies demonstrates that in sensitive periods during the early years of life, our brain circuitry is programmed in the interactions with our caregivers, with the imprinting of information over multiple attachment dimensions. Adopting a basic brain-computer analogy, we can think of this knowledge as the psycho-social firmware of our mind. According to a recently proposed extension of the classical three-dimensional view, one attachment dimension - somaticity - concerns the caregiver's task of reflecting and confirming the child's (internal) states - such as sensations, emotions, and representations - to support the child's ability to identify and define those entities autonomously. Relying on multidisciplinary evidence - from neuroscientific, developmental, evolutionary, and clinical sources - we suggest that somaticity (H1) has the adaptive function to modulate our tendency to comply and affiliate with a reference group but also (H2) increases the vulnerability to developing Social Anxiety (SA) and Eating Disorders (EDs). We evaluate H1-H2, (1) indicating the evolutionary role of somaticity in modulating our affiliation tendency to optimize the ancestral threat-opportunity balance coming from infectious diseases and (2) showing the deep connection between SA-EDs and the features most closely related to somaticity - interoception and parenting style. Finally, we discuss three relevant implications of H1-H2: (A) Bringing into research focus the adaptive role of our firmware knowledge system versus the hardware (neural substrate) and software (higher cognition) ones. (B) Complementing the well-grounded Objectification and Allocentric Lock Theories, allowing us to integrate multiple levels of explanation on the etiology of psychopathology. (C) Suggesting the design of new psychological treatments. While not aiming to prove H1-H2, our analysis supports them and encourages their direct testing.

The role of interpretation biases and safety behaviours in social anxiety: an intensive longitudinal study

BACKGROUND

Interpretation bias and safety behaviours (Safe-B) have been proposed as factors perpetuating social anxiety (SA). However, longitudinal research on how they contribute to SA in everyday life is scarce.

AIM

The aim was to examine whether interpretation bias predicts daily Safe-B and SA. A mediated moderation was hypothesized, where the relationship between daily social stressors and Safe-B would be moderated by interpretation bias, and Safe-B, in turn, would mediate the association between stressors and SA levels. In addition, it was hypothesized that prior levels of SA would predict higher Safe-B use, especially in co-occurrence with stressors.

METHOD

An intensive longitudinal design was employed, with 138 vocational training students (51% men, mean age 20.15 years). They completed initial measures of SA and interpretation bias and 7-day diaries with measures of social stressors, Safe-B, and SA. They reported SA levels two months later.

RESULTS

Both stressors and interpretation bias in ambiguous situations predicted Safe-B, which in turn predicted daily SA levels. However, neither interpretation bias nor Safe-B predicted SA levels at the follow-up, and interpretation bias did not moderate the association between stressors and daily SA. In addition, the relationship between stressors and Safe-B was stronger in people with higher initial SA levels.

CONCLUSIONS

The results suggest that Safe-B are a mechanism through which earlier SA levels and interpretation bias contribute to higher SA levels in daily life.

Social anxiety disorder in Black American adolescents: Cultural considerations in conceptualization, assessment, and treatment

Social anxiety disorder (SAD) is characterized by significant distress and avoidance surrounding social and performance situations, with marked interpersonal and academic impairment. This review article highlights cultural considerations relevant to the conceptualization, identification, and treatment of SAD in Black youth. Research evaluating the utility of evidence-based measures to assess SAD suggests they are culturally relevant; however, gaps in knowledge regarding the psychometric properties of even the most widely used instruments are evident. In regard to intervention, cognitive behavioral therapy (CBT) approaches hold promise, yet there is a lack of research on the use of CBT with Black adolescents. Recommendations to incorporate cultural factors into CBT are provided, and future work investigating culturally adapted interventions is needed. Finally, given significant disparities in access and utilization of mental health services among Black youth, strategies to increase treatment engagement, such as school-based services, are important to consider.

The Course of Anxiety-Specific Cognitive Bias Following Daycare/Inpatient Treatment in Youths with Social Phobia and School Absenteeism

Social phobia (SP) is a common mental disorder in youth often accompanied by absence from school, which may require daycare or inpatient intervention (DC/IN). Objective: The present explorative study investigates changes in anxiety-specific implicit assumptions and interpretation bias following DC/IN. Methods: The study included 16 youths with SP (M age = 15.8 [SD = 1.24], females: 62.5 %) participating in DC/IN. We assessed the main outcomes using the Implicit Association Test and Affective Misattribution Procedure. Results: A large effect was shown for reducing implicit assumptions of feeling anxious (p = .142; η2p = .171) and for reducing the implicit interpretation bias (p = .137; η2p = .162). No change was indicated by effect size in implicit assumptions of feeling socially rejected (p = .649; η2p = .016). Social phobia symptoms initially correlated with changes in implicit assumptions of feeling anxious (r = .45). Conclusion: Effect sizes indicate that implicit anxiety-specific assumptions and interpretation bias descriptively improved following DC/IN. Thus, DC/IN may lead to meaningful improvements of anxiety-specific cognition in some individuals with high SP symptoms, emphasizing the relevance of cognitive behavioral approaches in the treatment of SP. Several limitations are discussed.

Social interpretation inflexibility moderates emotional reactions to social situations in children and adolescents

Interpretation biases and inflexibility (i.e., difficulties revising interpretations) have been linked to increased internalizing symptoms. Although adolescence is a developmental period characterized by novel social situations and increased vulnerability to internalizing disorders, no studies have examined interpretation inflexibility in adolescents. Additionally, no studies (on adolescents or adults) have examined interpretation flexibility as a protective factor against adverse outcomes of interpersonal events. Using a novel task and a 28-day diary we examined relations among interpretation bias and inflexibility, internalizing symptoms, and negative interpersonal events in a sample of children and adolescents (N = 159, ages 9-18). At baseline, negative interpretation bias was positively correlated with social anxiety symptoms, and positive interpretation bias negatively correlated with social anxiety and depressive symptoms. Inflexible positive interpretations were correlated with higher social anxiety and depressive symptoms, while inflexible negative interpretations were correlated with higher social anxiety. Finally, interpretation inflexibility moderated daily associations between negative interpersonal events and depressive symptoms in daily life, such that higher inflexibility was associated with stronger associations between interpersonal events and subsequent depressive symptoms, potentially increasing depressive symptom instability. These results suggest that interpretation biases and inflexibility may act as both risk and protective factors for adolescent anxiety and depression.

A brain model of altered self-appraisal in social anxiety disorder

The brain's default mode network has a central role in the processing of information concerning oneself. Dysfunction in this self-referential processing represents a key component of multiple mental health conditions, particularly social anxiety disorder (SAD). This case-control study aimed to clarify alterations to network dynamics present during self-appraisal in SAD participants. A total of 38 adolescents and young adults with SAD and 72 healthy control participants underwent a self-referential processing fMRI task. The task involved two primary conditions of interest: direct self-appraisal (thinking about oneself) and reflected self-appraisal (thinking about how others might think about oneself). Dynamic causal modeling and parametric empirical Bayes were then used to explore differences in the effective connectivity of the default mode network between groups. We observed connectivity differences between SAD and healthy control participants in the reflected self-appraisal but not the direct self-appraisal condition. Specifically, SAD participants exhibited greater excitatory connectivity from the posterior cingulate cortex (PCC) to medial prefrontal cortex (MPFC) and greater inhibitory connectivity from the inferior parietal lobule (IPL) to MPFC. In contrast, SAD participants exhibited reduced intrinsic connectivity in the absence of task modulation. This was illustrated by reduced excitatory connectivity from the PCC to MPFC and reduced inhibitory connectivity from the IPL to MPFC. As such, participants with SAD showed changes to afferent connections to the MPFC which occurred during both reflected self-appraisal as well as intrinsically. The presence of connectivity differences in reflected and not direct self-appraisal is consistent with the characteristic fear of negative social evaluation that is experienced by people with SAD.

Social Anxiety in Autistic People: Does the Clark and Wells Model fit?

PURPOSE

Cognitive behaviour therapy based on the Clark and Wells (1995) model is a first-line treatment for neurotypical people seeking support for social anxiety. While autistic people frequently report high social anxiety, it is unclear how appropriate the model is for this population.

METHODS

Over 300 autistic and non-autistic adults completed an online survey measuring key variables of the Clark and Wells model (socially-related negative thoughts, safety behaviours, self-focused attention). Using multiple regression and structural equation modelling, we assessed whether these variables accounted for the link between autism and social fears.

RESULTS

In multiple regression, autistic people experienced greater social fears than expected based on Clark and Wells variables, and safety behaviours were less predictive of social fears in autistic people. In structural equation modelling, Clark and Wells variables only mediated half the link between autistic traits and social fears. In exploratory analysis, we found that distress relating to uncertainty was an additional variable that needed to be taken into consideration in the relationship between autistic traits and social fears.

CONCLUSION

The Clark and Wells variables were relevant in autism, but did not fully explain elevated social fears in autistic people, which suggests that other factors are also important in accounting for social anxiety in autistic people. This means that therapy informed by the model may not be optimal for autistic people. We recommend further research developing adapted therapy for social anxiety in autistic people.

Anxiety disorders in children and adolescents: A summary and overview of the literature

Considerable work has advanced understanding of the nature, causes, management, and prevention of anxiety disorders in children and adolescents over the past 30 years. Prior to this time the primary focus was on school refusal and specific phobias. It is now recognised that children and adolescents experience the full gamut of anxiety disorders in very similar ways to adults and that anxiety disorders in the paediatric years can predict a lifelong mental-health struggle. Given the vast array of specific studies in this field, the current review summarises current knowledge about these high prevalence disorders, points to overarching limitations, and suggests potentially important future directions. Following a brief historical overview, the review summarises knowledge about demographic and epidemiological characteristics, distal and proximal risk factors, current treatment directions, and prevention. There is still a great deal to learn about the causes and treatments of child and adolescent anxiety disorders. By amalgamating our current knowledge, this review provides a window to the research directions that are likely to lead to future advances.

Prevention and Treatment of Social Anxiety Disorder in Adolescents: Protocol for a Randomized Controlled Trial of the Online Guided Self-Help Intervention SOPHIE

BACKGROUND

Social anxiety symptoms are highly prevalent among adolescents and are associated with poor quality of life and low psychosocial functioning. If untreated, social anxiety often persists into adulthood and increases the risk for comorbid disorders. Therefore, early interventions for social anxiety to prevent negative long-term consequences are critical. However, adolescents rarely seek help and often avoid face-to-face psychotherapeutic interventions due to the perceived lack of autonomy and anonymity. Thus, online interventions represent a promising opportunity to reach adolescents who have social anxiety but do not seek help yet.

OBJECTIVE

This study aims to evaluate the efficacy, moderators, and mediators of an online intervention developed to reduce social anxiety in adolescents.

METHODS

A total of 222 adolescents aged 11-17 years with subclinical social anxiety (N=166) or with a diagnosis of social anxiety disorder (N=56) are randomly assigned to the online intervention or a care-as-usual control group. The 8-week guided online intervention is based on the Cognitive Model of Social Phobia and evidence-based online interventions for social anxiety adapted to the specific needs of adolescents. The care-as-usual group will be given access to the online intervention after the follow-up assessment. Participants are assessed at baseline, at 4 and 8 weeks post intervention, and at 3-month follow-up assessment on the primary outcome, that is, social anxiety, on secondary outcomes (eg, level of functioning, fear and avoidance, general anxiety, depression, quality of life, self-esteem, and negative effects of the intervention), on potential moderators (eg, therapy motivation, therapy expectancy, and satisfaction with the intervention), and potential mediators (eg, therapeutic alliance and adherence to the intervention). Data will be analyzed based on an intention-to-treat approach and both groups (intervention and care-as-usual) will be compared at each assessment time point. Furthermore, potential mechanisms of change and generalization of intervention effects on daily life are assessed using an ecological momentary assessment procedure that includes items on maintaining mechanisms of social anxiety, social context, and affect. Participants are prompted 3 times a day during the first 8 weeks of the study and again for 2 weeks following the follow-up assessment.

RESULTS

Recruitment is ongoing; initial results are expected in 2024.

CONCLUSIONS

Results are discussed considering the potential of online interventions as a low-threshold prevention and treatment option for adolescents with social anxiety and in light of current advances in dynamic modeling of change processes and mechanisms in early intervention and psychotherapy in adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04782102; https://clinicaltrials.gov/ct2/show/NCT04782102.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44346.

Saudi Arabian Perceptions of Childhood Anxiety, Parental Communication, and Parenting Style

Parenting communication and parenting style, including expressions of fear, worry, and threat, may contribute to children's anxiety and apprehension. This study examined the degree to which perceptions of parental communication (both verbal and nonverbal) and parenting style are linked with childhood anxiety. This is among the first studies to investigate these relationships in a Saudi Arabian context. We employed a sample of 121 Saudi adults who completed questionnaires measuring perceptions of 2 parenting styles (authoritative and authoritarian), parental anxiety, and childhood anxiety. Parental communication elements such as shouting, criticism, facial expression, and body expressions were included among assessments of perceived parental anxiety, authoritative style, and authoritarian style. The results indicated that perceptions of childhood anxiety were positively associated with parental anxiety but not consistently associated with other assessed variables. This research addressed perceptions of parental communication and parenting style in the development of childhood anxiety, extending upon previous research on Western samples to a Middle Eastern sample residing in Saudi Arabia.

Social Anxiety and Suicidality in Youth: A Systematic Review and Meta-analysis

Suicide is a leading cause of death among young people every year. Identifying risk factors provides opportunities to intervene, and social anxiety may represent one such factor. This systematic review and meta-analysis aimed to review the evidence of associations between social anxiety and suicidality in youth (10-25 years). Embase, PsycInfo, and Medline were searched to identify relevant articles. Meta-analysis was conducted to examine the mean effect sizes of concurrent and prospective associations between social anxiety and three indices of suicidality in adolescents aged 10-25 years. Meta-analyses of 16 studies showed that social anxiety was associated cross-sectionally with suicide attempt (r = 0.10, 95% CI: 0.04, 0.15), suicidal ideation (r = 0.22, 95% CI: 0.02, 0.41), and suicide risk (r = 0.24, 95% CI: 0.05, 0.41), and prospectively at trend level with suicidal ideation (r = 0.62, 95% CI: -0.03, 0.90). An examination of the prospective associations with suicide attempt and risk was not possible due to a lack of studies. Several studies suggested that results could not be solely attributed to depressive symptoms. A high level of heterogeneity was observed in each meta-analysis. Moderation analysis was possible for gender and publication year only; neither was significant. Findings provide further evidence of a link between social anxiety and suicidal thoughts and behaviors in youth but are limited by the small number of studies of mixed quality. This review supports future research into social anxiety symptoms as potential risk factors and treatment targets for suicidal youth.

Implicit assumptions and interpretation bias in youth with severe, chronic social phobia

Interpretation bias and dysfunctional social assumptions are proposed to play a pivotal role in the development and maintenance of social phobia (SP), especially in youth. In this study, we aimed to investigate disorder-specific implicit assumptions of rejection and implicit interpretation bias in youth with severe, chronic SP and healthy controls (CG). Twenty-seven youth with SP in inpatient/day-care treatment (M age = 15.6 years, 74% female) and 24 healthy controls (M age = 15.7 years, 54% female) were included. The Implicit Association Test (IAT) and the Affect Misattribution Procedure (AMP) were completed to assess implicit assumptions and interpretation bias related to the processing of social and affective stimuli. No group differences were observed for the IAT controlling for depressive symptoms in the analyses. However, group differences were found regarding interpretation bias (p = .017, η²_p = .137). Correlations between implicit scores and explicit questionnaire results were medium to large in the SP group (r =|.28| to |.54|, p_all ≤ .05), but lower in the control group (r =|.04| to |.46|, p_all ≤ .05). Our results confirm the finding of an interpretation bias in youth SP, especially regarding the implicit processing of faces, whereas implicit dysfunctional social assumptions of being rejected do not seem to be specific for SP. Future research should investigate the causal relationship of assumptions/interpretation bias and SP.

In the moment social experiences and perceptions of children with social anxiety disorder: A qualitative study

OBJECTIVES

Childhood social anxiety disorder (SAD) is a common and disabling condition. General forms of cognitive behavioural treatments have demonstrated poorer efficacy for childhood SAD when compared to other childhood anxiety disorders and further understanding of the psychological factors that contribute to the maintenance of childhood SAD is warranted. Examining the social experiences of children with SAD may help to identify relevant psychological factors and increase our understanding of what keeps childhood SAD going.

METHODS

The current study used reflexive thematic analysis to analyse the transcripts of interviews with 12 children aged 8-12 years with SAD who had been interviewed about their 'in the moment' social experiences during a social stress induction task. The interview topic guide included factors hypothesized to maintain SAD in adult cognitive models of the disorder.

RESULTS

The interviews revealed both variety and commonalities in the experiences and interpretations of social events in children with SAD, captured in three related main themes: (i) Discomfort being the centre of attention, (ii) (Lack of) awareness of cognitions and (iii) Managing social fears. Findings indicated likely developmental influences on which maintenance mechanisms apply at which point in time.

CONCLUSIONS

There is variation in the psychological mechanisms that children with SAD endorse and developmental factors are likely to influence when specific mechanisms are relevant. We now need further studies that take a developmentally informed approach to understand the nature of the association between the factors identified in this study and social anxiety in childhood to inform the development of more effective interventions for childhood SAD.

Examining the Latent Dimensions of Social Anxiety Disorder

While the body of literature has investigated the latent dimensions of Social Anxiety Disorder (SAD), only few have directly anchored in the DSM-5 SAD symptoms. Similarly, a continuing issue on measuring mental health disorders pertains to whether a symptom's frequency, intensity, or both, are appropriate and sufficient indicators of severity. To address this gap, the present study developed and validated a DSM-5-based measurement tool, the Social Anxiety Symptom Severity Inventory (SASSI), which assesses both the intensity (intensity of disturbance) and frequency (frequency of occurrence) of SAD symptoms. In study 1 (n = 6458, college students), the results revealed a two-factor structure using exploratory structural equation modeling. In study 2 (n = 425, left-behind emerging adults), confirmatory factor analysis, measurement invariance testing, and latent class analysis were used. Findings demonstrated the importance of using both frequency and intensity of symptoms in assessing SAD severity. Moreover, a five-class solution best fitted the sample. Studies 1 and 2 demonstrated the good psychometric properties of SASSI and filled an important gap among available measures in assessing SAD severity through symptom frequency and intensity.

Development of social anxiety cognition scale for college students: Basing on Hofmann's model of social anxiety disorder

Introduction

To develop the Chinese version of the Social Anxiety Cognition Scale for College Students (SACS-CS) based on Hofmann's model of social anxiety disorder and examine its reliability and validity.

Methods

Based on literature analysis and structured interviews, a theoretical model was constructed and behavioral examples were collected. According to the results of participants' and experts' evaluations, the initial SACS-CS was developed. The study data were collected from a total of 500 valid participants, randomly divided into two samples. Sample 1 (n = 200) and sample 2 (n = 300) were considered for exploratory factor analysis and confirmatory factor analysis (CFA), respectively. Internal reliability and validity were examined using all 500 participants, and temporal reliability was established using sample 3 (n = 70), who completed the scale again after 4 weeks.

Results

The SACS-CS consists of 21 items, grouped under four factors: self-perception, social skills, emotional control, and cost estimation. The four-factor model fits well. The internal consistency coefficient of the scale and the four factors ranged from 0.87 to 0.96, and the test-retest reliability ranged from 0.76 to 0.84. The scores of the scale and the four factors were significantly correlated with the score of the Interaction Anxiousness Scale (r = 0.54-0.64).

Discussion

The SACS-CS possesses good reliability and validity and can be applied in the cognitive assessment of college students' social anxiety. The scale could help people with different social anxiety disorder conditions receive more personalized interventions.

Remotely delivered cognitive therapy for social anxiety disorder in adolescence: Preliminary efficacy evidence based on changes throughout treatment

Cognitive therapy has been established as the frontline treatment for adults with social anxiety disorder (SAD); its efficacy with socially anxious adolescents is incipient but promising. This work investigated change in social anxiety symptoms reported by adolescents and their therapist as they go through remotely delivered 10-session cognitive therapy (i.e., CT@TeenSAD). Participants were 21 adolescents (81% females; M _age = 16.10) diagnosed with SAD. They reported on change on their social anxiety symptoms at the beginning of each session; their therapist reported on how their symptoms had improved at the end of each session. Results, though preliminary, show that sessions had a significant impact on self- and therapist reported change, with consistent and continuous improvement across intervention sessions. Gender did not impact on that change, but therapist did: though the same pattern of change emerged for both therapists, it was more evident for the therapist with the greatest previous clinical experience. Overall, current findings align with the cognitive therapy framework of progressive gains throughout therapy. They also add evidence on the applicability and usefulness of an online cognitive approach to adolescents diagnosed with SAD.

Functional connectivity strength and topology differences in social phobia adolescents with and without ADHD comorbidity

Social phobia (SP) is associated with changes in functional connectivity strength and topology. However, reported changes have been heterogeneous due to small sample sizes, inconsistent methodologies, and comorbidities, such as attention-deficit/hyperactivity disorder (ADHD), which has a high comorbidity rate with SP. Furthermore, there are few studies looking at SP in an adolescent population, a critical period for the development of the social brain. This project focuses on functional connectivity strength and topological differences in social phobia patients with and without ADHD comorbidity. We examined resting-state functional MRI images from 158 subjects, including 36 SP participants without ADHD comorbidity, 60 SP participants with ADHD comorbidity, and 62 healthy controls, with an overall average age of 14.16. We used a data-driven approach to examine impaired functional connectivity in a whole-brain analysis and higher-order topological differences in functional brain networks. We identified changes in the cerebellum and default mode network in social phobia patients as a whole, with the presence of ADHD comorbidity affecting various subsystems of the default mode network. Social phobia functional connectivity networks resembled random graphs, and local connectivity patterns in the superior occipital gyrus were different due to ADHD comorbidity. These alterations may indicate impairments in self-related processing, imagery, mentalizing, and predictive processes. We then used these changes in a linear support vector machine to distinguish between each pair of groups and achieved prediction accuracy significantly above chance rates. Our study extends prior research by showing that functional connectivity changes exist at adolescence, which are affected by ADHD comorbidity. As such, these results offer a new perspective in examining neurobiological changes in SP patients.

From fears of evaluation to social anxiety: The longitudinal relationships and neural basis in healthy young adults

BACKGROUND

Social anxiety disorder (SAD) is a common mental health problem, and its core cognitive manifestation is the persistent fear of being evaluated, including both negatively (FNE) and positively (FPE). This study aimed to examine the longitudinal relationships of FNE, FPE and SAD and explore their neural basis.

METHODS

Three samples were retrieved in this study. First, the data of 649 college students who completed a survey and fMRI scan were used to explore the neural basis of FNE, FPE, and SAD symptoms. Next, the data of 450 participants who completed the same survey twice were used to examine the longitudinal relationships of the variables. Finally, the overlapping of the two samples (N = 288) who completed two surveys and the fMRI scan were used to establish a brain-behavior model.

RESULTS

Both FNE and FPE predicted SAD, and SAD also predicted FPE. The neural signals of subregions in prefrontal cortex were correlated with the scores of FNE, FPE and SAD. Abnormal prefrontal signals influenced SAD symptoms via fears of evaluation.

CONCLUSIONS

Our findings explain the behavioral and neural underpinnings of social anxiety from a fear of evaluation angle. This contributes to a better theorical understanding of SAD and clinical practice.

Measuring social phobia symptoms in a community sample of adolescents: An examination of the psychometric properties of the SPAI-23

A number of studies to date examine dimensions of social phobia and anxiety in adolescents. A variety of tools has been developed, along with their abbreviated versions, that are used to assess Social Anxiety (SA) but little research has been devoted to the types of fears they each assess. Due to differences in the content of the multitude of instruments, different aspects of SA are addressed and this leads to confusion when the relationship between SA and other constructs is being investigated. The aim of the present study was to examine the psychometric properties of the abbreviated Social Phobia and Anxiety Inventory SPAI-23 in Greek-Cypriot community adolescents and describe dimensions of social fears at that age. Seven hundred twenty-one adolescent students from Cyprus, (Mean Age: 15.5, Range: 13-19, SD: 1.12, 64% female) participated in the study. Participants completed, among others, an abbreviated version of the Social Phobia and Anxiety Inventory (SPAI-23). Exploratory Factor Analysis on the SPAI-23 revealed a quite similar structure to the original questionnaire (SPAI). Three Social Phobia factors, describing distinct socially fearful situations, were identified (Performance, Interaction, and Presence in a social context) and one Agoraphobia factor after the evaluation of alternative solutions. Findings were verified by means of Confirmatory Factor Analysis, testing alternative models. Overall, findings were in line with recent evidence on youth samples, and contribute to significant insights towards more sophisticated and personalized assessments.

The development of Cognitive Behavioural Therapy (CBT) for chronic loneliness in children and young people: Protocol for a single-case experimental design

Loneliness is a significant problem for young people and is associated with a range of physical and mental health difficulties. Meta-analyses have identified that interventions aimed at young people who report loneliness as their primary problem are lacking within the literature. In adults, the most effective interventions for loneliness are those which target the underlying maladaptive social cognitions. Therefore, we have developed a modular Cognitive Behavioural Therapy (CBT) intervention for children and young people. The aim of this study is to conduct a multiple baseline single-case experimental design (SCED) to assess the efficacy, feasibility and acceptability of this intervention. In total 6-8 11-18-year-olds and their families will be recruited. The design consists of AB+ post-intervention, where A is the baseline phase, B is the intervention phase and then a post-intervention phase. Participants will complete a baseline assessment, before being randomised to one of four different baseline lengths (12 days, 19 days, 26 days or 33 days). Participants will then complete an average of 12 sessions of CBT, with the aim being to reduce their feelings of loneliness. Participants will then complete a 12-day post-intervention phase. Participant loneliness will be repeatedly assessed throughout the three phases of the intervention using the Three-item Loneliness Scale, which will be the primary outcome. Secondary outcomes will be reliable and clinically meaningful change on the UCLA Loneliness Scale, Revised Child Anxiety and Depression Scale (RCADS) and Strengths and Difficulties Questionnaire (SDQ). Feasibility and participant satisfaction will also be assessed and reported. Trial registration: ClinicalTrails.gov trial registration number: NCT05149963 (Date registered: 07.12.2021). https://www.clinicaltrials.gov/ct2/show/NCT05149963?term=cbt&cond=loneliness&draw=2&rank=1.

Clinical, demographic and theory-derived maintaining factors as moderators of treatment outcome in internet-delivered cognitive behavioural therapy for children and adolescents with social anxiety disorder

Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10-17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials.

Associations between humiliation, shame, self-harm and suicidal behaviours among adolescents and young adults: A systematic review protocol

BACKGROUND

Suicide is the second leading cause of death among young people worldwide and remains a major public health concern. Research indicates that negative social contexts involving familial and peer relationships, have far-reaching influences on levels of suicidal behaviours in later life. Previous systematic reviews have focused on evaluating associations between negative life events such as abuse and bullying in childhood and subsequent self-harm or suicidality. However, the association between adolescent experiences of humiliation and shame, and subsequent self-harm or suicidal behaviour among children and young adults has not been well examined. As such, this systematic review is conducted to examine the prevalence and association between humiliation and shame and self-harm, suicidal ideation, and death by suicide among adolescents and young adults.

METHODS

A systematic literature search in extant electronic databases including; MEDLINE, Web of Science Core Collection, CINAHL, PsycINFO, and Embase will be conducted to identify potential studies. Google Scholar, and the reference list of the retrieved articles and/or previous systematic reviews in this area, will also be scanned to identify further potential studies. ProQuest will be searched to identify relevant studies available within grey literature. There are no restrictions on the date of publications. Based on our initial review, the following terms were identified: Population: Adolescent (MESH), young adult (MESH), teen, teenage. Exposure: Humiliation, degradation, shame (MESH) or embarrassment (MESH), harassment victimisation, abasement. Outcome: Self-injurious behaviour (MESH), suicide (MESH), suicide attempted (MESH), suicide completed (MESH), self-harm, intentional self-injury, deliberate self-harm, overdose, deliberate self-poisoning, non-suicidal self-injury, self-mutilation, suicidal thought, suicidal ideation, suicidal intent, suicide. At least one term from each category will be used for conducting the literature search. All original quantitative studies published in the English language which examined the prevalence or association between humiliation or shame and self-harm and/or suicidal ideation and/or completed suicide will be included. The studies will be assessed for methodological quality using the Joanna Briggs Institute critical appraisal tools. Narrative synthesis will be performed for all of the studies. If the studies are sufficiently homogenous, the results will be pooled for a meta-analysis. This systematic review protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P) guidelines. The protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) [CRD42022289843].

DISCUSSION

This is the first review to synthesise evidence on the prevalence of, and associations between the experiences of humiliation and shame and subsequent self-harm and/or suicidal behaviours among adolescents and young adults. As there is growing evidence on increased self-harm among this age group, it is important to identify population-specific risk factors for self-harm and suicidality which will have significance in formulating tailored and effective treatment and therapeutic services for adolescents and young adults.

Videoconference anxiety: Conceptualization, scale development, and preliminary validation

As a result of the COVID-19 pandemic, activities involving a large part of life have started to be carried out via videoconferencing. Videoconferencing can be disadvantageous for individuals with social anxiety due to increased social presence, decreased mutual understanding, and awkward communication. The authors aimed to develop a scale to explore the difficulties experienced by individuals with social anxiety during videoconferencing. A total of 598 children and adolescents participated in the study. The data were collected with the Sociodemographic Information Form, the Videoconference Anxiety Scale, and the Liebowitz Social Anxiety Scale. According to exploratory factor analysis, the scale consisted of 25 items and a single factor. Factor loads were between 0.62 and 0.81; the single factor explained 52.95% of the variance. This study shows that the Videoconference Anxiety Scale is a valid and reliable instrument for Turkish children.

Diagnosis-Specific Group CBT Treating Social Anxiety in Adolescents: A Feasibility Study

Background

Social anxiety disorder (SAD) is one of the most common anxiety disorders among adolescents. It is associated with extensive distress and negative long-term consequences. Generic cognitive behavioral therapy (CBT) is one of the preferred treatments for anxiety disorders, but it has shown poorer outcome for adolescents with SAD than for other anxiety disorders.

Aim

As preparation for a randomized controlled trial the aim of the present study was to examine the feasibility of an adjusted diagnosis-specific CBT group intervention for adolescents with SAD, and provide preliminary information on adolescent and family outcomes.

Method

Thirteen adolescents (age 12-17 years) diagnosed with SAD received a group therapy version of the Cool Kids Anxiety Program, Social Enhanced (CK-E), a program developed at Macquarie University, Sydney, Australia. The treatment is a diagnosis-specific manualized CBT treatment for adolescents with SAD. Semi-diagnostic interviews and questionnaires were completed at baseline, post, 3-month follow-up and 1-year follow-up.

Results

Thirteen adolescents participated with no drop-outs. Most families attended all 10 intervention sessions. The families were generally satisfied with the treatment and would recommend it to others in need. Preliminary outcomes showed that participants had marked improvements in their anxiety symptoms and life interference, with significant medium to large baseline-post effect sizes durable at 1-year follow-up. Two of the adolescents were free of their SAD diagnosis at 3-month follow-up.

Conclusion

Results from this feasibility study indicate that the Danish-translated and revised version of Cool Kids Anxiety Program - Social Enhanced could be a feasible intervention for Danish adolescents with SAD. The intervention will be investigated further in a randomized controlled trial.

Comparison of Transdiagnostic Treatment and Specialized Social Anxiety Treatment for Children and Adolescents With Social Anxiety Disorder: A Randomized Controlled Trial

OBJECTIVE

Pediatric social anxiety disorder consistently shows the poorest treatment response of all anxiety disorders. The current study compared a generic cognitive-behavioral therapy (CBT) treatment for pediatric anxiety against a modified (social anxiety) treatment that incorporated specific components to target theoretically important maintaining processes.

METHOD

A total of 200 children and adolescents (mean age = 9.5 years, SD = 2.2 years; 47% boys) diagnosed with social anxiety disorder as either their principal or additional disorder were randomly allocated to either the generic or the modified treatment. Both treatments were based on a manualized, empirically validated program (Cool Kids) and comprised 10 sessions over 12 weeks. Assessments comprised structured diagnostic interview and parent and youth reports, and covered diagnoses, symptoms, life impairment, and assessment of maintaining processes at post-treatment and 6-month follow-up.

RESULTS

The treatments did not differ significantly on the primary outcome (remission of social anxiety disorder) at either post-treatment (remission in generic = 41%; modified = 44%) or follow-up (remission in generic = 51%; modified = 69%), although the latter approached significance (p = .08). They also did not differ at either time point on most secondary measures of outcome. The only maintaining process that changed more under modified treatment was attention to the current task.

CONCLUSION

Despite some positive hints in the data, there was little evidence that the modified intervention significantly improved treatment of pediatric social anxiety disorder, despite incorporating strategies to address putative maintaining mechanisms. The similar improvement between treatments on most maintaining processes suggests that new and innovative strategies may be needed to better target these processes.

CLINICAL TRIAL REGISTRATION INFORMATION

Efficacy of Cognitive Behavioural Treatment for Socially Anxious Youth; https://www.anzctr.org.au/; 12616001065482.

Displays of negative facial affect during parent-adolescent conflict and the bidirectional transmission of social anxiety

BACKGROUND

Symptoms of social anxiety rise rapidly during adolescence, particularly for girls. Pervasive displays of parental negative affect may increase adolescents' fear of negative evaluation (FNE), thereby increasing risk for social anxiety symptoms. Adolescent displays of negative affect may also exacerbate parents' social anxiety symptoms (via FNE of their child or their parenting skills), yet little research has tested transactional pathways of transmission in families. By early adolescence, rates of parent-child conflict rise, and offspring become increasingly independent in their own displays of negative affect, increasing opportunities for hypothesized transactional pathways between parent-adolescent displays of negative affect and social anxiety symptoms.

METHODS

This study included 129 parents and daughters (11-13; no baseline social anxiety disorder), two-thirds of whom were at high risk for social anxiety due to a shy/fearful temperament. We used actor-partner interdependence models (APIM) to test whether displays of negative facial affect, assessed individually for each parent and daughter during a conflict discussion, would predict their partner's social anxiety symptoms two years later. Automated facial affect coding assessed the frequency of negative affect during the discussion. Clinician ratings of social anxiety symptoms were completed at baseline and two-year follow-up.

RESULTS

Both parents and daughters who displayed more frequent negative facial affect at baseline had partners with higher follow-up social anxiety symptoms, an effect that was maintained after accounting for actors' and partners' baseline symptoms.

CONCLUSIONS

Findings are consistent with intergenerational models positing that parental negative affective behaviors increase risk for adolescent social anxiety symptoms but also suggest that adolescent negative facial affect may exacerbate parental social anxiety symptoms. These bidirectional effects improve understanding of how social anxiety is maintained within a transactional family structure and highlight that displays of negative affect during parent-adolescent interaction may warrant future examination as a potential treatment target for adolescent social anxiety.

Characterising Negative Mental Imagery in Adolescent Social Anxiety

Background

Understanding the role of self-imagery in the development of social anxiety in adolescence holds promise for improving intervention. Cross-sectional studies indicate that imagery characteristics are associated with social anxiety symptoms, however, prospective studies are lacking. The current study examined concurrent and prospective associations between two image characteristics, namely observer-perspective and vividness, with social anxiety symptoms in a community adolescent sample (N = 616; 53% girls; aged 11–15 years). In addition, we examined common themes in the negative social anxiety-related images.

Methods

Negative self-imagery and social anxiety symptoms were assessed using questionnaires at baseline and at 4–6-month follow-up. A series of multiple linear regression analyses were performed to see if each image characteristic predicts concurrent and prospective social anxiety symptoms. Topic modelling was performed to infer key topics from verbal data.

Results

Observer-perspective and vividness significantly predicted concurrent social anxiety symptoms beyond the influence of age and gender. Observer-perspective significantly predicted prospective levels of social anxiety symptoms beyond the influence of age, gender, and baseline social anxiety and depression symptoms. Negative self-images clustered into two themes: the fear of appearing anxious and the fear of being judged or viewed as unacceptable.

Conclusions

Specific characteristics and contents of negative self-images may be particularly relevant to the development of adolescent social anxiety.

Online Cognitive Therapy for Social Anxiety Disorder in Adolescence: A Clinical Case Study Using the CT@TeenSAD

SAD is an intense fear or anxiety associated with past, current, or future social situations. The Clark and Wells (1995) cognitive model for SAD has been proved to be clinically effective in adults, and its developmentally sensitive adaptations for adolescents have recently shown promising results. Given this evidence and considering that adolescence is typically the age of onset for the first SAD symptoms and a critical developmental period for the delivery of evidence-based interventions, we adapted CT for adolescents for online intervention (CT@TeenSAD) encompassing 10 weekly, 90 min sessions, extended by two booster sessions. This work presents the first case study of that intervention as applied to Merida (M.; pseudonym; 17-year-old, girl). The estimated Reliable Change Index shows M.’s progress for most of her symptoms, from pre-to post-treatment (RCI-1 range: −.53 to −8.03), and the maintenance of benefits at 3 months follow-up (RCI-2 range: .00 to −2.25). A relapse in the adoption of safety behaviors was seen between post-treatment and follow-up, which might be explained by the life-changing challenges experienced by M. between session 10 and follow-up, concerning her transition from high school to college. M.’s case study offers a first glance on the promising results of CT@TeenSAD related to its efficacy and feasibility. Likewise, it offers the opportunity to critically appraise the limitations of the intervention as well as practical challenges and suggestions thought to be useful for therapists willing to implement CT@TeenSAD in the future.

Avoidance Bias to Angry Faces Predicts the Development of Depressive Symptoms among Adolescent Girls

Interpersonal-motivational models posit that heightened avoidance of aversive social stimuli and diminished approach of appetitive social stimuli increases social withdrawal and reduces positive social interactions, thereby increasing risk for future social anxiety and depression. The current study examined if approach-avoidance biases toward angry and happy faces, measured during the Approach Avoidance Task (AAT), would be associated with the development of adolescent depressive and social anxiety symptoms. At baseline, participants included 129 never-depressed adolescent girls (ages 11-13), two-thirds of whom were at high-risk for internalizing problems due to shy/fearful temperament. Girls reported their depressive and social anxiety symptoms every 6 months for 24 months and completed the AAT at baseline and 24-mo follow-up. Heightened avoidance bias toward angry faces at baseline predicted increases in depressive symptoms across the follow-up, even after accounting for temperament and pubertal status. In contrast, girls with greater depression and social anxiety symptoms at 24-mo follow-up exhibited less avoidance bias for angry faces at the same time point. Findings suggest that avoidance behaviors (i.e., avoiding people or settings associated with angry faces, which are often perceived as hostile, critical, or rejecting) may be a risk factor for depression, above and beyond risk imparted by temperament or advances in puberty. However, with increasing internalizing symptoms, it may become more difficult for adolescents to maintain avoidance for aversive social stimuli, and without the introduction of more adaptive emotion regulation strategies, these biases may continue to increase and maintain risk for internalizing problems.

Development and Preliminary Validation of the Child & Adolescent Social Cognitions Questionnaire

Negative cognitions play a central role in adolescent social anxiety, and yet there is a lack of empirically validated measures assessing these in detail. This study describes the adaptation of the Child & Adolescent Social Cognitions Questionnaire (CASCQ) from the adult version of the scale and its preliminary validation in a general adolescent school sample (N = 671). Exploratory and confirmatory factor analysis on split halves of the data indicated two factors, labelled 'negative self-concept' and 'anxious appearance', provided the best fit. Totals and subscales possessed good internal consistency and convergent validity. Findings suggest that the CASCQ is a reliable and valid measure of social anxiety-related cognitions in youth and may be useful for research and clinical purposes. Further examination of the scale with pre-adolescents and clinical samples is warranted.

The Good, the Bad, and the Ugly-Chances, Challenges, and Clinical Implications of Avoidance Research in Psychosomatic Medicine

Avoidance behaviors are shaped by associative learning processes in response to fear of impending threats, particularly physical harm. As part of a defensive repertoire, avoidance is highly adaptive in case of acute danger, serving a potent protective function. However, persistent or excessive fear and maladaptive avoidance are considered key factors in the etiology and pathophysiology of anxiety- and stress-related psychosomatic disorders. In these overlapping conditions, avoidance can increase the risk of mental comorbidities and interfere with the efficacy of cognitive behavioral treatment approaches built on fear extinction. Despite resurging interest in avoidance research also in the context of psychosomatic medicine, especially in conditions associated with pain, disturbed interoception, and disorders of the gut-brain axis, current study designs and their translation into the clinical context face significant challenges limiting both, the investigation of mechanisms involved in avoidance and the development of novel targeted treatment options. We herein selectively review the conceptual framework of learning and memory processes, emphasizing how classical and operant conditioning, fear extinction, and return of fear shape avoidance behaviors. We further discuss pathological avoidance and safety behaviors as hallmark features in psychosomatic diseases, with a focus on anxiety- and stress-related disorders. Aiming to emphasize chances of improved translational knowledge across clinical conditions, we further point out limitations in current experimental avoidance research. Based on these considerations, we propose means to improve existing avoidance paradigms to broaden our understanding of underlying mechanisms, moderators and mediators of avoidance, and to inspire tailored treatments for patients suffering from psychosomatic disorders.

Excessive smartphone use and its correlations with social anxiety and quality of life among medical students in a public university in Malaysia: A cross-sectional study

INTRODUCTION

Smartphone usage has significantly increased in the last decade among young adults has significantly increased in the last decade. While its benefits are undeniable, its negative implications are increasingly emerging. Studies are needed to investigate the effects of excessive smartphone use on a young person's life. This study aimed to determine the prevalence of excessive smartphone use among medical students and its relations with social anxiety, self-esteem, and quality of life.

METHODS

A cross-sectional study was conducted among medical students from Universiti Kebangsaan Malaysia (UKM) in UKM Medical Center. A total of 273 students have consented to participate and completed self-reported questionnaires encompassing sociodemographic information, the Short Version Smartphone Addiction Scale (SAS-SV), the Social Interaction Anxiety Scale (SIAS), the World Health Organization Quality of Life (WHOQOL-BREF) and the Rosenberg Self-esteem Scale (RSES). Sociodemographic data, SIAS score, WHOQOL-BREF score and the Rosenberg Self-esteem Scale score were treated as independent variables. Smartphone addiction Scale score was treated as the dependent variable. Bivariate analysis was used to explore the relationship between independent and dependent variables using the Fisher exact test, Pearson Chi-Square and Pearson correlation coefficient. Multiple linear regression analysis was used to analyze the variables with a p-value of < 0.05 from the Pearson correlation coefficient test.

RESULTS

The percentage of excessive smarphone use among UKM medical students is 48%. The bivariate analysis showed that excessive smartphone use has a small but significant positive correlation with social anxiety (r = 0.173, p = 0.004) and negative correlations with physical health (r = -0.133, p = 0.028), psychological wellbeing (r =-0.135, p = 0.026), social relationships (r = -0.232, p = 0.001), environment (r = -0.260, p = 0.001) and self-esteem (r = -0.128, p = 0.035). In the multiple regression analysis, a better environment predicted a reduced risk for smartphone addiction (β = -0.233, p = 0.013).

CONCLUSION

Almost half of the students were found to have smartphone overdependence. Excessive smartphone use has shown a significant relationship with an increased risk for social anxiety, reduction in self-esteem, and quality of life among medical students. A closer look into the possible intervention is needed in the future to curb the negative effects arising from excessive smartphone use.

Apprehension about the future: Investigating the phenomenological characteristics of episodic future thinking in socially anxious adolescents

BACKGROUND AND OBJECTIVES

Social anxiety is a future-oriented mood characterized by apprehension about others' negative evaluations in anxiety-provoking social situations that may occur in the future. Episodic future thinking (EFT) is a form of future-oriented cognition that allows a pre-experiencing of our personal futures. The literature suggests that anxious individuals show increased negative expectancies about future events. However, few studies have been conducted on EFT in social anxiety. The current study investigated the phenomenological characteristics of EFT in adolescents with high and low social anxiety.

METHODS

Twenty-two high social anxiety (HSA) and 24 low social anxiety (LSA) adolescents simulated one anxiety-provoking social event and one neutral event. They then rated the phenomenological characteristics of the events.

RESULTS

HSA adolescents imagined anxiety-provoking social events from an observer perspective more than LSA adolescents. HSA adolescents also imagined anxiety-provoking social events as more negative and containing less clear contextual details than LSA adolescents. In contrast, no group differences were found for neutral events. Moreover, participants imagined more self-referential information for anxiety-provoking social events than neutral events. HSA participants imagined less other-referential information than LSA participants, regardless of the event type.

LIMITATIONS

This study used a subclinical sample with high and low social anxiety. The sample size was small, and only adolescents aged 15-17 years were included. It is difficult to generalize the present findings across different anxiety-provoking social events. The specificity of EFT was not evaluated.

CONCLUSIONS

Our findings highlight the importance of EFT in the psychopathology of adolescent social anxiety.

Adolescents' perioperative experiences in relation to inpatient and outpatient elective surgery - a qualitative study

BACKGROUND

Perioperative experience can be very distressing in adolescence if not managed properly by healthcare professionals. In the clinical context, the emotional expression of the adolescent is less spontaneous, which makes the assessment of anxiety, pain or even the desire to be involved in the perioperative process, difficult. Listening to their perioperative experiences will permit an understanding of their difficulties and expectations, regardless of the surgical intervention undergone.

AIM

To explore the adolescents' perioperative experiences in relation to inpatient and outpatient elective surgery.

METHODS

Qualitative exploratory study, with thematic analysis approach. A purposive sample of 40 adolescents aged 14-18 years and in the perioperative period, from two paediatric surgery settings in a university hospital, was questioned from January to July 2020. Data were collected using a semi-structured interview and analysed inductively with qualitative thematic analysis.

RESULTS

The data yielded one major theme, five themes, and 14 sub-themes. The major theme, Adolescent in perioperative period, included the five themes: (1) emotional and psychological aspects; (2) physical aspects; (3) social aspects; (4) organizational aspects; (5) previous surgical experience. Adolescents expressed fear of the unknown, anxiety, difficulty in pain control, and feelings of autonomy loss. Issues related to withdrawal from school and friends is also a focus of adolescent concern during the perioperative period. Despite showing satisfaction with the way they were cared for, they complained about the lack of pre- and post-operative preparation.

CONCLUSION

There are aspects that should be considered when caring for adolescents in perioperative period. As far as possible, programmes to prevent adolescents' anxiety in perioperative period should be designed in a holistic perspective, with aim at the psychological, physical, sociocultural, and organisational aspects.

Rumination in Children with Social Anxiety Disorder: Effects of Cognitive Distraction and Relation to Social Stress Processing

According to cognitive models of social anxiety disorder (SAD), both anticipatory processing and post-event processing are core mechanisms in disorder maintenance leading to dysfunctional coping with social situations through negative self-evaluation and increased anxiety. To date, little is known about these processes during late childhood, a critical period for disorder development. Further, it remains unclear if dysfunctional rumination in children can be altered through psychotherapeutic interventions such as cognitive distraction. In the current study, children aged 9 to 13 years with SAD and age- and gender-matched healthy controls (HCs, each: n = 30) participated in an experimental laboratory social stress task while anticipatory processing, post-event processing, subjective anxiety, self-evaluations, and autonomic arousal (skin conductance level) were assessed. Further, the impact of a brief cognitive distraction intervention on post-event processing was assessed. Children with SAD reported more negative anticipatory and post-event processing compared to HC children. Further, negative anticipatory processing was associated with higher subjective anxiety and reduced subjective performance ratings during the social stress task. In the aftermath of the stressor, distraction led to reduced subjective anxiety in the group with SAD and lower autonomic arousal in all children but did not alter post-event processing. The current study suggests that both anticipatory and post-event processing already play a key role in the maintenance of SAD in childhood. While distraction may be beneficial in reducing prolonged subjective anxiety and autonomic arousal after social situations, more research on interventions targeting ruminative processes is needed.

Cognitive Variables in Social Anxiety Disorder in Children and Adolescents: A Network Analysis

Clark and Wells' prominent model of social anxiety disorder (SAD) assumes that cognitive variables such as negative expectations or dysfunctional cognitions play a central role in the symptomatology of SAD. In contrast to adults, it is less clear how well the cognitive model can be applied to children and adolescents. A network analysis with seven nodes was conducted to explore the importance of cognitive variables and their interaction with symptoms of SAD based on N = 205 children and adolescents (8-18 years, M = 11.54 years). Cognitive variables had a high but differential impact within the positively connected network of SAD. Dysfunctional cognitions were most strongly connected within the network. Dysfunctional cognitions, as predicted by Clark and Wells' model, seem to act as a hub affecting several symptoms. The association between negative expectations and avoidance indicates that negative expectations may particularly contribute to the maintenance of SAD.

Pilot randomized trial of self-guided virtual reality exposure therapy for social anxiety disorder

BACKGROUND

Virtual reality exposure therapy (VRE) has shown promising efficacy for the treatment of social anxiety disorder (SAD) and related comorbidities. However, most trials conducted to date were therapist-led, and little is known about the efficacy of self-guided VRE. Therefore, this randomized controlled trial (RCT) aimed to determine the efficacy of a self-directed VRE for SAD.

METHOD

Forty-four community-dwelling or undergraduate adults diagnosed with SAD based on the Mini International Neuropsychiatric Interview were randomly assigned to VRE designed to last four sessions or more (n = 26) or waitlist (WL; n = 18). Self-reported SAD severity (Social Phobia Diagnostic Questionnaire and Social Interaction Anxiety Scale), job interview anxiety (Measure of Anxiety in Selection Interviews), trait worry (Penn State Worry Questionnaire), and depression symptoms (Patient Health Questionnaire-9) were administered at baseline, post-treatment, 3-month-follow-up (3MFU), and 6-month-follow-up (6MFU). Piecewise multilevel modeling analyses were conducted to manage clustering in the data.

RESULTS

VRE vs. WL resulted in greater reductions in SAD symptom severity, job interview fear, and trait worry, with moderate-to-large effect sizes (Hedge's g = -0.54 to -1.11) from pre-to-post treatment. Although significant between-group differences did not emerge for change in depression, VRE led to change in depression, whereas waitlist did not. These gains were also maintained at 3MFU and 6MFU. Further, facets of presence increased during the course of VRE (g = 0.36-0.45), whereas cybersickness decreased (g = -0.43).

DISCUSSION

Brief, self-guided VRE might ameliorate SAD and comorbid worry, for young-to-middle-aged adults with SAD. Other theoretical and practical implications were also discussed.

Safety behaviours in social anxiety: An examination across adolescence

BACKGROUND

Safety behaviours have been shown to be a key maintaining factor in Social Anxiety Disorder (SAD). In adults, a two-factor structure of safety behaviours reflecting 'avoidance' and 'impression-management' types has been identified. This has not yet been investigated in adolescents.

AIMS

We set out to investigate the factor structure of safety behaviours in relation to adolescent social anxiety symptoms and SAD, the extent to which this varies by age, and then to examine the association between the derived factor scores and other social anxiety related phenomena.

METHOD

Questionnaire measures of social anxiety symptoms, cognitions and safety behaviours, peer relationship outcomes, general anxiety and depression were collected from a community sample of 584 younger (11-14 years) and 208 older (16-18 years) adolescents, and a clinical sample of 80 adolescents (11-18 years) with a primary diagnosis of SAD. Four hypotheses were investigated using exploratory and confirmatory factor analyses, regressions, correlations and path analyses.

RESULTS

A two-factor structure reflecting 'avoidance' and 'impression-management' safety behaviours was supported in the community and clinical sample. Older adolescents were found to use 'impression-management' behaviours more than younger adolescents after controlling for overall safety behaviour score. Both types of safety behaviour were significantly positively associated with social anxiety symptoms and cognitions. Path analyses revealed an indirect effect of social anxiety symptoms on peer victimisation, social satisfaction and friendship quality via 'avoidance', but not 'impression-management' safety behaviours.

CONCLUSIONS

Both 'avoidance' and 'impression-management' safety behaviours are associated with social anxiety symptoms and cognitions in youth, with age-related differences in their frequency. 'Avoidance' behaviours are specifically associated with negative outcomes for quality of peer relationships.