What Is the Core Fear in Social Phobia? A New Model to Facilitate Individualized Case Conceptualization and Treatment

To avoid or not to avoid: impact of self-compassion on safety behaviors in social situations

BACKGROUND/OBJECTIVES

Safety behaviors are commonly used to decrease anxiety in social settings but maintain anxiety. Self-compassion has been shown to reduce anxiety and rumination, but the impact on safety behaviors has not been examined. For the present studies, it was hypothesized that inducing self-compassion would lead to lower safety behaviors compared to controls.

METHODS

In Study 1 (N = 390), participants with elevated social anxiety recalled a distressing social situation, were randomly assigned to a self-compassionate (n = 186) or control (n = 204) writing exercise, and then reported predicted self-compassion and safety behaviors for a future situation. In Study 2 (N = 114), the impact of self-compassionate (n = 56) or control writing (n = 58) on safety behaviors was investigated during a Zoom interaction.

RESULTS/CONCLUSIONS

In Study 1, as hypothesized, the self-compassion condition reported fewer expected avoidance behaviors compared to controls. In Study 2, state self-compassion and safety behaviors did not differ between conditions. In both studies, distress significantly mediated the relationship between condition and safety behaviors, such that the self-compassion condition reported significantly lower distress, which was associated with lower safety behaviors. Future research can examine whether reduced distress and safety behaviors allow for greater social connection.

Computational modeling of social evaluative decision-making elucidates individual differences in adolescent anxiety

Adolescents experience significant developmental changes during a time of heightened sensitivity to social cues, particularly rejection by peers, which can be especially overwhelming for those with elevated levels of social anxiety. Social evaluative decision-making tasks have been useful in uncovering the neural correlates of information processing biases; however, linking youths' task-based performance to individual differences in psychopathology (e.g., anxiety symptoms) has proven more elusive. Here, we address this weakness with drift diffusion modeling to decompose youths' performance on the social judgment paradigm (SJP) to determine if this approach is useful in discovering individual differences in anxiety symptoms, as well as puberty, age, and sex. A sample of 103 adolescents (55 males, Mage = 14.49, SD = 1.69) completed the SJP and self-report measures of anxiety, as well as self- and parent-reported measures of puberty. The decision threshold parameter, reflecting the amount of evidence needed to make a social evaluative decision, predicted youth self-reported anxiety, above and beyond typical metrics of SJP performance. Our results highlight the potential advantage of parsing task performance according to the underlying cognitive processes. Future research would likely benefit from applying computational modeling approaches to social judgment tasks when attempting to uncover performance-based individual differences in psychopathology.

The Efficacy of Web-Based Cognitive Behavioral Therapy With a Shame-Specific Intervention for Social Anxiety Disorder: Randomized Controlled Trial

Background

Social anxiety disorder (SAD) is one of the most prevalent psychological disorders and generally co-occurs with elevated shame levels. Previous shame-specific interventions could significantly improve outcomes in social anxiety treatments. Recent review suggests that integrating a more direct shame intervention could potentially increase the effectiveness of cognitive behavioral therapy. Web-based cognitive behavioral therapy (WCBT) has proven efficacy, sustaining benefits for 6 months to 4 years. Previous evidence indicated that shame predicted the reduction of social anxiety and mediated between engagements in exposure and changes in social anxiety during WCBT.

Objective

This study aimed to design a shame intervention component through a longitudinal study and conduct a randomized controlled trial to investigate the effectiveness of a shame intervention component in reducing social anxiety symptoms and shame experience in a clinical sample of people with SAD.

Methods

The development of a shame intervention component was informed by cognitive behavioral principles and insights from longitudinal data that measured the Experience of Shame Scale (ESS), the Coping Styles Questionnaire, and the Social Interaction Anxiety Scale (SIAS) in 153 participants. The psychoeducation, cognitive construct, and exposure sections were tailored to focus more on shame-related problem-solving and self-blame. A total of 1220 participants were recruited to complete questionnaires, including the ESS, the SIAS, the Social Phobia Scale (SPS), and diagnostic interviews. Following a 2-round screening process, 201 participants with SAD were randomly assigned into a shame WCBT group, a normal WCBT group, and a waiting group. After the 8-week WCBT intervention, the participants were asked to complete posttest evaluations, including the ESS, SIAS and SPS.

Results

Participants in the shame WCBT group experienced significant reductions in shame levels after the intervention (ESS: P<.001; ηp2=0.22), and the reduction was greater in the shame intervention group compared to normal WCBT (P<.001; mean deviation -12.50). Participants in both the shame WCBT and normal WCBT groups experienced significant reductions in social anxiety symptoms (SIAS: P<.001; ηp2=0.32; SPS: P<.001; ηp2=0.19) compared to the waiting group after intervention. Furthermore, in the experience of social interaction anxiety (SIAS), the shame WCBT group showed a higher reduction compared to the normal WCBT group (P<.001; mean deviation -9.58). Problem-solving (SE 0.049, 95% CI 0.025-0.217) and self-blame (SE 0.082, 95% CI 0.024-0.339) mediated the effect between ESS and SIAS.

Conclusions

This is the first study to design and incorporate a shame intervention component in WCBT and to validate its efficacy via a randomized controlled trial. The shame WCBT group showed a significant reduction in both shame and social anxiety after treatment compared to the normal WCBT and waiting groups. Problem-solving and self-blame mediated the effect of shame on social anxiety. In conclusion, this study supports previous findings that a direct shame-specific intervention component could enhance the efficacy of WCBT.

Studies of Social Anxiety Using Ambulatory Assessment: Systematic Review

BACKGROUND

There has been an increased interest in understanding social anxiety (SA) and SA disorder (SAD) antecedents and consequences as they occur in real time, resulting in a proliferation of studies using ambulatory assessment (AA). Despite the exponential growth of research in this area, these studies have not been synthesized yet.

OBJECTIVE

This review aimed to identify and describe the latest advances in the understanding of SA and SAD through the use of AA.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic literature search was conducted in Scopus, PubMed, and Web of Science.

RESULTS

A total of 70 articles met the inclusion criteria. The qualitative synthesis of these studies showed that AA permitted the exploration of the emotional, cognitive, and behavioral dynamics associated with the experience of SA and SAD. In line with the available models of SA and SAD, emotion regulation, perseverative cognition, cognitive factors, substance use, and interactional patterns were the principal topics of the included studies. In addition, the incorporation of AA to study psychological interventions, multimodal assessment using sensors and biosensors, and transcultural differences were some of the identified emerging topics.

CONCLUSIONS

AA constitutes a very powerful methodology to grasp SA from a complementary perspective to laboratory experiments and usual self-report measures, shedding light on the cognitive, emotional, and behavioral antecedents and consequences of SA and the development and maintenance of SAD as a mental disorder.

Vulnerabilities in social anxiety: Integrating intra- and interpersonal perspectives

What are the major vulnerabilities in people with social anxiety? What are the most promising directions for translational research pertaining to this condition? The present paper provides an integrative summary of basic and applied translational research on social anxiety, emphasizing vulnerability factors. It is divided into two subsections: intrapersonal and interpersonal. The intrapersonal section synthesizes research relating to (a) self-representations and self-referential processes; (b) emotions and their regulation; and (c) cognitive biases: attention, interpretation and judgment, and memory. The interpersonal section summarizes findings regarding the systems of (a) approach and avoidance, (b) affiliation and social rank, and their implications for interpersonal impairments. Our review suggests that the science of social anxiety and, more generally, psychopathology may be advanced by examining processes and their underlying content within broad psychological systems. Increased interaction between basic and applied researchers to diversify and elaborate different perspectives on social anxiety is necessary for progress.

Social anxiety and emotion regulation flexibility: a daily diary approach

Previous research suggests that social anxiety symptoms are maintained and intensified by inflexible emotion regulation (ER). Therefore, we examined whether trait-level social anxiety moderates ER flexibility operationalised at both between-person (covariation between variability in emotional intensity and variability in strategy use across occasions) and within-person (associations between emotional intensity and strategy use on a given day) levels. In a sample of healthy college-aged adults (N = 185, Mage = 21.89), we examined overall and emotion-specific intensities (shame, guilt, anxiety, anger, sadness) and regulatory strategies (i.e. experiential avoidance, expressive suppression, and rumination) in response to each day's most emotionally intense event over 6 days. During the study period, we found a positive association between variability in emotional intensity and variability of experiential avoidance in individuals with lower, rather than higher, levels of trait social anxiety after controlling for key covariates (i.e. gender, personality traits, and stress exposure). However, we did not find evidence for the moderating role of trait social anxiety in ER flexibility assessed at within-person levels. Our findings highlight the need to delineate dynamic ER flexibility across everyday events.

Social anxiety and interpersonal risk for suicidal ideation: A longitudinal daily diary analysis

INTRODUCTION

Social anxiety is associated with elevated suicidal ideation (SI). One potential explanation is that socially anxious persons experience frequent interpersonal stressors that elicit SI. Longitudinal designs with temporal ordering are needed to adequately test this hypothesis. Therefore, this study leveraged a longitudinal design combining trait and daily reports.

METHODS

Two hundred eleven community adult participants with elevated levels of depression and/or social anxiety completed social anxiety and SI measures at baseline and again at a 1.5-month follow-up. Between these assessments, participants completed a 14-day diary study that assessed three forms of interpersonal distress: unfavorable social comparisons, perceived barriers to seeking social support, and loneliness.

RESULTS

As predicted, simple mediation models revealed that baseline social anxiety had a significant indirect effect on SI severity at 1.5 months postbaseline via unfavorable social comparisons (indirect effect: β = 0.07, p < 0.05) and barriers to seeking support (indirect effect: β = 0.08, p < 0.05); however, social anxiety did not have a significant indirect effect on SI severity through loneliness.

CONCLUSION

Study results are consistent with the proposition that increases in interpersonal distress may explain socially anxious persons' vulnerability to SI. Implications of these findings for the research, assessment, and treatment of suicidality in social anxiety are discussed.

Values- versus monetary reward-enhanced exposure therapy for the treatment of social anxiety in emerging adulthood

Exposure therapy represents the gold-standard treatment for social anxiety, yet evidence indicates the need for improvement. One promising avenue involves linking exposures to a motivator. The current study examined the impact of intrinsically-rewarding, personal values-enhanced versus extrinsically-rewarding, monetary-enhanced exposure on short-term social anxiety fear and avoidance outcomes, and evaluated impacted initial treatment motivation and exposure generalization.

METHODS

Sixty emerging adults ages 17-26 with significantly elevated social and public speaking anxiety were randomized to receive values-enhanced exposure, monetary reward-enhanced exposure, or exposure alone. They completed a laboratory session with a brief intervention and speech exposure, one-week follow-up with novel exposure, and online follow-up two weeks later. Subjective and behavioral anxiety measures were collected.

RESULTS

Linking exposures to values decreased self-reported anxiety following the speech exposure retest, which generalized to anticipatory anxiety prior to a novel speech task. Linking exposures to money temporarily increased speech length, but this difference did not remain during the novel task. Conditions showed similar improvements on other outcomes.

CONCLUSION

Extrinsic motivators can temporarily motivate exposure engagement, whereas a brief values intervention can enhance exposure learning and decrease subjective anxiety across feared situations compared to monetary enhancement. If replicated, this has pragmatic implications for exposure framing within social anxiety treatment.

The relationship between openness and social anxiety: the chain mediating roles of social networking site use and self-evaluation

BACKGROUND

As social networking sites (SNSs) with diverse functions gradually become an important social place for modern people, openness, as a personality trait that represents the willingness to consider diverse things, will be more likely to affect people's cognitive and emotional experience (e.g., social anxiety) in social interactions. This study examined the relationship between openness and social anxiety and the underlying psychological mechanism in the internet age based on the cognitive-behavioral model of social anxiety.

METHODS

This cross‑sectional survey study conducted a questionnaire survey of 522 college students from two provinces in China (191 male; age range 18-25; M = 20.76, SD = 1.34).

RESULTS

The results showed that openness is negatively related to social anxiety. Self-evaluation and passive SNS use independently mediate the relationship between openness and social anxiety, respectively. Moreover, openness is associated with social anxiety both through the chain mediating roles of active SNS use and self-evaluation and through the chain mediating roles of passive SNS use and self-evaluation.

CONCLUSIONS

Openness is negatively associated with social anxiety, and the different ways of SNS use and self-evaluation are the underlying mechanisms. These results provide insights into the clinical treatment of social anxiety and how to benefit from online interactions.

Neurocognitive Model of Schema-Congruent and -Incongruent Learning in Clinical Disorders: Application to Social Anxiety and Beyond

Negative schemas lie at the core of many common and debilitating mental disorders. Thus, intervention scientists and clinicians have long recognized the importance of designing effective interventions that target schema change. Here, we suggest that the optimal development and administration of such interventions can benefit from a framework outlining how schema change occurs in the brain. Guided by basic neuroscientific findings, we provide a memory-based neurocognitive framework for conceptualizing how schemas emerge and change over time and how they can be modified during psychological treatment of clinical disorders. We highlight the critical roles of the hippocampus, ventromedial prefrontal cortex, amygdala, and posterior neocortex in directing schema-congruent and -incongruent learning (SCIL) in the interactive neural network that comprises the autobiographical memory system. We then use this framework, which we call the SCIL model, to derive new insights about the optimal design features of clinical interventions that aim to strengthen or weaken schema-based knowledge through the core processes of episodic mental simulation and prediction error. Finally, we examine clinical applications of the SCIL model to schema-change interventions in psychotherapy and provide cognitive-behavior therapy for social anxiety disorder as an illustrative example.

Pride in social anxiety disorder

The present study examined differences in the experience of pride between individuals with and without social anxiety disorder (SAD), and is the first to examine both the effects of context on pride and the temporal relationship between pride and anxiety in participants' daily lives. Eighty-eight participants took part in the study, half (n = 44) met diagnostic criteria for SAD and half (n = 44) did not. Both groups completed an experience sampling measurement (ESM) to assess the levels of pride and anxiety and the nature of interpersonal contexts in which these emotions were experienced every day for 21 consecutive days. Using multilevel linear modeling, our findings suggest that pride is diminished among individuals with SAD, that situations percieved as highly neagative and positive, or as highly meaningful and positive are associated with the highest levels of pride, and that the experience of pride is associated with subsequent reductions in anxiety among individuals with SAD. These findings point to the role of pride in the disorder and can be used to inform and enhance therapeutic interventions for SAD.

Altered Putamen Activation for Social Comparison-Related Feedback in Social Anxiety Disorder: A Pilot Study

INTRODUCTION

Social anxiety disorder (SAD) is characterized by abnormal processing of performance-related social stimuli. Previous studies have shown altered emotional experiences and activations of different sub-regions of the striatum during processing of social stimuli in patients with SAD. However, whether and to what extent social comparisons affect behavioural and neural responses to feedback stimuli in patients with SAD is unknown.

MATERIALS AND METHODS

To address this issue, emotional ratings and functional magnetic resonance imaging (fMRI) responses were assessed while patients suffering from SAD and healthy controls (HC) were required to perform a choice task and received performance feedback (correct, incorrect, non-informative) that varied in relation to the performance of fictitious other participants (a few, half, or most of others had the same outcome).

RESULTS

Across all performance feedback conditions, fMRI analyses revealed reduced activations in bilateral putamen when feedback was assumed to be received by only a few compared to half of the other participants in patients with SAD. Nevertheless, analysis of rating data showed a similar modulation of valence and arousal ratings in patients with SAD and HC depending on social comparison-related feedback.

CONCLUSIONS

This suggests altered neural processing of performance feedback depending on social comparisons in patients with SAD.

Brain mediators of biased social learning of self-perception in social anxiety disorder

Social anxiety disorder (SAD) is characterized by an excessive fear of social evaluation and a persistently negative view of the self. Here we test the hypothesis that negative biases in brain responses and in social learning of self-related information contribute to the negative self-image and low self-esteem characteristic of SAD. Adult participants diagnosed with social anxiety (N = 21) and matched controls (N = 23) rated their performance and received social feedback following a stressful public speaking task. We investigated how positive versus negative social feedback altered self-evaluation and state self-esteem and used functional Magnetic Resonance Imaging (fMRI) to characterize brain responses to positive versus negative feedback. Compared to controls, participants with SAD updated their self-evaluation and state self-esteem significantly more based on negative compared to positive social feedback. Responses in the frontoparietal network correlated with and mirrored these behavioral effects, with greater responses to positive than negative feedback in non-anxious controls but not in participants with SAD. Responses to social feedback in the anterior insula and other areas mediated the effects of negative versus positive feedback on changes in self-evaluation. In non-anxious participants, frontoparietal brain areas may contribute to a positive social learning bias. In SAD, frontoparietal areas are less recruited overall and less attuned to positive feedback, possibly reflecting differences in attention allocation and cognitive regulation. More negatively biased brain responses and social learning could contribute to maintaining a negative self-image in SAD and other internalizing disorders, thereby offering important new targets for interventions.

Social anxiety and MDMA-assisted therapy investigation: a novel clinical trial protocol

Background

Social anxiety disorder (SAD) is a serious and prevalent psychiatric condition that heavily impacts social functioning and quality of life. Though efficacious treatments exist for SAD, remission rates remain elevated and a significant portion of those affected do not access effective treatment, suggesting the need for additional evidence-based treatment options. This paper presents a protocol for an open-label pilot study of MDMA-assisted therapy (MDMA-AT) for social anxiety disorder. The study aims to assess preliminary treatment outcomes, feasibility and safety, and psychological and physiological processes of change in the treatment of SAD with MDMA-AT. A secondary aim includes the development of a treatment manual for MDMA-AT for SAD.

Method

The outlined protocol is a randomized, open-label delayed treatment study. We will recruit 20 participants who meet criteria with moderate-to-severe social anxiety disorder (SAD) of the generalized subtype. Participants will be randomly assigned to an immediate treatment (n = 10) or delayed treatment condition (n = 10). Those in the immediate treatment condition will proceed immediately to active MDMA-AT consisting of three preparation sessions, two medicine sessions in which they receive oral doses of MDMA, and six integration sessions over approximately a 16-week period. The delayed treatment condition will receive the same intervention after a 16-week delay. Our primary outcome is SAD symptom reduction as measured by the Liebowitz Social Anxiety Scale administered by blinded raters at post-treatment and 6 month follow up. Secondary outcomes include changes in functional impairment, feasibility and safety measures, and novel therapeutic processes of change including shame and shame-related coping, belongingness, self-concealment, and self-compassion at post-treatment. Exploratory outcomes are also discussed.

Discussion

The results of this pilot trial advance the field's understanding of the acceptability and potential effectiveness of MDMA-AT for social anxiety disorder and provide an overview of relevant therapeutic mechanisms unique to SAD. We hope findings from this protocol will inform the design of subsequent larger-scale randomized controlled trials (RCT) examining the efficacy of MDMA-AT for SAD.

Clinical trial registration

https://clinicaltrials.gov/, NCT05138068.

Appraisals of Social Trauma and Their Role in the Development of Post-Traumatic Stress Disorder and Social Anxiety Disorder

Cognitive theories of post-traumatic stress disorder (PTSD) feature appraisal of trauma as a critical factor in the development and maintenance of the disorder. Here we explored appraisals of social trauma (severe rejection or humiliation). Participants were outpatients with social anxiety disorder (SAD) and clinically significant PTSD symptoms (PTSS) after social trauma (n = 15); two clinical control groups of either SAD (n = 32) or obsessive-compulsive disorder (OCD; n = 13); and a control group with no diagnoses (n = 38). Measures included a clinical interview to assess social trauma and related open-ended appraisals and the Posttraumatic Cognitions Inventory (PTCI). Raters blind to group assignment performed content analyses of appraisals. Results showed that the PTSS group scored significantly higher than either clinical group on the PTCI SELF subscale. Only the SELF subscale predicted a diagnosis of both PTSS and SAD. All but one PTSS participant reported primarily negative beliefs about their social trauma, and the most common categories were flawed self and others are critical or cruel. Post-traumatic appraisals implicated in the course of PTSD are significant in how individuals respond to social trauma, with negative self-cognitions linked to both PTSS and SAD.

Self-evaluation of social-rank in socially anxious individuals associates with enhanced striatal reward function

BACKGROUND

Negative self-views, especially in the domain of power (i.e. social-rank), characterize social anxiety (SA). Neuroimaging studies on self-evaluations in SA have mainly focused on subcortical threat processing systems. Yet, self-evaluation may concurrently invoke diverse affective processing, as motivational systems related to desired self-views may also be activated. To investigate the conflictual nature that may accompany self-evaluation of certain social domains in SA, we examined brain activity related to both threat and reward processing.

METHODS

Participants (N = 74) differing in self-reported SA-severity underwent fMRI while completing a self-evaluation task, wherein they judged the self-descriptiveness of high- v. low-intensity traits in the domains of power and affiliation (i.e. social connectedness). Participants also completed two auxiliary fMRI tasks designated to evoke reward- and threat-related activations in the ventral striatum (VS) and amygdala, respectively. We hypothesized that self-evaluations in SA, particularly in the domain of power, involve aberrant brain activity related to both threat and reward processing.

RESULTS

SA-severity was more negatively associated with power than with affiliation self-evaluations. During self-evaluative judgment of high-power (e.g. dominant), SA-severity associated with increased activity in the VS and ventromedial prefrontal cortex. Moreover, SA-severity correlated with higher similarity between brain activity patterns activated by high-power traits and patterns activated by incentive salience (i.e. reward anticipation) in the VS during the reward task.

CONCLUSIONS

Our findings indicate that self-evaluation of high-power in SA involves excessive striatal reward-related activation, and pinpoint the downregulation of VS-VMPFC activity within such self-evaluative context as a potential neural outcome for therapeutic interventions.

Topography of the Anxious Self: Abnormal Rest-Task Modulation in Social Anxiety Disorder

Social anxiety disorder (SAD) is characterized by social anxiety/fear, self-attention, and interoception. Functional magnetic resonance imaging studies demonstrate increased activity during symptom-sensitive tasks in regions of the default-mode network (DMN), amygdala (AMG), and salience network (SN). What is the source of this task-unspecific symptom-sensitive hyperactivity in DMN? We address this question by probing SAD resting state (rs) changes in DMN including their relation to other regions as possible source of task-unspecific hyperactivity in the same regions. Our findings show the following: (1) rs-hypoconnectivity within-DMN regions; (2) rs-hyperconnectivity between DMN and AMG/SN; (3) task-evoked hyperactivity in the abnormal rs-regions of DMN and AMG/SN during different symptom-sensitive tasks; (4) negative relationship of rest and task changes in especially anterior DMN regions as their rs-hypoconnectivity is accompanied by task-unspecific hyperactivity; (5) abnormal top-down/bottom-up modulation between anterior DMN regions and AMG during rest and task. Findings demonstrate that rs-hypoconnectivity among DMN regions is negatively related to task-unspecific hyperactivity in DMN and AMG/SN. We propose a model of "Topography of the Anxious Self" in SAD (TAS-SAD). Abnormal DMN-AMG/SN topography during rest, as trait feature of an "unstable social self", is abnormally aggravated during SAD-sensitive situations resulting in task-related hyperactivity in the same regions with an "anxious self" as state feature.

Fear of positive evaluation differentially predicts social anxiety: a six-month longitudinal panel study

This study investigated whether (a) fear of negative evaluation (FNE) and fear of positive evaluation (FPE) prospectively predict the other, (b) FPE predicts social anxiety controlling for FNE, and (c) FPE predicts social anxiety symptoms but not general anxiety and depression. Data were collected from a student sample at two time points over six months. The cross-lagged structural equation modeling results revealed that FNE and FPE do not prospectively predict the other, FPE positively predicts social anxiety symptoms controlling for FNE, and FPE does not significantly predict general anxiety or depression. These results confirmed that FNE and FPE are distinctively related to social anxiety. Moreover, the study findings indicated that FPE may be a factor unique to social anxiety.

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.

Emotions in social anxiety disorder: A review

Extant cognitive behavioral models of social anxiety disorder (SAD) have primarily focused on cognitions and behaviors that maintain the disorder. Emotional aspects of SAD have been investigated but have not been sufficiently integrated into current models. To facilitate such integration, we reviewed the literature on emotional constructs (emotional intelligence, emotional knowledge, emotional clarity, emotion differentiation, and emotion regulation), and discrete emotions (anger, shame, embarrassment, loneliness, guilt, pride, and envy) in SAD and social anxiety. We present the studies conducted on these constructs, summarize the main findings, suggest areas for future research, discuss the findings in the context of existing models of SAD and attempt to integrate the findings into these existing models of the disorder. Clinical implications of our findings are also discussed.

Social anxiety inhibits needs repair following exclusion in both relational and non-relational reward contexts: The mediating role of positive affect

The pain of social exclusion can motivate people to capitalize on opportunities to reconnect with others and repair their self-esteem and feelings of belongingness. This effect is often diminished for those with high social anxiety (HSA). Prior research suggests this may be due to their diminished capacity for recognizing and emotionally responding to relational reward cues. We investigated whether non-relational success experiences in the aftermath of exclusion may be an alternative means of repairing threatened self-esteem and belongingness in HSA individuals. In a preregistered, online study, we threatened belongingness and self-esteem in 422 participants by excluding them in a Cyberball game and then assigned them to one of three conditions: Relational Repair, Non-Relational Repair, or a No-Repair control condition. Results showed that both repair contexts facilitated needs repair relative to the no-repair control condition, and mediation analyses suggested this effect was driven by increased positive affect (PA). HSA individuals were less likely to restore needs regardless of condition and this effect appeared to be driven by low PA. Findings emphasize the critical role of PA for restoring threatened needs in the aftermath of exclusion and suggest that HSA inhibits needs repair processes across both relational and non-relational reward contexts.

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.

Concurrent and prospective associations between negative social-evaluative beliefs, safety behaviours, and symptoms during and following cognitive behavioural group therapy for social anxiety disorder

BACKGROUND

Improving the delivery of cognitive-behavioural therapy (CBT) for social anxiety disorder (SAD) requires an in-depth understanding of which cognitive and behavioural mechanisms drive change in social anxiety symptoms (i.e., social interaction anxiety) during and after treatment. The current study explores the dynamic temporal associations between theory-driven cognitive and behavioural mechanisms of symptom change both during and following group CBT.

METHODS

A randomized controlled trial of imagery-enhanced CBT (n = 51) versus traditional verbal CBT (n = 54) for social anxiety was completed in a community mental health clinic setting. This study included data collected from 12-weekly sessions and a 1-month follow-up session. Mixed models were used to assess magnitude of change over the course of treatment. Cross-lagged panel models were fit to the data to examine temporal relationships between mechanisms (social-evaluative beliefs, safety behaviours) and social interaction anxiety symptoms.

RESULTS

Participants in both CBT groups experienced significant improvements across all cognitive, behavioural, and symptom measures, with no significant differences in the magnitude of changes between treatments. During treatment, greater social-evaluative beliefs (fear of negative evaluation, negative self-portrayals) at one time point (T) were predictive of more severe SAD symptoms and safety behaviours at T+1. Social-evaluative beliefs (fear of negative evaluation, probability and cost of social failure) and safety behaviours measured at post-treatment were positively associated with SAD symptoms at the 1-month follow-up.

CONCLUSIONS

The current study identifies social-evaluative beliefs that may be important targets for symptom and avoidance reduction during and following CBT. Assessment of these social-evaluative beliefs throughout treatment may be useful for predicting future SAD symptoms and avoidance, and for adapting treatment to promote optimal change for patients.

The impact of particular safety behaviours on perceived likeability and authenticity during interpersonal interactions in social anxiety disorder

BACKGROUND

Safety behaviours are hypothesized to play a vital role in maintaining social anxiety disorder (SAD), in part by orienting socially anxious individuals to adopt an avoidance-based mindset focused on self-protection and self-concealment. Evidence suggests an association between safety behaviour use and negative social outcomes for individuals with SAD. However, research has largely focused on the broad group of safety behaviours, whereas specific subtypes have received less attention.

AIM

The present study aimed to further our understanding of the negative interpersonal consequences of specific types of safety behaviours for individuals with SAD by examining whether active, inhibiting/restricting, or physical symptom management safety behaviour use affects perceived likeability and authenticity during a conversation with a stranger.

METHOD

Individuals with SAD (n = 29; mean age 35.5 years) and healthy control (non-SAD) participants (n = 40; mean age 18.6 years) engaged in a semi-structured social interaction with trained confederates.

RESULTS

Participants with SAD were perceived as significantly less likeable and authentic by the confederates, and rated themselves as significantly less authentic compared with those without SAD. The association between group status and likeability was mediated by the use of inhibiting/restricting safety behaviours and the association between group status and participant-rated authenticity was mediated by the use of both inhibiting/restricting and active safety behaviours, but not physical symptom management strategies.

CONCLUSIONS

These results contribute to a growing literature suggesting that some, but not all, safety behaviours may play an important role in creating the negative social outcomes that individuals with SAD experience.

Symptom association between social anxiety disorder, appearance anxiety, and eating disorders among Chinese University students: A network analysis to conceptualize comorbidity

Background

Incidences of social anxiety disorder (SAD), appearance anxiety, and eating disorders (ED) show an increased prevalence among young people. However, symptoms' associations between these disorders have not been investigated in depth. Network analysis is an approach that can be used to explain the relationship(s) between symptoms of different psychological disorders. Using network analysis, this study aimed to explore the association and potential interacting mechanisms between SAD, appearance anxiety, and ED.

Methods

This study included 96,218 University students from Jilin Province, China. SAD, appearance anxiety and ED were assessed using the Social Anxiety Subscale of the Self-Consciousness Scale (SASS), the Appearance Anxiety Scale Brief Version (AASBV), and the Sick, Control, One, Fat, Food questionnaire (SCOFF), Chinese versions. Network analysis was employed to investigate the symptom associations, while the stability of the network model was analyzed using statistical measures.

Results

The prevalence of ED among the total sample was 38% (95% CI: 38.1-38.8%), while this figure was 31.2% (95% CI: 30.7-31.6%) in males and 43.6% (95% CI: 43.2-44.0%) in females. Additionally, the total score of SAD was significantly higher in females (11.83 ± 5.37) than it in males (10.02 ± 5.46) (P < 0.001). While the total score of appearance anxiety was also different significantly in gender (39.21 ± 9.49 in females vs. 38 ± 9.42 in males) (P < 0.001). Results showed that ED was associated with all three aspects of appearance anxiety, including "appearance concern," "appearance satisfaction," and "wish for good looks." Appearance anxiety and SAD were also associated; specifically, symptoms of "appearance satisfaction" were significantly associated with the symptoms "easily talk to strangers" and "appearance concern", which was also significantly associated with "embarrassed". Compared with males, females showed significantly stronger associations with appearance anxiety symptoms, while ED symptoms were associated with "troubled by being watched" and "appearance concern".

Conclusion

Appearance anxiety was associated with both ED and SAD symptoms. ED may have a potential relationship with SAD, affecting appearance anxiety indirectly. Significant differences were found among males and females in symptom associations between appearance anxiety and SAD. This study therefore clarified that young people should have body-positive interventions and challenge the normative body image discourse, which may help alleviate symptoms of SAD and ED.

Technology-Mediated Sexual Interactions, Social Anxiety, and Sexual Wellbeing: A Scoping Review

Technology-mediated sexual interactions (TMSI) are interpersonal exchanges via technology of self-created sexual material, including photos, videos, and auditory or text messages. There is little research on the factors that predict both TMSI experiences and their sexual wellbeing outcomes. Social anxiety is anxiety experienced in response to social or performance situations. From a cognitive–behavioural perspective, people higher in social anxiety may avoid TMSI, preventing positive or negative consequences. They also may use TMSI to avoid the anxiety caused by in-person sexual interactions, benefiting from access to sexual interactions while perpetuating anxiety about them. The purpose of this scoping review was to explore the role of social anxiety in TMSI and its sexual wellbeing outcomes. We executed a comprehensive search strategy across eight academic databases and searched reference lists of included articles. We included 19 articles written in English or French that had a human sample and were published between 1991 and 2021 and evaluated connections between social anxiety constructs (e.g., shyness, anxiety) and TMSI-related experiences (e.g., sexting, internet sex addiction). The pattern of results suggested that social anxiety constructs may predict some but not all forms of TMSI. Future research from a cognitive–behavioural perspective will expand knowledge on social anxiety, TMSI, and its sexual wellbeing outcomes.

Eating disorder and social anxiety symptoms in Iranian preadolescents: a network analysis

PURPOSE

Network studies of eating disorder (ED) symptoms have identified central and bridge symptoms in Western samples, yet few network models of ED symptoms have been tested in non-Western samples, especially among preadolescents. The current study tested a network model of ED symptoms in Iranian preadolescents (ages 9 to 13), as well as a model of co-occurring social anxiety disorder (SAD) and ED symptoms.

METHOD

Preadolescent boys (n = 405) and girls (n = 325) completed the Children Eating Attitudes Test-20 and Social Anxiety Scale for Children. We estimated two network models (ED and ED/SAD networks) and identified central and bridge symptoms, as well as tested if these models differed by sex.

RESULTS

We found that discomfort eating sweets were the most central symptoms in ED networks. Concern over being judged was central in networks including both ED and SAD symptoms. Additionally, concern over being judged was the strongest bridge symptoms. Networks did not differ by sex.

CONCLUSION

Future research is needed to test if interventions focused on bridge symptoms (i.e., concern over being judged) as primary intervention points target comorbid ED-SAD pathology in preadolescents at risk for ED and SAD.

LEVEL OF EVIDENCE

Level III; Evidence obtained from well-designed observational study, including case-control design for relevant aspects of the study.

Imagery-enhanced v. verbally-based group cognitive behavior therapy for social anxiety disorder: a randomized clinical trial

BACKGROUND

Cognitive behavior therapy (CBT) is effective for most patients with a social anxiety disorder (SAD) but a substantial proportion fails to remit. Experimental and clinical research suggests that enhancing CBT using imagery-based techniques could improve outcomes. It was hypothesized that imagery-enhanced CBT (IE-CBT) would be superior to verbally-based CBT (VB-CBT) on pre-registered outcomes.

METHODS

A randomized controlled trial of IE-CBT v. VB-CBT for social anxiety was completed in a community mental health clinic setting. Participants were randomized to IE (n = 53) or VB (n = 54) CBT, with 1-month (primary end point) and 6-month follow-up assessments. Participants completed 12, 2-hour, weekly sessions of IE-CBT or VB-CBT plus 1-month follow-up.

RESULTS

Intention to treat analyses showed very large within-treatment effect sizes on the social interaction anxiety at all time points (ds = 2.09-2.62), with no between-treatment differences on this outcome or clinician-rated severity [1-month OR = 1.45 (0.45, 4.62), p = 0.53; 6-month OR = 1.31 (0.42, 4.08), p = 0.65], SAD remission (1-month: IE = 61.04%, VB = 55.09%, p = 0.59); 6-month: IE = 58.73%, VB = 61.89%, p = 0.77), or secondary outcomes. Three adverse events were noted (substance abuse, n = 1 in IE-CBT; temporary increase in suicide risk, n = 1 in each condition, with one being withdrawn at 1-month follow-up).

CONCLUSIONS

Group IE-CBT and VB-CBT were safe and there were no significant differences in outcomes. Both treatments were associated with very large within-group effect sizes and the majority of patients remitted following treatment.

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.

Evaluating the efficacy of common humanity-enhanced exposure for socially anxious young adults

Despite some evidence of the benefits of self-compassion training among socially anxious individuals, little is known about whether enhancing self-compassion prior to exposure therapy increases initial exposure engagement. Additionally, manipulations have relied on broad definitions of self-compassion, rendering it difficult to distinguish the impact of individual components. This study employed three experiential exercises designed to enhance one facet of self-compassion-common humanity. Socially anxious undergraduates (N = 63) were randomized in groups to 1) common humanity-enhanced exposure (n = 32) or 2) exposure alone (n = 31). In the common humanity condition, participants wrote self-compassionately, shared fears, and completed a common humanity-focused lovingkindness meditation. All participants then completed a speech exposure in front of live judges followed by an optional second exposure. Within the common humanity condition, positive self-responding to the speech exposure increased (b = 0.30, p = .026). Common humanity participants also remained in the first exposure longer, relative to exposure alone (b = -30.92, p = .002). Participants rated exercises as at least moderately helpful, with sharing fears rated most helpful. In sum, a brief group-based multi-modal common humanity induction represents a promising approach to improving initial engagement with feared contexts among socially anxious individuals.

"Early Negative Memories, Humiliation and Defectiveness/Shame Schema: An Emotion-Focused Therapeutic Approach to Social Anxiety"

"Introduction: Recently emotion-focused therapy has developed as an additional approach and considers the role of primary emotions such as shame in the formation and persistence of SAD. Objectives: The purpose of this study was to investigate the theoretical model of emotion-focused therapy for SAD by considering the role of early negative memories, humiliation and the mediating role of self-defectiveness/shame schema in the etiology of SAD. Method: This cross-sectional descriptive study recruited a sample of 105 students, 44 males (41.9%) 61 females (58.1%), diagnosed with SAD by psychologists from Shahid Beheshti University Counseling Center. Participants ranging in age from 18 to 34 with a mean age of 23.1 years (SD=3.5) completed the Social Phobia Inventory, Humiliation Inventory, Early Life Experiences Scale, Defectiveness /Shame Schema subscale of the Young Schema Questionnaire-Short Form. Results: Data were analyzed using SmartPLS-SEM. The results showed that early childhood experiences and humiliation significantly predict SAD. Also, the indirect effects of the independent variables through defectiveness/shame schema on SAD were significant. Conclusions: Consistent with the assumptions of the emotion-focused approach to SAD, these results confirm that early life experiences and humiliation with the development of shame schemes play an important role in the etiology of SAD and must be considered for therapy to be effective. The results of this study suggest that the components of the emotion-focused model can have therapeutic value as targets of intervention in randomized clinical trials."

Potential Applications of Social Robots in Robot-Assisted Interventions for Social Anxiety

Social anxiety disorder or social phobia is a condition characterized by debilitating fear and avoidance of different social situations. We provide an overview of social anxiety and evidence-based behavioural and cognitive treatment approaches for this condition. However, treatment avoidance and attrition are high in this clinical population, which calls for innovative approaches, including computer-based interventions, that could minimize barriers to treatment and enhance treatment effectiveness. After reviewing existing assistive technologies for mental health interventions, we provide an overview of how social robots have been used in many clinical interventions. We then propose to integrate social robots in conventional behavioural and cognitive therapies for both children and adults who struggle with social anxiety. We categorize the different therapeutic roles that social robots can potentially play in activities rooted in conventional therapies for social anxiety and oriented towards symptom reduction, social skills development, and improvement in overall quality of life. We discuss possible applications of robots in this context through four scenarios. These scenarios are meant as ‘food for thought’ for the research community which we hope will inspire future research. We discuss risks and concerns for using social robots in clinical practice. This article concludes by highlighting the potential advantages as well as limitations of integrating social robots in conventional interventions to improve accessibility and standard of care as well as outlining future steps in relation to this research direction. Clearly recognizing the need for future empirical work in this area, we propose that social robots may be an effective component in robot-assisted interventions for social anxiety, not replacing, but complementing the work of clinicians. We hope that this article will spark new research, and research collaborations in the highly interdisciplinary field of robot-assisted interventions for social anxiety.

Look at the Audience? A Randomized Controlled Study of Shifting Attention From Self-Focus to Nonsocial vs. Social External Stimuli During Virtual Reality Exposure to Public Speaking in Social Anxiety

Background: Enhanced self-focused attention plays a central role in the maintenance and treatment of Social Anxiety and is targeted in contemporary cognitive behavioral therapy. Actual developments use Virtual Reality (VR) for behavioral training. However, no VR attention training combining exposure to public speaking with shifting attention from self-focus to external focus has been investigated, and no experimental evidence exists on different kinds of external cues as targets of attention. Therefore, we investigated the effects of an attention training during public speaking in VR and examined differential effects of an external focus on nonsocial vs. social stimuli. Methods: In this randomized controlled study, highly socially anxious participants were instructed to focus on either objects or the audience within a virtual speech task. We assessed the pre-post effects on affective reactions, self-perception, and attentional processes during public speaking as well as general Social Anxiety using subjective, physiological, and eye-tracking measures. Repeated-measures analyses of variance (ANOVAs) were calculated to detect changes from pretest to posttest over both groups, and time × group interaction effects. Results: Within the analysis sample (n = 41), anxiety during public speaking and fear of negative evaluation significantly decreased, with no significant differences between groups. No significant time effect, but a significant time × group effect, was found for the looking time proportion on the audience members' heads. Follow-up tests confirmed a significant increase in the social-focus group and a significant decrease in the nonsocial-focus group. For all other variables, except external focus and fear of public speaking, significant improvements were found over both groups. Further significant time x group effects were found for positive affect during public speaking, with a significant increase in the social focus, and no significant change in the nonsocial-focus group. Conclusion: Our findings suggest that attention training to reduce self-focus can be successfully conducted in VR. Both training versions showed positive short-term effects in the highly socially anxious, with particular advantages of an external social focus concerning eye contact to the audience and positive affect. Further research should investigate whether social focus is even more advantageous long term and if reinterpretations of dysfunctional beliefs could be achieved by not avoiding social cues.

Are people with social anxiety disorder happier alone?

Quality contact with other people serves as a reliable mood enhancement strategy. We wondered if the emotional benefits of socializing are present even for those with a psychological disorder defined by social distress and avoidance: social anxiety disorder (SAD). We conducted two ecological momentary assessment (EMA) studies and analyzed 7243 total surveys. In both studies, community adults diagnosed with SAD and healthy controls received five surveys each day for 2 weeks. Consistent with research on positivity deficits in SAD, between-person analyses in both studies suggest that, on average, participants with SAD reported lower positive and higher negative affect in social and non-social situations than healthy controls. Within-person analyses, however, revealed that in both studies participants with SAD and healthy controls reported higher positive affect when with others than when alone; no differences were found for negative affect for those with SAD. The difference in positive affect between social and nonsocial situations was smaller for participants with SAD in Study 1, suggesting that people with SAD may experience diminished reward responding when socializing. Our results suggest that even those with a mental illness defined by interpersonal distress can and do derive positive emotions from social interactions.

Modeling the subjective perspective of consciousness and its role in the control of behaviours

Consciousness has been hypothesized to operate as a global workspace, which accesses and integrates multimodal information in a uni_ed manner, supports expectation violation monitoring and reduction, and the motivation, programming and control of action. One important yet open issue concerns how the subjective perspective at the core of consciousness, and subjective properties of manifestation of the environment in such perspective as an embodied experience, play a role in such process. We operationalised the concept of subjective perspective using the principles of the Projective Consciousness Model (PCM), based on the projective geometrical concept of Field of Consciousness. We show how these principles can account for documented relationships between appraisal and distance as an inverse distance law, yield a generative model of a_ective and epistemic drives based on purely subjective parameters, such as the apparent size of objects, and can be generalised to implement Theory of Mind, in a manner that is consistent with simulation theory. We used simulations of arti_cial agents, based on psychological rationale, to demonstrate how different model parameters could generate a variety of emergent adaptive and maladaptive behaviours that are relevant to developmental and clinical psychology: the ability to be resilient in the face of obstacles through imaginary projections, the emergence of social approach and joint attention behaviours, the ability to take advantage of false beliefs attributed to others, the emergence of avoidance behaviours as observed in social anxiety disorders, the presence of restricted interests as observed in autism spectrum disorders. The simulation of agents was applied to a speci_c robotic context, and agents' behaviours were demonstrated by controlling the corresponding robots. Our results contribute to advance the scienti_c understanding of the causal relationships between core aspects of the phenomenology of consciousness and its functions in human cybernetics.

Social Anxiety and the Generation of Positivity During Dyadic Interaction: Curiosity and Authenticity Are the Keys to Success

What drives positive affective and interpersonal experiences during social interaction? Undergraduates with high (n = 63) or low (n = 56) trait social anxiety (SA) were paired with unfamiliar low SA partners in a 45-minute conversation task. Throughout the task, participants and their conversation partners completed measures of affiliative goals, affect, curiosity, authenticity, and attentional focus. Both affective and interpersonal outcomes were assessed. Dyadic analyses revealed that participants' affiliative goals during the social interaction predicted positive outcomes for both themselves and their partners, although the link between affiliative goals and positive affect was weaker for participants with high SA. Mediation analyses demonstrated that adopting affiliative goals may promote more positive outcomes by increasing participants' curiosity and felt authenticity. Taken together, results illuminate the pathways through which people with varying levels of trait SA may derive interpersonally generated positive affect and positive social outcomes, with implications for clinical theory and practice.

Examining the relationship between shame and social anxiety disorder: A systematic review

This paper is the first systematic review of the literature on the relationship between shame and social anxiety (SA). We reviewed a total of 60 peer-reviewed empirical articles that met criteria for inclusion. We begin by summarizing literature investigating the empirical association between shame and SA and review literature on whether this association is impacted by cultural or diagnostic differences. Next, we briefly describe the updated version of Rapee and Heimberg's (1997) cognitive-behavioral model of social anxiety disorder (SAD; Heimberg, Brozovich, & Rapee, 2014) and propose how shame may interact with five processes described therein: environmental experiences, observations/images of the self, perceived negative evaluation by others, post-event cognitive processes, and behavioral manifestations of SA. We review the current literature on shame and SA as it relates to each of these domains. Thereafter, we discuss existing research on the role of shame in the treatment of SAD and the implications of the research discussed in this review. Finally, we conclude with a discussion of some key limitations in the existing literature and areas for future research.

The Medium is the Message: Effects of Mediums of Communication on Perceptions and Emotions in Social Anxiety Disorder

We examined the use of voice/text and visual mediums and their effects on perceptions and emotions in social anxiety disorder (SAD). Our sample included 88 individuals: 44 individuals with SAD and 44 non-socially-anxious (NSA) individuals. We used an experience sampling methodology (ESM) in which participants received daily links to online measures at random times during the day, for 21 days and reported on social interactions, emotions and perceptions. Results indicated that individuals with SAD used voice/text mediums to a greater extent and used visual mediums to a lesser extent compared to NSA individuals. However, despite preferring voice/text mediums, use of visual mediums resulted in immediate increases in positive perceptions and emotions for individuals with SAD. These findings were above and beyond the effect of depressive symptoms and remained when social anxiety was represented as a continuum of severity. This has important implications for exposure interventions in the treatment of SAD.

MDMA-Assisted Therapy as a Means to Alter Affective, Cognitive, Behavioral, and Neurological Systems Underlying Social Dysfunction in Social Anxiety Disorder

Social anxiety disorder (SAD) is a prevalent and often debilitating psychiatric disorder that can assume a chronic course even when treated. Despite the identification of evidence-based pharmacological and behavioral treatments for SAD, much room for improved outcomes exists and 3,4-methylenedioxymethamphetamine (MDMA) has been proposed as a promising adjunctive treatment to psychological interventions for disorders characterized by social dysfunction. A small randomized, placebo-controlled trial of MDMA-assisted therapy (MDMA-AT) for social anxiety in autistic adults offered encouraging results, but more research is sorely needed to explore the potential for MDMA-AT in treating SAD. This review aims to stimulate future study by summarizing research on disruptions in neurological, perceptual, receptive, and expressive systems regulating social behavior in SAD and proposing how MDMA-AT may alter these systems across four domains. First, we review research highlighting the roles of social anhedonia and reduced social reward sensitivity in maintaining SAD, with specific attention to the reduction in positive affect in social situations, infrequent social approach behaviors, and related social skills deficits. We posit that MDMA-AT may enhance motivation to connect with others and alter perceptions of social reward for an extended period following administration, thereby potentiating extinction processes, and increasing the reinforcement value of social interactions. Second, we review evidence for the central role of heightened social evaluative threat perception in the development and maintenance of SAD and consider how MDMA-AT may enhance experiences of affiliation and safety when interacting with others. Third, we consider the influence of shame and the rigid application of shame regulation strategies as important intrapersonal processes maintaining SAD and propose the generation of self-transcendent emotions during MDMA sessions as a mechanism of shame reduction that may result in corrective emotional experiences and boost memory reconsolidation. Finally, we review research on the role of dysfunctional interpersonal behaviors in SAD that interfere with social functioning and, in particular, the development and maintenance of close and secure relationships. We discuss the hypothesized role of MDMA-AT in improving social skills to elicit positive interpersonal responses from others, creating a greater sense of belonging, acceptance, and social efficacy.

Self-compassion and emotional regulation as predictors of social anxiety

OBJECTIVES

Self-compassion and emotional regulation have been identified as constructive attitudes towards the self which can reduce emotional distress. This study is the first to examine the role of a self-compassionate attitude towards the self in reducing symptoms of social anxiety. The study also explored the role of emotional regulation strategies of cognitive reappraisal (CR) and expressive suppression (ES) as mechanisms that mediate the impact of self-compassion on social anxiety.

DESIGN

Structural equation modelling (SEM) was conducted on cross-sectional correlational data with MPlus version 6.

METHODS

A sample of 750 undergraduate students (378 men and 372 women) completed an online survey comprised of well validated self-report measures of social anxiety, emotional regulation and self-compassion.

RESULTS

Structural equation modelling showed that self-compassion predicted lower social anxiety directly and indirectly through lower ES. Higher self-compassion also predicted higher CR. Contrary to expectation, CR did not predict lower social anxiety. Exploratory analyses of self-compassion divided into Compassionate Self-responding (CSR) and Refraining from Non-compassionate Responding (RUSR) identified RUSR as a predictor of lower social anxiety directly and indirectly via ES and CR. CSR had no direct effect on social anxiety but did so indirectly via CR.

CONCLUSIONS

The findings provide preliminary evidence that self-compassion can play an important role in alleviating social anxiety and that emotion regulation through ES and CR are important mechanisms of that influence.

PRACTITIONER POINTS

Adopting a more compassionate attitude towards the self can reduce the symptoms of social anxiety Emotional regulation through reducing emotional suppression may be a mechanism whereby higher levels of self-compassion reduce symptoms of social anxiety. Although higher levels of self-compassion predict greater use of emotional regulation through cognitive appraisal, cognitive appraisal does not predict levels of symptoms of social anxiety The capacity to refrain from non-compassionate self-responding may reduce symptoms of social anxiety directly and indirectly through lower levels of emotional suppression and greater cognitive reappraisal (CR). However, compassionate self-responding only influences symptoms of social anxiety through CR.

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.

A Randomized Trial of Brief Online Interventions to Facilitate Treatment Seeking for Social Anxiety

This study developed and evaluated a brief, single-session online intervention designed to facilitate treatment seeking among adults with clinically significant social anxiety (SA) symptoms, who generally seek treatment at exceptionally low rates. Adults (N = 267) reporting significant SA symptoms were recruited online and randomized to a brief, single-session online intervention: Education consisted of brief psychoeducation and treatment resources, or Education+Motivation which added treatment seeking-focused motivational content adapted from Motivational Interviewing and Acceptance and Commitment Therapy. Attitudes, intentions, perceived control, and treatment seeking were assessed at Pre, Post, and 1-month follow-up (FU). Both interventions were feasible (90% completion) and improved all outcomes. At FU, 70% reported engaging in one or more SA treatment-seeking behaviors. Education+Motivation was more effective than Education at improving treatment-seeking attitudes and behaviors. A brief online intervention with educational and motivational content is a promising direction for promoting treatment seeking for adults with SA symptoms.

The Importance of Learning Style in Case Formulation–Driven Cognitive Behavioral Therapy: A Case Study

Rather than structuring treatment based on diagnoses, case formulation–driven cognitive behavior therapy (CF-CBT) focuses on building an individualized formulation or map of how a patient’s presenting problems are being maintained and uses this formulation to guide treatment planning. A case formulation can include comorbid diagnoses, underlying mechanisms, relevant historical, biological, and social factors, and problems unrelated to a diagnosis (e.g., unemployment). Therapy is also a learning context, and clients vary in their learning styles and preferences. The success of treatment depends not only on what a client learns but also on how a client learns. Frequently, learning style is not considered when developing a case formulation or providing CBT. The present case study, based on a man with social anxiety disorder who was treated using CF-CBT, demonstrates the importance of including learning style to target both what and how the client learns.

Reconnecting in the Face of Exclusion: Individuals with High Social Anxiety May Feel the Push of Social Pain, but not the Pull of Social Rewards

Background

Previous research has shown that high levels of trait social anxiety (SA) disrupt the social repair processes following a painful social exclusion, but the cognitive mechanisms involved in these processes and how trait SA may disrupt them remain unknown.

Methods

We conducted a preregistered study on Prolific participants (N = 452) who were assigned to experience either social exclusion or inclusion and were then exposed to follow-up opportunities for social reconnection.

Results

Moderated mediation analyses revealed that irrespective of levels of SA, participants responded to social pain with heightened approach motivation and greater downstream positive affect. Exploratory analyses revealed that heightened desire to affiliate was driven by increased curiosity and attention to social rewards. Moreover, higher SA was associated with lower overall desire to affiliate and this relationship between SA and affiliation was mediated by diminished reward responsiveness.

Conclusions

Findings highlight the roles of goal pursuit and social reward responsiveness in social repair and how high levels of trait SA may disrupt these processes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-021-10263-z.