A model of the development and maintenance of generalized social phobia

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.

Neural response to monetary and social rewards and familial risk for psychopathology in adolescent females

BACKGROUND

Adolescence is a key developmental period for the emergence of psychopathology. Reward-related brain activity increases across adolescence and has been identified as a potential neurobiological mechanism of risk for different forms of psychopathology. The reward positivity (RewP) is an event-related potential component that indexes reward system activation and has been associated with both concurrent and family history of psychopathology. However, it is unclear whether the RewP is also associated with higher-order psychopathology subfactors and whether this relationship is present across different types of reward.

METHODS

In a sample of 193 adolescent females and a biological parent, the present study examined the association between adolescent and parental psychopathology subfactors and adolescent RewP to monetary and social reward.

RESULTS

Results indicated that the adolescent and parental distress subfactors were negatively associated with the adolescent domain-general RewP. The adolescent and parental positive mood subfactors were negatively associated with the adolescent domain-general and domain-specific monetary RewP, respectively. Conversely, the adolescent and parental fear/obsessions subfactors were positively associated with the adolescent domain-general RewP. The associations between parental and adolescent psychopathology subfactors and the adolescent RewP were independent of each other.

CONCLUSIONS

The RewP in adolescent females is associated with both concurrent and parental psychopathology symptoms, suggesting that it indexes both severity and risk for higher-order subfactors.

A comprehensive review on the role of testosterone on the neurobehavioral systems implicated in the reinforcement sensitivity theory of personality

OBJECTIVES

The Reinforcement Sensitivity Theory (RST) is a neuropsychological theory of personality emphasizing approach and avoidance as the two core behavioral aspects. Approach is represented by the behavioral approach system (BAS). Avoidance is represented by the behavioral inhibition system (BIS) and the fight-flight-freeze system (FFFS). Although the influence of testosterone on human behavior has been demonstrated, few studies have investigated the relation between testosterone and the RST. The aim of this narrative review was to decipher the possible role of testosterone on the biological systems involved in the RST in humans.

METHODS

Google scholar, PubMed, PsycARTICLES, PsycINFO, Scopus and Cochrane library databases were interrogated using keywords such as testosterone, BIS, BAS, FFFS, personality, reinforcement sensitivity theory.

RESULTS

Seven original articles, published between 2009 and 2022, assessing the relation between testosterone and the systems implicated in the RST, were included. The results of these studies suggested the presence of a possible positive relation between testosterone and the BAS. However, the impact of testosterone on the BIS and/or FFFS seems to be less clear.

DISCUSSION

The consistency in the results supporting the presence of a positive relation between testosterone and the BAS might lead to the consideration of testosterone as a potential correlate in the clinical assessment of several psychopathologies. The inconsistency in the conclusions regarding the impact of testosterone on the BIS and/or the FFFS might be attributed to the different questionnaires used as measurement tools. Additional research remains needed.

Underlying differences in resting-state activity metrics related to sensitivity to punishment

Reinforcement sensitivity theory (RST) of personality establishes the punishment sensitivity trait as a source of variation in defensive avoidance/approach behaviors. These individual differences reflect dissimilar sensitivity and reactivity of the fight-flight-freeze and behavioral inhibition systems (FFFS/BIS). The sensitivity to punishment (SP) scale has been widely used in personality research aimed at studying the activity of these systems. Structural and functional neuroimaging studies have confirmed the core biological correlates of FFFS/BIS in humans. Nonetheless, some brain functional features derived from resting-state blood-oxygen level-dependent (BOLD) activity and its association with the punishment sensitivity dimension remain unclear. This relationship would shed light on stable neural activity patterns linked to anxiety-like behaviors and anxiety predisposition. In this study, we analyzed functional activity metrics "at rest" [e.g., regional homogeneity (ReHo) and fractional amplitude of low-frequency fluctuation (fALFF)] and their relationship with SP in key FFFS/BIS regions (e.g., amygdala, hippocampus, and periaqueductal gray) in a sample of 127 healthy adults. Our results revealed a significant negative correlation between the fALFF within all these regions and the scores on SP. Our findings suggest aberrant neural activity (lower fALFF) within the brain's defense system in participants with high trait anxiety, which in turn could reflect lower FFFS/BIS activation thresholds. These neurally-located differences could lead to pathological fear/anxiety behaviors arising from the FFFS and BIS.

Behavioral problems in anxious youth: Cross-sectional and prospective associations with reinforcement sensitivity and parental rejection

A subsample of children and young people (CYP) with anxiety disorders presents with comorbid behavioral problems. These CYP have greater impairment in daily life, profit less from current treatments, and have an increased risk for continued mental problems. We investigated two potential explanations for these comorbid behavioral problems. First, high punishment sensitivity (PS) may lead to a strong inclination to experience threat, which may not only elicit anxiety but also defensive behavioral problems. Second, behavioral problems may arise from high reward sensitivity (RS), when rewards are not obtained. Behavioral problems may subsequently elicit parental rejection, thereby fueling anxiety. We used a cross-sectional (age = 16.1, N = 61) and prospective (age = 22.2, N = 91) approach to test the relationship between PS/RS and comorbid behavioral problems. Participants were a subsample of highly anxious CYP from a large prospective cohort study. PS/RS were indexed by a spatial orientation task. We also investigated the prospective association between behavioral problems and anxiety at 6-year follow-up, and the proposed mediation by parental rejection. PS and RS showed no cross-sectional or prospective relationships with comorbid behavioral problems in highly anxious CYP. Yet, behavioral problems in adolescence showed a small prospective relationship with anxiety in young adulthood, but this was not mediated nor moderated by parental rejection. No evidence was found for PS/RS being involved in comorbid behavioral problems in anxious CYP. Findings point to comorbid behavioral problems as potential factor contributing to the further increase of anxiety.

Social anxiety and rumination in the context of the revised reinforcement sensitivity theory and the mediation model of social anxiety

The aim of this study was to examine the relationship between temperament, ruminative thought style and social anxiety using latent variable modeling. Before examining the integrated model that specifies the relations between the constructs, relevant measurement issues were examined. The study was conducted on a heterogeneous sample from the general population that included 1,029 participants (62.1% female) aged 19 to 79. The findings show that the Behavioural Inhibition System is the most important vulnerability factor for the development of social anxiety, and it has both a direct effect and an indirect one through the ruminative thought style. Also, Freeze has an additional contribution to the increased experience of social anxiety. The Behavioural Approach System has complex effects on social anxiety ? with a direct protective effect, and indirectly ? with a facilitation of the ruminative thought style. Thus, BAS can also act as a risk factor. The findings support the revised Reinforcement Sensitivity Theory and provide a basis for the extension of the Kimbrel?s Mediation Model of Social Anxiety.

Anger Responses in Adolescents: Relationship with Punishment and Reward Sensitivity

A substantial proportion of youth with anxiety disorders shows comorbid behavioral (anger) problems. Such comorbid profile is associated with low treatment effectiveness and negative (longterm) outcomes. This study was therefore designed to examine trait factors that may promote anger responding in adolescents. By presenting participants (N = 158, mean age = 15.7, 56% female) with a series of common anger-eliciting situations, we tested whether high reward sensitivity would be associated with anger via perceived non-reward, and high punishment sensitivity via perceived threat. In line with the hypotheses, an indirect effect of reward sensitivity on anger was found via perceived non-reward, and an indirect effect of punishment sensitivity on anger via perceived threat. The latter association also had an indirect effect via perceived non-reward. High punishment and reward sensitivity may thus set adolescents at risk for developing (comorbid) anger problems via heightened threat and non-reward perceptions.

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.

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.

Expression and co-expression of serotonin and dopamine transporters in social anxiety disorder: a multitracer positron emission tomography study

Serotonin and dopamine are putatively involved in the etiology and treatment of anxiety disorders, but positron emission tomography (PET) studies probing the two neurotransmitters in the same individuals are lacking. The aim of this multitracer PET study was to evaluate the regional expression and co-expression of the transporter proteins for serotonin (SERT) and dopamine (DAT) in patients with social anxiety disorder (SAD). Voxel-wise binding potentials (BP_ND) for SERT and DAT were determined in 27 patients with SAD and 43 age- and sex-matched healthy controls, using the radioligands [¹¹C]DASB (3-amino-4-(2-dimethylaminomethylphenylsulfanyl)-benzonitrile) and [¹¹C]PE2I (N-(3-iodopro-2E-enyl)-2beta-carbomethoxy-3beta-(4'-methylphenyl)nortropane). Results showed that, within transmitter systems, SAD patients exhibited higher SERT binding in the nucleus accumbens while DAT availability in the amygdala, hippocampus, and putamen correlated positively with symptom severity. At a more lenient statistical threshold, SERT and DAT BP_ND were also higher in other striatal and limbic regions in patients, and correlated with symptom severity, whereas no brain region showed higher binding in healthy controls. Moreover, SERT/DAT co-expression was significantly higher in SAD patients in the amygdala, nucleus accumbens, caudate, putamen, and posterior ventral thalamus, while lower co-expression was noted in the dorsomedial thalamus. Follow-up logistic regression analysis confirmed that SAD diagnosis was significantly predicted by the statistical interaction between SERT and DAT availability, in the amygdala, putamen, and dorsomedial thalamus. Thus, SAD was associated with mainly increased expression and co-expression of the transporters for serotonin and dopamine in fear and reward-related brain regions. Resultant monoamine dysregulation may underlie SAD symptomatology and constitute a target for treatment.

Phenotypes of reinforcement sensitivity as predictors of the response to acute antidepressant treatment in rats

One of the biggest threats to modern societies is the increasing prevalence of mood disorders. Cognitive deficits associated with depressive and bipolar disorders are a major driver of functional impairment and the ensuing disability of the suffering individuals. Growing evidence has indicated strong inter-individual differences in the vulnerability to development and effectivity of treatment of these psychiatric conditions, linking various levels of reinforcement sensitivity with specific mood conditions. In this study, we took a unique opportunity to investigate how trait sensitivity to reinforcement determines the reactivity of rats to acute antidepressant treatment. For this, using a preclinical version of the probabilistic reversal-learning (PRL) paradigm, we identified 4 phenotypes of sensitivity to negative and positive feedback in rats, which could represent various types of potential vulnerability to affective disorders. Subsequently, using the light/dark box (LDB) and progressive ratio schedule of reinforcement (PRSR) tests, we evaluated inter-phenotypic differences in the effects of acute treatment with 3 different antidepressant drugs (escitalopram, mirtazapine and clomipramine, each in 3 doses) on anxiety and appetitive motivation of experimental animals. We report statistically significant differences between the investigated phenotypes of reinforcement sensitivity in the effects of acute escitalopram treatment on anxiety in the LDB test. We also report phenotype-independent effects of mirtazapine on motivation and anxiety and a lack of effect of clomipramine. These results demonstrate for the first time that trait sensitivity to reinforcement could have important implications for the effectiveness of treatment in affective disorders.

No1LikesU! – A pilot study on an ecologically valid and highly standardised experimental paradigm to investigate social rejection expectations and their modification

Background

Dysfunctional expectations have been suggested as core features in the development and maintenance of mental disorders. Thus, preventing development and promoting modification of dysfunctional expectations through intervention might improve clinical treatment. While there are well-established experimental procedures to investigate the acquisition and modification of dysfunctional performance expectations in major depression, paradigms for investigating other important types of dysfunctional expectations (e.g. social rejection expectations) are currently lacking. We introduce an innovative associative learning paradigm, which can be used to investigate the development, maintenance, and modification of social rejection expectations.

Method

A pilot sample of 28 healthy participants experienced manipulated social feedback after answering personal questions in supposed webcam conferences. While participants repeatedly received social rejection feedback in a first phase, differential feedback was given in a second phase (social rejection vs. social appreciation). In a third phase, explicit social feedback was omitted.

Results

Participants developed social rejection expectations in the first phase. For the second phase, we found an interaction effect of experimental condition; i.e. participants adjusted their expectations according to the differential social feedback. In the third phase, learned social expectations remained stable in accordance to the social feedback in the second phase.

Conclusion

Results indicate that the paradigm can be used to investigate the development, maintenance, and modification of social rejection expectations in healthy participants. This offers broad applications to explore the differential acquisition and modification of social rejection expectations in healthy vs. clinical samples. Further, the paradigm might be used to investigate therapeutic strategies to facilitate expectation change.

Can words be worse than stones? Understanding distressing social events and their relationship with social anxiety

Research on the relationship between distressing social events and social anxiety has focused on antagonistic social events (i.e., peer victimization, cyberbullying) in adolescent samples. There is little research examining such relationships in adults, and less examining the relationship between non-antagonistic distressing social events (i.e., accidental embarrassing events) and social anxiety. The current investigation utilized a retrospective design to examine how different distressing social events may be associated with posttraumatic stress-like reactions, which may relate to social anxiety in early adulthood. Characteristics of distressing social events (i.e., betrayal, presence of an antagonist) were explored as possible influences on the severity of stress responses. Community participants (n = 271; ages 18-25) completed online questionnaires measuring social anxiety and reactions to distressing social events. Antagonistic and non-antagonistic distressing social events were both related to social anxiety. Relationships between the frequencies of any distressing social events and social anxiety were mediated by reactions akin to posttraumatic stress. Responses to distressing social events were not influenced by the presence of an antagonist or betrayal. The results suggest that non-antagonistic distressing social events can be as distressing as antagonistic distressing social events and contribute to expanding evidence that reactions to distressing social events may resemble reactions to life-threatening events.

Reinforcement sensitivity, depression and anxiety: A meta-analysis and meta-analytic structural equation model

Reinforcement Sensitivity Theory (RST) posits that individual differences in reward and punishment processing predict differences in cognition, behavior, and psychopathology. We performed a quantitative review of the relationships between reinforcement sensitivity, depression and anxiety, in two separate sets of analyses. First, we reviewed 204 studies that reported either correlations between reinforcement sensitivity and self-reported symptom severity or differences in reinforcement sensitivity between diagnosed and healthy participants, yielding 483 effect sizes. Both depression (Hedges' g = .99) and anxiety (g = 1.21) were found to be high on punishment sensitivity. Reward sensitivity negatively predicted only depressive disorders (g = -.21). More severe clinical states (e.g., acute vs remission) predicted larger effect sizes for depression but not anxiety. Next, we reviewed an additional 39 studies that reported correlations between reinforcement sensitivity and both depression and anxiety, yielding 156 effect sizes. We then performed meta-analytic structural equation modeling to simultaneously estimate all covariances and control for comorbidity. Again we found punishment sensitivity to predict depression (β = .37) and anxiety (β = .35), with reward sensitivity only predicting depression (β = -.07). The transdiagnostic role of punishment sensitivity and the discriminatory role of reward sensitivity support a hierarchical approach to RST and psychopathology.

Interaction Effects of Behavioral Inhibition System/Behavioral Activation System and Cost/Probability Biases on Social Anxiety

Introduction

Social anxiety disorder (SAD) symptoms are maintained by cognitive biases, which are overestimations of the severity and likelihood of negative social events (cost/probability biases), and by sensitivity to rewards and punishments that are determined according to behavioral inhibition/behavioral activation systems (BIS/BAS). Cost/probability biases might activate the behavioral immune system and exacerbate the avoidance of social events. Earlier studies have proposed that low BIS or high BAS decrease SAD symptoms; BIS/BAS may even change the effects of cognitive biases on SAD symptoms. Hence, the current study investigates the interaction effects of BIS/BAS and cost/probability biases on SAD symptoms.

Method

Seventy-six Japanese undergraduate students completed the Japanese version of the Liebowitz Social Anxiety Scale (LSAS), which comprises Fear and Avoidance subscales, the BIS/BAS Scale, and the Social Cost Probability Scale.

Results

A multiple regression analysis was performed to examine whether cost/probability biases, BIS/BAS, and their interactions affected SAD symptoms; following this, the main effects of cost bias and BIS were determined for LSAS-Fear (β = 0.64, p < 0.001; β = 0.33, p < 0.01) and LSAS-Avoidance (β = 0.49, p < 0.001; β = 0.35, p < 0.01). The interaction effect between cost bias and BAS was significant for LSAS-Avoidance (β = -0.32, p < 0.05). Simple slope analysis showed that the slope of cost bias was significant for low-BAS individuals (β = 0.77, p < 0.001) but not for high-BAS individuals (β = -0.21, n.s.). The interaction effect between probability bias and BAS was significant for LSAS-Avoidance (β = 0.40, p < 0.01) as well. Further, simple slope analysis revealed that the slope of probability bias was significant for low-BAS individuals (β = -0.53, p < 0.05) but not for high-BAS individuals (β = 0.17, n.s.).

Discussion

The study found interesting results with respect to the avoidance of social events. Low-BAS individuals with high cost or low probability biases regarding social events may have a tendency to avoid social events. In contrast, if high-BAS individuals overestimate the cost of social events or underestimate the probability of social events, their anticipation of rewards might prevent them from avoiding social events.

Understanding Emotion Inflexibility in Risk for Affective Disease: Integrating Current Research and Finding a Path Forward

Emotion-related disorders (e.g., depression, anxiety, stress, eating, substance and some personality disorders) include some of the most common, burdensome, and costly diseases worldwide. Central to many, if not all of these disorders, may be patterns of rigid or inflexible emotion responses. Indeed, theorists point to emotion in-flexibility as a potential cause or maintaining factor in emotion-related diseases. Despite the increasing prominence of emotion inflexibility in theories of affective disease, a comprehensive review of the developing empirical literature has not yet been conducted. Accordingly, this review will examine the three dominant lines of inquiry assessing emotion flexibility. These include: (1) the capacity to use and vary deliberate emotion regulation strategies, (2) the context sensitivity of spontaneous emotional responses, and (3) flexibility in the appraisal of emotional events and experiences. Moreover, current evidence suggests that each of these three lines of research may converge to suggest the interplay of two key biological dimensions in emotion inflexibility, threat sensitivity, and cognitive control, known to be impaired in patients with affective disorders. In short, this developing body of work suggests a path by which future research could explicate and even exploit the ties between emotion inflexibility and affective disease, contributing to the development of improved models of risk, assessment, and intervention, with broad implications for psychological health.

Fear and Anxiety in Social Setting

Abstract. The purpose of this study was to examine the effects of dispositional and situational factors on cognitive biases. The theoretical background was based on Kimbrel’s Mediated Model of Social Anxiety and the revised reinforcement sensitivity theory by Gray and McNaughton. Two experiments were conducted. Study 1 (78 participants [85.9% females, aged 19–21 years]) included the induction of potential social threat, while in Study 2 (121 participants [85.1% females, aged 19–23 years]) real threat was used. The Reinforcement Sensitivity Questionnaire was employed as a measure of personality traits (Behavioral Inhibition System [BIS], Behavioral Approach System [BAS], Fight, Flight, and Freeze). Cognitive biases were assessed with the Dot Probe Task (attentional bias), Incidental Free Recall Task (memory bias), and Social Probability Cost Questionnaire (judgmental bias). The probability of occurrence of negative events was higher in the experimental group. BIS contributed positively to the prediction of probability of occurrence of negative events; and Freeze was positively related to attention bias toward pleasant stimuli. The results of the second study showed that experimentally induced circumstances of social threats did not affect cognitive biases. BIS and Freeze contributed positively to prediction of probability and distress in social context, while BIS was positively related with probability of occurrence of negative social events.

High risk, high reward: Daily perceptions of social challenge and performance in social anxiety disorder

Individuals with Social Anxiety Disorder (SAD) have difficulty engaging in social situations because their actions are predicated on minimizing the subjectively biased high potential for rejection. That is, individuals with SAD frequently perceive social situations as challenging, and their performance as subpar. Yet when individuals perceive themselves as succeeding in challenging situations, they typically report these situations as enjoyable and rewarding. This subjective experience of succeeding in a challenging situation has been studied as flow (Csikszentmihalyi, 1975; 2000). Thirty-three adults with SAD and 34 matched healthy controls completed a baseline assessment, along with daily and experience sampling entries for 14 days. Results were analyzed using three-level generalized linear mixed effects models, with observations nested within days, nested within participants. Although individuals with and without SAD experienced the same frequency of flow in daily life, social situations led to proportionally more flow in participants with SAD than healthy controls. Both results were unexpected, and reasons for them are explored at length. Several experiential variables (positive emotions during and importance ascribed to the event) predicted the probability of flow during each situation. These results offer intervention-relevant suggestions for how individuals may benefit from seeking out challenging situations that offer maximal rewards.

Altered activation of the ventral striatum under performance-related observation in social anxiety disorder

BACKGROUND

Social anxiety disorder (SAD) is characterized by fear of social and performance situations. The consequence of scrutiny by others for the neural processing of performance feedback in SAD is unknown.

METHODS

We used event-related functional magnetic resonance imaging to investigate brain activation to positive, negative, and uninformative performance feedback in patients diagnosed with SAD and age-, gender-, and education-matched healthy control subjects who performed a time estimation task during a social observation condition and a non-social control condition: while either being monitored or unmonitored by a body camera, subjects received performance feedback after performing a time estimation that they could not fully evaluate without external feedback.

RESULTS

We found that brain activation in ventral striatum (VS) and midcingulate cortex was modulated by an interaction of social context and feedback type. SAD patients showed a lack of social-context-dependent variation of feedback processing, while control participants showed an enhancement of brain responses specifically to positive feedback in VS during observation.

CONCLUSIONS

The present findings emphasize the importance of social-context processing in SAD by showing that scrutiny prevents appropriate reward-processing-related signatures in response to positive performances in SAD.

Social anxiety in pre-adolescent children: What do we know about maintenance?

The cognitive theory of social anxiety disorder (SAD) is one of the most widely accepted accounts of the maintenance of the disorder in adults, yet it remains unknown if, or to what extent, the same cognitive and behavioral maintenance mechanisms that occur in adult SAD also apply to SAD among pre-adolescent children. In contrast to the adult literature, current models of SAD in children mostly account for etiology and maintenance processes are given limited attention. Consequently, their clinical utility for the treatment of SAD in children may be limited. This narrative review, first, critically examines the different theoretical conceptualizations of the maintenance of social anxiety in the child and adult literature and illustrates how these have resulted in different treatment approaches and clinical understanding. Second, it reviews the available evidence relating to hypotheses about the maintenance of SAD in children as derived from adult cognitive and etiological models. Third, it highlights the need to attend directly to child specific maintenance mechanisms in SAD, to draw on cognitive theory, and to account for the influence of childhood-specific contextual (e.g. family and school-based interactions) and developmental factors on children's social experiences.

The Role of Environmental Factors in the Aetiology of Social Anxiety Disorder: A Review of the Theoretical and Empirical Literature

Social anxiety disorder (SAD) is characterised by a marked and persistent fear of social/performance situations, and a number of key environmental factors have been implicated in the aetiology of the disorder. Hence, the current article reviews theoretical and empirical evidence linking the development of SAD with parenting factors, traumatic life events, and aversive social experiences. Specifically, research suggests that the risk of developing SAD is increased by over-controlling, critical and cold parenting, an insecure attachment style, aversive social/peer experiences, emotional maltreatment, and to a lesser extent other forms of childhood maltreatment and adversity. Moreover, these factors may lead to posttraumatic reactions, distorted negative self-imagery, and internalised shame-based schemas that subsequently maintain SAD symptomatology. However, further research is necessary to clarify the nature, interactions, and relative contributions of these factors. It is likely that SAD develops via a complex interplay of biological and environmental factors, and that multiple aetiological pathways underlie the development of the disorder.

Maintenance of Social Anxiety in Stuttering: A Cognitive-Behavioral Model

PURPOSE

Stuttering is a speech disorder frequently accompanied by anxiety in social-evaluative situations. A growing body of research has confirmed a significant rate of social anxiety disorder among adults who stutter. Social anxiety disorder is a chronic and disabling anxiety disorder associated with substantial life impairment. Several influential models have described cognitive-behavioral factors that contribute to the maintenance of social anxiety in nonstuttering populations. The purpose of the present article is to apply these leading models to the experience of social anxiety for people who stutter.

METHOD

Components from existing models were applied to stuttering in order to determine cognitive-behavioral processes that occur before, during, and after social-evaluative situations, which may increase the likelihood of stuttering-related social fears persisting.

RESULTS

Maintenance of social anxiety in stuttering may be influenced by a host of interrelated factors, including fear of negative evaluation, negative social-evaluative cognitions, attentional biases, self-focused attention, safety behaviors, and anticipatory and postevent processing.

CONCLUSION

Given the chronic nature of social anxiety disorder, identifying factors that contribute to the persistence of stuttering-related social fears has the potential to inform clinical practice and the development of psychological treatment programs to address the speech and psychological needs of people who stutter with social anxiety.

Effects of cognitive bias modification on social anxiety: A meta-analysis

Background

Cognitive bias modification (CBM), a set of techniques for modifying bias in information processing—is considered a novel intervention for social anxiety disorder (SAD), which has drawn considerable interest from researchers. However, the effects of CBM on SAD are not consistent. Some studies have demonstrated significant positive effects compared to control groups, while others have found no such effects.

Aims

We conducted a meta-analysis aimed at quantitatively assessing the effects of CBM on SAD at post-test.

Method

Through a systematic literature search by two independent raters, 34 articles (36 randomized studies) including 2,550 participants were identified. A multilevel modeling approach was employed to assess the effects of CBM on SAD, and to explore the potentially crucial procedures and sample characteristics that enhance the effectiveness of benign training.

Results

In general, there were small but significant effects of CBM on the primary symptoms of SAD (g = 0.17), cognitive bias (CB) toward threat (g = 0.32), and reactivity in stressful situations (g = 0.25), but non-significant effects on secondary symptoms. However, the interpretation modification program was more effective than was attentional bias modification in reducing SAD primary symptoms and negative CB. Laboratory training procedures produced larger primary symptom reductions compared to Internet-based training, whereas the percentage of contingency and feedback about training performance boosted cognitive effects only. Finally, the following groups were more likely to benefit from CBM: younger participants (primary symptoms and cognitive effects), women (primary symptom effects), and samples with stronger CB (stressor effects). The quality of the randomized controlled trials was less than desirable, as there was some indication of publication bias in our study.

Conclusions

Current findings broadly supported cognitive theories of SAD that consider a bidirectional or mutually reinforcing relationship between symptoms and CBs. However, the small therapeutic effect observed here indicates that it is necessary to develop more reliable and efficient CBM interventions that are specific to SAD.

The aetiology and maintenance of social anxiety disorder: A synthesis of complimentary theoretical models and formulation of a new integrated model

BACKGROUND

Within maintenance models of social anxiety disorder (SAD), a number of cognitive and behavioural factors that drive the persistence of SAD have been proposed. However, these maintenance models do not address how SAD develops, or the origins of the proposed maintaining factors. There are also models of the development of SAD that have been proposed independently from maintenance models. These models highlight multiple factors that contribute risk to the onset of SAD, but do not address how these aetiological factors may lead to the development of the maintaining factors associated with SAD.

METHODS

A systematic review of the literature was conducted to identify aetiological and maintenance models of SAD. We then united key factors identified in these models and formulated an integrated aetiological and maintenance (IAM) model of SAD. A systematic review of the literature was then conducted on the components of the IAM model.

RESULTS

A number of aetiological and maintaining factors were identified in models of SAD. These factors could be drawn together into the IAM model. On balance, there is empirical evidence for the association of each of the factors in the IAM model with social anxiety or SAD, providing preliminary support for the model.

LIMITATIONS

There are relationships between components of the IAM model that require empirical attention. Future research will need to continue to test the IAM model.

CONCLUSIONS

The IAM model provides a framework for future investigations into the development and persistence of SAD.

Prevalence of anxiety disorders among children who stutter

PURPOSE

Stuttering during adulthood is associated with a heightened rate of anxiety disorders, especially social anxiety disorder. Given the early onset of both anxiety and stuttering, this comorbidity could be present among stuttering children.

METHOD

Participants were 75 stuttering children 7-12 years and 150 matched non-stuttering control children. Multinomial and binary logistic regression models were used to estimate odds ratios for anxiety disorders, and two-sample t-tests compared scores on measures of anxiety and psycho-social difficulties.

RESULTS

Compared to non-stuttering controls, the stuttering group had six-fold increased odds for social anxiety disorder, seven-fold increased odds for subclinical generalized anxiety disorder, and four-fold increased odds for any anxiety disorder.

CONCLUSION

These results show that, as is the case during adulthood, stuttering during childhood is associated with a significantly heightened rate of anxiety disorders. Future research is needed to determine the impact of those disorders on speech treatment outcomes.

Reinforcement Sensitivity and Social Anxiety in Combat Veterans

OBJECTIVE

The present study tested the hypothesis that low behavioral approach system (BAS) sensitivity is associated with social anxiety in combat veterans.

METHOD

Self-report measures of reinforcement sensitivity, combat exposure, social interaction anxiety, and social observation anxiety were administered to 197 Iraq/Afghanistan combat veterans.

RESULTS

As expected, combat exposure, behavioral inhibition system (BIS) sensitivity, and fight-flight-freeze system (FFFS) sensitivity were positively associated with both social interaction anxiety and social observation anxiety. In contrast, BAS sensitivity was negatively associated with social interaction anxiety only. An analysis of the BAS subscales revealed that the Reward Responsiveness subscale was the only BAS subscale associated with social interaction anxiety. BAS-Reward Responsiveness was also associated with social observation anxiety.

CONCLUSION

The findings from the present research provide further evidence that low BAS sensitivity may be associated with social anxiety over and above the effects of BIS and FFFS sensitivity.

A Comparison of Reinforcement Sensitivity Theory Measures: Unique Associations With Social Interaction Anxiety and Social Observation Anxiety

Evidence suggests that the behavior inhibition system (BIS) and fight-flight-freeze system play a role in the individual differences seen in social anxiety disorder; however, findings concerning the role of the behavior approach system (BAS) have been mixed. To date, the role of revised reinforcement sensitivity theory (RST) subsystems underlying social anxiety has been measured with scales designed for the original RST. This study examined how the BIS, BAS, and fight, flight, freeze components of the fight-flight-freeze system uniquely relate to social interaction anxiety and social observation anxiety using both a measure specifically designed for the revised RST and a commonly used original RST measure. Comparison of regression analyses with the Jackson-5 and the commonly used BIS/BAS Scales revealed important differences in the relationships between RST subsystems and social anxiety depending on how RST was assessed. Limitations and future directions for revised RST measurement are discussed.

The Take Control Course: Conceptual Rationale for the Development of a Transdiagnostic Group for Common Mental Health Problems

BACKGROUND

Increasingly, research supports the utility of a transdiagnostic understanding of psychopathology. However, there is no consensus regarding the theoretical approach that best explains this. Transdiagnostic interventions can offer service delivery advantages; this is explored in the current review, focusing on group modalities and primary care settings.

OBJECTIVE

This review seeks to explore whether a Perceptual Control Theory (PCT) explanation of psychopathology across disorders is a valid one. Further, this review illustrates the process of developing a novel transdiagnostic intervention (Take Control Course; TCC) from a PCT theory of functioning.

METHOD

Narrative review.

RESULTS AND CONCLUSIONS

Considerable evidence supports key tenets of PCT. Further, PCT offers a novel perspective regarding the mechanisms by which a number of familiar techniques, such as exposure and awareness, are effective. However, additional research is required to directly test the relative contribution of some PCT mechanisms predicted to underlie psychopathology. Directions for future research are considered.

Thwarted Belongingness Mediates the Relationship between Fear of Negative Evaluation and Suicidal Ideation

Fear of negative evaluation has been documented as a mechanism that explains variations in feelings of belongingness. According to the interpersonal theory of suicide (Joiner, 2005), feelings of thwarted belongingness, that one does not belong, can significantly increase desire and risk for suicide. We proposed that differences in thwarted belongingness may explain variations in suicidal ideation and behavior as a function of levels of fear of negative evaluation. This hypothesis was tested by examining self-reported fears of negative evaluation, thwarted belongingness, and suicidal ideation in 107 young adults, many who were explicitly targeted for recruitment due to a history of suicidal ideation and behavior (13.1% had thoughts about suicide without a previous attempt; 15.9% reported at least one previous attempt [max = 5 attempts]). Mediation analyses were conducted with suicidal ideation entered as the outcome variable. Results indicated that greater fears of negative evaluation were significantly and positively associated with levels of suicidal ideation. Differences in thwarted belongingness fully accounted for the relationship between fears of negative evaluation and suicidal ideation. We conclude with clinical implications and future directions.

Neural sensitivity to social reward and punishment anticipation in social anxiety disorder

An imbalance in the neural motivational system may underlie Social Anxiety Disorder (SAD). This study examines social reward and punishment anticipation in SAD, predicting a valence-specific effect: increased striatal activity for punishment avoidance compared to obtaining a reward. Individuals with SAD (n = 20) and age, gender, and education case-matched controls (n = 20) participated in a functional magnetic resonance imaging (fMRI) study. During fMRI scanning, participants performed a Social Incentive Delay (SID) task to measure the anticipation of social reward and punishment. The left putamen (part of the striatum) showed a valence-specific interaction with group after correcting for medication use and comorbidity. The control group showed a relatively stronger activation for reward vs. punishment trials, compared to the social anxiety group. However, post-hoc pairwise comparisons were not significant, indicating that the effect is driven by a relative difference. A connectivity analysis (Psychophysiological interaction) further revealed a general salience effect: SAD patients showed decreased putamen-ACC connectivity compared to controls for both reward and punishment trials. Together these results suggest that the usual motivational preference for social reward is absent in SAD. In addition, cortical control processes during social incentive anticipation may be disrupted in SAD. These results provide initial evidence for altered striatal involvement in both valence-specific and valence-nonspecific processing of social incentives, and stress the relevance of taking motivational processes into account when studying social anxiety.

When social anxiety co-occurs with substance use: does an impulsive social anxiety subtype explain this unexpected relationship?

Although most conceptualizations of social anxiety emphasise that socially anxious individuals are overtly shy, and utilise avoidant behavioural strategies (e.g., risk-aversion, passivity, and submissiveness), there is tentative support for the existence of an approach-motivated subtype, characterised by risk taking and a greater propensity for substance misuse. It is likely that this subtype may help explain the reported co-occurrence of substance misuse and social anxiety. The current study sought to test via latent class analysis whether an approach-motivated social anxiety subtype could be identified within a community sample. A self-report questionnaire was completed by 351 participants (age: 18-74 years). Two distinct social anxiety subgroups were identified: one characterised by prototypical SAD symptomatology (i.e., behavioural inhibition and risk-avoidance), the second by elevated levels of rash impulsiveness, reward sensitivity, risk-taking and co-occurring substance use problems. The current findings provides support for the existence of a distinct approach-motivated social anxiety subtype and indicates that impulsivity may be critical to understanding the comorbid substance use symptomatology of these individuals.

Pathways to social anxiety: the role of reinforcement sensitivities and emotion regulation

Past research has demonstrated a strong relationship between threat sensitivity and social anxiety; however, the relationship between reward sensitivity and social anxiety is less clear. Further, the role that emotion regulation (ER) may play in the expression of social anxiety disorder (SAD) is rarely considered. The current study tested whether two emotion regulation strategies (emotional suppression and cognitive reappraisal) mediated associations between threat sensitivity and reward sensitivity and social anxiety in a community sample (402 adults, 78% female; Mage=32.49, S.D.age=11.53). Path analyses indicated that low reappraisal mediated the relationship between high threat sensitivity and high social anxiety; and both low reappraisal and high suppression mediated the relationship between low reward sensitivity and high social anxiety. These results highlight the potential role that emotion regulation plays in the relationship between trait motivation and social anxiety.