Differentiating social phobia from shyness

Integrative neuro-cardiovascular dynamics in response to test anxiety: A brain-heart axis study

Test anxiety (TA), a recognized form of social anxiety, is the most prominent cause of anxiety among students and, if left unmanaged, can escalate to psychiatric disorders. TA profoundly impacts both central and autonomic nervous systems, presenting as a dual manifestation of cognitive and autonomic components. While limited studies have explored the physiological underpinnings of TA, none have directly investigated the intricate interplay between the CNS and ANS in this context. In this study, we introduce a non-invasive, integrated neuro-cardiovascular approach to comprehensively characterize the physiological responses of 27 healthy subjects subjected to test anxiety induced via a simulated exam scenario. Our experimental findings highlight that an isolated analysis of electroencephalographic and heart rate variability data fails to capture the intricate information provided by a brain-heart axis assessment, which incorporates an analysis of the dynamic interaction between the brain and heart. With respect to resting state, the simulated examination induced a decrease in the neural control onto heartbeat dynamics at all frequencies, while the studying condition induced a decrease in the ascending heart-to-brain interplay at EEG oscillations up to 12Hz. This underscores the significance of adopting a multisystem perspective in understanding the complex and especially functional directional mechanisms underlying test anxiety.

Factors affecting social phobia among Chinese college students in the context of COVID-19 pandemic: a cross-sectional study

Social phobia (SP) refers to excessive anxiety about social interactions. College students, with their exposure to academic, familial, and job-related pressures, are an ideal population for early screening and intervention of social phobia. Additionally, COVID-19 prevention measures including keeping social distance may further impact social phobia. This study aims to investigate the influencing factors of social phobia among Chinese college students and to tentatively explore the impact of COVID-19 prevention measures on social phobia. Respondents were recruited through Chinese Internet social platforms for an online survey. College students' social phobia scores in pre- and early-COVID-19 periods were measured using Peters' short form of the Social Interaction Anxiety Scale and Social Phobia Scale (SIAS-6/SPS-6). Demographic information, family information, social relations, self-evaluation, and subjective feelings regarding the impact of COVID-19 preventive measures on social phobia were collected. A multivariable logistic regression model was used to analyze the influencing factors. A total of 1859 valid questionnaires were collected, revealing that the social phobia scores increased from 12.3 ± 11.9 to 13.4 ± 11.9 between pre- and early-COVID-19 periods, with an increase of 1.0 ± 6.4 (p < 0.001). Low GPA rank, mobile phone dependence, distant family relationships, indulgent parents, childhood adversity, and childhood bullying were risk factors for social phobia among Chinese college students. Female gender, being a senior university student or postgraduate, satisfaction with physical appearance, self-reported good mental health and high level of interpersonal trust were protective factors for social phobia. Although most respondents believed that COVID-19 prevention measures (e.g., mask wearing and social distancing rules) reduced their social phobia, these measures were not significantly associated with social phobia levels in the multivariable analyses. In conclusion, Chinese college students' social phobia was widely influenced by diverse factors and warrants increased attention, with early intervention aimed at high-risk individuals being crucial for their mental health. Additional research is necessary to understand the impact of COVID-19 preventive measures on social phobia among college students.

Developmental patterns of children's shyness: Relations with physiological, emotional, and regulatory responses to being treated unfairly

The dysregulation of social fear has been widely studied in children's shyness, but we know little about how shy children regulate during unfair treatment. We first characterized developmental patterns of children's shyness (N = 304, ngirls  = 153; 74% White, 26% Other) across 2 (Mage  = 2.07), 3 (Mage  = 3.08), 4 (Mage  = 4.08), and 6 (Mage  = 6.58) years of age. Data collection occurred from 2007 to 2014. At age 6, the high stable group had higher cardiac vagal withdrawal and lower expressed sadness and approach-related regulatory strategy than the low stable group when being treated unfairly. Although shy children may be more physiologically impacted by being treated unfairly, they may mask their sadness to signal appeasement.

Changes in the communicative skills of young people as a result of a communication training

PURPOSE

To analyze the effect of communication training developed for adolescents on the youth's communication skills.

METHODS

Forty-one young people participated in the study and were divided into two groups. Group I received intervention - communication training for five weeks; Group II - were guided on the importance of voice for communication. Participants had their communication skills assessed before/after interventions through a self-administered questionnaire, answered by the participant and parents. Both groups had oral presentations recorded on video, which were analyzed by speech therapists through the evaluation of the communication profile, listing the aspects that should be observed as a point of strength/opportunity for improvement. Association between qualitative variables was assessed using Fischer's exact test, Pearson's chi-square test, McNemar's test, and McNemar-Bowker's test. To compare groups, paired t-test and t-test for independent samples, p level <0.05, were used.

RESULTS

The analysis of questionnaires showed improvement in GI in two of the four skills assessed and no difference for GII. The video evaluations showed a significant difference between the groups in terms of eye contact and speech velocity.

CONCLUSION

This study points out that the communication training method applied to young people might improve communicative skills, providing some insights into their communication strengths and potential areas for development.

Encouraging a Peer in Need: The Impacts of Social Anxiety and Peer Familiarity

Extant research has produced conflicting findings regarding the link between social fearfulness and prosocial behavior, with some studies reporting negative relations and others reporting null effects. Furthermore, these studies have focused predominantly on toddlerhood, and few have examined prosociality between peers. The present study investigated whether the link between social anxiety and a prosocial behavior (i.e., providing encouragement) varied depending on interpersonal and situational factors (i.e., one's familiarity with a peer, the level of support sought by a peer, respectively). We tested this question using a multimethod approach, which included an ecologically valid stress inducing task and dyadic design with a sample of 9- to 10-year-olds (N = 447). Results revealed that social anxiety was related negatively to providing encouragement among familiar and unfamiliar dyads. In familiar dyads, however, this main effect was qualified by an interaction with the level of support sought by one's peer. Compared to those low in social anxiety, children high in social anxiety provided relatively less encouragement in response to higher levels of support seeking from their peers. The findings are considered in relation to theorizing regarding the effect of overarousal on children's prosocial behavior.

Developmental changes in the structure of shyness and internalizing symptoms from early to middle childhood: A network analysis

Shyness is a temperamental trait that shares considerable conceptual overlap with aspects of internalizing problems, creating difficulties in operationalizing and assessing these two constructs and their association. This study addresses these issues by employing network analyses. Participants were, white, N = 555 children (M_age  = 52.45 months, SD = 15.96, 55% girls) followed longitudinally over 4 years (2016-2010) in Norway. Teachers rated child shyness and assessed children's internalizing symptoms. Results suggest that two behavioral shyness traits were the most central aspects of shyness. The centrality of these aspects was robust across age. The most influential symptom connecting internalizing symptoms with shyness was "unhappy." Shyness became more differentiated with development, and associations between anxiety-related symptoms and shyness increased as children entered formal schooling.

Social anxiety in adolescents and young adults from the general population: an epidemiological characterization of fear and avoidance in different social situations

Social Anxiety Disorder (SAD) and, more generally, social fears are common in young people. Although avoidance behaviors are known to be an important maintaining factor of social anxiety, little is known about the severity and occurrence of avoidance behaviors in young people from the general population, hampering approaches for early identification and intervention. Symptoms, syndromes, and diagnoses of DSM-5 mental disorders including SAD were assessed in a random population-based sample of 14-21-year-olds (n = 1,180) from Dresden, Germany, in 2015/2016 using a standardized diagnostic interview (DIA-X-5/D-CIDI). An adapted version of the Liebowitz Social Anxiety Scale was used to ascertain the extent of social fears and avoidance. Diagnostic criteria for lifetime SAD were met by n = 82 participants, resulting in a weighted lifetime prevalence of 6.6%. Social anxiety was predominantly reported for test situations and when speaking or performing in front of others. Avoidance was most prevalent in the latter situations. On average, anxiety and avoidance first occurred at ages 11 and 12, respectively, with avoidance occurring in most cases either at about the same age as anxiety or slightly later. In the total sample, lifetime prevalence for most DSM-5 disorders increased with the severity of social anxiety and avoidance. Results underline the need for preventive or early intervention efforts especially regarding test anxiety and fear and avoidance of speaking in front of others. These situations are particularly relevant in youth. Avoidance behaviors may also be discussed as diagnostic marker for early case identification.

Childhood inhibition predicts adolescent social anxiety: Findings from a longitudinal twin study

An enduring issue in the study of mental health is identifying developmental processes that explain how childhood characteristics progress to maladaptive forms. We examine the role that behavioral inhibition (BI) has on social anxiety (SA) during adolescence in 868 families of twins assessed at ages 8, 13, and 15 years. Multimodal assessments of BI and SA were completed at each phase, with additional measures (e.g., parenting stress) for parents and twins. Analyses were conducted in several steps: first, we used a cross-lagged panel model to demonstrate bidirectional paths between BI and SA; second a biometric Cholesky decomposition showed that both genetic and environmental influences on childhood BI also affect adolescent SA; next, multilevel phenotypic models tested moderation effects between BI and SA. We tested seven potential moderators of the BI to SA prediction in individual models and included only those that emerged as significant in a final conditional model examining predictors of SA. Though several main effects emerged as significant, only parenting stress had a significant interaction with BI to predict SA, highlighting the importance of environmental moderators in models examining temperamental effects on later psychological symptoms. This comprehensive assessment continues to build the prototype for such developmental psychopathology models.

The Development of Explicit and Implicit Game-Based Digital Behavioral Markers for the Assessment of Social Anxiety

Social relationships are essential for humans; neglecting our social needs can reduce wellbeing or even lead to the development of more severe issues such as depression or substance dependency. Although essential, some individuals face major challenges in forming and maintaining social relationships due to the experience of social anxiety. The burden of social anxiety can be reduced through accessible assessment that leads to treatment. However, socially anxious individuals who seek help face many barriers stemming from geography, fear, or disparities in access to systems of care. But recent research suggested digital behavioral markers as a way to deliver cheap and easily accessible digital assessment for social anxiety: As earlier work shows, players with social anxiety show similar behaviors in virtual worlds as in the physical world, including tending to walk farther around other avatars and standing farther away from other avatars. The characteristics of the movement behavior in-game can be harnessed for the development of digital behavioral markers for the assessment of social anxiety. In this paper, we investigate whether implicit as well as explicit digital behavioral markers, proposed by prior work, for social anxiety can be used for predicting the level of social anxiety. We show that both, explicit and implicit digital behavioral markers can be harnessed for the assessment. Our findings provide further insights about how game-based digital behavioral markers can be used for the assessment of social anxiety.

Detecting Subclinical Social Anxiety Using Physiological Data From a Wrist-Worn Wearable: Small-Scale Feasibility Study

BACKGROUND

Subclinical (ie, threshold) social anxiety can greatly affect young people's lives, but existing solutions appear inadequate considering its rising prevalence. Wearable sensors may provide a novel way to detect social anxiety and result in new opportunities for monitoring and treatment, which would be greatly beneficial for persons with social anxiety, society, and health care services. Nevertheless, indicators such as skin temperature measured by wrist-worn sensors have not been used in prior work on physiological social anxiety detection.

OBJECTIVE

This study aimed to investigate whether subclinical social anxiety in young adults can be detected using physiological data obtained from wearable sensors, including heart rate, skin temperature, and electrodermal activity (EDA).

METHODS

Young adults (N=12) with self-reported subclinical social anxiety (measured using the widely used self-reported version of the Liebowitz Social Anxiety Scale) participated in an impromptu speech task. Physiological data were collected using an E4 Empatica wearable device. Using the preprocessed data and following a supervised machine learning approach, various classification algorithms such as Support Vector Machine, Decision Tree, Random Forest, and K-Nearest Neighbours (KNN) were used to develop models for 3 different contexts. Models were trained to differentiate (1) between baseline and socially anxious states, (2) among baseline, anticipation anxiety, and reactive anxiety states, and (3) social anxiety among individuals with social anxiety of differing severity. The predictive capability of the singular modalities was also explored in each of the 3 supervised learning experiments. The generalizability of the developed models was evaluated using 10-fold cross-validation as a performance index.

RESULTS

With modalities combined, the developed models yielded accuracies between 97.54% and 99.48% when differentiating between baseline and socially anxious states. Models trained to differentiate among baseline, anticipation anxiety, and reactive anxiety states yielded accuracies between 95.18% and 98.10%. Furthermore, the models developed to differentiate between social anxiety experienced by individuals with anxiety of differing severity scores successfully classified with accuracies between 98.86% and 99.52%. Surprisingly, EDA was identified as the most effective singular modality when differentiating between baseline and social anxiety states, whereas ST was the most effective modality when differentiating anxiety among individuals with social anxiety of differing severity.

CONCLUSIONS

The results indicate that it is possible to accurately detect social anxiety as well as distinguish between levels of severity in young adults by leveraging physiological data collected from wearable sensors.

Predictors of social anxiety disorder with major depressive episodes among Japanese university students

Background

Social anxiety disorder (SAD) develops in the early teens and is a common disorder among university students. Understanding the predictive factors of SAD comorbid with major depressive episode (MDE) is important for student mental health care. The aim of this study was to identify the personality traits that predict SAD with MDE by analyzing longitudinal data of Japanese university students.

Methods

In this retrospective study, Japanese university students who visited the health care center of Hokkaido University for the first time were divided into the following four groups: “Control” (n = 43), “MDE” (n = 16), “SAD” (n = 28), and “SAD with MDE” (n = 61) based on the Patient Health Questionnaire-9 (PHQ-9), the Liebowitz Social Anxiety Scale, and core anxiety symptoms for SAD in the Mini International Neuropsychiatric Interview during screening. Predictors for SAD with MDE were identified by a four-group comparison of the Temperament and Character Inventory and PHQ-9 data previously obtained at the enrollment using analysis of variance and post-hoc tests.

Results

Upon comparing the four groups using analysis of variance, there were significant differences in the baseline PHQ-9 summary score, Harm-Avoidance (HA), and Self-Directedness (SD). According to results of the post-hoc test, all three showed a significant difference between the “Control” and “SAD with MDE.” Furthermore, there was a significant difference in HA scores between “SAD” and “Control.” In all the groups, the mean time from enrollment to the first visit to the center was >2 years.

Conclusion

A higher HA score at baseline is a predictor of SAD with or without MDE. Higher PHQ-9 summary and lower SD scores at baseline are predictive factors of SAD with MDE.

Longitudinal investigation of shyness and physiological vulnerability: Moderating influences of attention biases to threat and safety

Shyness has long been identified as a vulnerability factor to developing psychosocial problems, but there is heterogeneity in these observed outcomes. One potential factor underlying these relations is individual differences in threat sensitivity. Using a longitudinal design, we examined whether attentional biases toward social threat and safety measured during adulthood moderated the association between shyness measured in emerging adulthood (N = 83, n_female = 48; M_age = 23.56 years, SD_age = 1.09 years) and frontal electroencephalogram (EEG) asymmetry at rest, a physiological index of vulnerability to psychopathology, measured nearly a decade later in adulthood (M_age = 31.68 years, SD_age = 2.27 years). We found that only biases to threat moderated the association between shyness and resting frontal EEG asymmetry longitudinally. In individuals who displayed relative vigilance to social threat, shyness was associated with greater relative right frontal EEG activity at rest (i.e., increased physiological vulnerability). These findings suggest that attentional biases to threat may play a role in understanding the relation between shyness and some known physiological vulnerabilities to psychopathology in adults.

Positive Shyness in the Brain: Frontal Electroencephalogram Alpha Asymmetry and Delta-Beta Correlation in Children

Positive shyness is thought to be an approach-dominant form of shyness, whereas non-positive shyness is thought to be an avoidance-dominant form of shyness. This study examined electrocortical and behavioral correlates of motivation and emotion in relation to these shy subtypes in 67 children (M_age  = 10.41 years, SD = 3.23). Using resting state electroencephalography, findings revealed that positive shy and low shy children had greater relative left frontal alpha asymmetry compared to non-positive shy children, and positive shy children had a higher frontal delta-beta correlation compared to other groups. Non-positive shy children scored highest on parent-reported school avoidance. These findings converge with previous work reporting distinct correlates in positive and non-positive shyness, extending this to two brain measures of motivation and emotion.

To Express or to End? Personality Traits Are Associated With the Reasons and Patterns for Using Emojis and Stickers

Emojis and stickers are becoming increasingly popular in computer-mediated communications. The present study examined the associations between personality traits and people’s reasons and patterns for using both emojis and stickers. Participants (n = 312) completed three online questionnaires assessing shyness, the Big Five personality traits, and why and how they used emojis and stickers. Results revealed that shyness, neuroticism, extraversion, and agreeableness were correlated with different reasons of usage. Moreover, some participants exhibited a tendency to adjust frequency of usage depending on who the target person was and whether they were in a private or group chat. People who showed such tendencies were found to differ in personality with those who did not. Some differences in usage patterns were also observed between emojis and stickers. Together, the present study has produced more insight into how emojis and stickers can help people with different personality traits to achieve different purposes in their daily communication.

Autopercepção de timidez e sua relação com aspectos da fala em público

RESUMO Objetivo: Determinar a prevalência da timidez em estudantes universitários e analisar dentre os fatores sociodemográficos e da comunicação em público, aqueles que mais se relacionam com sua presença. Método: estudo transversal analítico realizado com 1124 universitários com idade entre 17 e 63 anos. Utilizou-se um questionário com perguntas referentes às características sociodemográficas; frequência de participação em atividades de fala em público, autorrelato do medo de falar, autopercepção dos aspectos não verbais da comunicação oral: tom de voz, velocidade de fala, intensidade de voz, projeção vocal, contato visual com a plateia durante o discurso, uso das mãos nas apresentações em público; autoavaliação da fala em público (Escala para Auto Avaliação ao Falar em Público) e autopercepção da timidez (Escala Revisada de Timidez). A análise dos fatores associados à timidez com as demais variáveis foi realizada por meio do teste Qui-quadrado de Pearson e regressão logística uni e multivariada. O nível de significância adotado foi de 5%. Resultados: a maioria da população universitária autorreferiu traços de timidez e medo de falar em público. Houve associação da timidez com a idade de 17 a 30 anos, medo de falar em público, pouca participação em atividades de fala em público, autopercepção negativa da fala e com aspectos não verbais da comunicação. Conclusão: A timidez é prevalente em estudantes universitários jovens, que participam de poucas atividades de fala em público, que apresentam medo de falar em público, autorrelatam falar em intensidade baixa e apresentam inabilidade de usar as mãos com naturalidade durante apresentações em público.

Variations in Parent and Teacher Ratings of Internalizing, Externalizing, Adaptive Skills, and Behavioral Symptoms in Children with Selective Mutism

Selective mutism (SM) is an anxiety disorder that impacts communication. Children with SM present concerns to parents and teachers as they consistently do not speak in situations where there is an expectation to speak, such as at school, but speak in other settings where they feel more comfortable, such as at home. The purpose of this study was to investigate the relationship between parents’ and teachers’ perceptions of children with SM on behavioral rating scales and language measures. Forty-two children (22 boys and 20 girls, ranging from 2.4 to 13.8 years, with a mean age of 7.1 years) took part in this study. Parents and teachers completed the Behavior Assessment System for Children (BASC-3) measuring internalizing behaviors, externalizing behaviors, adaptive skills, and behavioral symptoms. Frequency of speaking and language abilities were also measured. Parents and teachers both identified withdrawal as the most prominent feature of SM but parents saw children as significantly more withdrawn than did their teachers. Both rated children similarly at-risk on scales of functional communication and social skills. Higher adaptive skills (including functional communication and social skills) were positively correlated with vocabulary, narrative language, and auditory serial memory according to teachers. Parent and teacher rating scales provide valuable information for diagnosis and progress monitoring. Children with SM can benefit from mental health practitioners who can identify and enhance their emotional well-being.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder

Objective:

To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand.

Method:

Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders.

Results:

The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy.

Conclusion:

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.

Role of rumination in the relationship between metacognition and shyness

AIM

To explore the association between metacognitive beliefs, rumination and shyness in a non-clinical sample of adults.

METHODS

One hundred and three healthy subjects from the general population were enrolled in the study. Shyness was evaluated using the Revised Cheek and Buss Shyness Scale, rumination was assessed using the Ruminative Response Scale, metacognition was evaluated using the Meta-Cognitions Questionnaire 30, and anxiety levels were measured using the State Trait Anxiety Inventory form Y. Correlation analyses, mediation models and 95% bias-corrected and accelerated (BCaCI) bootstrapped analyses were performed. Mediation analyses were adjusted for sex and anxiety.

RESULTS

Shyness, rumination and metacognition were significantly correlated (P < 0.05). The relationship between metacognition and shyness was fully mediated by rumination (Indirect effect: 0.20; 95% BCaCI: 0.08-0.33).

CONCLUSION

These findings suggest an association between metacognition and shyness. Rumination mediated the relationship between metacognition and shyness, suggesting that rumination could be a cognitive strategy for shy people. Future research should explore the relationship between these constructs in more depth.

Social anxiety disorder: looking back and moving forward

Fifty years have passed since social anxiety disorder (SAD) was first differentiated from other phobias. In the years since research has largely aligned with the zeitgeist of categorical classificatory frameworks, and has spanned identifying causes, maintenance factors and innovative interventions. Despite significant advances in the field, the capacity to conceptualise SAD as an independent entity is limited given the heterogeneity and dimensionality of diagnostic criteria, high rates of comorbidity, and non-specificity of aetiological mechanisms, maintaining factors and approaches to treatment. The Research Domain Criteria (RDoC) initiative was developed in an effort to overcome the inherent limitations posed by descriptive diagnostic systems - particularly in terms of reliability and validity - and in doing so seeks to facilitate research into underlying pathophysiological and behavioural mechanisms that cut across traditional diagnostic boundaries. The RDoC framework is furnished with a 'matrix', which in essence corresponds to a set of research principles that attempt to reconcile neuroscience and psychopathology. This review outlines a rationale for integrating SAD research with the RDoC approach, and offers examples of how future studies may wish to frame hypotheses and design experiments as the field moves towards classifying dimensions of psychopathology through a mechanistic understanding of underlying neurobiological and behavioural processes.

Mothers' and Fathers' Worry and Over-Control: One Step Closer to Understanding Early Adolescent Social Anxiety

This study investigated the links between parental worry, parental over-control and adolescent social anxiety in parent-adolescent dyads. Using a longitudinal sample of adolescents (M_age = 14.28) and their parents (224 mother-daughter, 234 mother-son, 51 father-daughter, and 47 father-son dyads), comparisons were conducted using cross-lagged path models across two time points. We used adolescent reports of social anxiety and feelings of being overly controlled by parents, and mother and father self-reports of worries. Our results show that boys' social anxiety predicted higher perceived parental overcontrol, whereas girls' social anxiety predicted higher paternal worry over time. In addition, girls' reports of feeling overly controlled by parents predicted higher maternal worry but lower paternal worry over time. For boys, feeling overly controlled predicted less social anxiety instead. The study illustrates how mothers and fathers might differ in their behaviors and concerns regarding their children's social anxiety and feelings of overcontrol.

Shyness and Social Anxiety Assessed Through Self-Report: What Are We Measuring?

The distinction between shyness and social anxiety remains unclear in the literature. In an attempt to shed further light on this issue, our research evaluated whether shyness and social anxiety were the same construct underlying various measurement scales. Participants (N = 801, M_age = 36.21, range = 18-74, female = 53.10%) responded to 10 questionnaires assessing either shyness or social anxiety. Evidence indicated that the scales were highly correlated and loaded onto 1 factor. Confirmatory factor analysis corroborated this finding. A second exploratory factor analysis revealed that all the shyness and social anxiety items best loaded together onto 3 factors: one corresponding to fear of negative evaluation, embarrassment, self-consciousness, scrutiny, authority, interaction anxiety, and shyness (71.0%); a second comprised of primarily interaction anxiety and shyness (17.7%); and a third associated with performance anxiety (7.5%). All scales were similarly discriminated from sociability. Overall, the constructs of shyness and social anxiety were not differentiated from each other. Researchers should carefully consider what items are included in shyness and social anxiety scales if these constructs are to be distinguished from one another.

Co-rumination buffers the link between social anxiety and depressive symptoms in early adolescence

OBJECTIVES

We examined whether co-rumination with online friends buffered the link between social anxiety and depressive symptoms over time in a community sample.

METHODS

In a sample of 526 participants (358 girls; Mage  = 14.05) followed at three time points, we conducted a latent cross-lagged model with social anxiety, depressive symptoms, and co-rumination, controlling for friendship stability and friendship quality, and adding a latent interaction between social anxiety and co-rumination predicting depressive symptoms.

RESULTS

Social anxiety predicted depressive symptoms, but no direct links between social anxiety and co-rumination emerged. Instead, co-rumination buffered the link between social anxiety and depressive symptoms for adolescents with higher but not lower levels of social anxiety.

CONCLUSIONS

These findings indicate that co-rumination exerted a positive influence on interpersonal relationships by diminishing the influence from social anxiety on depressive symptoms over time.

Intrinsic Brain Activity Responsible for Sex Differences in Shyness and Social Anxiety

Male and female show significant differences in important behavioral features such as shyness, yet the neural substrates of these differences remain poorly understood. Previous neuroimaging studies have demonstrated that both shyness and social anxiety in healthy subjects are associated with increased activation in the fronto-limbic and cognitive control areas. However, it remains unknown whether these brain abnormalities would be shared by different genders. Therefore, in the current study, we used resting-state fMRI (r-fMRI) to investigate sex differences in intrinsic cerebral activity that may contribute to shyness and social anxiety. Sixty subjects (28 males, 32 females) participated in r-fMRI scans, and the amplitude of low-frequency fluctuations (ALFF) and fractional ALFF (fALFF) were used to measure the spontaneous regional cerebral activity in all subjects. We first compared the differences between male and female both in the ALFF and fALFF and then we also examined the whole brain correlation between the ALFF/fALFF and the severity of shyness as well as social anxiety by genders. Referring to shyness measure, we found a significant positive correlation between shyness scores (CBSS) and ALFF/fALFF value in the frontoparietal control network and a negative correlation in the cingulo-insular network in female; while in male, there is no such correlation. For the social anxiety level, we found positive correlations between Leibowitz Social Anxiety Scale (LSAS) scores and spontaneous activity in the frontal-limbic network in male and negative correlation between the frontal-parietal network; however, such correlation was not prominent in female. This pattern suggests that shy female individuals engaged a proactive control process, driven by a positive association with activity in frontoparietal network and negative association in cingulo-insular network, whereas social anxiety males relied more on a reactive control process, driven by a positive correlation of frontal-limbic network and negative correlation of frontoparietal network. Our results reveal that shyness or social anxiety is associated with disrupted spontaneous brain activity patterns and that these patterns are influenced by sex.

Selective mutism

PURPOSE OF REVIEW

Selective mutism is a disorder in which an individual fails to speak in certain social situations though speaks normally in other settings. Most commonly, this disorder initially manifests when children fail to speak in school. Selective mutism results in significant social and academic impairment in those affected by it. This review will summarize the current understanding of selective mutism with regard to diagnosis, epidemiology, cause, prognosis, and treatment.

RECENT FINDINGS

Studies over the past 20 years have consistently demonstrated a strong relationship between selective mutism and anxiety, most notably social phobia. These findings have led to the recent reclassification of selective mutism as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. In addition to anxiety, several other factors have been implicated in the development of selective mutism, including communication delays and immigration/bilingualism, adding to the complexity of the disorder. In the past few years, several randomized studies have supported the efficacy of psychosocial interventions based on a graduated exposure to situations requiring verbal communication. Less data are available regarding the use of pharmacologic treatment, though there are some studies that suggest a potential benefit.

SUMMARY

Selective mutism is a disorder that typically emerges in early childhood and is currently conceptualized as an anxiety disorder. The development of selective mutism appears to result from the interplay of a variety of genetic, temperamental, environmental, and developmental factors. Although little has been published about selective mutism in the general pediatric literature, pediatric clinicians are in a position to play an important role in the early diagnosis and treatment of this debilitating condition.

Neurocircuitry underlying risk and resilience to social anxiety disorder

BACKGROUND

Almost half of children with an inhibited temperament will develop social anxiety disorder by late adolescence. Importantly, this means that half of children with an inhibited temperament will not develop social anxiety disorder. Studying adults with an inhibited temperament provides a unique opportunity to identify neural signatures of both risk and resilience to social anxiety disorder.

METHODS

Functional magnetic resonance imaging (fMRI) was used to measure brain activation during the anticipation of viewing fear faces in 34 young adults (17 inhibited, 17 uninhibited). To identify neural signatures of risk, we tested for group differences in functional activation and connectivity in regions implicated in social anxiety disorder, including the prefrontal cortex, amygdala, and insula. To identify neural signatures of resilience, we tested for correlations between brain activation and both emotion regulation and social anxiety scores.

RESULTS

Inhibited subjects had greater activation of a prefrontal network when anticipating viewing fear faces, relative to uninhibited subjects. No group differences were identified in the amygdala. Inhibited subjects had more negative connectivity between the rostral anterior cingulate cortex (ACC) and the bilateral amygdala. Within the inhibited group, those with fewer social anxiety symptoms and better emotion regulation skills had greater ACC activation and greater functional connectivity between the ACC and amygdala.

CONCLUSIONS

These findings suggest that engaging regulatory prefrontal regions during anticipation may be a protective factor, or putative neural marker of resilience, in high-risk individuals. Cognitive training targeting prefrontal cortex function may provide protection against anxiety, especially in high-risk individuals, such as those with inhibited temperament.

Somatic symptoms in children with anxiety disorders: an exploratory cross-sectional study of the relationship between subjective and objective measures

Symptoms of childhood anxiety disorders include activation of bodily stress systems to fear stimuli, indicating alterations of the autonomic nervous system (ANS). Self-reported somatic symptoms are frequently reported, while studies including objective measures of ANS are scarce and show inconsistent results. Even less studied is the relationship between subjective and objective measures of somatic symptoms in anxious children. Increased knowledge of this relationship may have relevance for treatment programmes for anxiety disorders. This cross-sectional study examined subjective and objective measures of ANS responsiveness in a clinical sample of children with anxiety disorders (7-13 years; n = 23) and in healthy controls (HC; n = 22) with equal distributions of gender and age. The subjective measure used was the Multidimensional Anxiety Scale for Children, which includes a subscale on somatic symptoms. The objective measures consisted of an orthostatic challenge (head-up tilt test), and an isometric muscular exercise (handgrip) while the participants were attached to the Task Force Monitor, a combined hardware and software device used for continuous, non-invasive recording of cardiovascular variables. The anxiety disorder group reported significantly more somatic symptoms than HCs (both by mother and child reports). In contrast, no relevant differences in cardiovascular variables were demonstrated between the anxiety group and HCs. Finally, there were no significant correlations between subjective and objective measures in either group. Because of the small sample size, the findings must be interpreted carefully, but the results do not support previous reports of functional alterations of the ANS in anxious children.

The reaction to social stress in social phobia: discordance between physiological and subjective parameters

Background

Research on the biopsychological background of social phobia (SP) is scarce and inconsistent. We investigated endocrine and autonomic markers along with subjective responses to a standardized stress situation (Trier Social Stress Test, TSST) in SP patients and healthy controls (HC).

Methods

We examined 88 patients with the primary diagnosis of SP as well as 78 age and sex comparable HCs with the TSST. Blood and saliva samples were obtained before and after the TSST for the assessment of salivary cortisol, plasma cortisol, salivary alpha-amylase (sAA), and prolactin. Heart rate (HR) and heart rate variability (HRV) were recorded continuously. Scalp-near hair samples were collected for the assessment of long-term cortisol secretion. The self-reported stress response was measured with different state and trait scales.

Results

While self-reported anxiety was elevated in SP before, during, immediately after, and one week after the TSST, no significant differences in biological stress responses were observed between SP and HC. There was a trend for SP to show higher baseline stress markers. Also long-term cortisol deposition in hair remained unaltered.

Conclusions

Our results suggest that the excessive self-reported stress in SP is not reflected by a respective biological stress response. Patients with SP apparently show neither an extreme form of focused fear reactivity nor excessive defensive impairment.

The importance of perceived care and connectedness with friends and parents for adolescent social anxiety

Nonclinical social anxiety in adolescence can be highly problematic, as it likely affects current and especially new social interactions. Relationships with significant others, such as close friends, mothers, and fathers, could aid socially anxious adolescents' participation in social situations, thereby helping reduce feelings of social anxiety. We examined whether making friends as well as high friendship quality help reduce social anxiety over time, and whether friends', mothers', and fathers' care interact in reducing social anxiety. Using longitudinal data from 2,194 participants in a social network (48% girls; Mage  = 13.58) followed for 3 years, we estimated friendship selection and influence processes via a continuous time-modeling approach using SIENA. We controlled for the effects of depressive symptoms, self-esteem, gender, age, and family structure. Our findings suggest that perceived care by friends mediated the effect of making friends on social anxiety. Perceptions of mother and father, as well as friend care and connectedness, respectively, did not interact in decreasing social anxiety. Nonetheless, care and connectedness with mothers, fathers, and friends jointly predicted decreases in social anxiety. Caring relationships with friends and parents each play a role in mutually protecting early adolescents against increasing in social anxiety over time.

Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology

This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.

Psychophysiological arousal and biased perception of bodily anxiety symptoms in socially anxious children and adolescents: a systematic review

Cognitive models of social anxiety [Clark and Wells, Social phobia: Diagnosis, assessment, and treatment, Guilford Press, New York, 1995], diagnostic criteria and studies on adult samples suggest that both an overestimation of bodily anxiety symptoms and psychophysiological abnormalities play an important role in social anxiety. To date, less is known about such a perception bias and physiological characteristics in children and adolescents with social anxiety. We performed a systematic review of the literature in the electronic databases Medline, PsycINFO, and PSYNDEX. Additional studies were identified by hand search using the ancestry approach. We identified 1,461 studies, screened their titles and abstracts, viewed 94 papers, and included 28 of these. Study samples were heterogeneous and consisted of socially phobic, high socially anxious, shy and test anxious children and adolescents. Regarding a biased perception, most studies in the review suggest that bodily symptoms of anxiety were overestimated by children and adolescents across the social anxiety spectrum when compared with control groups. An elevated psychophysiological reactivity to social stress was present in samples of high social anxiety, shyness, and test anxiety. In clinical samples with social phobia, by contrast, no differences or an even lower physiological responding compared with healthy control groups were reported. In addition, some evidence for a chronic psychophysiological hyperarousal was found across all sample types. The results are discussed with regard to current models of social anxiety, psychophysiological theories, and treatment implications.

More than a face: a unified theoretical perspective on nonverbal social cue processing in social anxiety

Processing of nonverbal social cues (NVSCs) is essential to interpersonal functioning and is particularly relevant to models of social anxiety. This article provides a review of the literature on NVSC processing from the perspective of social rank and affiliation biobehavioral systems (ABSs), based on functional analysis of human sociality. We examine the potential of this framework for integrating cognitive, interpersonal, and evolutionary accounts of social anxiety. We argue that NVSCs are uniquely suited to rapid and effective conveyance of emotional, motivational, and trait information and that various channels are differentially effective in transmitting such information. First, we review studies on perception of NVSCs through face, voice, and body. We begin with studies that utilized information processing or imaging paradigms to assess NVSC perception. This research demonstrated that social anxiety is associated with biased attention to, and interpretation of, emotional facial expressions (EFEs) and emotional prosody. Findings regarding body and posture remain scarce. Next, we review studies on NVSC expression, which pinpointed links between social anxiety and disturbances in eye gaze, facial expressivity, and vocal properties of spontaneous and planned speech. Again, links between social anxiety and posture were understudied. Although cognitive, interpersonal, and evolutionary theories have described different pathways to social anxiety, all three models focus on interrelations among cognition, subjective experience, and social behavior. NVSC processing and production comprise the juncture where these theories intersect. In light of the conceptualizations emerging from the review, we highlight several directions for future research including focus on NVSCs as indexing reactions to changes in belongingness and social rank, the moderating role of gender, and the therapeutic opportunities offered by embodied cognition to treat social anxiety.

Structural and functional connectivity changes in the brain associated with shyness but not with social anxiety

Shyness and social anxiety are correlated to some extent and both are associated with hyper-responsivity to social stimuli in the frontal cortex and limbic system. However to date no studies have investigated whether common structural and functional connectivity differences in the brain may contribute to these traits. We addressed this issue in a cohort of 61 healthy adult subjects. Subjects were first assessed for their levels of shyness (Cheek and Buss Shyness scale) and social anxiety (Liebowitz Social Anxiety scale) and trait anxiety. They were then given MRI scans and voxel-based morphometry and seed-based, resting-state functional connectivity analysis investigated correlations with shyness and anxiety scores. Shyness scores were positively correlated with gray matter density in the cerebellum, bilateral superior temporal gyri and parahippocampal gyri and right insula. Functional connectivity correlations with shyness were found between the superior temporal gyrus, parahippocampal gyrus and the frontal gyri, between the insula and precentral gyrus and inferior parietal lobule, and between the cerebellum and precuneus. Additional correlations were found for amygdala connectivity with the medial frontal gyrus, superior frontal gyrus and inferior parietal lobule, despite the absence of any structural correlation. By contrast no structural or functional connectivity measures correlated with social or trait anxiety. Our findings show that shyness is specifically associated with structural and functional connectivity changes in cortical and limbic regions involved with processing social stimuli. These associations are not found with social or trait anxiety in healthy subjects despite some behavioral correlations with shyness.

Social discomfort in preadolescence: predictors of discrepancies between preadolescents and their parents and teachers

The present study investigated whether salient preadolescent behaviors and experiences predicted parents' and teachers' underestimation of preadolescents' shyness. Participants included a community sample of 129 fifth and sixth graders, along with one parent and teacher per preadolescent. Preadolescents, parents, and teachers provided reports about preadolescents' shyness, and parents and teachers rated preadolescents' prosocial and aggressive behaviors, peer victimization experiences, and academic performance. Results indicated that parent- and teacher-reported prosocial behavior, teacher-reported aggressive behavior, and parent-reported peer victimization were associated with lower parent and teacher reports of preadolescent shyness, relative to preadolescent reports, controlling for demographic variables and parent stress. Additionally, higher parent-reported academic performance was associated with lower teacher reports of preadolescent shyness, compared to preadolescent reports. These findings suggest that preadolescents with higher levels of relatively conspicuous behaviors and experiences feel more shyness than their parents and teachers report.

Neural response to the observable self in social anxiety disorder

BACKGROUND

Distorted images of the observable self are considered crucial in the development and maintenance of social anxiety. We generated an experimental situation in which participants viewed themselves from an observer's perspective when exposed to scrutiny and evaluation by others. Method Twenty patients with social anxiety disorder (SAD) and 20 control subjects were assessed using functional magnetic resonance imaging (fMRI) during the public exposure of pre-recorded videos in which they were each shown performing a verbal task. The examiners acted as the audience in the experiment and rated performance. Whole-brain functional maps were computed using Statistical Parametric Mapping.

RESULTS

Robust activation was observed in regions related to self-face recognition, emotional response and general arousal in both study groups. Patients showed significantly greater activation only in the primary visual cortex. By contrast, they showed significant deactivation or smaller activation in dorsal frontoparietal and anterior cingulate cortices relevant to the cognitive control of negative emotion. Task-related anxiety ratings revealed a pattern of negative correlation with activation in this frontoparietal/cingulate network. Importantly, the relationship between social anxiety scores and neural response showed an inverted-U function with positive correlations in the lower score range and negative correlations in the higher range.

CONCLUSIONS

Our findings suggest that exposure to scrutiny and evaluation in SAD may be associated with changes in cortical systems mediating the cognitive components of anxiety. Disorder severity seems to be relevant in shaping the neural response pattern, which is distinctively characterized by a reduced cortical response in the most severe cases.

Measurement invariance of the Social Phobia and Anxiety Inventory

The Social Phobia and Anxiety Inventory (SPAI) is a commonly used self-report measure of social phobia that has demonstrated adequate reliability, convergent validity, discriminant validity, and criterion-related validity. However, research has yet to address whether this measure functions equivalently in (a) individuals with and without a diagnosis of social phobia and (b) males and females. Evaluating measurement equivalence/invariance is necessary in order to determine that the construct of social anxiety is interpreted similarly across these populations. The results of the current investigation, using a series of nested factorial models proposed by Vandenberg and Lance (2000), provide evidence for strong equivalence across 420 individuals with and without diagnoses of social phobia and across male and female samples. Accordingly, these results provide psychometric justification for comparison of SPAI scores across the symptom continuum and sexes.

Mood regulation and quality of life in social anxiety disorder: an examination of generalized expectancies for negative mood regulation

The present study examined negative mood regulation expectancies, anxiety symptom severity, and quality of life in a sample of 167 patients with social anxiety disorder (SAD) and 165 healthy controls with no DSM-IV Axis I disorders. Participants completed the Generalized Expectancies for Negative Mood Regulation Scale (NMR), the Beck Anxiety Inventory, and the Quality of Life Enjoyment and Satisfaction Questionnaire. SAD symptom severity was assessed using the Liebowitz Social Anxiety Scale. Individuals with SAD scored significantly lower than controls on the NMR. Among SAD participants, NMR scores were negatively correlated with anxiety symptoms and SAD severity, and positively correlated with quality of life. NMR expectancies positively predicted quality of life even after controlling for demographic variables, comorbid diagnoses, anxiety symptoms, and SAD severity. Individuals with SAD may be less likely to engage in emotion regulating strategies due to negative beliefs regarding their effectiveness, thereby contributing to poorer quality of life.

Integrating etiological models of social anxiety and depression in youth: evidence for a cumulative interpersonal risk model

Models of social anxiety and depression in youth have been developed separately, and they contain similar etiological influences. Given the high comorbidity of social anxiety and depression, we examine whether the posited etiological constructs are a correlate of, or a risk factor for, social anxiety and/or depression at the symptom level and the diagnostic level. We find core risk factors of temperament, genetics, and parent psychopathology (i.e., depression and anxiety) are neither necessary nor sufficient for the development of social anxiety and/or depression. Instead, aspects of children's relationships with parents and/or peers either mediates (i.e., explains) or moderates (i.e., interacts with) these core risks being related to social anxiety and/or depression. We then examine various parent- and peer-related constructs contained in the separate models of social anxiety and depression (i.e., parent-child attachment, parenting, social skill deficits, peer acceptance and rejection, peer victimization, friendships, and loneliness). Throughout our review, we report evidence for a Cumulative Interpersonal Risk model that incorporates both core risk factors and specific interpersonal risk factors. Most studies fail to consider comorbidity, thus little is known about the specificity of these various constructs to depression and/or social anxiety. However, we identify shared, differential, and cumulative risks, correlates, consequences, and protective factors. We then put forth demonstrated pathways for the development of depression, social anxiety, and their comorbidity. Implications for understanding comorbidity are highlighted throughout, as are theoretical and research directions for developing and refining models of social anxiety, depression, and their comorbidity. Prevention and treatment implications are also noted.