Fear of blushing: fearful preoccupation irrespective of facial coloration

Sympathicotomy for isolated facial blushing: long-term follow-up of a randomized trial

OBJECTIVES

Thoracoscopic sympathicotomy may be an effective treatment for disabling facial blushing in selected patients. Short- and mid-term results are good but very long-term results are scarce in the medical literature and there is no knowledge which extent of sympathicotomy is better long-term for isolated facial blushing.

METHODS

We previously randomized 100 patients between a rib-oriented R2 or R2-R3 sympathicotomy for isolated facial blushing, and reported local effects, side effects and quality of life after 12 months. In the present study, we sent identical questionnaires to all patients after a median of 16 years (interquartile range 15-17 years).

RESULTS

The response rate was 66%. Overall, 82% reported excellent or satisfactory results on facial blushing, with significant better local effect after R2 sympathicotomy compared with R2-R3 sympathicotomy. Patients who underwent R2 sympathicotomy were also significantly more satisfied with the operation. We found no significant difference between R2 and R2-R3 sympathicotomy in quality of life or rates of compensatory sweating (77%) and recurrence of blushing (41%) which was milder than preoperatively in most patients.

CONCLUSIONS

R2 sympathicotomy should be the preferred approach for isolated facial blushing because of better local effect and higher satisfaction rates. Although this was a very long-term follow-up of the only randomized trial of its kind the response rate was limited leaving a risk of undetected bias.

Always Saying the Wrong Thing: Negative Beliefs About Losing Control Cause Symptoms of Social Anxiety

Background

Individuals with social anxiety disorder (SAD) often report a fear that they will lose control of their emotions or report intense, unpleasant thoughts or images of uncontrollably humiliating themselves in social situations. These fears and associated beliefs that one is likely to lose control may underlie the anxiety and/or cognitive biases (e.g., self-focused attention and negative post-event processing) experienced during and following social situations. The present experiment examined whether manipulating beliefs about losing control would cause changes in symptoms of SAD.

Methods

One hundred and twenty-six undergraduate psychology students were given false feedback that they were either at high or low risk of losing control, and then completed a social interaction task with an actor. Participants rated their anxiety before and during the interaction and completed a post-event processing questionnaire 24-hours later.

Results

Participants in the high beliefs about losing control (HLC) condition reported significantly greater subjective anxiety than those in the low beliefs about losing control (LLC) condition leading up to the social interaction task, and significantly more negative post-event processing.

Conclusion

Results suggest beliefs about losing control may play a causal role in the development and maintenance of SAD. These beliefs may represent a novel domain to be targeted in CBT.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-022-10325-w.

Seeing a Blush on the Visible and Invisible Spectrum: A Functional Thermal Infrared Imaging Study

So far blushing has been examined in the context of a negative rather than a positive reinforcement where visual displays of a blush were based on subjective measures. The current study used infrared imaging to measure thermal patterns of the face while with the use of a video camera quantified on the visible spectrum alterations in skin color related to a compliment. To elicit a blush a three-phase dialog was adopted ending or starting with a compliment on a female sample (N = 22). When the dialog ended with a compliment results showed a linear increase in temperature for the cheek, and forehead whereas for the peri-orbital region a linear decrease was observed. The compliment phase marked the highest temperature on the chin independent of whether or not the experiment started with a compliment contrary to other facial regions, which did not show a significant change when the experiment started with a compliment. Analyses on the visible spectrum showed that skin pigmentation was getting deep red in the compliment condition compared to the serious and social dialog conditions for both the forehead and the cheeks. No significant association was observed between temperature values and erythrocyte displays on the forehead and cheek. Heat is the physiological product of an arousing social scenario, however, preconceived notions about blushing propensity seem to drive erythrocyte displays and not necessarily conscious awareness of somatic sensations.

Role of surgical thoracic sympathetic interruption in treatment of facial blushing: a systematic review

OBJECTIVES

This paper aims to review the evidence to support the effectiveness of sympathectomy as a treatment for facial blushing in terms of relief of facial blushing, patient satisfaction, recurrence of blushing, patients regretting treatment and its associated complications.

METHODS

A systematic search strategy was performed in Ovid-Medline, Embase, Cochrane library and NICE. Studies reporting outcomes of sympathetic interruption in the treatment of facial blushing were retrieved.

RESULTS

Nine studies met the inclusion criteria with 1369 patients included in the final analysis. The age range of patients was 8 to 74 years (from 7 studies) with 56% females. Mean follow up was 21 months in 8 studies (range 6 to 30 months). The pooled proportion of patients who had good relief of facial blushing was 78.30% (95% C.I. 58.20% - 98.39%). Complete satisfaction was reported in 84.02% (95% C.I. 71.71% - 96.33%). Compensatory sweating and gustatory sweating were the commonest complications occurring in 74.18% (95% C.I. 58.10% - 90.26%) and 24.42% (95% C.I. 12.22% - 36.61%) respectively. The estimated proportion of patients regretting surgery was 6.79% (C.I 2.08% 11.50%).

CONCLUSION

Sympathetic interruption at T2 or T2-3 ganglia appears to be an effective treatment for facial blushing. However, lack of randomized trials comparing sympathetic interruption with non-surgical methods of treatment and heterogeneity of included studies with respect to assessment of outcome measures preclude strong evidence and definitive recommendations.

Intrapersonal and interpersonal concomitants of facial blushing during everyday social encounters

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

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.

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

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

Fear, avoidance and physiological symptoms during cognitive-behavioral therapy for social anxiety disorder

We examined fear, avoidance and physiological symptoms during cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD). Participants were 177 individuals with generalized SAD who underwent a 14-week group CBT as part of a randomized controlled treatment trial. Participants filled out self-report measures of SAD symptoms at pre-treatment, week 4 of treatment, week 8 of treatment, and week 14 of treatment (post-treatment). Cross-lagged Structural Equation Modeling indicated that during the first 8 weeks of treatment avoidance predicted subsequent fear above and beyond previous fear, but fear did not predict subsequent avoidance beyond previous avoidance. However, during the last 6 weeks of treatment both fear and avoidance predicted changes in each other. In addition, changes in physiological symptoms occurred independently of changes in fear and avoidance. Our findings suggest that changes in avoidance spark the cycle of change in treatment of SAD, but the cycle may continue to maintain itself through reciprocal relationships between avoidance and fear. In addition, physiological symptoms may change through distinct processes that are independent from those involved in changes of fear and avoidance.

Effects of false feedback on affect, cognition, behavior, and postevent processing: the mediating role of self-focused attention

Current social phobia models (e.g., Clark & Wells, 1995; Leary & Kowalski, 1995) postulate that socially anxious individuals negatively appraise their anxiety sensations (e.g., sweating, heart racing, blushing) as evidence of poor social performance, and thus fear these anxiety symptoms will be noticed and judged negatively by others. Consequently, they become self-focused and hypervigilant of these sensations and use them to judge how they appear to others. To test this model, high (N=41) and low (N=38) socially anxious participants were shown false physiological feedback regarding an increase or decrease in heart rate prior to and during an impromptu speech task. Relative to participants who observed a false heart rate decrease, those in the increase condition reported higher levels of negative affect, more negative performance appraisals, and more frequent negative ruminative thoughts, and these effects were mediated by an increase in self-focused attention. The unhelpful effects of the physiological feedback were not specific to high socially anxious participants. The results have implications for current cognitive models as well as the treatment of social phobia.

Objective and perceived arousal during performance of tasks with elements of social threat: the influence of anxiety sensitivity

BACKGROUND AND OBJECTIVES

Physiological arousal serves to maintain social anxiety disorder by skewing self-perception. Anxiety sensitivity is associated with the disorder and exaggerated perceptions of arousal, but has not been tested as explaining exaggerated perceived arousal in social contexts. The aim of this investigation was to address this issue.

METHODS

A total of 42 individuals participated in three tasks associated with potential social threat (i.e., a speech, typing task, hyperventilation) and completed measures of trait social anxiety and anxiety sensitivity. State anxiety, perceived arousal, and objective arousal were assessed during each task.

RESULTS

Trait social anxiety and anxiety sensitivity were correlated with state anxiety and perceived arousal, but not objective arousal, during the tasks. Anxiety sensitivity mediated the relationships between trait social anxiety and perceived arousal and between trait social anxiety and state anxiety for the typing and hyperventilation tasks.

LIMITATIONS

Although the sample likely included a number of individuals with social anxiety disorder, the sample was mostly comprised of individuals without a diagnosis. The current results can be extended to clinical presentations to some extent, but future research is needed to further explore the demonstrated relationships in samples of individuals with social anxiety disorder.

CONCLUSIONS

Anxiety sensitivity may play a crucial role in perceptions of arousal and state anxiety in the context of potential social threats, warranting attention from researchers and clinicians focussing on social anxiety disorder.

[Results of video-assisted thoracoscopic sympathectomy for facial blushing]

BACKGROUND

Involuntary craniofacial erythema, or blushing, due to autonomic dysfunction can be a cause of psychological distress. Although anecdotal reports have suggested that pharmacologic treatments or cognitive behavioral therapy can be used to treat the condition, no rigorous analyses of their efficacy have been reported.

OBJECTIVES

To assess the efficacy of video-assisted thoracoscopic sympathectomy and to study phobic anxiety and other personality traits in a series of patients with involuntary facial blushing.

MATERIALS AND METHODS

We carried out a retrospective observational study of patients treated with bilateral video-assisted thoracoscopic sympathectomy for blushing over a 7-year period (2001-2008). All the patients were treated by a dermatologist, a psychologist, and a thoracic surgeon and were informed of the predicted outcomes.

RESULTS

A total of 204 patients with a mean age of 34 years (range, 15-67 years) were included; the numbers of males and females were similar. Only 10% had unpredicted outcomes; in such cases, either the procedure was insufficiently effective or postoperative reflex sweating developed (and was considered serious in 2%). There were no deaths and only 1 case of transient Horner syndrome. Video-assisted thoracotomy was required for pleural symphysis in 1 patient; 5 patients developed pneumothorax, but only 1 of them required pleural drainage.

CONCLUSIONS

Video-assisted sympathectomy is a safe, effective and definitive treatment for disabling blushing. Anxiety that is detected before surgery is a reaction to blushing rather than a cause of it.

The effect of facial blood flow on ratings of blushing and negative affect during an embarrassing task: preliminary findings

Expecting to blush is a common source of social anxiety, and is associated with heightened perceptions of blushing and embarrassment. To assess whether sensory cues associated with heightened facial blood flow are an additional source of anxiety, the vasodilator niacin (100mg) or placebo was administered double-blind to 33 participants, and facial blood flow was investigated when they sang a children's song. Vasodilatation during singing was greater in the niacin than placebo condition, and niacin-evoked flushing and increases in pulse rate were greater in participants with high than low fear of negative evaluation. Nevertheless, ratings of embarrassment, anxiety, blushing and facial heat were similar in both drug conditions. This dissociation implies that cognitive appraisals or negative affect overrode more subtle physiological cues of blushing during embarrassment. Clarifying how judgments about blushing are made could be crucial for correcting faulty assumptions about blushing in people who are frightened of this response.

The effect of niacin on facial blood flow in people with an elevated fear of negative evaluation

The vasodilator niacin may provoke greater facial flushing and other symptoms of anxiety in patients with social anxiety disorder than in non-anxious controls. To determine whether this also applies in non-clinical samples, niacin (100mg) or placebo was administered double-blind to 33 young adults and flushing was investigated in relation to fear of negative evaluation (a cardinal feature of social anxiety). Increases in facial blood flow were greater in people with high than low fear of negative evaluation in the niacin condition, but were similar in both groups in the placebo condition. However, changes in pulse rate and ratings of embarrassment, anxiety, blushing and facial heat were similar in both groups in both drug conditions. These findings suggest that the facial vessels of people with a heightened fear of negative evaluation are particularly responsive to niacin under conditions of low anxiety and embarrassment.

Dealing with fear of blushing: a psychoeducational group intervention for fear of blushing

The clinical impression is that people who fear blushing do not easily seek psychological help for their complaints. Therefore, we designed a low-threshold psychoeducational group intervention to reduce fear of blushing. The intervention followed a cognitive-behavioural approach, but in a course setting, e.g., with 'participants' and 'teachers' instead of 'patients' and 'therapists'. The effectiveness of the course in reducing fear of blushing and social anxiety was tested in a group of blushing-fearful individuals (n = 47) by using an uncontrolled study design. The course consisted of six weekly sessions and one booster session 3 months after the last regular session. Assessments took place upon application, immediately before the intervention, after the sixth session, before the booster session, and at 1-year follow-up. Results showed that the course was effective in reducing fear of blushing as well as symptoms of social anxiety. The positive effect of the course on anxiety measures suggests that it might be a promising approach for treating fear of blushing.

KEY PRACTITIONER MESSAGE

The course 'dealing with fear of blushing' is a cognitive-behavioural group intervention in a course setting, e.g., with 'participants' and 'teachers' instead of 'patients' and 'therapists'. The course was effective in reducing anxiety complaints. An effect size of 1.4 and a reduction of approximately 30 points on this Blushing, Trembling and Sweating Questionnaire are comparable with what was reported for individual cognitive-behavioural treatments. Participants evaluated the course positively.

Prospective study of percutaneous radiofrequency sympathicolysis in severe hyperhidrosis and facial blushing: efficacy and safety findings

OBJECTIVE

Hyperhidrosis (Hh) and facial blushing (Fb) are conditions caused by hyperactivity of the sympathetic system; they affect around 2% of the population. Severe cases have been typically treated with thoracic sympathectomy through a minimally invasive approach. We sought to determine if severe Hh and/or Fb patients, who are reluctant to go through an operation with general anaesthesia, could benefit from receiving percutaneous radiofrequency ablation of the sympathetic chain.

METHODS

Prospectively collected data obtained from May 2007 to May 2010 were analysed to compare the treatment efficacy and effects on quality of life of the two procedures.

RESULTS

From a total of 58 patients enrolled in the study, 31 were treated with radiofrequency procedures, whereas 27 received surgical sympathectomy. Patients with Hh had better results with surgery than with radiofrequency sympathicolysis in terms of efficacy (p=0.0001) and quality of life (p=0.0002). However, there was still a significant improvement in quality of life in the group of patients treated with radiofrequency sympathicolysis (p=0.004). Patients with Fb had good results with surgical procedures and poor outcomes with radiofrequency ablation, resulting in significant differences in treatment efficacy (p=0.005) and in quality of life (p=0.003). Fb patients treated with radiofrequency procedures had no improvement in quality of life after the intervention (p=0.28).

CONCLUSION

Our results support the view of surgical sympathectomy as the gold-standard treatment in severe cases of Hh and Fb. Radiofrequency sympathicolysis is useful as a second-treatment choice for Hh patients. Fb patients do not benefit from radiofrequency sympathicolysis.

Cognitive-evaluative features of childhood social anxiety in a performance task

Using an experimental design, we analysed differences in the occurrence of cognitive-evaluative distortions and performance deficits across children with social anxiety disorder, with subclinical anxiety and without any anxiety symptoms. Twenty-one children with full syndrome social phobia, 18 children with partial syndrome social phobia and 20 children without any symptoms of social phobia were compared with respect to their degree of anxiety, negative thinking and task performance during two social-evaluative tasks. In addition, self-ratings of task performance, performance estimations for other children and objective behavioural ratings by two independent observers were obtained. Children with social anxiety disorder and subclinical social anxiety showed higher degrees of experienced anxiety and negative thinking than healthy control children. There was no group difference in respect to actual task performance. Findings are discussed with regard to the continuum assumption of childhood social anxiety disorder and the need of well-adapted early interventions.

Blushing-Fearful Individuals' Judgmental Biases and Conditional Cognitions: An Internet Inquiry

The present study examines two mechanisms that might explain why blushing-fearful individuals fear blushing: Judgmental biases for blushing in ordinary social situations that usually do not elicit a blush, and negative conditional cognitions about blushing irrespective of situation. A web-based self-report measure, linked to a German internet forum for people with fear of blushing, was completed by a group of high blushing-fearful participants (n = 155) and a low fear group (n = 61). Supporting the idea that cognitive biases are involved in fear of blushing, blushing-fearful participants showed inflated estimates of both the probability and the costs of blushing in these situations. In addition, blushing-fearful individuals were characterized by relatively negative conditional cognitions about blushing.

A demonstration of the efficacy of two of the components of cognitive therapy for social phobia

Cognitive-behavioral treatments have demonstrated efficacy in the treatment of social phobia. However, such treatments comprise a complex set of procedures, and there has been little investigation of the effects of individual procedures. The current study investigates the effects of two single session procedures that form part of cognitive therapy for social phobia [Clark, D., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., et al. (2003). Cognitive therapy vs fluoxetine in the treatment of social phobia: A randomised placebo controlled trial. Journal of Consulting and Clinical Psychology, 71, 1058-1067; Clark, D., Ehlers, A., McManus, F., Fennell, M., Grey, N., Waddington, L., et al. (2006). Cognitive therapy versus exposure and applied relaxation in social phobia: A randomised controlled trial. Journal of Consulting and Clinical Psychology, 74, 568-578], namely the "self-focused attention and safety behaviors experiment" and the "video feedback experiment." Results suggest that both procedures are effective in achieving their aims, which are: (i) demonstrating to patients the role of self-focused attention, safety behaviors, and excessively negative self-impressions in maintaining social phobia and (ii) reducing the symptoms of social phobia.

Management of facial blushing

Patients complaining of facial blushing should be investigated by a dermatologist or an internist to rule out serious underlying disorders. Patients with emotionally triggered blushing should be encouraged to try nonsurgical options as the first line of treatment. Provided there is still an indication for treatment, facial blushing may be treated effectively by thoracoscopic sympathectomy. The type of blushing likely to benefit from sympathectomy is mediated by the sympathetic nerves and is the uncontrollable, rapidly developing blush typically elicited when one receives attention from other people. Side effects are frequent, but most patients are satisfied with the operation. In the short term, the key to success in sympathetic surgery for facial blushing lies in a meticulous and critical patient selection and in ensuring that the patient is thoroughly informed about the high risk of side effects. In the long term, the key to success in sympathetic surgery for facial blushing lies in more quality research comparing surgical, pharmacologic, and psychotherapeutic treatments.

Perception of arousal in social anxiety: effects of false feedback during a social interaction

Cognitive models suggest that during social interactions, socially anxious individuals direct their attention to internal cues of arousal and use this information to erroneously infer how they appear to others. High (N=36) and low (N=36) socially anxious adults had a conversation with a stooge, and were led to believe by false feedback that they were experiencing either an increase or decrease in arousal, or evaluating the comfort level of the feedback equipment. Compared to the other groups, participants who believed their arousal had increased, reported greater anxiety, poorer perceived performance, more physical cues of anxiety, and greater underestimation of their performance and overestimation of the visibility of their anxiety. The effects were not specific to participants with high social anxiety. Observers rated the behaviour of participants who believed that their arousal had decreased most favourably. The results have implications for the treatment of social phobia.

When the present visits the past: updating traumatic memories in social phobia

Research suggests that distorted images of the self are common in social phobia and play a role in maintaining the disorder. The images are often linked in thematic and sensory detail to distressing memories that are clustered around the onset or worsening of the disorder. This has led to speculation about the likely benefit of working directly with these memories to improve symptoms of social phobia. In this exploratory study, we describe a process of cognitive restructuring followed by imagery rescripting to update the meanings of distressing memories and images in social phobia. We first present illustrative clinical examples and then data of 14 patients with social phobia, on whom we developed this approach. Patients attended an imagery rescripting session in which a semi-structured interview was used to identify their recurrent images, the associated memories and their meanings. Next the identified memory was evoked and elaborated. We updated the meaning of the memory by first using cognitive restructuring to arrive at new perspectives and then linking these perspectives with the memory using imagery techniques. The procedure resulted in significant within session change in beliefs, and in image and memory distress and vividness. One week later significant change was seen in social phobia cognitions and a self-report measure of social anxiety. Rescripting distressing memories in social phobia appears to be an effective way of modifying maladaptive beliefs linked to recurrent negative imagery. This paper presents our exploratory investigation of how to work with the memories and encourages more rigorous investigation in this area.

Blushing during social interactions in people with a fear of blushing

Changes in facial blood flow were investigated during an introductory conversation, delivering a speech, and listening to the speech afterwards in 16 people with a fear of blushing and 16 controls. It was hypothesized that fear of blushing would be associated with high ratings of self-reported blushing intensity and embarrassment during the tasks, and with persistence of the blushing reaction between tasks. Embarrassment and self-reported blushing intensity were greater in the fear-of-blushing group than in controls throughout the experiment. Increases in facial blood flow were similar in the two groups during each of the tasks. However, blushing dissipated more slowly after each task in the fear-of-blushing group than in controls, resulting in an incremental increase in facial blood flow over the course of the experiment. The slow recovery after an episode of blushing might result in physiological or social cues that help to maintain a fear of blushing.

Autonomic correlates of social anxiety and embarrassment in shy and non-shy individuals

Social anxiety and embarrassment are closely related constructs, both of which are relevant to the study of shyness. To examine the psychophysiological correlates of anxiety and embarrassment in relation to shyness, we measured autonomic arousal (heart rate, respiratory sinus arrhythmia, skin conductance level, and blushing response) in shy and non-shy female participants while they performed tasks designed to elicit either social anxiety or embarrassment. Results indicated that social anxiety and embarrassment are difficult to disentangle at the autonomic level. Blushing may be an important psychophysiological marker of shyness and social anxiety.

Thoracoscopic Sympathectomy for Isolated Facial Blushing

BACKGROUND

Facial blushing is one of the most peculiar of human expressions and has become a cardinal symptom of social phobia. The pathophysiology is unclear and the prevalence is unknown. Thoracoscopic sympathectomy may cure the symptom, but very few surgeons treat patients with isolated facial blushing. The literature is limited, and there are few long-term follow-up studies.

METHODS

A follow-up study by questionnaire in 180 consecutive patients who underwent thoracoscopic sympathectomy for isolated facial blushing at two Danish university hospitals during a 6-year period. Patients routinely underwent T2 sympathectomy at the university hospital in Aarhus (n = 101) and T2-T3 sympathectomy at the university hospital in Odense (n = 79).

RESULTS

The questionnaire was returned by 96% of the patients after a median follow-up time of 20 months. Overall, 90% of the patients had some effect from the operation, and the result was excellent or satisfactory in 75%. There was no significant difference between the two extents of sympathectomy. Compensatory sweating occurred in 88% of all patients and was significantly more frequent after T2-T3 sympathectomy (p = 0.02) Ten percent of our patients regretted the operation because of side effects or no effect of the operation.

CONCLUSIONS

This study demonstrates that thoracoscopic sympathectomy is an effective treatment for isolated facial blushing. The majority of patients achieve an excellent or satisfactory long-term result. Our results suggest that a T2 sympathectomy is superior for patients with isolated facial blushing because side effects are lower compared with a T2-T3 sympathectomy.

Do blushing phobics overestimate the undesirable communicative effects of their blushing?

Previous research indicated that blushing has socially threatening revealing effects in ambiguous situations. To explain blushing phobics' fearful preoccupation with blushing, we tested the hypothesis that blushing fearful individuals overestimate its revealing effects. High (n = 20) and low (n = 20) blushing fearful individuals read vignettes describing prototypical mishaps and ambiguous social events. Participants were prompted in the perspective of the actor, and were asked to indicate their expectations of the observers' judgments (meta-perceptions). Blushing fearful individuals overestimated the probability and the costs of undesirable outcomes. However, this judgmental bias was not inflated by displaying a blush. Thus, the results provide no evidence to support the idea that fear of blushing is fuelled by a biased conception of its communicative effects.

The nature and expression of social phobia: Toward a new classification

Social phobia (social anxiety disorder) was officially recognized as a distinct clinical entity only with the publication of the DSM-III in 1980. Research on the psychopathology of this disorder has revealed a great degree of heterogeneity in its symptomatology. In order to acknowledge this heterogeneity, later versions of the nosological system introduced the generalized subtype of social phobia to describe individuals who fear most or all social situations. The empirical literature on the differences between the diagnostic subtypes has yielded inconsistent findings. Based on the recent emotion literature and concepts from evolutionary psychology, we discuss fearfulness, anxiousness, shyness, self-consciousness, submissiveness, and anger as dimensions of social phobia. The empirical evidence for this classification system and its relationship to the diagnostic subtypes will be discussed.

Information-processing bias in social phobia

Social phobia is a persistent disorder that is unlikely to be maintained by avoidance alone. One reason for the enduring nature of social phobia may be the way individuals with the disorder process social information. It is important for those involved in social phobia to have an understanding of information-processing biases, because it has the potential to guide psychological interventions. In this review of social phobia, probability and cost estimates of social situations are examined, interpretive biases are evaluated and findings relating to memory and negative imagery are also reviewed. The clinical implications of social-phobia-related information-processing biases are discussed and possible avenues for future research are outlined.

Staring at one side of the face increases blood flow on that side of the face

To investigate the effect of observation on blushing, an experimenter sat next to 28 participants and looked closely at one cheek while the participant sang (embarrassing) or read aloud (not embarrassing). Increases in cheek temperature were greater on the observed than the unobserved side during both tasks. Changes in cheek temperature were symmetrical when the experimenter sat next to another 23 participants and looked straight ahead, as well as when the experimenter stared at one side of the participant's face through a glass window while the participant sang. However, increases in cutaneous blood flow were greater on the observed than the unobserved side of the forehead during singing. These findings suggest that staring at one side of the face triggers an ipsilateral increase in facial blood flow.

Autonomic recovery and habituation in social anxiety

Growing evidence suggests that, contrary to expectation, high trait socially anxious (HTSA) and low trait socially anxious (LTSA) individuals show comparable autonomic reactivity during stressful speech tasks. To test the hypothesis that autonomic differences between groups might emerge during recovery or habituation, 35 HTSA and LTSA participants gave two impromptu speeches. Measures of anxiety experience as well as cardiovascular, electrodermal, respiratory, and vagal activation were obtained. Despite greater reports of anxiety experience in the HTSA versus the LTSA participants, autonomic measures showed comparable reactivity, habituation, and recovery in the two anxiety groups. These results suggest minimal autonomic differences between HTSA and LTSA individuals, thus supporting theories of social anxiety that emphasize cognitive factors.

The impact of verbal feedback about blushing on social discomfort and facial blood flow during embarrassing tasks

To investigate whether verbal feedback about blushing influences subsequent social discomfort or blushing itself, changes in facial blood flow and ratings of blushing and embarrassment were investigated in high (N=28) and low scorers (N=28) on the Blushing Propensity scale while singing and reading aloud, and while listening to audiotapes of their performance. After each task half of the participants were told that they had blushed, and the rest were told that they had not blushed. Blood flow increased progressively in participants with high blushing propensity scores who were given "blushing" feedback, but not in the other participants. This finding suggests that expecting to blush may become a self-fulfilling prophecy. Verbal feedback about blushing strongly influenced subsequent social discomfort, and mimicked the effects of blushing propensity on ratings of embarrassment and blushing intensity. In sum, the findings support the view that preconceptions about blushing propensity are shaped by past learning experiences, that concern about blushing is a major source of discomfort in embarrassing situations, and that these concerns are often unrelated to the actual intensity of blushing.