Amanda S. Morrison

Social Anxiety and Social Anxiety Disorder

Research on social anxiety and social anxiety disorder has proliferated over the years since the explication of the disorder through cognitive-behavioral models. This review highlights a recently updated model from our group and details recent research stemming from the (a) information processing perspective, including attention bias, interpretation bias, implicit associations, imagery and visual memories, and (b) emotion regulation perspective, including positive emotionality and anger. In addition, we review recent studies exploring the roles of self-focused attention, safety behaviors, and post-event processing in the maintenance of social anxiety. Within each area, we detail the ways in which these topics have implications for the treatment of social anxiety and for future research. Finally, we conclude with a discussion of how several of the areas reviewed contribute to our model of social anxiety disorder.

Group CBT versus MBSR for social anxiety disorder: A randomized controlled trial.

OBJECTIVE The goal of this study was to investigate treatment outcome and mediators of cognitive-behavioral group therapy (CBGT) versus mindfulness-based stress reduction (MBSR) versus waitlist (WL) in patients with generalized social anxiety disorder (SAD). METHOD One hundred eight unmedicated patients (55.6% female; mean age = 32.7 years, SD = 8.0; 43.5% Caucasian, 39% Asian, 9.3% Hispanic, 8.3% other) were randomized to CBGT versus MBSR versus WL and completed assessments at baseline, posttreatment/WL, and at 1-year follow-up, including the Liebowitz Social Anxiety Scale-Self-Report (primary outcome; Liebowitz, 1987) as well as measures of treatment-related processes. RESULTS Linear mixed model analysis showed that CBGT and MBSR both produced greater improvements on most measures compared with WL. Both treatments yielded similar improvements in social anxiety symptoms, cognitive reappraisal frequency and self-efficacy, cognitive distortions, mindfulness skills, attention focusing, and rumination. There were greater decreases in subtle avoidance behaviors following CBGT than MBSR. Mediation analyses revealed that increases in reappraisal frequency, mindfulness skills, attention focusing, and attention shifting, and decreases in subtle avoidance behaviors and cognitive distortions, mediated the impact of both CBGT and MBSR on social anxiety symptoms. However, increases in reappraisal self-efficacy and decreases in avoidance behaviors mediated the impact of CBGT (vs. MBSR) on social anxiety symptoms. CONCLUSIONS CBGT and MBSR both appear to be efficacious for SAD. However, their effects may be a result of both shared and unique changes in underlying psychological processes.

The Role of Emotion and Emotion Regulation in Social Anxiety Disorder

Many psychiatric disorders involve problematic patterns of emotional reactivity and regulation. In this review, we consider recent findings regarding emotion and emotion regulation in the context of social anxiety disorder (SAD). We first describe key features of SAD which suggest altered emotional and self-related processing difficulties. Next, we lay the conceptual foundation for a discussion of emotion and emotion regulation and present a common framework for understanding emotion regulation, the process model of emotion regulation. Using the process model, we evaluate the recent empirical literature spanning self-report, observational, behavioral, and physiological methods across five specific families of emotion regulation processes—situation selection, situation modification, attentional deployment, cognitive change, and response modulation. Next, we examine the empirical evidence behind two psychosocial interventions for SAD: cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR). Throughout, we present suggestions for future directions in the continued examination of emotion and emotion regulation in SAD.

Attentional control mediates the effect of social anxiety on positive affect

The goal of the present studies was to examine whether attentional control, a self-regulatory attentional mechanism, mediates the effect of social anxiety on positive affect. We tested this mediation in two studies using undergraduate students selected to represent a broad range of severity of social anxiety. Self-report assessments of social anxiety, attentional control, and positive affect were collected in a cross-sectional design (Study 1) and in a longitudinal design with three assessment points (Study 2). Results of both studies supported the hypothesized mediational model. Specifically, social anxiety was inversely related to attentional control, which itself positively predicted positive affect. This mediation remained significant even when statistically controlling for the effects of depression. Additionally, the hypothesized model provided superior model fit to theoretically-grounded equivalent models in both studies. Implications of these findings for understanding diminished positive affect in social anxiety are discussed.

Social anxiety, submissiveness, and shame in men and women: a moderated mediation analysis.

OBJECTIVES Research suggests a positive relationship between social anxiety and shame; however, few studies have examined this relationship or potential mechanisms. Common behaviours of persons with social anxiety disorder (SAD), such as submissive behaviours, may be more consistent with societal expectations of women than men and therefore more likely to be associated with shame in socially anxious men than women. We examined the hypothesis that submissive behaviours would mediate the relationship between social anxiety and shame in men, but not in women, with SAD. DESIGN Moderated mediation was examined in a cross-sectional dataset. Gender was modeled to moderate the paths from social anxiety to submissive behaviours and from submissive behaviours to shame. We also examined an alternative model of the relationships among these variables and the potential contributory role of depression. METHODS Men (n = 48) and women (n = 40) with SAD completed the Social Interaction Anxiety Scale, Submissive Behaviour Scale, Internalized Shame Scale, and Beck Depression Inventory. RESULTS Analyses supported the hypothesized model. The relationship between submissive behaviours and shame was greater in men than women with SAD; the relationship between social anxiety and submissive behaviours was not. Controlling for depression, moderation remained evident although diminished. Results for the comparison model did not support gender moderation. CONCLUSIONS Submissive behaviours mediated the relationship between social anxiety and shame in men, but not women, with SAD. These findings provide preliminary evidence for a model of shame in SAD and may help to further elucidate specific features of SAD that differ between men and women. PRACTITIONER POINTS Although researchers have argued that the display of submissive behaviours might allow the socially anxious individual to limit or prevent attacks on the self, our results suggest that there are greater costs, with regard to feelings of shame, associated with such behaviours for men. In men with SAD, the greater shame associated with submissive behaviours can be understood when considering that socially anxious individuals appear to be particularly concerned with concealing aspects of the self believed to violate perceived societal norms and that traditional masculine gender roles revolve around the theme of dominance. Because the study was conducted in individuals with SAD, it is possible that the restricted range of social anxiety severity may have precluded the observation of gender differences in the relationship between social anxiety and submissive behaviour. Measures were administered in a cross-sectional design, which limits potential inferences of causality.

The Social Interaction Phobia Scale: Continued support for the psychometric validity of the SIPS using clinical and non-clinical samples.

The present study sought to extend findings supporting the psychometric validity of a promising measure of social anxiety (SA) symptoms, the Social Interaction Phobia Scale (SIPS; Carleton et al., 2009). Analyses were conducted using three samples: social anxiety disorder (SAD) patients, generalized anxiety disorder (GAD) patients, and healthy controls. SIPS scores of SAD patients demonstrated internal consistency and construct validity, and the previously demonstrated three-factor structure of the SIPS was replicated. Further, the SIPS total score uniquely predicted SA symptoms, and SIPS scores were significantly higher for SAD patients than GAD patients or controls. Two cut-off scores that discriminated SAD patients from GAD patients and from healthy controls were identified. The current study is the first to replicate the SIPS three-factor model in a large, treatment-seeking sample of SAD patients and establish a cut-off score discriminating SAD from GAD patients. Findings support the SIPS as a valid, SAD-specific assessment instrument.

Intolerance of Uncertainty and Immediate Decision-Making in High-Risk Situations

Given evidence that individuals high in intolerance of uncertainty (IU; the tendency to experience unknown outcomes as unacceptably threatening) exhibit poorer decision-making strategies and are more behaviorally inhibited in unpredictable situations than those low in IU, the present study sought to elucidate the relationship between IU and decision-making by studying confidence and speed in making repeated decisions in high-risk scenarios with an immediate threat given limited but changing information. Seventy undergraduates high or low in IU completed a repeated decision-making task involving hypothetical risk scenarios and rated their confidence in their decisions, given first two options or then three options from which to select. Response times for each decision were recorded. Individuals high in IU became less confident in their decisions across blocks of decision-making trials, whereas individuals low in IU became more confident in their decisions. Response times did not significantly differ between high IU and low IU individuals. However, individuals high in IU tended to be less likely to change their decision when presented with new information and an additional response option than participants low in IU, although this trend fell just short of statistical significance. Implications for the role of IU in the maintenance of anxiety and depression are discussed.

Anxiety trajectories in response to a speech task in social anxiety disorder: Evidence from a randomized controlled trial of CBT ☆

The subjective experience of anxiety plays a central role in cognitive behavioral models of social anxiety disorder (SAD). However, much remains to be learned about the temporal dynamics of anxiety elicited by feared social situations. The aims of the current study were: (1) to compare anxiety trajectories during a speech task in individuals with SAD (n=135) versus healthy controls (HCs; n=47), and (2) to compare the effects of CBT on anxiety trajectories with a waitlist control condition. SAD was associated with higher levels of anxiety and greater increases in anticipatory anxiety compared to HCs, but not differential change in anxiety from pre- to post-speech. CBT was associated with decreases in anxiety from pre- to post-speech but not with changes in absolute levels of anticipatory anxiety or rates of change in anxiety during anticipation. The findings suggest that anticipatory experiences should be further incorporated into exposures.

Trajectories of social anxiety, cognitive reappraisal, and mindfulness during an RCT of CBGT versus MBSR for social anxiety disorder

Cognitive-Behavioral Group Therapy (CBGT) and Mindfulness-Based Stress Reduction (MBSR) are efficacious in treating social anxiety disorder (SAD). It is not yet clear, however, whether they share similar trajectories of change and underlying mechanisms in the context of SAD. This randomized controlled study of 108 unmedicated adults with generalized SAD investigated the impact of CBGT vs. MBSR on trajectories of social anxiety, cognitive reappraisal, and mindfulness during 12 weeks of treatment. CBGT and MBSR produced similar trajectories showing decreases in social anxiety and increases in reappraisal (changing the way of thinking) and mindfulness (mindful attitude). Compared to MBSR, CBGT produced greater increases in disputing anxious thoughts/feelings and reappraisal success. Compared to CBGT, MBSR produced greater acceptance of anxiety and acceptance success. Granger Causality analyses revealed that increases in weekly reappraisal and reappraisal success predicted subsequent decreases in weekly social anxiety during CBGT (but not MBSR), and that increases in weekly mindful attitude and disputing anxious thoughts/feelings predicted subsequent decreases in weekly social anxiety during MBSR (but not CBGT). This examination of temporal dynamics identified shared and distinct changes during CBGT and MBSR that both support and challenge current conceptualizations of these clinical interventions. CLINICALTRIALS. GOV IDENTIFIER NCT02036658.

Treatment Motivation Predicts Substance Use Treatment Retention Across Individuals with and Without Co-Occurring Mental Illness

Motivation is considered a critical component for initiating change, reducing risky behaviors (Dam et al. 2004), and optimizing treatment outcomes (Prochaska et al. 1992). Specifically, treatment motivation has been conceptualized as the “moving force in the client” (Bell et al. 1998), responsible for directing a client both to and through treatment (Miller 1985). Motivation for treatment is thought to be multidimensional (Carey et al. 1999; Drieschner and van der Staak 2004), involving both factors related to treatment readiness (e.g., commitment to participate, willingness to receive help) and treatment resistance (e.g., little confidence in treatment benefits) (Longshore and Teruya 2006). Motivation has been consistently linked to positive outcomes in the treatment of substance use disorders (SUD) such as alcohol abuse and dependence, and cannabis abuse and dependence (De Leon et al. 2000; DiClemente et al. 1999; Gregoire and Burke 2004). Motivation is associated with better treatment engagement, attendance, and retention (Ryan et al. 1995; Simpson et al. 1995), and both SUD treatment entry and completion are affected by motivational factors (Cunningham et al. 1994; Jakobsson et al. 2005). Additionally, high motivation is associated with greater confidence and commitment to treatment (Broome et al. 1999), as well as better emotional acknowledgement of problem behaviors and their impact (Conner et al. 2009). The influence of motivation has also been observed across different treatment modalities, as pre-treatment motivation predicted retention in long-term residential, outpatient Int J Ment Health Addiction (2014) 12:795–805 DOI 10.1007/s11469-014-9510-5