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Background and Objectives: Although cognitive behavioral group therapy (CBGT) is an effective treatment for social anxiety disorder, many socially anxious patients are still symptomatic after treatment. A possible improvement for CBGT could come from the more experiential group psychotherapy, psychodrama (PD). The integration of CBGT and PD (labeled CBPT) might offer an even more effective treatment than CBGT or PD alone. With the present study, we investigated first whether three kinds of group therapy (CBGT, PD, and CBPT) are superior to a waitlist (WL). Second, we investigated whether CBPT is more effective than CBGT or PD alone., Methods: One hundred and forty-four social anxiety patients were randomly assigned to three active conditions or a WL. After wait, WL-participants were randomized over the active treatment conditions., Results: The results of a multilevel analysis showed that all treatments were superior to WL in reducing social anxiety complaints. Only CBGT and CBPT differed significantly from WL in reducing fear of negative evaluations. There were no significant differences between active conditions in any of the variables after treatment and after six-month follow up, neither were there significant differences in treatment dropout., Limitations: First there is the lack of a long-term follow-up. Second, because of loss of participants, we did not reach the planned numbers in the active treatment groups in comparison to WL. Moreover, this study was not designed as a non-inferiority or equivalence trial., Conclusions: Although the integrative CBPT showed good results, it was not more effective than the other treatments., Competing Interests: Declaration of competing interest Given their role as an Editorial Board Member, Arntz A., had no involvement in the peer-review of this article and had no access to information regarding its peer-review. All other authors have declared no conflicts of interest., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background and Objectives: People with Social Anxiety Disorder (SAD) evaluate themselves negatively before, during, and after anxiety-provoking social situations, which leads to negative consequences (e.g., performance deficits, memory impairments, and post-event processing). Despite decades of research, little is known regarding whether these evaluations generalize to how they view others. Social projection theory-the belief that others are similar to oneself-might further extend the basic Cognitive Behavioural Therapy (CBT) model. Our aim was to understand whether the degree to which people negatively evaluate a visibly anxious person causes them to negatively evaluate themselves., Methods: 172 unselected participants completed several baseline questionnaires. We then randomly assigned participants to provide high-, medium-, or no-evaluation of a videotaped anxious person (i.e., other-evaluations) while we assessed their state anxiety. After, they evaluated the anxious person on multiple criteria. Participants then participated in an impromptu conversation task and subsequently evaluated their own performance., Results: Although our manipulation was effective, we found no emotional or behavioural differences between conditions. However, people in the high-evaluation condition recalled significantly fewer facts about their conversation partner than did people in the medium- and no-evaluation conditions., Limitations: After data cleaning, the sample size was slightly smaller than planned; most analyses were nonetheless appropriately powered. Our findings may not generalize beyond unselected undergraduate students; replication in a clinical sample is warranted., Conclusions: These findings highlight the cognitive consequences (i.e., memory impairments) of other-evaluations, which cognitive behavioural therapists should consider when treating individuals with SAD., Competing Interests: Declaration of competing interest The authors report no conflict of interest. This work was supported by a Social Sciences and Humanities Research Council of Canada (SSHRC) Doctoral Scholarship to the first author [grant number 752-2019-1659] and a Discovery Grant from the Natural Sciences and Engineering Research Council of Canada (NSERC) to the second author [RGPIN 2017–05295]. Neither funding source had any role in: study design; data collection, analysis, or interpretation; writing of the report, or; decision to submit the article for publication., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background & Objectives: Social anxiety disorder (SAD) is characterized by a fear of showing anxiety symptoms, which may manifest in greater physiological sensation (PS) word usage, especially when describing their anxious experiences. However, the role of comorbid major depressive disorder (MDD) is unknown. Given blunted physiological arousal in MDD, the SAD only group (SAD) may use more PS words than the comorbid (COM) group with SAD and MDD when discussing anxious memories. Due to more severe symptomology, however, the COM group may use more PS words than the SAD group. We examined these competing hypotheses., Methods: The SAD (n = 30), COM (n = 19), and control (CTL; n = 30) groups recalled their happiest, saddest, and most anxious events. The proportion of PS words was examined., Results: The SAD group used significantly more PS words than the CTL group, whose PS words did not differ significantly from the COM group; the SAD group used marginally more PS words than the COM group. Anxious memories contained significantly more PS words than happiest and saddest memories. Happiest and saddest memories did not significantly differ in PS words., Limitations: The PS words list was created by the authors, and a LIWC dictionary was not used., Conclusions: Blunted physiological arousal in MDD may have contributed to lower PS word usage in the COM group than the SAD group. Understanding linguistic differences between these groups may provide clinicians with insight into these individuals' preoccupations with bodily sensations that may maintain or exacerbate symptoms of anxiety., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background and Objectives: Negative beliefs about other's judgments play an important role in the development and maintenance of social anxiety disorder. The present experiment examined the effects of role-playing followed by role reversal compared to role-playing twice on altering these negative cognitions., Methods: Thirty-six adult social anxiety patients were randomized into two conditions: a role-playing condition in which 18 participants role-played an anxiety-provoking social situation twice, or a role reversal condition in which 18 participants role-played an anxiety-provoking social situation followed by enacting the same situation using role reversal. Before the start of the experiment, patients were asked to report their negative cognitions about the other's judgments. Next, they were asked to rate the believability of these negative cognitions, as well as the probability and cost estimates of negative judgments by the other person, at three time-points: before the first block of role-playing, after the first block of role-playing, and after the second block of the experiment., Results: Results demonstrated that role-playing followed by role reversal had a stronger effect on the most negative cognitions than role-playing twice., Limitations: The most important limitation of the present study is that there was no control group to assess the effects of role-playing alone. Moreover, the second block of the experiment was repetitive in role-playing, however, it was a new task in role reversal., Conclusions: The results support the hypothesis that role reversal is an effective technique that can be used to correct negative cognitions about other's judgments in SAD., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background and Objectives: Fixation on another person's eye-region may be an effective measure of one's level of empathy. In the present study, we tested the hypothesis that this type of empathy measure may not be appropriate for individuals with high levels of social anxiety, since avoidance or hypervigilance attentional biases towards emotional faces are frequent in this condition., Methods: Using eye-tracking, we measured fixation time on the eye-region of another person in participants with low vs. high social anxiety, and we correlated this measure with empathy levels. In a second eye-tracking task, the two groups of participants were presented with pairs of emotional-neutral faces to determine the presence of attentional biases., Results: While participants with low social anxiety showed an association between empathy and fixation time on the other person's eyes, the association was null for participants with high social anxiety. Attentional biases towards emotional faces were absent in high social anxiety, but social anxiety correlated negatively with fixation on the eye region., Limitations: Our sample was made up of Psychology undergraduates, and this may have had an influence on gaze behavior towards the eye region., Conclusion: Fixation on the eye region is not a valid measure of empathy in high social anxiety, possibly due to systematic eye-region avoidance., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background and Objectives: Motivated by their fear of disapproval, individuals with social anxiety continually monitor their own behaviour during social interactions hoping to prevent dreaded negative outcomes. Ironically, they do evoke less positive reactions from others. This study investigated whether lower engagement in the interpersonal process of joint action by socially anxious individuals leads them to attract less positive ratings by their conversation partners., Method: High socially anxious (HSA; N = 36) and low socially anxious individuals (LSA; N = 36) had separate conversations with a naïve conversation partner (N = 36). Conversations were filmed and analysed for joint action using the conventional manual way and a more exploratory automated way. Conversation partners rated the quality of the interaction and the person they talked to., Results: Conversation partners rated HSA participants less positively than LSA participants. The conventional manual method showed less joint action in conversations with LSA participants and crucially, joint action served as mediator between social anxiety status and general impression, quality of interaction and desire to meet again. These results were not replicated with the automated method., Limitations: The study used an analogue sample and future research should investigate whether these findings also apply to a clinical sample. Future studies should further explore the utility of automated techniques to measure joint action., Conclusion: Reduced joint action may explain why socially anxious individuals tend to be perceived less positively by others. The findings emphasise the importance of taking an interpersonal and holistic approach to understanding aspects of social anxiety disorder., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background and Objectives: Attentional Bias Modification (ABM) paradigms targeting anxiety aim to reduce attentional biases for threatening stimuli and thereby reduce anxiety. Based on cognitive theories of performance and learning, elevated levels of arousal during ABM might enhance its effectiveness by making training more engaging and activating fear schemas. This study investigated whether elevated levels of arousal during ABM would increase its effectiveness in reducing attentional bias, stress reactivity, and post-event processing., Method: We randomly assigned 79 high socially anxious students to a session of ABM or control training preceded by either a social stress or control induction to manipulate arousal. Training outcomes were attentional bias, stress reactivity, and post-event processing. Subjective arousal was assessed before, during, and after training., Results: Results indicated that ABM was not successful in reducing attentional bias, stress reactivity or post-event processing, and that the effects of ABM were not moderated by subjective arousal. There was a trend towards ABM being more effective than control training in reducing attentional bias directly after training when participants were more aroused. However, this effect was not maintained one day after the training., Limitations: The arousal manipulation did not result in significant between-group differences in subjective arousal., Conclusions: This study did not provide support for the moderating role of arousal in ABM training effects. Replications with more effective mood induction procedures and more power are needed as a trend finding was observed suggesting that higher levels of arousal improved the direct ABM effects on attentional bias., (Copyright © 2019. Published by Elsevier Ltd.)

Background and Objectives: Difficulty disengaging attention from threat has been observed in some anxious samples, but the evidence to date is mixed. The current study examines temporal trends in attention disengagement and compares this construct across multiple forms of social threat., Methods: Participants (85 adults with a principal diagnosis of social anxiety disorder) completed a spatial cueing task with four image categories (angry faces, disapproving faces, neutral faces, neutral objects). Attention disengagement was assessed via reaction time (RT) over 256 trials., Results: Participants with greater social anxiety exhibited an initial delay in attention disengagement from disapproving faces that habituated over the course of the task. RTs to angry and neutral stimuli did not differ as a function of social anxiety., Limitations: The current task only allowed for examining speed of attention disengagement, and thus we were unable to compare our results to trajectories of speed at which participants orient towards threat. Additionally, disapproving facial images were created for this paradigm and may benefit from further validation., Conclusions: Findings suggest that social anxiety is associated with an initial delay in attention disengagement from social threat that resolves over the course of repeated exposures to such stimuli. Treatment implications are discussed., Competing Interests: Declaration of competing interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background and Objectives: Attention avoidance of feedback-related stimuli is proposed to be associated with and maintain social anxiety. However, previous research has mainly focused on comparing the attention bias between two types of stimuli, while little is known about attention distribution patterns among positive, neutral, and negative feedback and non-feedback stimuli in individuals with high trait social anxiety (HSA) or low trait social anxiety (LSA)., Methods: The current study assessed eye movement pattern of participants with HSA or LSA during a speech task (high anxiety condition) or while solely watching audience feedback of the speech (low anxiety condition). A pre-recorded audience who displayed approving, neutral, or disapproving gestures was presented as feedback stimuli, while neutral facial photos were used as non-feedback stimuli., Results: Only in the high anxiety condition, participants with HSA exhibited longer total fixation on non-feedback stimuli compared to those with LSA; whereas in the low anxiety condition, both groups paid more attention to emotional feedback stimuli., Limitations: The final sample size was modest due to a high suspicion rate of the reality of the audience., Conclusions: These findings suggest that only in highly anxious social situations, socially anxious individuals lack the attentional preference toward positive feedback that individuals with low anxious have., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background and Objectives: Cognitive models assume that negative self-evaluations are automatically activated in individuals with Social Anxiety Disorder (SAD) during social situations, increasing their individual level of anxiety. This study examined automatic self-evaluations (i.e., implicit self-esteem) and state anxiety in a group of individuals with SAD (n = 45) and a non-clinical comparison group (NC; n = 46)., Methods: Participants were randomly assigned to either a speech condition with social threat induction (giving an impromptu speech) or to a no-speech condition without social threat induction. We measured implicit self-esteem with an Implicit Association Test (IAT)., Results: Implicit self-esteem differed significantly between SAD and NC groups under the speech condition but not under the no-speech condition. The SAD group showed lower implicit self-esteem than the NC group under the speech-condition. State anxiety was significantly higher under the speech condition than under the no-speech condition in the SAD group but not in the NC group. Mediation analyses supported the idea that for the SAD group, the effect of experimental condition on state anxiety was mediated by implicit self-esteem., Limitations: The causal relation between implicit self-esteem and state anxiety could not be determined., Conclusion: The findings corroborate hypotheses derived from cognitive models of SAD: Automatic self-evaluations were negatively biased in individuals with SAD facing social threat and showed an inverse relationship to levels of state anxiety. However, automatic self-evaluations in individuals with SAD can be unbiased (similar to NC) in situations without social threat., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background and Objectives: Young people with social anxiety display poor social functioning but it is unclear whether this is underscored by difficulties in key social cognitive abilities, such as perspective taking. Here, we examined whether increased social anxiety is associated with reduced accuracy on a perspective taking task and whether this relationship is stronger at particular periods within adolescence., Methods: Fifty-nine adolescents aged 11-19 years completed the computerised Director Task (DT) and the Social Anxiety Scale for Adolescence. In the DT, participants virtually move objects by following either instructions given by the 'Director' (who can see only some objects), or a simple rule to ignore certain objects., Results: Participants who scored above the clinical cut-off for social anxiety (n = 17) were less accurate when they had to take the perspective of the Director into account than those scoring below cut-off, yet performed similarly on control trials. Preliminary analysis indicated that poorer performance was most strongly associated with social anxiety in mid-adolescence (14-16.5 years)., Limitations: The DT has been used previously to measure online perspective taking but the underlying cognitive mechanisms have not been fully elucidated. Extending these findings using additional measures of perspective taking would be valuable., Conclusions: Adolescents with higher social anxiety were less accurate at taking the perspective of a computerised character, with some suggestion that this relationship is strongest during mid-adolescence. If replicated, these findings highlight the importance of addressing specific social cognitive abilities in the assessment and treatment of adolescent social anxiety., (Copyright © 2016. Published by Elsevier Ltd.)

Background and Objectives: Patients with social anxiety disorder suffer from pronounced fears in social situations. As gaze perception is crucial in these situations, we examined which factors influence the range of gaze directions where mutual gaze is experienced (the cone of gaze)., Methods: The social stimulus was modified by changing the number of people (heads) present and the emotional expression of their faces. Participants completed a psychophysical task, in which they had to adjust the eyes of a virtual head to gaze at the edge of the range where mutual eye-contact was experienced., Results: The number of heads affected the width of the gaze cone: the more heads, the wider the gaze cone. The emotional expression of the virtual head had no consistent effect on the width of the gaze cone, it did however affect the emotional state of the participants. Angry expressions produced the highest arousal values. Highest valence emerged from happy faces, lowest valence from angry faces., Conclusion: These results suggest that the widening of the gaze cone in social anxiety disorder is not primarily mediated by their altered emotional reactivity. Implications for gaze assessment and gaze training in therapeutic contexts are discussed., Limitations: Due to interindividual variability, enlarged gaze cones are not necessarily indicative of social anxiety disorder, they merely constitute a correlate at the group level., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background and Objectives: Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) have both garnered empirical support for the effective treatment of social anxiety disorder. However, not every patient benefits equally from either treatment. Identifying moderators of treatment outcome can help to better understand which treatment is best suited for a particular patient., Methods: Forty-nine individuals who met criteria for social anxiety disorder were assessed as part of a randomized controlled trial comparing 12 weeks of CBT and ACT. Pre-treatment avoidance of social situations (measured via a public speaking task and clinician rating) was investigated as a moderator of post-treatment, 6-month follow-up, and 12-month follow-up social anxiety symptoms, stress reactivity, and quality of life., Results: Public speaking avoidance was found to be a robust moderator of outcome measures, with more avoidant individuals generally benefitting more from CBT than ACT by 12-month follow-up. In contrast, clinician-rated social avoidance was not found to be a significant moderator of any outcome measure., Limitations: Results were found only at 12-month follow-up. More comprehensive measures of avoidance would be useful for the field moving forward., Conclusions: Findings inform personalized medicine, suggesting that social avoidance measured behaviorally via a public speaking task may be a more robust factor in treatment prescription compared to clinician-rated social avoidance., (Published by Elsevier Ltd.)

Background and Objectives: This two-year follow-up study evaluated the long-term outcomes of two early interventions that aimed at reducing social and test anxiety in young adolescents at risk for developing social anxiety disorder., Methods: In this RCT, moderately socially anxious adolescents (N=240, mean age 13.6 years) were randomly assigned to a 10-week internet-based multifaceted cognitive bias modification training (CBM), a 10-week school-based cognitive behavioral group training (CBT), or a no-intervention control condition. Using multiple imputation, this study examined the changes in primary and secondary outcome measures from pretest to follow-up in a repeated measures design., Results: Primary outcome: Self-reported social and test anxiety generally decreased from pre-test to two-year follow-up, regardless of treatment condition. The percentage of adolescents who developed a social anxiety disorder was very low (6%) and similar across conditions. Secondary outcome: There were beneficial changes in self-esteem, self-reported prosocial behaviors, and fear of negative evaluation, but none of these were related to treatment condition. Automatic social-threat associations did not significantly change. The CBM intervention was effective in changing interpretative bias as indexed by the Recognition Task but this long-term effect did not transfer to the Adolescent Interpretation and Belief Questionnaire., Limitations: There was a substantial (50%) though seemingly non-selective attrition at follow-up., Conclusions: This RCT does not support the longer-term efficacy of school-based CBT or CBM as an early intervention for social and test anxiety. Rather, it emphasizes the positive 'natural' course of highly socially anxious adolescents over two years., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background and Objectives: According to cognitive models of Social Anxiety Disorder (SAD), negative rumination is a key maintaining factor in the vicious cycle of social anxiety. However, there is a scarcity of research investigating treatment effects on rumination in social anxiety, as well as other key cognitive variables. The current study aimed to determine the effectiveness of a brief intervention on a range of cognitive processes, most notably negative rumination. Additionally, predictors of negative rumination and state anxiety are also investigated., Methods: Participants with a diagnosis of SAD were randomly allocated to an intervention (n = 24) or control group (n = 23). Participant's initially completed trait and state based measures with the intervention group also completing a brief cognitive intervention. One-week later participants completed state anxiety and cognitive measures before and after a speech task. Finally, one-week post-speech task participants completed further trait and state based measures., Results: While the brief cognitive intervention had positive effects on some of the cognitive processes measured at different time points of the study, levels of negative rumination remained stable. Predictors of negative rumination and state anxiety were consistent with cognitive models of SAD., Limitations: The brief nature of the intervention and temporal stance of the intervention (delivered one-week before the speech) may have impacted outcomes., Conclusions: Cognitive technique can potentially impact a range of key processes that maintain SAD, however, more powerful and tailored interventions are needed that address the different processes at play before, during and after a social situation for socially anxious individuals., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background and Objectives: Numerous studies have supported attentional biases toward social threats in socially anxious individuals. The aim of the present study was to investigate the time-course of sustained attention for multiple emotional stimuli using a free-viewing paradigm in social anxiety., Methods: Thirty-two socially anxious (SA) and 30 non-anxious (NA) participants completed the free-viewing task. Participants were presented with a face array composed of angry, sad, happy and neutral faces for 10 s in each trial. Eye movements were recorded throughout the trial to assess the time-course of attentional processing., Results: Although SA participants did not exhibit initial orienting bias, they had higher fixation probability for angry faces during the 250-1000 ms time intervals, relative to NA participants. SA participants also maintained their attention longer than NA participants did when angry faces were initially fixated upon. Moreover, NA participants showed higher fixation probability for happy faces during the 6-8 s after stimulus onset. We failed to observe attentional avoidance of threat in SA participants., Limitations: First, this study used a non-clinical sample. Second, the stimuli used in this study were static., Conclusions: The present findings suggest that, relative to non-anxious individuals, socially anxious individuals are characterized by enhanced engagement with social threat at an early stage of processing and difficulty in disengaging from social threat once their initial attention is located on it. Conversely, non-anxious individuals are characterized by enhanced engagement with positive stimuli at a later stage of processing., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background and Objectives: Research shows that people tend to consider believable conclusions as valid and unbelievable conclusions as invalid (belief bias). When applied to anxiogenic beliefs, this belief bias could well hinder the correction of dysfunctional convictions. Previous work has shown that high socially anxious students indeed display such fear-confirming, belief biased, reasoning. A critical next question is whether these findings translate to a clinical population of people with social anxiety disorder (SAD). We test whether (i) patients with SAD show belief bias with regard to SAD-relevant themes, (ii) this belief bias is specific for SAD patients or can also be found in panic disorder (PD) patients, (iii) differential belief bias effects in SAD are restricted to social anxiety concerns or are also evident in the context of reasoning with neutral themes., Method: 45 SAD patients, 24 PD patients, and 45 non-symptomatic controls (NSCs) completed a syllogistic belief bias task with SAD-relevant and neutral content., Results: SAD patients displayed belief bias for social anxiety related materials, while the PD group and the NSC group did not. Yet, the difference between SAD and PD was not significant. All groups showed similar belief bias effects for neutral content., Limitations: Content of the belief bias task was not tailored to idiosyncratic beliefs. The study lacked power to detect medium or small differences., Conclusions: SAD patients showed concern-congruent belief biased interference effects when judging the logical validity of social anxiety relevant syllogisms. Such concern-relevant belief bias may contribute to the persistence of anxiogenic beliefs., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background and Objectives: Perception of trustworthiness in other people is essential for successful social interaction. Facial expressions-as conveyers of feelings and intentions-are an important source of this information. We investigated how social anxiety is related to biases in the judgment of faces towards un/trustworthiness depending on type of emotional expression and expressive intensity., Methods: Undergraduates with clinical levels of social anxiety and low-anxiety controls were presented with 1-s video-clips displaying facial happiness, anger, fear, sadness, disgust, surprise, or neutrality, at various levels of emotional intensity. Participants judged how trustworthy the expressers looked like., Results: Social anxiety was associated with enhanced distrust towards angry and disgusted expressions, and this occurred at lower intensity thresholds, relative to non-anxious controls. There was no effect for other negative expressions (sadness and fear), basically ambiguous expressions (surprise and neutral), or happy faces., Limitations: The social anxiety and the control groups consisted of more females than males, although this gender disproportion was the same in both groups. Also, the expressive speed rate was different for the various intensity conditions, although such differences were equated for all the expressions and for both groups., Conclusions: Individuals with high social anxiety overestimate perceived social danger even from subtle facial cues, thus exhibiting a threat-related interpretative bias in the form of untrustworthiness judgments. Such a bias is, nevertheless, limited to facial expressions conveying direct threat such as hostility and rejection., (Copyright © 2016 Elsevier Ltd. All rights reserved.)