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Background: Social anxiety disorder (SAnD) is a highly prevalent condition, characterised by an intense fear of social or performance situations where individuals worry about being negatively evaluated by others. An up to date systematic review of the effectiveness of cognitive behavioural therapies for SAnD is required to guide practice. Objectives: To assess the efficacy and acceptability of cognitive behavioural therapy (CBT) compared with treatment as usual/waiting list (TAU/WL) for individuals with SAnD. Search methods: We searched the Cochrane Depression, Anxiety and Neurosis Group (CCDAN) Controlled Trials Register and conducted supplementary searches of MEDLINE, PsycInfo, EMBASE, and international trial registers (ICTRP; ClinicalTrials.gov) in October 2011 and CINAHL in October 2012. We also searched reference lists of retrieved articles, and contacted trial authors for information on ongoing/completed trials. Selection criteria: Randomised and quasi-randomised controlled trials undertaken in out-patient settings, involving adults aged 18-75 years with a primary diagnosis of SAnD, assigned either to CBT or TAU/WL. Data collection and analysis Data on patients, interventions and outcomes were extracted by two review authors independently, and the Risk of bias in each study was assessed. The primary outcomes were social anxiety reduction (based on relative risk (RR) of clinical response and mean difference in symptom reduction), and treatment acceptability (based on RR of attrition). Results: Thirteen studies (715 participants) were included in the review, of which 11 studies (599 participants) contributed data to meta-analyses. Based on four studies, CBT was more effective than TAU/WL in achieving clinical response at post-treatment (RR 3.60, 95% CI 1.35 to 9.57), and on eleven studies (599 participants) it was more effective than TAU/WL in reducing symptoms of social anxiety. No significant difference was found between CBT and TAU/WL for attrition. No significant difference was demonstrated for social anxiety at follow-up and no studies examined follow-up data for clinical response or attrition. Authors' conclusions: The available evidence suggests that cognitive behavioural therapy might be effective in reducing anxiety symptoms for the short-term treatment of SAnD. However, the body of evidence comparing CBT with TAU/WL is small and heterogeneous.

Introduction: This study applies positive emotion regulation models to identify within-person and between-person mechanisms that contribute to co-occurrence of Alcohol Use Disorder (AUD) and Social Anxiety Disorder (SAD) symptoms. SAD is a risk factor for the development of AUD, and comorbid SAD and AUD confer greater detrimental effects than either disorder alone. People high in social anxiety have difficulties regulating positive emotions, including difficulty accepting positive emotions. Although people with AUD symptoms often experience trait-level difficulties regulating positive emotions, in the short term, alcohol use may facilitate adaptive positive emotion regulation. Thus, an understudied area of research is whether alcohol consumption temporarily allows people experiencing elevated social anxiety symptoms to accept positive emotions, which, in the long term, could lead to alcohol-related problems. To address this gap in research, the present study (1): Tested whether alcohol consumption moderated within-person relations between state social anxiety and positive emotion acceptance in emerging adult hazardous drinkers, and (2): Tested whether, on a between-person level, the extent to which alcohol helped people accept positive emotions was associated with alcohol-related problems. Method: 104 young adults (aged 18-25) who reported hazardous drinking participated in a baseline session and a 14-day ecological momentary assessment (EMA) data collection period. During the EMA data collection period, participants initiated EMA reports about each social interaction they experienced, which assessed their social anxiety, positive emotion acceptance, and alcohol use. Results: Social anxiety was associated with lower positive emotion acceptance during social interactions. Alcohol consumption occurrence, but not quantity, was associated with lower positive emotion acceptance. Alcohol consumption did not moderate the relation between state social anxiety and positive emotion acceptance, and the moderation effect did not correlate with alcohol-related problems. Conclusion: These findings lay important groundwork in determining how within-person transdiagnostic processes, such as difficulty accepting positive emotions, help explain the relation between social anxiety and alcohol use. Results provide strong support for the connection between social anxiety and difficulty accepting positive emotions, and also provide evidence that, at a moment-to-moment level, alcohol use and positive emotion regulation difficulties often co-occur. These results have important clinical implications for hazardous drinking interventions, and may provide a foundation for future research focused on reducing the negative societal and personal costs of hazardous drinking and social anxiety.

Individuals with Social Anxiety Disorder (SAD) are typically perceived by others as shy, submissive, or risk-averse. However, recent work has identified an understudied subtype within SAD characterized by high levels of anger and high-risk or novelty-seeking impulsive behaviors. Interestingly, this subtype bears conceptual similarities with prior accounts of vulnerable narcissism. For example, both are associated with concerns regarding self-presentation and how they are perceived by others. The angry-impulsive subtype and vulnerable narcissism may further share similar etiologic origins and similar associations with self-reported anger, impulsivity, and anxiety-related characteristics. However, despite these key similarities no prior work has systematically evaluated the common and potentially distinguishing factors within and between these conceptually similar but diagnostically distinct groups. For example, cognitive features such as fear of negative evaluation and interpersonal rivalry could be distinguishing features of SAD and vulnerable narcissism, although the utility of these distinguishing features to clarify the differential diagnosis remains unknown. Accordingly, the purpose of this study was to utilize a person-centered analytic approach (latent profile analysis; LPA) to empirically establish whether vulnerable narcissistic traits exist within high anger, risk-prone individuals who are also socially anxious, or alternatively whether specific features of each disorder can be used to disambiguate them empirically. Results of this work supported the existence of the angry impulsive socially anxious subtype and supported a relationship between that group and vulnerable narcissistic traits. These findings have implications for treatment selection among affected individuals and may further clarify why prior work evaluating interventions for adults with SAD and angry impulsive features has been met with only limited success.

Social anxiety is a type of anxiety triggered by social situations whereby the individual feels scrutinized by others, and which may contribute to avoidance of certain situations. This avoidance can interfere with personal, academic, and career endeavors. Cognitive behavioral therapy can help manage social anxiety. However, social anxiety is often underrecognized and under treated. A survey with the Liebowitz Social Anxiety Scale (LSAS) was disseminated to identify and address this need among students in a large Northeastern university in the United States. The study is valuable as a pilot study. There was a small response rate for participation in the study, but the findings did indicate some possible trends. Data interpretations suggest females were more likely to take the survey and had higher scores on the LSAS as compared to males. Other findings indicated that students majoring in biological science scored higher than students compared to other majors. Fear and avoidance for acting, performing, or giving a talk in front of an audience scored the highest by most of the respondents when compared to all other situations for social anxiety. Future studies to guide interventions are warranted.

Social anxiety disorder (SAD) is prevalent and debilitating. More research is needed on a) the factors driving SAD symptoms and b) targeted interventions to shift these factors. Experiential avoidance (EA) has been identified as a possible factor driving SAD symptoms. Many empirically-supported treatments focus on reducing EA as a mechanism of symptom change. However, past research on the relation between EA and SAD symptoms has almost exclusively focused on explicit (i.e., consciously controlled) as compared to implicit (i.e., outside of conscious control) measures of EA. Further, little is known about how EA and SAD symptoms bidirectionally interact throughout the course of an intervention. To address these limitations of past research, the present study: 1) evaluated the psychometric properties of two implicit measures of EA, 2) dynamically modeled the week-to-week temporal relations between explicit EA and SAD symptoms, and 3) tested the efficacy and acceptability of a novel, 3-session pilot intervention targeting EA, which included a computerized program and psychoeducation. Participants (N = 78) consisted of undergraduates with elevated explicit EA and SAD symptoms. There was mixed evidence that the implicit measures demonstrated adequate validity and reliability. In partial support of hypotheses, bidirectional models of explicit EA and SAD symptoms suggested that changes in SAD symptoms preceded and predicted changes in explicit EA from week to week, but not vice versa. Further, the pilot intervention was not associated with reductions in EA and SAD symptoms, but generally, was found to be acceptable and credible. These novel findings advance our understanding of the dynamic relationships between EA and SAD symptoms throughout treatment. Given that many empirically-supported treatments target EA as a mechanism of symptom change, this study highlights a need for future work to more clearly delineate the time course by which changes in mechanisms leads to changes in symptoms. Ultimately, this could provide patients with more realistic expectations for recovery.

Social Anxiety Disorder (SAD) is characterized by excessive concern or fear of negative evaluation in one or more social situations and ranks as one of the most common psychiatric disorders. SAD has also been characterized by significant deficits in social motivation and a lack of reactivity to pleasurable stimuli (i.e., positive affect; [PA]), particularly within social contexts. Recent neuroimaging work has shifted towards examining positively-valenced motivational systems in SAD focused on reward responses to social and nonsocial stimuli. These studies have revealed aberrant reward processing during social reward tasks in individuals with SAD. However, not all individuals with SAD exhibit reward circuitry dysfunction. Therefore, the current study aimed to examine if functional patterns of connectivity in the brain underlie heterogeneity in PA differences in individuals with SAD. Results revealed several functional connectivity strength differences between SAD and control groups within reward regions. Additionally, associations between regions of interest (ROIs)-couplings (i.e., OFC and insula, OFC and subgenual cingulate, insula and cingulate, and cingulate and subgenual cingulate) and diminished PA were present in individuals with SAD, but not controls. Lastly, results demonstrated that individuals with SAD had higher variability in their reward connectivity strength presentations and reports of PA as compared to controls. These results hold significance for the development of interventions for SAD that focus on the enhancement of PA to bolster social reward responsivity.

The dot probe task has become the most widely used experimental paradigm for empirically investigating attention biases in anxiety. However, this task’s classic reaction time index for calculating mean attention bias toward threat has shown very low reliability. In response to these findings, new indices of attention bias variability and trial-level bias score (TL-BS) strategies have been developed. The purpose of the current study is to evaluate the reliability of all dot probe attention bias indices in the scientific literature. Forty-four community participants with social anxiety disorder completed a facial dot probe task at two sessions one week apart. TL-BS indices of mean attention bias and attention bias variability demonstrated superior reliability to other indices. The findings demonstrate that the TL-BS method is psychometrically superior to other indices for measuring mean attention bias to threat and attention bias variability in people with social anxiety disorder.

Social anxiety symptoms are associated with diminished ability to up-regulate, or savor, positive emotional experiences. This study tested whether experiential avoidance, fear of positive evaluation, and fear of positive emotion, mediated the relation between social anxiety symptoms and change in positive emotions following a reminiscence savoring task, and whether reminiscence instructions moderated the relations between these mediators and change in positive emotions. 196 unselected participants were randomized to immersed, first-person reminiscence or distanced, third-person reminiscence, and reported positive emotions before and after reminiscence. As expected, in the immersed condition, participants high (vs. low) in experiential avoidance benefited less from reminiscence, and experiential avoidance mediated the relationship between social anxiety symptoms and change in positive emotions. Surprisingly, for participants in the immersed condition, fear of positive evaluation was positively associated with positive emotions, whereas for those in the distanced condition, fear of positive evaluation was negatively associated with positive emotions. Finally, there was no evidence of a moderated mediation effect for fear of positive emotion. Together, data suggest that social anxiety symptoms may lead to diminished positive emotions through multiple, disparate mechanisms, and that these mechanisms differentially interact with savoring strategies to influence change in positive emotions.

Though exposure-based treatments for social anxiety disorder (SAD) are efficacious, not everyone benefits, and we still do not fully understand how and under what conditions this treatment works. Fruitful approaches to better understanding and improving exposure therapy 1) identify predictors of treatment outcome based on theory and 2) manipulate proposed predictors to improve outcomes. Theoretical models of exposure therapy implicate reduction in threat-related avoidance (or, increases in threat-related attention and approach) as a mechanism of fear reduction. The studies in this dissertation follow this theory-driven approach by testing the hypothesized relation between changes in implicit measures of threat-related attention and treatment outcome (Studies 1 and 2) and testing the efficacy of a strategy aimed to manipulate threat approach to improve exposure outcomes (Study 3). Specifically, in Study 1 we examined how social threat-related attentional biases change during exposure therapy for SAD, and attempted to relate these changes in attention bias with symptom change. Additionally, we tested a computational method used to yield attention bias scores that may be more reliable for repeated measurement. Our results indicated that while social threat-related attention bias did decrease over the course of exposure therapy, these changes were not predictive of symptom change. Study 2 examines the language used during speech exposures (i.e., linguistic style) as a potential predictor of exposure outcome, relating these variables to SAD symptom severity a week after a single exposure session. We found that increased use of first-person plural pronouns during the public speaking exposure was predictive of superior exposure outcomes, in line with an hypothesis that first-person plural pronoun is indicative of threat-related attentional focus during exposure therapy. Finally, Study 3 tested whether a behavioral manipulation thought to temporarily increase endogenous testosterone (a hormone associated with social threat approach) would augment exposure therapy. We found no evidence to suggest that testosterone levels can be manipulated via our behavioral strategy and were thus unable to test whether increasing testosterone facilitates exposure therapy outcomes. We discuss some limitations to the research, as well as recommendations for future directions.

Social Anxiety Disorder is characterized by irrational and persistent fears of potential evaluation and scrutiny by others. For socially anxious youth, the core, maladaptive cognition is fear of negative evaluation (FNE). Whereas Cognitive Behavioral Therapy (CBT) targets remediation of intense and unfounded FNE, Attention Bias Modification Treatment (ABMT) targets attention bias. The degree to which FNE and biased attention are related processes is unknown. This study sought to assess the relationship between FNE and two indices of attention bias (dot probe and eye-tracking). In addition, this study examines differences in attention bias between a clinically confirmed group of youth SAD and healthy controls. A significant group difference in average latency to fixate on angry faces was found [F(1,65) = 31.94, p < .001, ηp2 = .33]. However, the pattern was not consistent across the other attention bias metrics (i.e., dot probe bias scores and first fixation direction percentage towards angry faces). In addition, associations between FNE and the attention bias metrics were not statistically significant in either group. Future directions and implications of these findings within the context of refinements to existing interventions are discussed.

Cognitive models of social anxiety disorder (SAD) emphasize repetitive negative thinking as a prominent maintaining factor that occurs both before (anticipatory processing) and after (post-event processing) social-evaluative events. While evidence suggests that repetitive negative thinking is a maladaptive process that has damaging cognitive, behavioural, and affective consequences for those with SAD, the cognitive mechanisms thought to underlie ineffective control of attention on these modes of thought was unclear. Cognitive interference theories, such as attentional control theory, propose that high levels of anxiety negatively impact the processing efficiency on tasks that require high cognitive resources. Accordingly, this thesis aimed to elucidate the role of executive functions on repetitive negative thinking in social anxiety by employing a combination of self-report and experimental methodologies with social anxiety analogue samples. Studies 1A and 1B explored the correlational relationships between social anxiety, anticipatory processing and post-event processing, and attentional control, as an initial step prior to conducting experimental studies. Poorer total attentional control was associated with social anxiety in both studies and diminished attentional shifting was associated with increased levels of PEP, but not AP. Mediation modelling suggested that trait anxiety mediated the relationship between attentional shifting and PEP, and positive affect mediated the relationship between total attentional control and PEP. Drawing from attentional control theory, studies 2 and 3, manipulated both anticipatory processing (study 2) and post-event processing (study 3), to examine the underlying executive functions responsible for ineffective control of attention in anxiety (i.e., inhibition and shifting) using the mixed emotional saccade task. Both studies 2 and 3 did not demonstrate an anxiety-related effect on attentional control and were comparable in showing that both AP and PEP appear to have an adaptive component on attentional control for low socially anxious individuals as indicated by improved task performance. Taken together, these findings highlight that other potential factors may underlie anticipatory and post-event processing in social anxiety, which appear to be complex and interacting. For example, other potential contributing factors that underlie AP and PEP may include the role of motivation, manipulating the cognitive load of the task, self-control strength, and valence of AP and PEP thoughts. However, an examination of these factors was beyond the aim and scope of the current PhD research program and needs to be investigated in future research.

Social anxiety disorder (SAD), also known as social phobia, is a major physical and mental health concern with a high lifetime prevalence. Despite being the most common anxiety disorder, current treatment options available are unsatisfactory among SAD patients. Therefore, we adapted a social fear conditioning (SFC) paradigm to mimic the main behavioral symptoms of SAD of humans in mice. In this protocol, social fear is induced by administering foot shocks during social interaction with an unknown conspecific. This form of conditioning did not induce any other behavioral alterations such as general anxiety. The negative social experience inducing social fear in this animal model and SAD patients satisfies construct validity, whereas the similarity in behavioral phenotypes satisfies face validity. After establishing that our model of social fear has face and construct validity, we aim to assess 1) whether this model has predictive validity, and 2) test the therapeutic efficacies of three novel therapeutic strategies: cognitive behavioral therapy, pharmacological selective-serotonin reuptake inhibitor, and targeted brain stimulation.

Despite evidence supporting a robust relation between common factors- aspects of the therapeutic setting that are common across all types of treatment- and treatment response, little is known about the mechanisms by which these common factors effect change. Two of the most well-researched common factors include the client’s expectations about the effectiveness of treatment (termed outcome expectancy), and the quality of the therapeutic relationship (termed working alliance). Using archival data, the present study tests the hypothesis that the relation between outcome expectancy and symptom reduction is mediated by the alliance following treatment for social anxiety disorder. Data were collected in a sample of 65 individuals who received cognitive behavioral therapy for social phobia with public speaking fears. Mediation analyses were conducted using Andrew Hayes’ Process Macro (Hayes, 2013). None of the mediation analyses were significant. These findings suggest that the mechanisms of common factor variables may vary by disorder.

This thesis project explores Social Anxiety Disorder, by showing emotions and feelings of the person who suffers from social phobia to help his/her friends and classmates to understand them. The symptoms of a person with social phobia can be seen as being afraid of communicating with other people, appearing in public, and/or being the center of attention. In such situations, others may easily misunderstand them, so the patient can lose the chance to communicate to others. As a result, the patient's condition will be getting worse. Therefore, it is very hard for people with social phobia to make new friends. So, their friends and classmates need to know the true thoughts and feelings of the person who suffers from social phobia for understanding the patient's behaviors to help him/her. Social anxiety disorder, also called social phobia, can result in individual issues in human relations. Sometimes, some minor words from others may stimulate people with social phobia and their emotions and make their current situation worse. When their friends do not have much knowledge about their status, a person suffering from social phobia can be frustrated with his/her sensitive mind. The purpose of this thesis project is to raise public awareness and spread basic information about social phobia through a short motion graphic. It includes some signs and symptoms of the social phobia, and show what kind of behaviors indicate a potential social anxiety disorder. Through this motion graphic, people whose friends suffer Social Anxiety Disorder can learn more about it and better understand them.

Social Anxiety Disorder (SAD) is a chronic and pervasive disorder that is relatively prevalent in children and adolescents and is associated with numerous short and long term consequences. SAD is commonly comorbid with other mood and anxiety disorders, and in particular, with Generalized Anxiety Disorder (GAD). In fact, research suggests that pure forms of either GAD or SAD are relatively rare (Walkup et al., 2008). Worry and the cognitive variables found to be associated with it, such as intolerance of uncertainty (IU), positive and negative beliefs about worry (PBW and NBW), negative problem orientation (NPO) and cognitive avoidance (CA), feature prominently in the theoretical models of adult GAD put forward by Dugas and colleagues (Dugas, Marchand & Ladouceur, 2005; Dugas & Robichaud, 2007; Dugas et al., 2007) and Wells (1995). Empirical research has not only found evidence for the importance of these variables to GAD in adults (Boelen, Vrinssen & van Tulder, 2010; Dugas, Gosselin & Ladouceur, 2001; Freeston, Rhéaume, Letarte, Dugas & Ladouceur, 1994; Ladouceur, Blais, Freeston & Dugas, 1998; Laugesen, 2007), but also in youth (Boelenet al., 2010; Fialko, Bolton & Perrin, 2012; Holmes, Donovan, Farrell & March, 2014). Recently, the suggestion has been made that worry and some of its associated cognitive variables might not be specific to GAD, but in fact may be more transdiagnostic in nature, and that there is some, albeit limited, evidence to date supporting this supposition, particularly with adults.

Current theoretical models of social anxiety disorder (SAD) emphasize the importance of information processing biases in its etiology and maintenance. Prior research findings have been mixed with regard to the precise nature of both attention and memory biases among individuals with SAD, with some studies finding weak evidence and others finding support. The current study used a novel approach to studying attention and encoding among with the SAD (n=26) and non-SAD (n=25) groups. This approach involved asking participants to view a series of faces in a spatial grid for a short time, and then asking them to pick the faces they saw from among a series of distractor faces and place them in their original correct spatial location in a blank grid. Faces varied by displayed emotional expression (happy, angry, or neutral) as well as by apparent eye contact with the participant (direct gaze, averted gaze). Results showed that participants were generally more adept at recalling neutral faces compared to angry or happy faces, and more adept at recalling averted gaze faces than direct gaze faces, and this effect did not differ across social anxiety groups. Reasons for the lack of interaction effects are explored, and implications and future directions are discussed.

Social Anxiety Disorder (SAD) is a chronic mental illness that affects a large number of people and is difficult to treat. There is a wealth of research identifying cognitive, behavioral, and biological mechanisms that contribute to the development and maintenance of this disorder. However, the phenomenology of fear, the emotion central to this disorder, is less well studied. It is assumed that individuals with SAD experience more fear than non-anxious individuals, but the empirical support stems primarily from self-report and laboratory studies. In fact, studies of physiological responses associated with fear (e.g., sympathetic nervous system arousal) have not consistently shown elevated fear. Although emotions are recognized as multi-dimensional response systems, fear has not yet been examined in more than one dimension at a time across contexts in daily life in SAD. This study measured fear in two dimensions (self-report and sympathetic nervous system arousal) over five days using experience-sampling and ambulatory monitoring equipment. Social context was also measured. Both the relative frequency of fear and concordance across fear dimensions were compared in individuals with SAD and healthy controls (HC). Findings reveal that individuals with SAD exhibit a higher relative frequency of fear as compared to HC and this finding was moderated by social context. Additionally, when compared to HCs, individuals with SAD did not exhibit greater concordance, or positive association between response dimensions. These findings support the dominant theoretical assumptions that individuals with SAD experience more fear, however, there are several caveats that have important implications for theories of fear in this disorder.

The default mode network (DMN) is active in the absence of task demands and during self-referential thought. Considerable evidence suggests that the DMN is involved in normative aspects of social cognition, and as such, disruptions in the function of DMN would be expected in disorders characterized by alterations in social function. Consistent with this notion, work in autism spectrum disorder (ASD) and social anxiety disorder (SAD) has demonstrated altered activation of several core regions of the DMN relative to neurotypical controls. Despite emergent evidence for alterations within the same brain systems in SAD and ASD, as well as a behavioral continuum of social impairments, no study to date has examined what is unique and what is common to the brain systems within these disorders. Therefore, the primary aim of the current study is to precisely characterize the topology of neural connectivity within the DMN in SAD and ASD and neurotypical controls in order to test the following hypotheses through functional and structural connectivity analyses of the DMN. Our analyses demonstrate increased coavtivation of the dorsomedial prefrontal cortex in ASD and SAD compared to controls, as well as over and under connectivity in structural brain connectivity in ASD. These results may reflect general deficits in social function at rest, and disorder specific alterations in structural connectivity in ASD.

Research on implicit associations in psychopathology suggests that socially anxious individuals may have implicit associations congruent with the core cognitive constructs/concerns in social anxiety, such as stronger negative associations for social stimuli and fears of evaluation. The literature also indicates that implicit associations are useful for predicting spontaneous behavioral reactions. The present study recruited two groups (n=25 for each group) of persons high in social anxiety versus persons low in social anxiety (i.e., N = 50). Participants engaged in three implicit tests that assessed their attitudes towards: general social stimuli, positive social stimuli, and negative social stimuli. Participants then delivered an impromptu speech task, after which they completed each of the implicit tests once more. It was hypothesized that: (a) groups would differ significantly on implicit associations for social stimuli and fears of evaluation, such that persons high in social anxiety would demonstrate more negative implicit associations across social stimuli compared to low socially anxious persons; and (b) implicit measures would predict behavioral anxiety ratings based on performance during a speech task within the overall sample. Results were in partial support of the study hypotheses: (a) partially consistent with hypotheses, highly socially anxious persons demonstrated significantly greater negative implicit associations for negatively valenced social stimuli (but not general or positive social stimuli); and (b) implicit 4 measures assessing associations for general social stimuli, and negatively valenced social stimuli, significantly to marginally predicted observer-rated eye gaze during the speech task. There was also a significant decrease in the strength of implicit associations for positively-valenced social stimuli following the impromptu speech task. Treatment and assessment implications, and limitations to the study, will be discussed.

The present study examined the social skills and social acceptance of children with SAD (n=20), children with GAD (n=18), and typically developing (TD) children (n=20). A multimodal assessment paradigm was employed to address three study objectives: (a) to determine whether social skills deficits are unique to children with SAD or extend to children with GAD, (b) to assess whether skills vary as a function of social context (in vivo peer interaction Wii Task versus hypothetical Social Vignette Task) and (c) to examine the relationship between anxiety diagnosis and social acceptance. Parent questionnaire data indicated that both youth with SAD and GAD experienced difficulties with assertiveness, whereas children with SAD experienced a broader range of social skills difficulties. Blinded observers’ ratings during the behavioral assessment social tasks indicated that compared to children with GAD and TD children, children with SAD have deficits in social behaviors and social knowledge across settings, including speech latency, a paucity of speech, few spontaneous comments, questions and exclamations, and ineffective social responses. In addition, vocal analysis revealed that children with SAD were characterized by anxious speech patterns. By comparison, children with GAD exhibited non-anxious speech patterns and did not differ significantly from TD youth on social behaviors, with the exception of fewer spontaneous comments and questions. Lastly, children with SAD were perceived as less likeable and less socially desirable by their peers than both children with GAD and TD children. Clinical implications of these findings are discussed

Although social anxiety disorder is most often diagnosed during adolescence, few investigations have examined the clinical presentation of this disorder exclusively in adolescents. Prior studies have demonstrated that some clinical features of SAD in adolescents are unique relative to younger children with the condition. Furthermore, the extant literature on daily functional impairment in this population is limited. In this investigation, multiple areas of functioning were examined in adolescents with SAD (n = 16) and normal control adolescents (n = 14): specific social skills, subjective distress and physiological reactivity during one speech performance task and one social interaction task; alcohol use and expectancies; subjective and objective quality of sleep; and daily distressing social activities. No differences were observed in sleep actigraphy, self-reported sleep difficulties, alcohol use, or alcohol expectancies. Adolescents with SAD reported greater distress during both analogue tasks relative to NC adolescents. During the speech task, adolescents with SAD exhibited significantly greater speech latency (4.42 seconds vs. 1.75 seconds) and spoke significantly less (83.09 seconds vs. 167.75 seconds) than NC adolescents. Additionally, SAD participants manifested greater skin conductance during the speech task. During the social interaction, adolescents with SAD asked significantly fewer questions (2.20 vs. 7.07) and required significantly more confederate prompts (2.33 vs. 1.14) to stimulate interaction. Finally, adolescents with SAD reported more frequent anxiety-provoking situations in their daily lives and greater avoidance of these situations, including answering questions in class, assertive communication, and interacting with a group. iv The findings are discussed with respect to the current understanding of alcohol use, quality of sleep, and social functioning in adolescents with SAD.

The present study examined the ability of a Virtual Reality (VR) public speaking task to elicit physiological arousal in adults with SAD (n=25) and Controls (n=25). A behavioral assessment paradigm was employed to address three study objectives: (a) to determine whether the VR task can elicit significant increases in physiological response over baseline resting conditions (b) to determine if individuals with SAD have a greater increase from baseline levels of physiological and self-reported arousal during the in vivo speech task as opposed to the VR speech task and (c) to determine whether individuals with SAD experience greater changes in physiological and selfreported arousal during each speech task compared to controls. Results demonstrated that the VR task was able to elicit significant increases in heart rate, skin conductance, and respiratory sinus arrhythmia, but did not elicit as much physiological or self-reported arousal as the in vivo speech task. In addition, no differences were found between groups. Clinical implications of these findings are discussed

Social anxiety disorder (SAD) is the 3rd most common psychiatric diagnosis, and is associated with significant social, occupational, health, and educational impairment. Fortunately, both pharmacological and psychological treatments can reduce symptoms. Cognitive behavioral therapy is considered the gold standard treatment for SAD, and a robust literature supports its effectiveness. In contrast, process related factors, including the role of the working alliance, have received less attention in treatment of SAD. The current study examined development of the working alliance for a SAD sample. The working alliance is characterized as the collaborative relationship between a client and therapist, and includes shared goals, strategies, and an attachment bond. Within the context of SAD, the working alliance is particularly interesting, as the alliance itself is a social relationship that may elicit anxiety, which, in turn, may impact development of the alliance. The present study also investigated whether treatment type, that is, exposure group therapy (EGT) versus virtual reality exposure (VRE) therapy, or pre-treatment symptom severity influenced the working alliance trajectory. Data were provided by an adult sample presenting with a primary diagnosis of SAD. Participants were randomly assigned to one of two treatment conditions, both involved use of a manualized CBT treatment approach. Standardized measures of social anxiety were administered pre-treatment whereas working alliance ratings were obtained after each session. Results indicated high levels of working alliance and significant change in ratings over time. Treatment condition did not contribute to significant differences in the working alliance trajectory. Regarding the impact of SAD symptoms, initially high ratings of fear was associated with progressively increasing rates of growth in the working alliance whereas high initial ratings of avoidance signified steeper increase in the working alliance earlier in treatment followed by a declining rate of change over time. The current study contributes to the limited literature regarding the working alliance trajectory for clients with SAD, and is the first to consider the impact of VRE treatment on this trajectory. Findings also provide preliminary evidence for the differential impact of initial fear and avoidance as well as a potential curvature for the working alliance trajectory when using CBT.

Individuals diagnosed with social anxiety disorder (SAD) tend to form negatively-distorted and inaccurate self-images during social situations (Clark & Wells, 1995; Heimberg, Brozovich, & Rapee, 2010). Extensive research has provided support for the existence of these negative mental representations, and has shown how they contribute to the maintenance of SAD symptoms. A cognitive-behavioral treatment component known as video feedback (VF) has been shown to be effective in altering such distorted self-representations; additionally, a modified VF technique involving cognitive preparation has been shown to enhance VF treatment effects. The present study evaluated whether the effects of VF with cognitive preparation replicate and extend to a semi-structured social interaction, and further examined the link between VF-induced changes in self-perception and state anxiety. A sample of 29 participants who met diagnostic criteria for SAD were randomly assigned to receive VF (VF condition) or a mental arithmetic task (No-VF condition) in between two social interaction role-plays with a trained confederate. Results suggest that, in response to a social interaction, VF: [1] results in improved self-evaluation of performance, and [2] exerts an effect on state anxiety in SAD individuals.

Social anxiety disorder is the third most common mental disorder with the lifetime prevalence rate of 13.3% in the US population. Typically, it causes significant impairment in a wide range of functioning and follows a chronic, unremitting course if untreated. Over the past two decades, there has been a dramatic increase in clinical research aimed at examining underlying mechanisms maintaining social anxiety. One line of research has investigated attentional biases in social anxiety, using various cognitive experiment paradigms, including the emotional Stroop and the modified dotprobe tasks. However, overall findings are equivocal about the nature of attentional biases in social anxiety and several methodological problems limit the interpretability of the data. The present study examined attentional biases associated with social anxiety using a new research paradigm in the field of anxiety disorders: the inattentional blindness paradigm. This paradigm presents a social cue in the absence of the subjects’ expectation while they are engaged in a cognitively demanding task, thereby enabling the more purely attentional aspect of information processing to be examined reducing the influence of potential response biases or effortful strategies. Two independent experiments were conducted using nonclinical student samples consisting of individuals high in social anxiety (HSAs) versus individuals low in social anxiety (LSAs) based on the static and sustained inattentional blindness tasks. Overall, results revealed that HSAs were more likely to detect or identify a socially-threatening cue, relative to LSAs; whereas LSAs were more likely to detect or identify a non-threatening social cue, relative to HSAs. These findings were observed only in the presence of a bogus-speech manipulation. These data suggest the promising utility of the inattentional blindness paradigm in investigating attentional biases in social anxiety and perhaps other psychopathological conditions. Theoretical and clinical implications are discussed.

Although meta-analytic studies support the efficacy of cognitive-behavioral therapy for social anxiety disorder, a proportion of patients drop out of treatment or fail to benefit. Research to date has explored patient- and treatment-specific predictors of poor treatment response, including comorbid depression, but has not evaluated variables related to the patient's social environment. Expressed emotion (EE), an index of critical, hostile, and overprotective attitudes expressed by a significant other toward an individual with a psychiatric or medical condition, has been found to predict psychiatric relapse and poor treatment outcome in a wide range of disorders. Because EE and a closely related construct, perceived criticism, have been shown to predict treatment outcome and course in anxiety and mood disorders, it was expected that EE and perceived criticism would also predict treatment outcome in social anxiety disorder. Forty patients undergoing 12-session group cognitive-behavioral therapy for social anxiety disorder completed questionnaires about their symptoms of social anxiety and depression, and levels of perceived criticism, before and after treatment. Each participant designated one significant other who was then assessed for EE using the Camberwell Family Interview, a semi-structured interview method. Results indicate that higher initial severity of social anxiety and lower levels of perceived criticism predicted treatment dropout. There was also a trend for participants with a significant other rated as high in emotional overinvolvement, one of the EE-subscales, to show less change on a composite measure of anxiety symptoms. Comorbid depression and critical EE were associated with pretreatment severity of social anxiety but not outcome. These findings add to an increasing body of literature showing that the manifestation of significant others' EE, and EE's effect on clinical outcome, can vary as a function of the identified patient's diagnosis. For socially anxious individuals, perceiving criticism in the social environment may provide an important impetus for seeking and adhering to treatment, whereas significant others' overprotective behavior may negatively impact their ability to benefit from treatment. Further research replicating these findings, clarifYing the mechanisms and developing supplemental interventions, are important future directions.