Social Anxiety, Second Edition: Clinical, Developmental, and Social Perspectives

607 Pages·2010·16.35 MB·English

by  Stefan G Hofmann & Patricia M Dibartolo

Social Anxiety
Social Anxiety
Clinical, Developmental, and
Social Perspectives
Second Edition
Edited by
Stefan G. Hofmann and Patricia M. DiBartolo
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Contributors
Anne Marie Albano, NYS Psychiatric Institute, New York, NY 10032
Lynn E. Alden, Department of Psychology, University of British Columbia, Vancouver,
Canada
Danielle Amado, Department of Psychology, University of Montreal, QC, Canada
Nader Amir, Joint Doctoral Program, San Diego State University/University of
California, San Diego, CA, USA
Carlos Blanco, Department of Psychiatry, Columbia University, New York, NY 10032
Jessica Bomyea, Joint Doctoral Program, San Diego State University/University of
California, San Diego, CA, USA
Lynn L. Brandsma, Department of Psychology, Drexel University, Philadelphia,
PA 90102
Faith A. Brozovich, Adult Anxiety Clinic of Temple University, Philadelphia, PA 19122
Michelle C. Capozzoli, Center for the Treatment and Study of Anxiety, University of
Pennsylvania, Philadelphia, PA 19104
Leslie G. Cohn, Private Practice, Seattle, WA, USA
Jonathan S. Comer, NYS Psychiatric Institute, New York, NY 10032
Michael F. Detweiler, USAF Educational, Developmental, and Intervention Services
(EDIS) Program, RAF Lakenheath, UK
Randy O. Frost, Department of Psychology, Clark Science Center, Smith College,
Northampton, MA 01060
Joel Gelernter, Yale University School of Medicine, VA CT Healthcare Center, West
Haven, CT 06516
Katharine Glossner, Department of Psychology, Clark Science Center, Smith College,
Northampton, MA 01060
Pamela Handelsman, Anxiety Research and Treatment Program, Southern Methodist
University, Dallas, TX 75205
Bridget A. Hearon, Center for Anxiety and Related Disorders, Boston University, MA
02215
Richard G. Heimberg, Adult Anxiety Clinic of Temple University, Philadelphia, PA
19122
Lynne Henderson, The Shyness Institute, Palo Alto, CA 94306; Stanford University
Continuing Studies, Stanford, CA, 94305
James D. Herbert, Department of Psychology, Drexel University, Philadelphia,
PA 90102
xv
xvi Contributors
Debra A. Hope, Department of Psychology, University of Nebraska–Lincoln,
NE 68588
Jerome Kagan, Department of Psychology, Harvard University, Cambridge,
MA 02138
Todd B. Kashdan, Department of Psychology, George Mason University, Fairfax,
VA 22030
Heide Klumpp, Department of Psychiatry, University of Michigan, Ann Arbor, MI
48109
Angela Kyparissis, Department of Psychology, University of Montreal, QC, Canada
Mark R. Leary, Department of Psychology, Duke University, Durham, NC 27708
C.W. Lejuez, Department of Psychology, University of Maryland, MD 20742
Michael R. Liebowitz, Department of Psychology, Columbia University, New York,
NY 10032
Sarah Maxner, Department of Psychology, Clark Science Center, Smith College,
Northampton, MA 01060
Daniel W. McNeil, Anxiety, Psychophysiology, and Pain Research Laboratory,
Department of Psychology, West Virginia University, Morgantown, WV 26506
Rowland S. Miller, Department of Psychology and Philosophy, Sam Houston State
University, Huntsville, TX 77341
Mayumi Okuda, Department of Psychiatry, Columbia University, New York, NY 10032
Michael W. Otto, Center for Anxiety and Related Disorders, Boston University,
MA 02215
K. Luan Phan, Department of Psychiatry, University of Michigan, Ann Arbor,
MI 48109; Mental Health Service, VA Ann Arbor Healthcare System, MI 48105
Mark B. Powers, Center for the Treatment and Study of Anxiety, University of
Pennsylvania, Philadelphia, PA 19104
Ronald M. Rapee, Centre for Emotional Health, Macquarie University, Sydney,
NSW, Australia
Marci J. Regambal, Department of Psychology, University of British Columbia,
Vancouver, BC, Canada
James Reich, Department of Psychiatry, UCSF Medical School, and Department
of Psychiatry and Behavioral Health, Stanford Medical School, San Francisco,
CA 94123
Alyssa A. Rheingold, Department of Psychiatry, Drexel University, Philadelphia,
PA 90102
Steven A. Safren, Center for Anxiety and Related Disorders, Boston University,
MA 02215
Franklin R. Schneier, Department of Psychiatry, Columbia University, New York,
NY 10032
Contributors xvii
Jasper A.J. Smits, Anxiety Research and Treatment Program, Southern Methodist
University, Dallas, TX 75205
John T. Sorrell, Department School of Medicine, Department of Anaesthesia,
Stanford University, CA 94305
Murray B. Stein, University of California, San Diego La Jolla, CA 92093
Ariel Stravynski, Department of Psychology, University of Montreal, QC, Canada
Justin W. Weeks, Department of Psychology, Ohio University, Athens, OH 45701
Brandon J. Weiss, Department of Psychology, University of Nebraska–Lincoln, NE
68588
Amy Wenzel Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
19104
Philip Zimbardo The Shyness Institute, Palo Alto, CA 94306; Palo Alto University,
Palo Alto, CA, 94304
Introduction
Toward an Understanding of
Social Anxiety Disorder
Stefan G. Hofmann and Patricia M. DiBartolo
Humans are social creatures. We have a strong need to be liked, valued, and
approved of by others. As a result, we have generated sophisticated social
structures and hierarchies that greatly determine an individual’s value.
Ostracism from these social groups negatively impacts a variety of health-
related variables, and social exclusion is experienced as a punishment. For
example, violations of social norms can lead to imprisonment, which limits an
individual’s social contacts. Moreover, violating prison rules can lead to a fur-
ther restriction of social relationships and even solitary confinement. Due to
the importance of our social structures, humans naturally fear negative evalua-
tion by their peers.
The clinical expression of this evolutionarily adaptive concern is social
anxiety disorder (SAD). In Western cultures, the lifetime prevalence rates of
SAD range between 7 and 12% of the population (Furmark, 2002; Kessler,
Berglund, Demler, Jin, & Walters, 2005). This disorder affects men and
women relatively equally, with the average gender ratio (female : male) ranging
between 1 : 1 (Moutier & Stein, 1999) and 3 : 2 (Kessler et al., 2005) in com-
munity studies. During childhood, SAD is often associated with shyness and
behavioral inhibition (BI). If the problem is left untreated, it typically follows
a chronic, unremitting course and can lead to substantial impairments in voca-
tional and social functioning (Stein & Kean, 2001).
When reading the existing literature of social anxiety, one is struck by the
lack of integration of the research findings that have been gathered by the vari-
ous scientific disciplines, including social psychology, clinical psychology,
psychiatry, developmental psychology, and behavior genetics. For example,
clinical psychologists and psychiatrists tend to know relatively little about
the relationship between social anxiety, shyness, and embarrassment or about
contributions from behavior genetics. Conversely, social and developmental
psychologists know relatively little about SAD subtypes, biological theories
Social Anxiety: Clinical, Developmental, and Social Perspectives. Doi:10.1016/B978-0-12-375096-9.00028-6
© 2010 Elsevier Inc. All rights reserved. xix
xx Toward an Understanding of Social Anxiety Disorder
of SAD, and cognitive behavioral or pharmacological treatment outcome stud-
ies. In order to address these gaps in knowledge, we (Hofmann & DiBartolo,
2001) recruited some of the most distinguished theorists and researchers from
the various fields to initiate an interdisciplinary dialogue in one edited volume
almost 10 years ago. The field has progressed considerably since that first book
was published. This current volume updates the status of the scientific findings
across a variety of diverse disciplines with contributors providing data and the-
ory from their own conceptual perspectives relevant to their area of expertise.
Delineation of social anxiety
Chapter 1 by McNeil reviews the evolution of the terms social anxiety, SAD,
and related constructs. Constructs such as shyness, introversion, BI, social anx-
iety, and SAD all share very similar meanings and are often used interchange-
ably, which can complicate things enormously. Choosing the right terminology
is not a trivial thing. It reflects, and possibly determines, our understanding
and conceptualization of the issue under investigation. McNeil proposes a
number of specific ways in which these terms may inter-relate. He concludes
that different forms of “social anxieties” exist along a continuum, and that
related constructs, such as shyness, span from “normal” and “high normal” to
pathological levels of social anxiety.
A similar dimensional approach towards psychopathology is the implicit
model of many psychological assessment procedures for social anxiety and
social SAD. Consistent with this notion, Herbert and colleagues (Chapter 2) start
from the basic premise that social anxiety and SAD do not differ qualitatively but
rather quantitatively. Therefore, the various assessment methods (which should
include a multimodal approach) can be used for assessing social anxiety as well
as SAD. However, as we note below, other theorists believe that such a dimen-
sional perspective toward SAD and shyness is problematic (e.g., see Chapter 12).
The aforementioned terminology problem becomes even more complex
when we consider the construct of shyness, which is covered by Henderson
and Zimbardo (Chapter 3). As their chapter shows, it seems almost impossi-
ble to discuss the psychopathology of shyness without referring to social anxi-
ety or related constructs. Their chapter notes the overlap between shyness and
SAD while recognizing that individuals who label themselves as shy often
express heterogeneous behavioral and symptom profiles. A little clearer seems
to be the distinction between social anxiety/SAD and embarrassment, which
is discussed by Miller (Chapter 4). Unlike SAD, the experience of embarrass-
ment is something ordinary, normal, and adaptive because it provides an effec-
tive way to overcome minor and inevitable mishaps that occur in interactions
with other people. Miller points to one important commonality between social
anxiety/SAD and embarrassment: both constructs include the fear of negative
evaluation by others. Neither SAD nor embarrassment would exist if people
did not care what others thought of them.
Toward an Understanding of Social Anxiety Disorder xxi
Does this mean that socially anxious individuals are overly perfectionis-
tic when it comes to social interactions? This hypothesis is investigated in the
chapter by Frost, Glossner, and Maxner (Chapter 5). They conclude that cer-
tain characteristics of perfectionism, and in particular the maladaptive evalua-
tive concern dimensions, are in fact associated with social anxiety and related
constructs. A review of the literature suggests that, compared to nonanxious
controls, individuals with clinical levels of social anxiety are more perfec-
tionistic. The central features of perfectionism related to SAD are an exces-
sive concern over mistakes, doubts about the quality of one’s actions, and the
perception that other people have excessively high expectations. Although
similar differences in perfectionism dimensions can also be found when com-
paring nonclinical participants with other anxiety-disordered groups, certain of
these dimensions are elevated in samples with SAD relative to other anxiety
patients.
The next chapter, by Stravynski, Kyparissis, and Amado (Chapter 6),
deals in detail with the relationship between social anxiety/SAD and social
skills, and more specifically with the (once) popular assumption that SAD is
caused by a deficit in social skills. Based on a critical review of the literature,
Stravynski et al. conclude that there is very little empirical evidence to suggest
that SAD is caused by, or even consistently linked with, deficits in social skills.
They argue that the main problem lies in the conceptualization and operational
definition of the construct of social skills. The authors encourage researchers
to take a fresh look at the “social” aspect of SAD by investigating the pattern
of social behaviors characterizing SAD in real-life situations.
Two of the remaining chapters of the first part of the volume deal with
contemporary diagnostic controversies, namely with the relationship between
SAD and other DSM (Diagnostic and statistical manual of mental disorders)
Axis I disorders in adulthood (Chapter 7 by Wenzel), and Axis II disorders
(Chapter 8 by Reich). Comorbidity, which refers to the co-occurrence of two
or more mental disorders in one person, is an inevitable “side effect” of our
existing categorical diagnostic classification system (the DSM). Based on the
existing literature, Wenzel concludes that comorbidity is common, even typi-
cal, for individuals with SAD. Rates of comorbidity between SAD and other
anxiety and mood disorder are high and there is growing evidence of height-
ened risk for substance use disorders as well. Wenzel also notes emerging evi-
dence indicating increased risk of comorbidity for SAD and a variety of other
conditions (e.g., eating disorders, bipolar disorder). She urges the field to begin
to identify the pathogenesis of these comorbidities, rather than merely docu-
ment their co-occurrence.
Among the Axis II disorders, the most highly comorbid (and most contro-
versial) diagnostic category is avoidant personality disorder (APD). The empir-
ical evidence, as reviewed by Reich, suggests that SAD and APD probably
relate to the same disorder with different subtypes. SAD and APD cannot be
distinguished on the basis of symptomatology or treatment response. Although
xxii Toward an Understanding of Social Anxiety Disorder
individuals with both SAD and APD seem to report a greater degree of distress
in social situations, they respond equally well to treatment to those without
this additional Axis II diagnosis. Reich points out that this raises the question
of whether APD is in fact a viable Axis II diagnosis because our diagnostic
system defines a personality disorder as an enduring, inflexible, and pervasive
problem. Reich offers a creative solution to this problem by creating a sub-
category in Axis II for chronic Axis I disorders “with significant personality
features.”
The final chapter of Part I, by Detweiler, Comer, and Albano (Chapter 9),
examines the risks, phenomenology, etiology, and empirically supported treat-
ments for socially anxious children and adolescents. Their review reveals the
considerable social, occupational, and emotional tolls associated with SAD in
developing youth. Furthermore, Detweiler et al. present the latest research on
the biological, social, and developmental risks associated with SAD in youth
and describe a model to guide clinicians considering a SAD diagnosis in this
demographic. Throughout the chapter, their work emphasizes the importance
of sensitivity to developmental expectations, as well as appreciation of the per-
sistence and functional interference associated with social anxiety. Fortunately,
there are options for effective treatments for youth with social anxiety.
Nonetheless, they argue continued attention needs to be paid to the develop-
mental pathways of socially anxious youth in order to identify children at risk
for clinical diagnosis and to continue the development of effective prevention
and treatment programs for this costly disorder.
theoretical perspectives
This next section of this book deals with the most prominent theoretical per-
spectives on social anxiety and SAD discussed by social psychologists, devel-
opmental psychologists, behavior geneticists, clinical psychologists, and
psychiatrists. These different theoretical perspectives emphasize different fac-
tors that might contribute to the etiology and/or maintenance of social anxi-
ety/SAD. They can be classified into the following four broad categories: (1)
biological mechanisms, including temperamental factors (Chapters 10–12);
(2) behavioral factors (Chapter 13); (3) cognitive variables (Chapters 14–17);
and (4) interpersonal processes that are relevant in social interactions (Chapter
18). As pointed out by a number of our contributors, these perspectives are not
mutually exclusive; the “real world” is probably a combination of all of these
theories.
In a new contribution to this edition, Phan and Klumpp (Chapter 10) review
the emerging findings from two areas of science – neuroimaging and neuroen-
docrinology – that help inform our understanding of the physiology of SAD.
Although evidence from neuroendocrinology studies sometimes finds cortisol
dysregulation in individuals with SAD, this finding has been inconsistent, indi-
cating the need for future research on how to predict and understand the role of