Emotion regulation in social anxiety and depression: a systematic review of expressive suppression and cognitive reappraisal.

Social anxiety disorder (SAD) and major depressive disorder (MDD) are highly comorbid, and together they result in greater functional impairment and a poorer prognosis than either condition alone. Theoretical models implicate impairments in emotion regulation in the development and maintenance of internalizing disorders, yet there has been no systematic comparison of emotion regulation in social anxiety and depression. The current review presents an in-depth examination of the literature on two widely-studied emotion regulation strategies, expressive suppression (ES) and cognitive reappraisal (CR), in SAD and MDD. Our review indicated that SAD is broadly characterized by an overreliance on ES, which is associated with negative social and emotional consequences. SAD is also characterized by ineffective utilization of CR, which inhibits the potential positive emotional benefits of this adaptive emotion regulation strategy. In contrast, MDD is broadly characterized by an underutilization of CR, which may be particularly detrimental in stressful or uncontrollable situations. For both SAD and MDD, treatment intervention appears to address deficits in CR but not ES. After reviewing the literature, we propose multiple pathways by which impairments in ES and CR may increase risk for the co-occurrence of SAD and MDD. Clinical implications and future research directions are also discussed.

Evaluation of an open-access CBT-based Internet program for social anxiety: Patterns of use, retention, and outcomes.

OBJECTIVE: Internet-delivered cognitive-behavioral therapy (ICBT) has been established as both efficacious and effective in reducing symptoms of social anxiety. However, most research has been conducted in controlled settings, and little is known regarding the utility of such programs in an open-access format. The present study examined the use, adherence, and effectiveness of Joyable, an open-access, Internet-delivered, coach-supported CBT-based intervention for social anxiety. METHOD: Participants were 3,384 registered users (Mage [SD] = 29.82 [7.89]; 54% male) that created an account between 2014 and 2016. Characteristics of use, factors related to attrition and adherence, and within-group outcomes were examined. The primary outcome measure was the Social Phobia Inventory. RESULTS: On average, participants remained in the program for 81.02 days (SD = 60.50), during which they completed 12.14 activities (SD = 11.09) and 1.53 exposures (SD = 3.18). About half (57%) had contact with a coach. Full adherence to the program was achieved by 16% of participants, a rate higher than previously published open-access studies of ICBT. Social anxiety symptoms were significantly reduced for participants that engaged in the program, with medium within-group effects from baseline through the cognitive restructuring module (d = 0.63-0.76) and large effects from baseline through the exposure module (d = 1.40-1.83). Response rates were high (72%). Exposures and coach contact were significant predictors of retention and outcome. CONCLUSIONS: This open-access online CBT-based program is effective in reducing social anxiety symptoms and has the potential to extend Internet-based mental health services to socially anxious individuals unwilling or unable to seek face-to-face evidence-based therapy. (PsycINFO Database Record

Social anxiety disorder and quality of life: How fears of negative and positive evaluation relate to specific domains of life satisfaction.

Individuals with social anxiety disorder (SAD) experience functional impairment in social, educational, and occupational arenas, contributing to poor quality of life. Previous research using the Quality of Life Inventory (QOLI) has identified four distinct domains of quality of life among individuals with SAD: Achievement, Personal Growth, Social Functioning, and Surroundings. The present study was designed to investigate how fear of negative evaluation (FNE) and fear of positive evaluation (FPE) relate to the four QOLI domains among individuals with SAD. We also examined the relationships of FNE and FPE to Satisfaction and Importance ratings on the QOLI. Individuals with SAD (N=129) completed a battery of questionnaires prior to initiating treatment. FNE and FPE showed distinct relationships with the four QOLI domains, even after controlling for demographic characteristics and comorbid depression. Both FNE and FPE were associated with ratings of Satisfaction with the QOLI domains, but neither was associated with ratings of Importance. Our findings highlight the differential impacts of FNE and FPE on SAD. Treatment implications are discussed.

Enmeshment Schema and Quality of Life Deficits: The Mediating Role of Social Anxiety.

Social anxiety is associated with significant functional impairment and poor quality of life. However, there is a paucity of research on how early childhood and family dynamics may be related to social anxiety and its impact on quality of life. We investigated the role of enmeshment schemas, cognitive structures associated with emotional over-involvement with and lack of differentiation from family. Enmeshment is associated with considerable functional impairment, including elevated anxiety and depression and impaired relationship satisfaction. As enmeshment schemas predict withdrawal from stressful social interactions, they may facilitate the development of social anxiety and, through that mechanism, lead to reduced quality of life. Participants completed measures of these constructs. Social anxiety mediated the negative association between enmeshment and quality of life, particularly within the domains of personal growth, social functioning, and achievement. Implications for novel etiological conceptualizations of social anxiety and subsequent treatment interventions are discussed.

Smiles may go unseen in generalized social anxiety disorder: evidence from binocular rivalry for reduced visual consciousness of positive facial expressions.

Research has demonstrated increased attention to negative social cues and reduced attention to positive social cues in generalized social anxiety disorder (GSAD), but little is known about whether GSAD also involves differences in lower levels of visual processing. This study explored visual experience in GSAD compared to participants with generalized anxiety disorder (GAD) and healthy controls using binocular rivalry. Participants were presented with dissimilar images to each eye, and the two images competed for perceptual dominance. Consistent with the hypothesis that GSAD involves a reduced visual salience for positive social cues, we found that smiling faces were dominant for significantly shorter durations in GSAD compared to GAD and controls. Contrasting with our hypothesis of greater visual salience of negative social cues, we found no difference in negative stimuli salience. These findings are consistent with the broader view that a perceiver's affective state directly influences the content of visual consciousness.

Complicated grief symptoms in anxiety disorders: prevalence and associated impairment.

BACKGROUND: Previous research has identified high rates of comorbid anxiety disorders among individuals presenting with primary CG. In the present study, we examined the prevalence of comorbid CG in bereaved primary anxiety disorder (AD) patients compared to bereaved healthy controls. We also examined the impairment associated with comorbid CG in AD. METHODS: Participants were 242 bereaved adults (mean (SD) age = 41.5 (13.1), 44.2% women) with a primary AD diagnosis, including generalized anxiety disorder (GAD; n = 57), panic disorder (PD; n = 49), posttraumatic stress disorder (PTSD; n = 29), and generalized social anxiety disorder (GSAD; n = 107), as well as 155 bereaved healthy controls with no current DSM-IV Axis I diagnosis (mean (SD) age = 43.0 (13.6), 51.0% women). CG symptoms were measured using the 19-item inventory of complicated grief (ICG), with threshold CG defined as an ICG score of ≥30. Quality of life and functional impairment were assessed with the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and the Range of Impaired Functioning Tool (LIFE-RIFT), respectively. RESULTS: Participants with primary ADs had significantly higher rates of threshold CG symptoms than bereaved controls (12.0% vs. 0.65%; Fisher's Exact P < 0.001). Rates of threshold CG were significantly elevated for each AD when compared to bereaved controls. After adjustment for age, sex, education, and comorbid major depressive disorder, threshold CG was associated with lower quality of life (ß = -0.140, P = 0.023) and greater impairment (ß = 0.141, P = 0.035) among individuals with AD. CONCLUSIONS: Our findings suggest that threshold CG is of clinical relevance in bereaved individuals with a primary anxiety disorder. Screening for CG in patients with ADs may be warranted.

Complicated grief among individuals with major depression: prevalence, comorbidity, and associated features.

BACKGROUND: Growing data suggest that complicated grief (CG) may be common in clinical care settings, but there are few prior reports about CG in outpatients presenting with primary mood disorders. METHODS: The present study examined rates of bereavement and threshold CG symptoms (defined as a score ≥ 25 on the Inventory of Complicated Grief scale) in 111 outpatients with major depressive disorder (MDD) and 142 healthy controls participating in a study of stress and depression. Clinical and demographic characteristics were also compared for bereaved individuals with CG (MDD+CG) to those without (MDD-CG). Participants completed structured diagnostic interviews as well as measures of CG, depression, anxiety, exposure to traumatic events, and perceived social support. RESULTS: Lifetime history of a significant loss did not differ for the MDD and control groups (79.3% vs. 76.1%), but bereaved participants with MDD had higher rates of threshold CG (25.0% vs. 2.8%). Among those with MDD, CG was associated with a higher prevalence of lifetime alcohol dependence, greater exposure to traumatic events, and lower perceived social support. Depressed women, but not men, with CG also had higher rates of panic disorder, social anxiety disorder, and posttraumatic stress disorder. LIMITATIONS: Our findings are limited by the lack of a clinician confirmatory assessment of CG diagnosis, absence of complete information about the nature and timing of the loss, and relatively narrow generalizability. CONCLUSIONS: We found high rates of CG in a group of psychiatric outpatients with chronic MDD, suggesting that patients with depression should be routinely screened for CG.

Informing the symptom profile of complicated grief.

BACKGROUND: Complicated Grief (CG) is under consideration as a new diagnosis in DSM5. We sought to add empirical support to the current dialogue by examining the commonly used Inventory of Complicated Grief (ICG) scale completed by 782 bereaved individuals. METHODS: We employed IRT analyses, factor analyses, and sensitivity and specificity analyses utilizing our full sample (n = 782), and also compared confirmed CG cases (n = 288) to noncases (n = 377). Confirmed CG cases were defined as individuals bereaved at least 6 months who were seeking care for CG, had an ICG ≥ 30, and received a structured clinical interview for CG by a certified clinician confirming CG as their primary illness. Noncases were bereaved individuals who did not present with CG as a primary complaint (including those with depression, bipolar disorder, anxiety disorders, and controls) and had an ICG<25. RESULTS: IRT analyses provided guidance about the most informative individual items and their association with CG severity. Factor analyses demonstrated a single factor solution when the full sample was considered, but within CG cases, six symptom clusters emerged: (1) yearning and preoccupation with the deceased, (2) anger and bitterness, (3) shock and disbelief, (4) estrangement from others, (5) hallucinations of the deceased, and (6) behavior change, including avoidance and proximity seeking. The presence of at least one symptom from three different symptom clusters optimized sensitivity (94.8%) and specificity (98.1%). CONCLUSIONS: These data, derived from a diverse and predominantly clinical help seeking population, add an important perspective to existing suggestions for DSM5 criteria for CG.