Linguistic processing and Script-Driven Imagery for trauma exposure: A proof of concept pilot trial.

While several empirically supported treatments for posttraumatic stress disorder (PTSD) have been developed, these treatments are neither widely available nor universally efficacious. This pilot, proof of concept study evaluated a computerized imaginal exposure Script-Driven Imagery Training (SDI-T) for individuals with elevated trauma reactivity. The training was supplemented with two forms of linguistic processing, affect labeling (SDI-T + AL) and distraction (SDI-T + D), to determine whether linguistic inhibitory regulation augmented the effects of SDI-T. METHODS: Participants (n = 64) with trauma-related distress were randomized to SDI-T, SDI-T + AL, or SDI-T + D. Physiology and self-reported trauma distress were measured at pre- and post-training. RESULTS: The training was acceptable to participants and effective at reducing self-reported distress (d = -0.41), and physiological activation from pre- to post-training (d = -0.49, ps < .01), with some evidence that linguistic processing (SDI-T + AL and SDIT-T + D) conferred a benefit over SDI-T. The linguistic processing groups had significantly steeper reduction in physiology relative to the non-linguistic processing group (p < .05, d = 0.59). There was no benefit of SDI-T + AL over SDI-T + D. CONCLUSIONS: This pilot study provides initial support for the acceptability and efficacy of computerized imaginal exposure training for PTSD. Clinical implications and future directions are discussed.

Building physiological toughness: Some aversive events during extinction may attenuate return of fear.

BACKGROUND AND OBJECTIVES: Although exposure therapy is an effective treatment for anxiety disorders, fear sometimes returns following successful therapy. Recent literature in animal models indicates that incorporating some aversive events into extinction training may offset these return of fear effects. METHODS: The effect of occasional reinforced extinction trials was investigated in a sample of thirty-nine participants using a fear conditioning and extinction paradigm. Participants either underwent traditional extinction procedures during which the conditional stimulus which had been paired with the unconditional stimulus (US) during acquisition training (CS+) was presented alone with no presentations of the US or partially reinforced extinction during which there were several unpredicted CS+/US pairings. RESULTS: As measured by skin conductance responses, physiological fear responding remained elevated during extinction for participants who experienced partially reinforced extinction; however, these participants demonstrated protection from rapid reacquisition effects. Results from the subjective US-expectancy ratings did not provide evidence of protection against rapid reacquisition in the partially reinforced extinction group; however, there was evidence of protection from spontaneous recovery effects. Lastly, as measured by valence ratings, it was unclear whether partially reinforced extinction provided protection from fear recovery effects. LIMITATIONS: Although participants who experienced partially reinforced extinction demonstrated protection from rapid reacquisition as measured by skin conductance responses, they also demonstrated significantly higher levels of physiological fear responding during extinction which made the results of the spontaneous recovery test more difficult to interpret. CONCLUSIONS: Occasional CS-US pairings during extinction may protect against return of fear effects. Clinical implications are discussed.

Feeling safe but appearing anxious: Differential effects of alcohol on anxiety and social performance in individuals with social anxiety disorder.

Social anxiety disorder (SAD) and alcohol use disorders (AUD) co-occur frequently and there is preliminary evidence that alcohol might reduce social anxiety. It is, however, unclear which mechanisms contribute to the anxiety reducing effect, particularly regarding key aspects of social anxiety such as deficits in social performance. We compared self-rated and physiological measures of anxiety as well as self- and observer-rated social performance in a sample of 62 individuals with SAD and 60 nonanxious control participants during a speech task after receiving either alcohol, an alcohol-free placebo drink or orange juice. SAD patients reported more anxiety during the speech task than did control participants. Furthermore, SAD patients underestimated their performance in comparison to observer ratings. Alcohol reduced self-report anxiety only in SAD patients, while observers rated all participants as less competent when intoxicated. Although individuals with SAD experience a reduction in anxiety when drinking alcohol, simultaneous decreases in social performance might contribute to negative reactions from others and consequently increase the risk of further alcohol use to cope with these negative reactions.

What does the facial dot-probe task tell us about attentional processes in social anxiety? A systematic review.

BACKGROUND/OBJECTIVES: Current models of SAD assume that attentional processes play a pivotal role in the etiology and maintenance of social anxiety disorder. Social anxiety is supposedly associated with an attentional bias towards disorder related stimuli such as threatening faces. Using the facial dot probe task in socially anxious individuals has, however, revealed inconsistent findings. METHODS: The current systematic review aims at disentangling the heterogeneous findings using effect sizes across results by systematically taking into account potential moderating variables (stimulus type, stimulus duration, situational anxiety, disorder severity). RESULTS: Results provide some evidence that socially anxious individuals preferentially allocate their attention towards threat faces compared to non-anxious controls. This bias seems to depend on the type of reference stimulus, stimulus duration and clinical level of social anxiety. Avoidance of threat was neither found at early, nor at later stages of attentional processing. LIMITATIONS: Importantly, the results have to be considered in the light of the only few studies available. Given the heterogeneity of results and some methodological restrictions of the studies included, the picture of attentional bias seems to be much less clear than suggested in the recent social anxiety literature. CONCLUSIONS: Methodologically, combined measures of dot-probe and eye movement measures might be beneficial to detect overt attentional biases. Importantly, our results show that preferential processing of threat cues might guide early attentional processes in social anxiety, depending however on several contextual and situational factors. Clinically, patients with greater severity of SAD may be more prone to such an attentional bias, thus therapists should take this into account when planning behavioral experiments and exposure therapy.

Oxytocin receptor gene methylation: converging multilevel evidence for a role in social anxiety.

Social anxiety disorder (SAD) is a commonly occurring and highly disabling disorder. The neuropeptide oxytocin and its receptor (OXTR) have been implicated in social cognition and behavior. This study-for the first time applying a multilevel epigenetic approach-investigates the role of OXTR gene methylation in categorical, dimensional, and intermediate neuroendocrinological/neural network phenotypes of social anxiety. A total of 110 unmedicated patients with SAD and matched 110 controls were analyzed for OXTR methylation by direct sequencing of sodium bisulfite-converted DNA extracted from whole blood. Furthermore, OXTR methylation was investigated regarding SAD-related traits (Social Phobia Scale (SPS) and Social Interaction Anxiety Scale (SIAS)), salivary cortisol response during the Trier social stress test (TSST), and amygdala responsiveness to social phobia related verbal stimuli using fMRI. Significantly decreased OXTR methylation particularly at CpG Chr3: 8 809 437 was associated with (1) the categorical phenotype of SAD (p<0.001, Cohen's d=0.535), (2) increased SPS and SIAS scores (p<0.001), (3) increased cortisol response to the TSST (p=0.02), and (4) increased amygdala responsiveness during social phobia-related word processing (right: p(corr)<0.001; left: p(corr)=0.005). Assuming that decreased OXTR methylation confers increased OXTR expression, the present finding may reflect a compensatory upregulation for pathologically reduced oxytocin levels or a causally relevant increased OXTR activation in SAD and related traits. OXTR methylation patterns might thus serve as peripheral surrogates of oxytocin tone and aid in establishing accessible biomarkers of SAD risk allowing for indicated preventive interventions and personalized treatment approaches targeting the oxytocin system.

Enhanced avoidance behavior in social anxiety: evidence from a probabilistic learning task.

BACKGROUND AND OBJECTIVES: Social phobia is characterized by avoidance of feared social situations. Although avoidance is a central feature of social anxiety, few studies have examined avoidance learning. METHODS: We used a probabilistic instrumental learning paradigm where participants had to learn by trial and error which response led to the disappearance of a neutral or angry face. 20 high socially anxious and 20 non-socially anxious individuals with an average level of social anxiety learned to avoid an angry or a neutral face by choosing one of two cues. Each of the cues led to the disappearance of the face either with high or low reinforcement probability. RESULTS: Groups learned to choose the more effective cue across trials and did not differ with regard to self-report valence, arousal for the faces or the a posteriori estimated reinforcement probability for both cues. High socially anxious individuals as compared to the controls chose the high probability cue significantly more often and were slower particularly when the neutral face could be avoided. Notably, HSA engaged in more avoidance responding to the neutral as compared to the angry face early on during the experiment. LIMITATIONS: Due to the experimental design, the observed avoidance behavior most likely reflects the motivation for avoidance rather than contingency learning per se. CONCLUSIONS: In social anxiety, neutral faces might be processed as ambiguous social cues and strongly motivate avoidance behavior.

Influence of alcohol on social anxiety: an investigation of attentional, physiological and behavioral effects.

Social anxiety disorder and alcohol use disorders are highly comorbid. It remains unclear, however, if and how alcohol influences attentional processes and physical symptoms in social anxiety. In a balanced-placebo-design, high and normally socially anxious participants gave a speech while performing a task, which simultaneously measures internal and external attention. Only high anxious participants showed a preferential processing of external probes, which was eliminated by alcohol or the mere expectation of drinking alcohol. Furthermore, alcohol reduced facial blushing as well as self-reported social anxiety during public speaking. Decreases in anxiety were significantly associated with a reduction of the external focus in the high anxious group. Understanding alcohol as a substance influencing cognitive processes as well as physiological symptoms of anxiety further contributes to our understanding of alcohol use as a safety behavior in social anxiety disorder.

The motive to drink due to social anxiety and its relation to hazardous alcohol use.

Although studies on social anxiety and alcohol-related problems are numerous, the exact nature of the relationship remains unclear. In the present study, we investigate how the motive to drink due to social anxiety is associated with hazardous alcohol use over and above habitual alcohol use, social anxiety, and alcohol outcome expectancies. We also examine which factors define the motive to drink due to social anxiety and clarify the impact of the type of social situation. Drinking due to social anxiety, habitual alcohol use, and gender, but not social anxiety, were associated with hazardous alcohol use. Social anxiety increased the motive to drink due to social anxiety, but fear of cognitive performance deficits after drinking reduced it. Alcohol was used to reduce anxiety more frequently in situations where intake of alcohol is deemed socially acceptable. These findings suggest that the motive drinking due to social anxiety, not social anxiety per se, is related to hazardous alcohol use. The motive is weakened by the expectation of alcohol-induced cognitive deficits, as well as by the type of social situation in which alcohol is to be used.

Self-referential and anxiety-relevant information processing in subclinical social anxiety: an fMRI study.

The fear of negative evaluation is one of the hallmark features of social anxiety. Behavioral evidence thus far largely supports cognitive models which postulate that information processing biases in the face of socially relevant information are a key factor underlying this widespread phobia. So far only one neuroimaging study has explicitly focused on the fear of negative evaluation in social anxiety where the brain responses of social phobics were compared to healthy participants during the processing of self-referential relative to other-referential criticism, praise or neutral information. Only self-referential criticism led to stronger activations in emotion-relevant regions of the brain, such as the amygdala and medial prefrontal cortices (mPFC), in the social phobics. The objective of the current study was to determine whether these findings could be extended to subclinical social anxiety. In doing so, the specificity of this self-referential bias was also examined by including both social and non-social (physical illness-related) threat information as well as a highly health anxious control group in the experimental paradigm. The fMRI findings indicated that the processing of emotional stimuli was accompanied by activations in the amygdala and the ventral mPFC, while self-referential processing was associated with activity in regions such as the mPFC, posterior cingulate and temporal poles. Despite the validation of the paradigm, the results revealed that the previously reported behavioral and brain biases associated with social phobia could not be unequivocally extended to subclinical social anxiety. The divergence between the findings is explored in detail with reference to paradigm differences and conceptual issues.

Internal and external attention in speech anxiety.

BACKGROUND AND OBJECTIVES: Cognitive models of social phobia propose that socially anxious individuals engage in heightened self-focused attention. Evidence for this assumption was provided by dot probe and feedback tasks measuring attention and reactions to internal cues. However, it is unclear whether similar patterns of attentional processing can be revealed while participants actually engage in a social situation. The current study used a novel paradigm, simultaneously measuring attention to internal and external stimuli in anticipation of and during a speech task. METHODS: Participants with speech anxiety and non-anxious controls were asked to press a button in response to external or internal probes, while giving a speech on a controversial topic in front of an audience. The external probe consisted of a LED attached to the head of one spectator and the internal probe was a light vibration, which ostensibly signaled changes in participants' pulse or skin conductance. RESULTS: The results indicate that during speech anticipation, high speech anxious participants responded significantly faster to internal probes than low speech anxious participants, while during the speech no differences were revealed between internal and external probes. LIMITATIONS: Generalization of our results is restricted to speech anxious individuals. CONCLUSIONS: Our results provide support for the pivotal role of self-focused attention in anticipatory social anxiety. Furthermore, they provide a new framework for understanding interaction effects of internal and external attention in anticipation of and during actual social situations.

Predicting post-event processing in social anxiety disorder following two prototypical social situations: state variables and dispositional determinants.

This study investigated self-reported state (anxiety, physical symptoms, cognitions, internally focused attention, safety behaviors, social performance) and trait (social anxiety, depressive symptoms, dysfunctional self-consciousness) predictors of post-event processing (PEP) subsequent to two social situations (interaction, speech) in participants with a primary diagnosis of social anxiety disorder (SAD) and healthy controls (HC). The speech triggered significantly more intense PEP, especially in SAD. Regardless of the type of social situation, PEP was best predicted by situational anxiety and dysfunctional cognitions among the state variables. If only trait variables were considered, PEP following both situations was accounted for by trait social anxiety. In addition, dysfunctional self-consciousness contributed to PEP-speech. If state and trait variables were jointly considered, for both situations, situational anxiety and dysfunctional cognitions were confirmed as the most powerful PEP predictors above and beyond trait social anxiety (interaction) and dysfunctional self-consciousness (speech). Hence, PEP as assessed on the day after a social situation seems to be mainly determined by state variables. Trait social anxiety and dysfunctional self-consciousness also significantly contribute to PEP depending on the type of social situation. The present findings support dysfunctional cognitions as a core cognitive mechanism for the maintenance of SAD. Implications for treatment are discussed.

Eye movement assessment in individuals with social phobia: differential usefulness for varying presentation times?

Visual dot probe tasks are used to examine attentional biases towards threat faces in social phobia. Based on eye movement assessments, short presentation times of stimuli have been proposed to investigate initial attentional processes. However, it remains unclear if eye movements contribute to anxiety related biases as measured in dot probe tasks when presentation times below 200 ms are used. In this study the electrooculogram (EOG) was recorded in a sample of 17 participants with social phobia and 13 controls performing a visual dot probe task in two presentation time conditions. In the 175 ms condition, half of the participants moved their eyes in only 10% of the trials. Significantly more participants moved their eyes in the 600 ms condition and individuals with social phobia directed their gaze more often to the threat faces than to the neutral faces. Eye movement measures were not related to reaction time measures but the number of initial eye movements towards threatening faces correlated with measures of social anxiety. For dot probe paradigms, the additional use of eye movement measures seems to be particularly appropriate for longer presentation times. The dissociation between attentional bias scores as measured with reaction time versus eye movement measures and their relation to different presentation times underlines the need for both measures when conducting visual probe studies.

Heartbeat perception in social anxiety before and during speech anticipation.

According to current cognitive models of social phobia, individuals with social anxiety create a distorted image of themselves in social situations, relying, at least partially, on interoceptive cues. We investigated differences in heartbeat perception as a proxy of interoception in 48 individuals high and low in social anxiety at baseline and while anticipating a public speech. Results revealed lower error scores for high fearful participants both at baseline and during speech anticipation. Speech anticipation improved heartbeat perception in both groups only marginally. Eight of nine accurate perceivers as determined using a criterion of maximum difference between actual and counted beats were high socially anxious. Higher interoceptive accuracy might increase the risk of misinterpreting physical symptoms as visible signs of anxiety which then trigger negative evaluation by others. Treatment should take into account that in socially anxious individuals perceived physical arousal is likely to be accurate rather than false alarm.

What determines observer-rated social performance in individuals with social anxiety disorder?

Clark and Wells (1995) proposed that cognitive variables and safety behaviors are related to social performance in social anxiety disorder (SAD). Here, we tested this relationship by concurrent assessment of cognitive, behavioral, and physiological variables and social performance in a prototypical social interaction situation. 103 participants with SAD and 23 healthy controls interacted with a confederate. Anxiety, self-focused attention, cognitions, and safety behaviors were assessed by self-report and by confederate ratings. Social performance was evaluated by independent observers using a behavioral coding system. Social performance was predicted using two regression models for self-report and confederate ratings. Between-group differences in social performance disappeared when talking time was taken into account. Talking time emerged as the most powerful predictor of social performance (54% and 58% accounted variance). Positive cognitions, self-focused attention and safety behaviors accounted for an additional, but marginal amount of variance. Reduced talking time might represent a safety behavior and may be considered an easy to measure final common behavioral outcome of cognitive processes underlying social anxiety.

Interoceptive sensitivity in anxiety and anxiety disorders: an overview and integration of neurobiological findings.

Interoceptive sensitivity, particularly regarding heartbeat, has been suggested to play a pivotal role in the pathogenesis of anxiety and anxiety disorders. This review provides an overview of methods which are frequently used to assess heartbeat perception in clinical studies and summarizes presently available results referring to interoceptive sensitivity with respect to heartbeat in anxiety-related traits (anxiety sensitivity, state/trait anxiety), panic disorder and other anxiety disorders. In addition, recent neurobiological studies of neuronal activation correlates of heartbeat perception using positron emission tomography (PET), functional magnetic resonance imaging (fMRI) or electroencephalographic (EEG) techniques are presented. Finally, possible clinical and therapeutic implications (e.g., beta-blockers, biofeedback therapy, cognitive interventions and interoceptive exposure) of the effects of heartbeat perception on anxiety and the anxiety disorders and the potential use of interoceptive sensitivity as an intermediate phenotype of anxiety disorders in future neurobiological and genetic studies are discussed.

A spectralanalytic approach to emotional responses evoked through picture presentation.

Frontal EEG asymmetry has been linked to emotional and motivational reactivity. A frequently applied method to provoke specific asymmetry profiles is the presentation of affective film clips. Although these films might elicit strong emotional reactions, the exact time course and peak of an affective response remains unclear. In an alternative attempt, stimuli from the International Affective Picture System (IAPS), known to reliably alter emotional states, are utilized. These stimuli are less likely to cause excessive variations in affective responding. However, relevant studies have most often been unable to find the predicted effects. One reason for such failures might be the inadequate knowledge about the minimum number of stimuli needed for psychometrically stable results. In the present study, an adequate split-half reliability for the experimental procedure was assured and substantial effects of affective picture category were found. This pattern of results was robust for both Cz and linked ears as reference. Thus, presenting pictures with an adequate recording length might be a reliable alternative for inducing affective reactions in alpha asymmetry research.

Influence of alcohol on the processing of emotional facial expressions in individuals with social phobia.

OBJECTIVES: Individuals with social phobia are at an increased risk to develop alcohol problems. However, the mechanism responsible for this association is unclear. It has been suggested that alcohol reduces anxiety by impairing initial appraisal of threatening stimuli. Information that is especially threatening, however, may be resistant to such an effect of alcohol. We tested the influence of alcohol on the appraisal of five emotional facial expressions. METHODS: 40 social phobia patients and 40 controls performed a dot probe task, after drinking either alcohol or orange juice. Stimuli were faces with happy, angry, neutral and also two ambiguous expressions that were formed by blending angry or happy faces and neutral faces. Stimuli were presented for either 175 or 600 ms. RESULT: Sober patients showed an attentional bias towards angry faces, indicating preferential processing of threat stimuli. Alcohol significantly reduced this bias. Only in sober participants, this attentional bias correlated with measures of social anxiety. In controls, no biases were observed. CONCLUSIONS: Alcohol seems to attenuate the impact of threatening social stimuli on social phobia patients, which may negatively reinforce the consumption of alcohol and at least partially explain the heightened comorbidity with alcohol related problems known from epidemiological studies. The dot probe task with short stimulus presentation times seems to provide an adequate method to demonstrate alcohol effects on information processing.

Blushing propensity in social anxiety disorder: influence of serotonin transporter gene variation.

Blushing is considered to be one of the prime pathophysiological markers of social anxiety disorder, potentially mediated by serotonergic function. Therefore, in the present study 62 patients with social anxiety disorder and 62 age- and sex-matched healthy controls were investigated for the influence of serotonin transporter (5-HTT) gene variation (5-HTTLPR, rs25531) on blushing propensity as measured by the blushing propensity scale (BPS). The less active 5-HTTLPR genotypes were nominally significantly associated with increased blushing propensity in patients with social anxiety disorder as compared to controls with an equidirectional trend for the less active 5-HTTLPR/rs25531 haplotypes. Even when statistically controlled for influence of depression, this association remained significant. In summary, the present pilot study suggests a potential role of functional serotonin transporter gene variation in blushing propensity warranting replication and encouraging genetic analyses of further intermediate phenotypes of social anxiety disorder.

Effects of alcohol on ratings of emotional facial expressions in social phobics.

Social phobics have an increased risk of alcoholism. The mechanism behind this co-morbidity is not well understood. According to the appraisal-disruption model [Sayette, M. A. (1993). An appraisal-disruption model of alcohol's effects on stress responses in social drinkers. Psychological Bulletin, 114, 459-476], alcohol disrupts appraisal of threat stimuli unless the stimuli are easy to process. We investigated whether alcohol alters the judgment of emotional facial expressions in social phobics and controls. We also tested the judgment of emotionally ambiguous faces which should be more difficult to process. Forty social phobics and controls rated faces depicting five emotional expressions on an animosity rating scale. For two ambiguous facial expressions, angry, respectively, happy faces were blended with neutral faces. Half of the participants consumed alcohol. Socially phobic participants rated neutral and happy facial expressions as less friendly than controls, irrespective of alcohol consumption. In both groups, consuming alcohol reduced the perceived rejection of angry faces. In line with current theories of social phobia, patients interpreted neutral facial expressions as more rejecting than controls. The rejection perceived in explicitly angry facial expressions was less after drinking alcohol. This reduction of the adversity of socially threatening stimuli by alcohol might act as negative reinforcement and thus contributes to alcohol problems.

Blood-injury phobia with and without a history of fainting: disgust sensitivity does not explain the fainting response.

OBJECTIVE: Individuals diagnosed with blood-injury phobia respond to venipuncture with strong psychophysiological responses. We investigated whether disgust sensitivity contributes to the fainting response and is associated with parasympathetic activation, as suggested by previous research. METHODS: Twenty individuals diagnosed with blood-injury phobia (9 with a history of fainting to the sight of blood, 11 without such a fainting history) and 20 healthy controls were compared. Psychophysiological responses and self-report measures of anxiety, disgust, and embarrassment were monitored during rest, a paced breathing task, and venipuncture. In addition, trait disgust sensitivity and blood-injury fears were assessed. RESULTS: Blood-injury phobics reported enhanced anxiety, disgust, and embarrassment during venipuncture. They also experienced heightened arousal, as indicated by heart rate, respiration rate, and minute ventilation. Blood-injury phobics without a fainting history tended toward higher anxiety and disgust scores. There was no evidence for increased parasympathetic activation in either blood-injury phobic subgroup or of an association of disgust and parasympathetic activation. CONCLUSION: The tendency to faint when exposed to blood-injury stimuli may suffice as a conditioning event leading into phobia, without specific involvement of disgust sensitivity and parasympathetic activation.