Interventions Targeting Negative Mental Imagery in Social Anxiety: A Systematic Review and Meta-Analysis of Characteristics and Outcomes.

Psychological treatment for social anxiety disorder (SAD) has been found to be less effective than for other anxiety disorders. Targeting the vivid and distressing negative mental images typically experienced by individuals with social anxiety could possibly enhance treatment effectiveness. To provide both clinicians and researchers with an overview of current applications, this systematic review and meta-analysis aimed to evaluate the possibilities and effects of imagery-based interventions that explicitly target negative images in (sub)clinical social anxiety. Based on a prespecified literature search, we included 21 studies, of which 12 studies included individuals with a clinical diagnosis of SAD. Imagery interventions (k = 28 intervention groups; only in adults) generally lasted one or two sessions and mostly used imagery rescripting with negative memories. Others used eye movement desensitization and reprocessing and imagery exposure with diverse intrusive images. Noncontrolled effects on social anxiety, imagery distress and imagery vividness were mostly large or medium. Meta-analyses with studies with control groups resulted in significant medium controlled effects on social anxiety (d = -0.50, k = 10) and imagery distress (d = -0.64, k = 8) and a nonsignificant effect on imagery vividness. Significant controlled effects were most evident in individuals with clinically diagnosed versus subclinical social anxiety. Overall, findings suggest promising effects of sessions targeting negative mental images. Limitations of the included studies and the analyses need to be considered. Future research should examine the addition to current SAD treatments and determine the relevance of specific imagery interventions. Studies involving children and adolescents are warranted.

Imagery rescripting: The value of an added positive emotion component.

BACKGROUND AND OBJECTIVES: Imagery Rescripting (ImRs) aims to reduce trauma-related negative emotions and intrusions. Positive emotions during ImRs may aid coping with the consequences of trauma, but protocols vary in the extent to which they explicitly target such positive emotions. We used a multiple-day design with a trauma film paradigm to investigate whether adding an explicit positive emotion component to ImRs improved intervention effects in a non-clinical sample. In addition, we explored potentially differential effects on high, medium, and low arousal positive affect. METHODS: Participants (n = 105) were randomly assigned to either a standard ImRs condition, to an ImRs condition with an added explicit positive emotion component targeting joy (ImRs+), or to a non-intervention control (NIC) condition. Participants watched a trauma film on day 1, received the condition-specific intervention on day 2, and completed additional post-assessments of positive and negative affect on day 3. In addition, participants recorded intrusions from the trauma film from day 1 until day 3. RESULTS: Compared to standard ImRs and NIC, ImRs + significantly increased positive affect. Exploratory analyses showed that this increase concerned medium and high, but not low arousal positive affect. No significant between-group differences were found for negative affect and intrusion-related outcomes. LIMITATIONS: Floor effects for intrusions and negative affect limited our ability to fully investigate the potential benefits of targeting positive affect. CONCLUSIONS: Adding a positive emotion component to ImRs reliably improved positive affect. More research is needed to determine whether explicitly targeting positive affect improves efficacy of ImRs for intrusion-related outcomes.

Targeting negative flashforward imagery in speech anxiety with a visuospatial dual-task: Do attenuated flashforwards lead to less anxiety and avoidance?

BACKGROUND AND OBJECTIVES: It has been proposed that negative mental imagery plays an important role in the persistence of social fears. Experiencing vivid and distressing 'flashforward' images of a potential social catastrophe appears to be of relevance in speech anxiety. To clarify the role of these images, the current experimental study tested if reducing the vividness and distressing properties of recurring negative flashforward images subsequently reduces anxiety and avoidance tendencies regarding a speech. METHODS: Participants were female undergraduates high in speech anxiety (N = 134) who joined our study online. In the experimental condition, we used a visuospatial dual-task to reduce the vividness and distress of flashforward imagery. Primary outcomes were participants' self-reported anxiety and avoidance ratings in anticipation of and during an actual speech. As a secondary outcome, we used observer ratings of participants' anxiety during the speech. RESULTS: Participants reported moderate to high frequency and interference of their vivid and distressing flashforward images in daily life. The dual-task resulted in reductions in image vividness and distress. However, we found no differences between conditions in anxiety and avoidance ratings before and during the speech. LIMITATIONS: The imagery manipulation effect was moderate to small. Moreover, we included a subclinical sample. CONCLUSIONS: Reducing negative flashforward imagery vividness and distress with a visuospatial dual-task did not directly lead to less anxiety and avoidance tendencies related to a later speech. Thus, findings provided no support for the hypothesis that experiencing highly vivid and distressing flashforward images causally contributes to social fears.

Should cognitive restructuring precede imagery rescripting? An experimental pilot study.

BACKGROUND AND OBJECTIVES: Imagery rescripting (ImRs) is a promising therapeutic technique used in treatment for a variety of psychiatric disorders. During an ImRs session, an aversive disorder-related memory, is activated in imagination and rescripted to a more positive outcome. It has been shown to successfully weaken the negative cognitive meaning, so-called encapsulated beliefs of the targeted aversive memory. In many studies, ImRs is preceded by a cognitive restructuring (CR) technique focused on the encapsulated belief of the target memory. It is not clear whether adding such a CR technique is necessary or that ImRs as standalone technique can achieve comparable effects. METHODS: Students with mild psychological distress (N = 53) were randomized over one session of cognitive restructuring plus imagery rescripting (CR + ImRs), a therapist attention placebo plus imagery rescripting (PLA + ImRs) and a double therapist attention placebo (PLA + PLA). Believability of the idiosyncratic encapsulated belief (primary outcome) and quality (vividness, distress and emotional connotation: secondary outcome) of the target memory were assessed at pre, post and at 1-week follow-up. RESULTS: Results indicate that both, CR + ImRs and PLA + ImRs, reduced the believability of the encapsulated beliefs in greater extent than PLA + PLA. No differences appeared between the two ImRs conditions. For the secondary outcomes no differences between the three conditions were found. LIMITATIONS: This study should be seen as a pilot study, moreover a non-clinical sample was used. CONCLUSION: Findings suggest that a CR technique preceding ImRs is redundant. However, this study needs replication in a larger sample.

Flashforward imagery in speech anxiety: Characteristics and associations with anxiety and avoidance.

Speech anxiety (SA) is a highly prevalent social fear. Prospective 'flashforward' (FF) imagery of an upcoming social catastrophe may be a particularly important cognitive factor in SA persistence via eliciting anxiety and avoidance behaviors. Since earlier research on imagery and social anxiety has not strictly differentiated between types of negative imagery, the occurrence, precise features, and impact of FF imagery remain unclear. We therefore examined the phenomenological characteristics of FF imagery in SA and mapped the relationship between FF imagery features and anxiety and avoidance. Female participants who approached clinical levels of SA (N = 60) completed questionnaires on SA and avoidance behaviors, and rated anxiety and avoidance in anticipation of an actual speech. FF imagery and emotionally linked autobiographical memories were assessed with semi-structured interviews. All participants reported recurring FF images, which were experienced as vivid, distressing, field perspective images with accompanying negative feelings. Image distress and feelings of threat showed most consistent associations with SA and avoidance measures. Findings add to the conceptualization of SA, and support the clinical relevance of assessing FF imagery. Future experimental studies on FF imagery characteristics are necessary to test the proposed causal impact in SA persistence and to inform additional treatment targets.

Empathy Modulates the Effects of Acute Stress on Anxious Appearance and Social Behavior in Social Anxiety Disorder.

Patients suffering from social anxiety disorder (SAD) fear social interaction and evaluation, which severely undermines their everyday life. There is evidence of increased prosocial behavior after acute social stress exposure in healthy individuals, which may be interpreted as stress-regulating "tend-and-befriend" behavior. In a randomized controlled trial, we measured empathic abilities in a first diagnostic session. In the following experimental session, we investigated how patients with SAD (n = 60) and healthy control participants (HC) (n = 52) respond to an acute social stressor (Trier Social Stress Test for groups) or a non-stressful control condition, and whether empathic abilities and acute social stress interact to modulate anxious appearance and social behavior in a social conversation test. Salivary cortisol, heart rate, and subjective stress response were repeatedly measured. The anxious appearance and social behavior of participants were rated by the conversation partner. SAD patients demonstrated stronger subjective stress responses while the biological responses did not differ from HC. Moreover, patients performed worse overall in the conversation task, which stress additionally undermined. Finally, we found that both emotional and cognitive empathy buffered the negative effects of acute stress on social behavior in SAD, but not in HC. Our data highlight the importance of empathic abilities for SAD during stressful situations and call for multimodal clinical diagnostics. This may help to differentiate clinical subtypes and offer better-tailored treatment for patients. General Scientific Summary: This study shows that high levels of cognitive and emotional empathy can buffer the negative effects of acute stress on social behavior in social anxiety disorder (SAD). Empathic abilities may be included as an additional diagnostic resource marker for SAD.

The effect of intranasally administered oxytocin on observed social behavior in social anxiety disorder.

Research has shown that patients with a social anxiety disorder (SAD) show social performance deficits. These deficits are a maintaining factor in SAD, as mending social behavior improves interpersonal judgments and reduces social anxiety. Thus finding ways to enhance social behavior is evidently of importance in the treatment of SAD. This double-blind, placebo-controlled study investigated the effect of an intranasal administration of the hormone oxytocin (24 IU) on social behavior and anxious appearance in SAD patients (N = 40) and healthy controls (N = 39). Forty minutes after oxytocin administration participants were submitted to two live social situations (i.e., a waiting room situation and a getting acquainted task). The participants ('self-rated') and observers ('observer-rated') scored participants' social behavior and anxious appearance. Participants also rated their positive and negative affect. Confirming the social performance deficits in SAD, observers regarded SAD patients as more anxious and less socially skilled than healthy controls. Results indicated oxytocin-induced improvement of observer-rated social behavior in SAD patients compared to placebo but only in the getting acquainted task. This effect was not perceived as such by patients themselves and did not improve their affect ratings. In conclusion, this study found support for the idea that oxytocin helps SAD patients to perform better in social interactions, although this improvement seemed context-dependent (i.e., only present in the getting-acquainted task) and 'not perceived by the patient.

The efficacy of incorporating mental imagery in cognitive restructuring techniques on reducing hostility: A randomized controlled trial.

BACKGROUND AND OBJECTIVES: Cognitive restructuring (CR) is an effective intervention for hostility. However, the number of patients who fail to benefit suggest that the efficacy of CR can be further improved. The present study investigated whether enhancing CR with mental imagery techniques can increase its efficacy. METHODS: A high hostility sample (28% male, and 72% female) was randomized over one session of imagery enhanced CR (I-CR) (n = 34), traditional CR (n = 32) or an active control session (AC) (n = 21). Changes in hostile beliefs, aggressive tendencies, state anger and hostility traits were assessed pre- and post-treatment, and at one-week follow-up. RESULTS: Results showed that both I-CR and CR efficaciously reduced hostile beliefs, aggressive tendencies and anger, to a stronger degree than AC. I-CR was more efficacious and sustainable over time than both CR and AC in reducing hostile beliefs and aggressive tendencies. LIMITATIONS: This study was conducted using a small, non-treatment seeking sample. CONCLUSIONS: Findings suggest that implementing imagery techniques in CR for hostile beliefs enhances its' efficacy.

Interpretation bias modification for hostility: A randomized clinical trial.

Objective: Hostility is a transdiagnostic phenomenon that can have a profound negative impact on interpersonal functioning and psychopathological severity. Evidence suggests that cognitive bias modification for interpretation bias (CBM-I) potentially reduces hostility. However, stringent efficacy studies in people with clinical levels of hostility are currently lacking. Method: The present study investigated the effects of CBM-I in two studies: one feasibility study (Study 1) in a mixed clinical-community sample of men (N = 29), and one randomized clinical study (Study 2) in a mixed-gender sample with clinical levels of hostility (N = 135), pre-registered at https://osf.io/r46jn. We expected that CBM-I would relate to a larger increase in benign interpretation bias and larger reductions in hostile interpretation bias, hostility symptoms and traits, and general psychiatric symptoms at post-intervention compared to an active control (AC) condition. We also explored the beneficial carry-over effects of CBM-I on working alliance in subsequent psychotherapy 5 weeks after finishing CBM-I (n = 17). Results: Results showed that CBM-I increased benign interpretation bias in both studies and partially reduced hostile interpretation bias in Study 2, but not in Study 1. Findings of Study 2 also showed greater reductions in behavioral (but not self-reported) aggression in CBM-I relative to control, but no condition differences were found in self-report hostility measures and general psychiatric symptoms. Conclusions: Overall, we found modest support for CBM-I as an intervention for hostility, with some evidence of its efficacy for hostile interpretation bias and aggression. We discuss study limitations as well as directions for future research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Uncovering the hierarchical structure of self-reported hostility.

Hostility and other related terms like anger and aggression are often used interchangeably to describe antagonistic affect, cognition, and behavior. Psychometric studies suggest that hostility consists of multiple separate factors, but consensus is currently lacking. In the present study we examined the hierarchical structure of hostility. The hierarchical structure of hostility was examined in N = 376 people (i.e., a mixed community and highly hostile sample), using both specific and broad hostility self-report measures. A series of Principal Components Analyses revealed the structure of hostility at five levels of specificity. At intermediate levels, hostility can consistently be expressed in affective, cognitive, and behavioral components. At the most specific level, hostility can be expressed in terms of Angry Affect; Hostile Intent; and Verbal, Relational, and Physical Aggression. The pattern of associations showed significant convergence, and some divergence with broad and more specific hostility measures. The present findings stress the need for novel instruments that capture each hostility facet separately to reduce conceptual confounding.

Behavior when socially anxious individuals expect to be (dis)liked: The role of self-disclosure and mimicry in actual likeability.

BACKGROUND AND OBJECTIVES: This study aimed to unravel the relationship between socially anxious individuals' expectation of being (dis)liked and actual likeability by looking at the mediating role of both strategic and automatic social behavior: Self-disclosure as well as mimicry were examined. METHOD: Female participants (N = 91) with various levels of social anxiety participated in a social task with a confederate. Before the task, participants indicated their expectation of being liked by the confederate. Afterwards, objective video-observers rated the likeability of the participants before and after the social task as well as their level of self-disclosure and mimicry. RESULTS: Social anxiety correlated negatively with the expectation to be liked but was not related to observer ratings of likeability, self-disclosure or mimicry. However, degree of social anxiety moderated the relation between expectations and self-disclosure. As expected, participants with low levels of social anxiety disclosed more if they expected to be liked. A reversed pattern was found for the high socially anxious participants: Here, higher expectations of being liked were related to less self-disclosure. LIMITATIONS: The study used an analogue female sample. Our social interaction task was highly structured and does not reflect informal day-to-day conversations. CONCLUSION: Socially anxious individuals function rather well in highly structured social tasks. No support was found for declined likeability or disrupted mimicry. Nevertheless, high socially anxious individuals did have a cognitive bias and show a self-protective strategy: when expecting a neutral judgment they reduce their level of self-disclosure. This pattern probably adds to their feelings of social disconnectedness.

Turning negative memories around: Contingency versus devaluation techniques.

BACKGROUND AND OBJECTIVES: It is assumed that fear responses can be altered by changing the contingency between a conditioned stimulus (CS) and an unconditioned stimulus (US), or by devaluing the present mental representation of the US. The aim of the present study was to compare the efficacy of contingency- and devaluation-based intervention techniques on the diminishment in - and return of fear. We hypothesized that extinction (EXT, contingency-based) would outperform devaluation-based techniques regarding contingency measures, but that devaluation-based techniques would be most effective in reducing the mental representation of the US. Additionally, we expected that incorporations of the US during devaluation would result in less reinstatement of the US averseness. METHODS: Healthy participants received a fear conditioning paradigm followed by one of three interventions: extinction (EXT, contingency-based), imagery rescripting (ImRs, devaluation-based) or eye movement desensitization and reprocessing (EMDR, devaluation-based). A reinstatement procedure and test followed the next day. RESULTS: EXT was indeed most successful in diminishing contingency-based US expectancies and skin conductance responses (SCRs), but all interventions were equally successful in reducing the averseness of the mental US representation. After reinstatement EXT showed lowest expectancies and SCRs; no differences were observed between the conditions concerning the mental US representation. LIMITATIONS: A partial reinforcement schedule was used, resulting in a vast amount of contingency unaware participants. Additionally, a non-clinical sample was used, which may limit the generalizability to clinical populations. CONCLUSION: EXT is most effective in reducing conditioned fear responses.

Responses to dominance challenge are a function of psychopathy level: A multimethod study.

This study assesses the relationship between psychopathy and dominance, both as a trait level and in 2 interpersonal contexts. Following the interpersonal circumplex model, we expected that interacting with a dominant interviewer would reduce dominance displays by low psychopathy participants (interpersonal complementarity) but might increase such displays in those with higher psychopathy (anticomplementarity). Psychopathic traits and dominance were assessed in a community sample (N = 91) using multiple dominance indicators: self-reported overall dominance level, job preference, dominance displays observed during identical interviews with a subordinate and dominant interviewer, and baseline and postinterview measures of personal space and testosterone level. Psychopathic traits were positively related to dominance on both trait measures and in the interviews. As a trait, higher self-reported psychopathy scores were associated with higher levels of self-reported dominance and preference for supervisory job positions. Higher Factor 1 psychopathy scores were associated with increased dominance display in interaction with the dominant interviewer. Higher Factor 2 scores were associated with allowing the dominant interviewer to approach more closely (reduced physical distancing). Psychopathy was partly related to a delayed increase in testosterone levels after interaction. Psychopathic traits may include a general tendency to dominate, a tendency which increases when interacting with a dominant other. The emotional/interpersonal psychopathy factor is specifically related to increased dominance displays when interacting with a dominant individual, while the behavioral factor of psychopathy is related to reduced physical distancing of a dominant partner. At higher psychopathy levels the general rule of dominant-subordinate reciprocity during social interaction is reversed. (PsycINFO Database Record

Imagery rescripting and eye movement desensitisation and reprocessing for treatment of adults with childhood trauma-related post-traumatic stress disorder: IREM study design.

BACKGROUND: Post-traumatic stress disorder (PTSD) that originates from childhood trauma experiences can develop into a chronic condition that has lasting effects on an individual's functioning and quality of life. While there are evidence-based guidelines for treating adult onset PTSD, treatments for adults with childhood trauma-related PTSD (Ch-PTSD) are varied and subject to ongoing debate. This study will test the effectiveness of two trauma-focused treatments, imagery rescripting (ImRs) and eye movement desensitisation and reprocessing (EMDR) in participants with Ch-PTSD. Both have been found effective in treatment of adult PTSD or mixed onset PTSD and previous research indicates they are well-tolerated treatments. However, we know less about their effectiveness for treating Ch-PTSD or their underlying working mechanisms. METHODS: IREM is an international multicentre randomised controlled trial involving seven sites across Australia, Germany and the Netherlands. We aim to recruit 142 participants (minimum of n = 20 per site), who will be randomly assigned to treatment condition. Assessments will be conducted before treatment until 1-year follow-up. Assessments before and after the waitlist will assess change in time only. The primary outcome measure is change in PTSD symptom severity from pre-treatment to 8-weeks post-treatment. Secondary outcome measures include change in severity of depression, anger, trauma-related cognitions, guilt, shame, dissociation and quality of life. Underlying mechanisms of treatment will be assessed on changes in vividness, valence and encapsulated belief of a worst trauma memory. Additional sub-studies will include qualitative investigation of treatment experiences from the participant and therapists' perspective, changes in memory and the impact of treatment fidelity on outcome measures. DISCUSSION: The primary aims of this study are to compare the effectiveness of EMDR and ImRs in treating Ch-PTSD and to investigate the underlying working mechanisms of the two treatments. The large-scale international design will make a significant contribution to our understanding of how these treatments address the needs of individuals with Ch-PTSD and therefore, potentially improve their effectiveness. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614000750684 . Registered 16 July 2014.

Through rose-coloured glasses: An empirical test of narcissistic overestimation.

BACKGROUND: Grandiosity is designated as a hallmark trait of narcissism. The current study tested whether narcissistic traits are related to overestimation of a range of agentic performances. METHOD: Eighty-five non-patients executed six objective tasks to assess their level of (emotional) intelligence, first impression, attractiveness, social skills and learning performance. They were also asked to estimate their level of functioning in these six areas. This estimation was given on two moments: before and after performing the objective tasks. Our main variable of interest was the degree to which subjective estimation exceeds objective scores. RESULTS: Narcissistic traits were related to overestimation of (emotional) intelligence, attractiveness and social skills, particularly at a global level before performing the tasks. LIMITATIONS: The use of a homogenous student sample; Mainly agentic performances, were studied. CONCLUSION: Overall, the findings provide a theoretical validation of unwarranted feelings of grandiosity as a core narcissistic criterion. Copyright © 2016 John Wiley & Sons, Ltd.

The SPAI-18, a brief version of the social phobia and anxiety inventory: reliability and validity in clinically referred and non-referred samples.

We developed a new version of the Social Phobia and Anxiety Inventory (SPAI) in order to have a brief instrument for measuring social anxiety and social anxiety disorder (SAD) with a strong conceptual foundation. In the construction phase, a set of items representing 5 core aspects of social anxiety was selected by a panel of social anxiety experts. The selected item pool was validated using factor analysis, reliability analysis, and diagnostic analysis in a sample of healthy participants (N = 188) and a sample of clinically referred participants diagnosed with SAD (N = 98). This procedure resulted in an abbreviated version of the Social Phobia Subscale of the SPAI consisting of 18 items (i.e. the SPAI-18), which correlated strongly with the Social Phobia Subscale of the original SPAI (both groups r = .98). Internal consistency and diagnostic characteristics using a clinical cut-off score > 48 were good to excellent (Cronbach's alpha healthy group = .93; patient group = .91; sensitivity: .94; specificity: .88). The SPAI-18 was further validated in a community sample of parents-to-be without SAD (N = 237) and with SAD (N = 65). Internal consistency was again excellent (both groups Cronbach's alpha = .93) and a screening cut-off of > 36 proved to result in good sensitivity and specificity. The SPAI-18 also correlated strongly with other social anxiety instruments, supporting convergent validity. In sum, the SPAI-18 is a psychometrically sound instrument with good screening capacity for social anxiety disorder in clinical as well as community samples.

The effect of a retrieval cue on the return of spider fear.

BACKGROUND AND OBJECTIVES: Exposure therapy is often used as treatment for anxiety disorders. However, a change in context after exposure can result in fear renewal. This renewal can be attenuated by using retrieval cues stemming from the exposure context. The present study investigated the effect of such a cue in spider-fearful persons. METHODS: Thirty-three participants underwent an in vivo exposure session while wearing a bracelet (retrieval cue). After exposure, half of the participants continued to wear the bracelet at home until follow-up (cue groups); the other half handed over the bracelet after exposure (no cue groups). Half of the participants in each group received the follow-up in the exposure context (AAcue and AAnocue); for the other half follow-up was conducted in a novel environment (ABcue and ABnocue). RESULTS: A switch in context at follow-up resulted in more self-reported anxiety and arousal compared to no switch. However, the retrieval cue did not attenuate this renewed responding. LIMITATIONS: The number of participant per condition was limited, which might have obscured possible retrieval cue effects due to a lack of power. Additionally, information about the retrieval cue was provided after exposure, which might have weakened the association between the cue and exposure therapy. Furthermore, no autonomic measures were incorporated, restricting the effect to self-report measures. For future studies we would recommend to explicitly link the retrieval cue before onset of the exposure session and to incorporate autonomic measures. CONCLUSIONS: Our findings indicate that a switch in context resulted in more self-reported anxiety and arousal, but that a cue stemming from the exposure context did not attenuate this renewal.

Not self-focused attention but negative beliefs affect poor social performance in social anxiety: an investigation of pathways in the social anxiety-social rejection relationship.

Patients with social anxiety disorder (SAD) not only fear negative evaluation but are indeed less likeable than people without SAD. Previous research shows social performance to mediate this social anxiety-social rejection relationship. This study studied two pathways hypothesized to lead to poor social performance in social anxiety: increased self-focused attention and negative beliefs. State social anxiety was experimentally manipulated in high and low-blushing-fearful individuals by letting half of the participants believe that they blushed intensely during a 5 min getting-acquainted interaction with two confederates. Participants rated their state social anxiety, self-focused attention, and level of negative beliefs. Two confederates and two video-observers rated subsequently likeability (i.e., social rejection) and social performance of the participants. In both groups, the social anxiety-social rejection relationship was present. Although state social anxiety was related to heightened self-focused attention and negative beliefs, only negative beliefs were associated with relatively poor social performance. In contrast to current SAD models, self-focused attention did not play a key-role in poor social performance but seemed to function as a by-product of state social anxiety. Beliefs of being negatively evaluated seem to elicit changes in behavioral repertoire resulting in a poor social performance and subsequent rejection.

Social anxiety disorder: questions and answers for the DSM-V.

BACKGROUND: This review evaluates the DSM-IV criteria of social anxiety disorder (SAD), with a focus on the generalized specifier and alternative specifiers, the considerable overlap between the DSM-IV diagnostic criteria for SAD and avoidant personality disorder, and developmental issues. METHOD: A literature review was conducted, using the validators provided by the DSM-V Spectrum Study Group. This review presents a number of options and preliminary recommendations to be considered for DSM-V. RESULTS/CONCLUSIONS: Little supporting evidence was found for the current specifier, generalized SAD. Rather, the symptoms of individuals with SAD appear to fall along a continuum of severity based on the number of fears. Available evidence suggested the utility of a specifier indicating a "predominantly performance" variety of SAD. A specifier based on "fear of showing anxiety symptoms" (e.g., blushing) was considered. However, a tendency to show anxiety symptoms is a core fear in SAD, similar to acting or appearing in a certain way. More research is needed before considering subtyping SAD based on core fears. SAD was found to be a valid diagnosis in children and adolescents. Selective mutism could be considered in part as a young child's avoidance response to social fears. Pervasive test anxiety may belong not only to SAD, but also to generalized anxiety disorder. The data are equivocal regarding whether to consider avoidant personality disorder simply a severe form of SAD. Secondary data analyses, field trials, and validity tests are needed to investigate the recommendations and options.