Social Anxiety Clinical, Developmental, and Social Perspectives Third Edition Edited by Stefan G. Hofmann and Patricia M. DiBartolo AMSTERDAM • BOSTON • HEIDELBERG • LONDON NEW YORK • OXFORD • PARIS • SAN DIEGO SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO Academic Press is an imprint of Elsevier 32 Jamestown Road, London NW1 7BY, UK 225 Wyman Street, Waltham, MA 02451, USA 525 B Street, Suite 1800, San Diego, CA 92101-4495, USA Third edition Copyright © 2014, 2010, 2000 Elsevier Inc. All rights reserved No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the publisher Permissions may be sought directly from Elsevier's Science & Technology Rights Department in Oxford, UK: phone (+44) (0) 1865 843830; fax (+44) (0) 1865 853333; email: [email protected]. Alternatively, visit the Science and Technology Books website at www.elsevierdirect.com/rights for further information Notice No responsibility is assumed by the publisher for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN : 978-0-12-394427-6 For information on all Academic Press publications visit our website at http://store.elsevier.com/ Typeset by Thomson Printed and bound in United States of America 14 15 16 17 18 10 9 8 7 6 5 4 3 2 1 Contributors Anne Marie Albano, Division of Child and Adolescent Psychiatry, Department of Psychiatry and New York State Psychiatric Institute/Columbia University Medical Center, New York, NY Lynn E. Alden, Department of Psychology, University of British Columbia, Vancouver, Canada Danielle Amado, Department of Psychology, University of Montreal, Montreal, Canada Nader Amir, Department of Psychology, San Diego State University/Department of Psychiatry, University of California, San Diego, CA Kristin N. Anderson, Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE Karen W. Auyeung, Department of Psychology, University of British Columbia, Vancouver, Canada Paula Barrett, School of Education, University of Queensland, St Lucia, Australia; Centre for Mental Health Research, Australian National University, Canberra, Australia; Pathways Health and Research Centre, West End, Queensland, Australia Carlos Blanco, Department of Psychiatry, New York State Psychiatric Institute/ Columbia University, New York, NY Bram Van Bockstaele, Department of Developmental Psychology, Department of Child Development and Education, University of Amsterdam, the Netherlands Susan M. Bögels, Department of Child Development and Education, University of Amsterdam, the Netherlands Laura Bragdon, Department of Psychiatry, New York State Psychiatric Institute/Columbia University, New York, NY Lynn L. Brandsma, Department of Psychology, Chestnut Hill College, Philadelphia, PA Keila C. Brockveld, Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia Faith A. Brozovich, Department of Psychology, Stanford University, Stanford, CA Jonathan S. Comer, Department of Psychology, Florida International University, Miami, Florida, FL Marita Cooper, Centre for Mental Health Research, Australian National University, Canberra, Australia; Pathways Health and Research Centre, West End, Queensland, Australia Kathleen I. Crum, Department of Psychology, Florida International University, Miami, Florida, FL Michael F. Detweiler, Air Force Medical Operations Agency, San Antonio, Texas, TX xxi xxii Contributors Allison Diamond, Department of Psychology, University of Texas-Austin, Austin, TX Antonina S. Farmer, Department of Psychology, George Mason University, Fairfax, VA Laura Fischer, Department of Psychology, Drexel University, Philadelphia, PA Gordon L. Flett, Department of Psychology, York University, Toronto, Ontario, Canada Paul Gilbert, Mental Health Research Unit, Derbyshire Mental Health Services NHS Trust, Derby, UK Eva Gilboa-Schechtman, Psychology Department and the Gonda Brain Science Center, Bar-Ilan University, Ramat-Gan, Israel Philippe R. Goldin, Department of Psychology, Stanford University, Stanford, CA James J. Gross, Department of Psychology, Stanford University, Stanford, CA Bridget A. Hearon, Department of Psychological and Brain Sciences, Boston University, Boston, MA Richard G. Heimberg, Adult Anxiety Clinic/Department of Psychology, Temple University, Philadelphia, PA Liat Helpman, Psychology Department and the Gonda Brain Science Center, Bar-Ilan University, Ramat-Gan, Israel Lynne Henderson, The Shyness Institute, Berkeley, CA James D. Herbert, Department of Psychology, Drexel University, Philadelphia, PA Paul L. Hewitt, Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada Debra A. Hope, Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE Shari Jager-Hyman, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA Hooria Jazaieri, Department of Psychology, University of California, Berkeley, CA Katrina P. Jongman-Sereno, Department of Psychology and Neuroscience, Duke University, Durham, NC Jerome Kagan, Department of Psychology, Harvard University, Cambridge, MA Todd B. Kashdan, Department of Psychology, George Mason University, Fairfax, VA Brooke Y. Kauffman, Department of Psychology, University of Texas-Austin, Austin, TX Heide Klumpp, Department of Psychiatry, University of Illinois, Chicago, IL Jennie M. Kuckertz, Department of Psychology, San Diego State University/ Department of Psychiatry, University of California, San Diego, CA Angela Kyparissis, Department of Psychology, University of Montreal, Montreal, Canada Mark R. Leary, Department of Psychology and Neuroscience, Duke University, Durham, NC C.W. Lejuez, Department of Psychology, University of Maryland, College Park, MD Contributors xxiii Michael R. Liebowitz, Department of Psychiatry, New York State Psychiatric Institute/ Columbia University, New York, NY Daniel W. McNeil, Department of Psychology, West Virginia University, Morgantown, WV Rowland S. Miller, Department of Psychology and Philosophy, Sam Houston State University, Huntsville, TX Michael W. Otto, Department of Psychological and Brain Sciences, Boston University, Boston, MA Sarah J. Perini, Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia K. Luan Phan, Department of Psychiatry, University of Illinois, Chicago, IL; Mental Health Service Line, Jesse Brown VA Medical Center, Chicago, IL Leili Plasencia, Department of Psychology, University of British Columbia, Vancouver, Canada Mark B. Powers, Department of Psychology, University of Texas-Austin, Austin, TX Cameron L. Randall, Department of Psychology, West Virginia University, Morgantown, WV Ronald M. Rapee, Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia James Reich, Department of Psychiatry, UCSF Medical School, and Department of Psychiatry and Behavioral Health, Stanford Medical School, San Francisco, CA Steven A. Safren, Massachusetts General Hospital and Harvard Medical School, Boston, MA Franklin R. Schneier, Department of Psychiatry, New York State Psychiatric Institute/ Columbia University, New York, NY Iris Shachar, Psychology Department and the Gonda Brain Science Center, Bar-Ilan University, Ramat-Gan, Israel Jasper A.J. Smits, Department of Psychology, University of Texas-Austin, Austin, TX John T. Sorrell, Department of Anaesthesia, Stanford University School of Medicine, Redwood City, CA Ariel Stravynski, Department of Psychology, University of Montreal, Montreal, Canada Justin W. Weeks, Department of Psychology, Ohio University, Athens, OH Amy Wenzel, Department of Psychiatry, University of Pennsylvania, Pennsylvania, PA Philip Zimbardo, The Shyness Institute, Berkeley, CA; Palo Alto University, Palo Alto, CA Introduction Stefan G. Hofmann and Patricia M. DiBartolo Based on the success of our earlier two volumes, we were encouraged to pursue another edition to update the field with the dramatic changes that have occurred in the field of social anxiety. This third edition of our volume includes again many of the foremost experts in the field of social anxiety from a variety of dif- ferent disciplines, including social psychology, clinical psychology, psychiatry, developmental psychology, neuroscience, and behavior genetics. The volume is separated into three parts: Part 1: Delineation of Social Anxiety; Part 2: Theo- retical Perspectives; and Part 3: Treatment Approaches. The first part (Part 1: Delineation of Social Anxiety) examines the clini- cal definition of social anxiety disorder (Chapter 1 by Daniel W. McNeil and Cameron L. Randall), its overlap with avoidant personality disorder (Chapter 2 by James Reich), methods to assess social anxiety and its clinical expressions (Chapter 3 by James D. Herbert, Lynn L. Brandsma, and Laura Fischer) and the overlap between social anxiety and shyness (Chapter 4 by Lynne Henderson, Paul Gilbert, and Philip Zimbardo) and embarrassment (Chapter 5 by Rowland Miller). Moreover, this section examines the different expressions of social anx- iety across different cultures (Chapter 6 by Keila C. Brockveld, Sarah J. Perini, and Ronald M. Rapee), the overlap between social anxiety and perfectionism (Chapter 7 by Gordon L. Flett and Paul L. Hewitt), social skills (Chapter 8 by Ariel Stravynski, Angela Kyparissis, and Danielle Amado), and the expression of social anxiety disorder in adults (Chapter 9 by Amy Wenzel and Shari Jager- Hyman), and children and adolescents (Chapter 10 by Michael F. Detweiler, Jonathan S. Comer, Kathleen I. Crum, and Anne Marie Albano). We also in- cluded a chapter on prevention and early intervention (Chapter 11 by Paula Barrett and Marita Cooper). The second part (Part 2: Theoretical Perspectives) includes a chapter re- viewing the neuroendocrinological and neuroimaging studies in social anxiety disorder (Chapter 12 by K. Luan Phan and Heide Klumpp) as well as basic issues in temperament (Chapter 13 by Jerome Kagan) and the relationship be- tween social anxiety and one particularly relevant temperament—behavioral inhibition (Chapter 14, also by Jerome Kagan). Chapter 15 by Daniel W. McNeil, Cameron L. Randall, C. W. Lejuez, and John T. Sorrell presents learn- ing and behavior change mechanisms related to social anxiety disorder while Chapter 16 (by Jennie M. Kuckertz and Nader Amir) reviews the cognitive bias literature, followed by emotion dysregulation models (Chapter 17 by Philippe xxv xxvi Introduction R. Goldin, Hooria Jazaieri, and James J. Gross), self-related processes (Chapter 18 by Lynn E. Alden, Karen W. Auyeung, and Leili Plasencia), and deficits in positive emotions (Chapter 19 by Antonina S. Farmer, Todd B. Kashdan, and Justin W. Weeks). Also included is a revision of Mark R. Leary’s early warning system (Chapter 20, written with Katrina P. Jongman- Sereno) and a chapter on evolutionary perspectives (Chapter 21 by Eva Gilboa- Schechtman, Iris Shachar, and Liat Helpman). In the final part (Part 3: Treatment Approaches), authors review the ther- apy literature, including pharmacological treatments (Chapter 22 by Carlos Blanco, Laura Bragdon, Franklin R. Schneier, and Michael R. Liebowitz) and various psychological interventions (Chapter 23 by Kristin N. Anderson and Debra A. Hope). Chapter 24 by Richard G. Heimberg, Faith A. Brozovich and Ronald M. Rapee provides an update of the influential cognitive model. Bram Van Bockstaele and Susan M. Bögels (Chapter 25) review mindfulness-based therapy for social anxiety disorder. Mark B. Powers, Brooke Y. Kauffman, Allison Diamond, and Jasper A. J. Smits review the literature comparing pharma- cotherapy and psychological treatments (Chapter 26) and the volume concludes with a review by Michael W. Otto, Steven A. Safren, and Bridget A. Hearon of the mechanisms of action in treatment (Chapter 27). As is evident, social anxiety has captured the interest of some of the bright- est contemporary thinkers of our time and from a multitude of different dis- ciplines. This explosion of research interest and theoretical developments has provided much needed understanding into the universal and transient feelings of social anxiety as well as the less common, but unremitting and debilitating, condition of social anxiety disorder. It is our hope that our volume consolidates some of the latest evidence and conceptual theories on this topic. We also hope that the breadth of perspective represented in this volume will provide a step further toward understanding so- cial anxiety and its clinical expression. This continues to be an exciting time as our field continues to make significant advances in our understanding, concep- tualization, and treatment of a defining aspect of humans that can turn into a debilitating problem. Chapter 1 Conceptualizing and Describing Social Anxiety and Its Disorders Daniel W. McNeil and Cameron L. Randall Department of Psychology, West Virginia University, Morgantown, WV INTRODUCTION Social anxieties and fears exist along continua of intensity, ranging from the helpful and adaptive (e.g., keeping one on one’s “social toes” in uncertain so- cial situations) to the disabling and impairing (e.g., being unable to develop or maintain close relationships in spite of loneliness). Unpleasant emotional states and maladaptive behaviors associated with social situations can be sig- nificant, life-affecting problems for many people. Given the social nature of human beings, and the functional nature of social relationships (e.g., social sup- port), discomfort associated with interacting with others is particularly difficult, as socialization cannot easily be avoided on a consistent basis. In other phobias or phobic-like disorders, avoidance often can be effective in the short term, to prevent or reduce anxiety, albeit temporarily in many situations. Social anxieties and fears were described by Hippocrates and were systemati- cally delineated with other phobias beginning in the 1870s (Marks, 1970, 1985). Over the past 40 years, the social psychological focus on shyness (e.g., Zimbardo, 1977), the work of Marks and others in the 1960s and 1970s, and the identification of social phobia as a distinct disorder in the Diagnostic and Sta- tistical Manual–III (e.g., American Psychiatric Association [APA], 1980) and subsequent revisions, including the new Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; APA, 2013), have been part of a massive growth in the related scientific and self-help literatures. This general arena of problems includes several somewhat overlapping con- structs; the scientific language has many different terms that apply or relate, in- cluding: shyness, social anxiety, social withdrawal, social phobia, social anxiety disorder, behavioral inhibition, communication apprehension, and introversion. In both everyday and scientific language, these states have been described in a myriad of ways. Leitenberg (1990), in introducing his book in the area, states: Social anxiety has been studied in various guises. Shyness, performance anxiety, social phobia, avoidant personality disorder, social withdrawal, social isolation, Social Anxiety. DOI: 10.1016/B978-0-12-394427-6.00001-7 Copyright © 2014 Elsevier Inc. All rights reserved 3 4 PART | I Delineation of Social Anxiety public speaking anxiety, speech anxiety, communication apprehension, fear of interpersonal rejection, dating anxiety, separation anxiety, stage fright, fear of strangers, shame, embarrassment, social inhibition, social timidity – all of these and more fall under the umbrella of social anxiety. (p. 2) Other anxiety-related syndromes, such as test anxiety and selective mutism, also likely have a strong social component, and may be instantiations of social anxiety disorder (SAD) (Bögels et al., 2010). Body dysmorphic disorder, highly comorbid with SAD, similarly is socially determined, at least in part, in that the perception of others regarding (imagined) defects may be an underlying feature. There also are a variety of terms that suggest, at least somewhat, deficient social skills, such as nerd, geek, and wall flower. Masia and Morris (1998) iden- tify terms related to social distress in children across areas of psychology: de- velopmental (i.e., peer neglect, social withdrawal), personality (i.e., shyness), and clinical (i.e., social phobia, avoidant personality disorder [APD]). Stranger anxiety and separation anxiety likely are related constructs as well (Thompson & Limber, 1990). Masia and Morris note that this varying “psychological lan- guage” (p. 212) creates problems in investigating phenomena (e.g., parental be- havior and its relation to child social anxiety) that span across subdisciplines in psychology, and presumably across related disciplines (e.g., psychiatry). It should be noted that comparative psychology has contributions to this area as well. Social anxieties are not solely human phenomena; such social/ emotional problems are shared by other primates (Mineka & Zinbarg, 1995; Suomi, Chaffin, & Higley, 2011), and lower animals. Social dominance and submissiveness hierarchies have been suggested as important determinants of socially anxious behavior across species of primates, including humans (Schneier & Welkowitz, 1996; Trower & Gilbert, 1989). Facial expressions, for example, provide important social interactional cues in humans and other pri- mates, including both aggression and appeasement related to anxiety (Mogg & Bradley, 2002; Öhman, 1986). Early learning history, particularly mother- offspring interaction, also has been suggested as an important determinant of socially anxious behavior in primates (e.g., Schino, Speranza & Troisi, 2001). One of the issues that continues to be an albatross for the field is the every- day language basis of the most frequently used terms: shyness, stage fright, and social anxiety. Some years ago, Harris (1984) detailed a number of problems inherent in using the lay language of “shyness” in scientific discourse, a prob- lem that still exists today. Clinically-oriented scientists may try to “distance” SAD from shyness, perhaps to emphasize that individuals who meet criteria for the disorder suffer with impairment in social and occupational functioning that can be quite terrible, leading to chronic suffering. Issues related to the ter- minology used to describe social fears and anxieties can obfuscate the already complex and sometimes controversial task of understanding and defining SAD (Dalrymple, 2012). Adding further complexity, some degree of social anxiety can be adaptive (Schneier & Welkowitz, 1996). Moreover, the social consequences of Chapter | 1 Conceptualizing and Describing Social Anxiety 5 some socially anxious behaviors are quite positive. One example is a “bashful” child who hides his or her face by planting it directly in a part of his or her par- ent’s body, resulting in adult laughter and encouragement to socialize. A further example is a distant, detached person who is regarded as “coy,” “interesting,” or even “mysterious,” relating to his or her lack of social initiation or response. Defining social anxieties and fears, and specifying what types or degrees of behavior are most appropriately classified as pathological or a “disorder,” is an involved and often perplexing undertaking. The definitions we create are in- formed by research and clinical experience, and indeed inform future research and clinical intervention. The National Institute of Mental Health (NIMH) recently initiated the Research Domain Criteria project (RDoC) in an effort to “develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures” (NIMH, 2013). Research that transcends standard diagnosing and steps away from strict definitions of mental illness based on diagnostic criteria, such as those presented in the DSM-5, now is preferred by the NIMH. This effort rep- resents an understanding that the task of defining any psychological disorder indeed is complex. SAD is no exception. Research in the area of SAD that con- siders definitional issues and acknowledges the limits of even new diagnostic criteria allows for a more comprehensive understanding of its psychopathol- ogy and more appropriate translation of research findings to clinical work. This chapter provides a perspective on conceptual, definitional, and diag- nostic nosology issues for the field, including a focus on the DSM-5. It is pro- posed that social anxieties and fears, like other phobic disorders, exist along a continuum across the general population, as explicated later in this chapter, and as shown in Figure 1.1. The range of social anxieties/fears along this con- tinuum is from no anxiety/fear, to “normal” levels, to psychopathological ex- tremes. The debate (e.g., Campbell-Sills & Stein, 2005; Wakefield, Horowitz, & Schmitz, 2005a; Wakefield, Horowitz, & Schmitz, 2005b) on “overpatholo- gizing” socially anxious people then may be somewhat addressed by a concep- tualization that acknowledges both “normal” social anxieties that are mildly FIGURE 1.1 Model of the continuum of social anxieties and fears across the general population.