Emotion 2016 American Psychological Association

2017, Vol. 17, No. 2, 231239 1528-3542/17/$12.00 http://dx.doi.org/10.1037/emo0000223

Once Hurt, Twice Shy: Social Pain Contributes to Social Anxiety

Klint Fung and Lynn E. Alden
University of British Columbia

Social rejection has been consistently linked to the development of social anxiety. However, mechanisms
underlying the relation have been largely unexplored, which presents an obstacle to fully understanding
the origins of social anxiety and to the development of effective prevention and treatment strategies. Two
studies were conducted to test the hypothesis that the emotion of social pain following rejection promotes
the development of social anxiety in subsequent situations. In Study 1, undergraduate participants were
exposed to 2 social situations (Cyberball) 2 days apart. Participants who were rejected in the first
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situation reported higher social anxiety before and during the second situation relative to those who were
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included. This effect was fully mediated by initial social pain intensity. In Study 2, all participants were
initially rejected. Using double-blinded drug administration, participants were randomly assigned to
ingest acetaminophen to alleviate the social pain from rejection, or a sugar placebo. As predicted, the
acetaminophen group reported lower social anxiety before and during the second situation. Approxi-
mately half of the effect was mediated by reduction in social pain. Notably, the immediate effect of
acetaminophen was specific to social pain rather than social anxiety. Results were discussed in the
context of literature on the etiology of social anxiety and social pain. Future directions were suggested.

Keywords: social acceptance, emotions, social anxiety, etiology

Current evidence suggests that adverse social events, such as
peer rejection, exclusion, and criticism, play a causative role in the
development of social anxiety. Identifying mechanisms underlying
this link has broad implications for informing conceptualizations
of the etiology of social anxiety, as well as developing preventative
policies and treatment strategies that specifically target these
mechanisms. As a preliminary study, we propose that social anx-
iety may develop from social pain, a negative, immediate emotion
in response to rejection that is at least partially distinct from social
anxiety. Two studies were conducted to evaluate this hypothesis.
In Study 1, we tested whether social pain mediates the link
between rejection and social anxiety. In Study 2, we reduced social
pain, the proposed mechanism, with an over-the-counter pain
medication and examined whether it led to lowered social anxiety.
Rejection and Social Anxiety
Social anxiety is a negative state of arousal that arises before
and during situations in which the individual feels scrutinized by
This article was published Online First September 8, 2016.
Klint Fung and Lynn E. Alden, Department of Psychology, University of
British Columbia.
This research was conducted as part of the first authors masters thesis.
It was supported by Social Sciences and Humanities Research Council of
Canada (SSHRC) scholarship 766-2013-0796 awarded to the first author
and SSHRC research Grant 435-2012-0350 awarded to the second author.
We thank Toni Schamder, Amori Mikami, and Daniel Randles for helpful
suggestions throughout the research process, and Rayna Sanghvi, Cassie
Cowie, and Jennie Kostiuk for assistance with data collection.
Correspondence concerning this article should be addressed to Klint
Fung, Department of Psychology, University of British Columbia, 2136
West Mall, Vancouver, British Columbia, Canada V6T 1Z4. E-mail:
fung@psych.ubc.ca
231
others and doubts their own ability to make an adequate impres-
sion (Clark & Wells, 1995; Schlenker & Leary, 1982). Although
the emotion is adaptive in that it motivates individuals to take steps
to prevent social rejection, chronic social anxiety causes extreme
distress and dysfunction for approximately 8% of the population
(American Psychiatric Association, 2013; Baumeister & Tice,
1990). Much research has been devoted to examining the causes of
social anxiety. Among the major hypothesized contributors are
adverse social experiences (e.g., Carleton, Peluso, Collimore, &
Asmundson, 2011; Erwin, Heimberg, Marx, & Franklin, 2006;
Rapee & Spence, 2004). Experimental studies have shown that
children who were made to believe that they were rejected by peers
became more avoidant in subsequent interactions (Gazelle &
Druhen, 2009; Goetz & Dweck, 1980). Longitudinal, multi-
informant studies indicate that peer rejection, especially being
deliberately excluded from desired groups, was associated with
subsequent increases in social anxiety and avoidance in children
and adolescents (e.g., Gazelle & Rudolph, 2004; Ranta, Kaltiala-
Heino, Frjd, & Marttunen, 2013; Siegel, La Greca, & Harrison,
2009; Storch, Masia-Warner, Crisp, & Klein, 2005; Vernberg,
Abwender, Ewell, & Beery, 1992). Retrospective reports of so-
cially anxious adults suggest the same pattern, in that these indi-
viduals tend to recall experiencing more instances of bullying and
teasing in the past (e.g., Ishiyama, 1984; McCabe, Antony, Sum-
merfeldt, Liss, & Swinson, 2003; McCabe, Miller, Laugesen,
Antony, & Young, 2010; st & Hugdahl, 1981; Stemberger,
Turner, Beidel, & Calhoun, 1995). The deleterious effects of such
events appear to carry over such that in contemporary social
situations, these individuals tend to imagine themselves being
rejected in a manner similar to the original rejection (Hackmann,
Clark, & McManus, 2000).
Despite an abundance of research suggesting that rejection
contributes to the development of social anxiety, few studies have
 232 FUNG AND ALDEN
examined mechanisms underlying that relationship. One process
through which social anxiety may be acquired is associative learn-
ing (e.g., Mineka & Zinbarg, 2006). Specifically, social anxiety
may be acquired when certain social stimuli, such as specific
situations or personal characteristics, are paired with negative
emotions as a consequence of rejection. Accordingly, the devel-
opment of social anxiety may depend on two factors. Conditioning
studies suggest that social anxiety development may depend on the
ease with which individuals associate negative emotions with
social stimuli, that is, associative processes (Lissek et al., 2008;
Pejic, Hermann, Vaitl, & Stark, 2013). Another line of research
suggests that the intensity of negative emotions triggered by re-
jection may contribute to social anxiety development. In controlled
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studies, children who were made to believe that they were rejected
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by their peers were less likely to approach other peers, an effect
that was mediated by how upset the children were (Erdley, Cain,
Loomis, Dumas-Hines, & Dweck, 1997; Gazelle & Druhen, 2009).
In a similar vein, Levinson, Langer, and Rodebaugh (2013) found
that reactivity to peer rejection, and not self-reported history of
rejection itself, predicted subsequent increases in social anxiety.
Following these findings, we propose and test whether social pain,
a negative emotion closely associated with rejection, is an active
ingredient that contributes to the development of social anxiety.
Social Pain
Social pain is a general term describing the immediate, unpleas-
ant emotional state elicited by social disconnection (MacDonald &
Leary, 2005). Social pain has been proposed to arise in response to
events that cause victims to interpret others actions as devaluing
their relationship (Leary & Springer, 2001). These events and the
resulting pain are hypothesized to facilitate the development of
social anxiety in the long term (Leary & Springer, 2001; Leary,
Springer, Negel, Ansell, & Evans, 1998). Conceivably, individu-
als propensity toward experiencing social pain varies widely
(Leary & Springer, 2001). The same instance of teasing interpreted
as being playful in nature may elicit less pain and may even
promote bonding compared with when teasing is interpreted as
being malicious (e.g., Leary et al., 1998; Nowakowski & Antony,
2013).
There are notable similarities between social pain and social
anxiety. For example, both are negative emotions that evolved to
preserve social relationships, and rejection may cause individuals
to feel pain and anxiety at the same time. However, research has
shown that the two emotions are partially distinct (Leary & Leder,
2009). In particular, social pain, and not social anxiety, appears to
be a staple element of rejection. Whereas social pain has been
found to be uniquely associated with the perception that social
connections have already been severed, social anxiety was
uniquely associated with the anticipation of social disconnection
(Leary & Leder, 2009).
The phenomenology of social pain has been more closely com-
pared with that of physical pain (MacDonald & Leary, 2005). The
experience of physical pain can be divided into two components:
sensation, which allows individuals to locate the source of the
injury but does not have motivational properties, and unpleasant-
ness, which makes pain inherently undesirable and motivates in-
dividuals to withdraw from the source (Price, 2000). Social pain
has been proposed to involve the latter, specifically, unpleasant-
ness as represented by neural activity in the dorsal anterior cingu-
late cortex (dACC; Eisenberger & Lieberman, 2004; MacDonald
& Leary, 2005). Neuroimaging studies indicate that the dACC is
activated in response to both social pain and physical pain (Rain-
ville, Duncan, Price, Carrier, & Bushnell, 1997; Rotge et al.,
2015). Moreover, acetaminophen, an active ingredient in over-the-
counter painkillers, and possibility opiate analgesics, also allevi-
ates social pain by virtue of reducing dACC unpleasantness (De-
Wall et al., 2010; Panksepp, 2003; Zubieta et al., 2003). Not
surprisingly, individuals with high physical pain sensitivity also
show higher social pain sensitivity (e.g., Eisenberger, Jarcho,
Lieberman, & Naliboff, 2006). Social and physical pain also cause
similar cognitive and affective consequences that are characteristic
of dACC unpleasantness, for example, seizing and redirecting
attention to the source of unpleasantness and eliciting low mood
and frustration (e.g., Buckley, Winkel, & Leary, 2004; DeWall &
Baumeister, 2006; Riva, Wesselmann, Wirth, Carter-Sowell, &
Williams, 2014; Spunt, Lieberman, Cohen, & Eisenberger, 2012).
Although much research has focused on the common causes and
consequences of physical and social pain because of shared phe-
nomenological unpleasantness associated with the dACC, it is
important to note that this unpleasantness underlies a more general
experience of conflict or error that encompasses both experiences
(Eisenberger & Lieberman, 2004, Box 3). Recent empirical re-
search suggests that dACC unpleasantness is experienced in re-
sponse to conflict or error is detected in external surroundings, for
example, anxiety from meaning threats and cognitive dissonance
in addition to physical and social pain (DeWall, Chester, & White,
2015; Randles, Heine, & Santos, 2013). Importantly, extant evi-
dence from cognitive neuroscience suggests that the dACC un-
pleasantness may motivate individuals to adjust future cognition
and behavior to avoid similar unpleasantness (e.g., Spunt et al.,
2012). Further, dACC unpleasantness as part of physical pain
alerts individuals that certain circumstances are undesirable, and as
a result, can come to induce anxiety during subsequent encounters
(Price, 2000). For example, reducing pain unpleasantness in the
anterior cingulate cortex also attenuates aversive learning in rats
(Johansen & Fields, 2004; Johansen, Fields, & Manning, 2001).
Current Hypothesis
We hypothesize that the same unpleasantness underlying social
pain may similarly warn victims that certain social situations elicit
undesirable outcomes, and when victims are reexposed to situa-
tions associated with past social pain, they may then experience
social anxiety (Eisenberger, Inagaki, Muscatell, Byrne Haltom, &
Leary, 2011; Gazelle & Druhen, 2009; Leary et al., 1998; Mac-
Donald & Leary, 2005). Preliminary evidence comes from a study
by Leary et al. (1998) in which participants reported a past instance
in which they experienced social pain and rated perceived conse-
quences. The intensity of social pain during the episode was
moderately associated with lowered self-esteem, self-confidence,
and worry about experiencing social pain again. In addition, par-
ticipants judged painful events to have long-term consequences for
their self-perceived social desirability. Through the current inves-
tigation, we wish to extend findings from retrospective self-reports
by prospectively examining whether individuals experiencing so-
cial pain via actual rejection would report higher social anxiety in
subsequent situations.
 SOCIAL PAIN AND SOCIAL ANXIETY
Study 1
As an initial test, we examined whether social pain intensity
mediated the relation between rejection and subsequent social
anxiety. Undergraduate participants were exposed to two virtual
social situations (Cyberball) in which they were led to believe that
they were either rejected (experimental condition) or included
(control condition) by the first peer group. Two days later, all
participants interacted with a second group of inclusive peers. We
predicted that participants who were initially rejected would report
greater anticipatory and state social anxiety associated with the
second interaction, and that social pain intensity after the first
interaction would mediate these effects.
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Method
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Participants. Based on previous research, the effect size for
Cyberball rejection versus inclusion was estimated to be .64 stan-
dard deviations (Williams, Cheung, & Choi, 2000, p. 751). Ac-
cording to the computer program GPower, 40 participants per
condition were needed to detect two-tailed significance at the level
of .05, with a power of .80 (Faul, Erdfelder, Lang, & Buchner,
2007). Data collection continued after achieving the required sam-
ple size and stopped at the end of the university school term when
the online participant recruitment system closed. The entire pro-
cess lasted 3 months. Accordingly, 88 undergraduate students
(66% female) were recruited for the study in exchange for partial
course credit. Mean participant age was 19.99 years (SD 2.05).
Of the sample, 46% self-identified as East Asian or East Asian
Canadian, 36% self-identified as North American, European, Eu-
ropean Canadian, or White, and 18% self-identified with other
cultures.
Materials and measures.
Cyberball 4.0 (Williams, Yeager, Cheung, & Choi, 2012).
Cyberball is a computer program that is commonly used as a social
rejection manipulation and reliably elicits social pain (e.g., DeWall
et al., 2010). Participants engage in a virtual ball tossing game
apparently with two other players (one female and one male),
whose passes are actually controlled by a preset computer script. In
the current study, the entire game lasted 40 ball tosses. Participants
were randomly assigned to rejection and control conditions. Par-
ticipants in the rejection condition were only passed the ball three
times spread throughout the entire game, whereas those in the
control condition were passed the ball as many times as other
players.
The name and photo of each player, including the participant,
appeared beside their ball-tossing avatar. The photos of the two
other players had neutral facial expressions, but participants were
allowed to adopt any expression or posture when their photo was
taken. The purpose of these arrangements was to increase Cyber-
balls believability. Specifically, the presentation of other players
names and photos may convince participants that other players
were present, and, for rejected participants, that others might have
rejected them because of their name or appearance.
Round 1 social pain. Social pain intensity after the Round 1
Cyberball was measured with three items (i.e., I was bothered by
how the game went, My feelings were hurt from not being
involved in the game, and I felt bad being left out by other
players). Participants rated the degree to which each statement
reflected their experience on a 9-point scale ranging from 0 (not at
233
all) to 8 (very much so). The three items had excellent reliability
( .93).
Round 2 anticipatory social anxiety. Three items were used to
measure anticipatory social anxiety before Round 2 Cyberball (i.e.,
I wonder if I will get along with the players in the coming game,
I feel self-conscious about how I will appear to others in the
coming game, and I feel nervous about how the coming game
will go. Participants rated the degree to which each statement
reflected their experience on a 9-point scale ranging from 0 (not
at all) to 8 (very much so). The three items had good reliability
( .79).
Round 2 state social anxiety. Cognitive and physical symp-
toms of state social anxiety were measured immediately after
Round 2 Cyberball. A global composite measure was created by
summing the standardized scores of Round 2 cognitive anxiety and
the Round 2 Brief State Anxiety Measure (BSAM; Berg, Shapiro,
Chambless, & Ahrens, 1998). The two scales were intercorrelated
but not isomorphic (r .57, p .001). Reliability for the com-
posite score calculated using the formula provided by Nunnally
and Bernstein (1994, p. 268) was .90.
Cognitive anxiety. Three items were used to measure cogni-
tive symptoms (i.e., I felt uneasy throughout the game, I was
concerned that others thought poorly of me, and I felt self-
conscious). These items reflect common cognitive symptoms of
state social anxiety. Participants rated the degree to which each
statement reflected their experience on a 9-point scale ranging
from 0 (not at all) to 8 (very much so). The three items had good
reliability ( .84).
Brief State Anxiety Measure (BSAM; Berg, Shapiro, Chamb-
less, & Ahrens, 1998). The BSAM consists of six items mea-
suring physical symptoms (i.e., I felt relaxed/steady/strained/
comfortable/worried/tense) and has been used to measure state
social anxiety in previous studies (e.g., Rodebaugh, Heimberg,
Schultz, & Blackmore, 2010). Participants indicated the degree to
which they experienced each item on a four-point scale ranging
from 1 (not at all) to 4 (very much so). The scale had good
reliability ( .84).
Procedure. The study comprised of two sessions 2 days apart.
During the first session, participants played Round 1 Cyberball,
where they were randomly assigned to be either rejected (n 44)
or included (n 44). Immediately after the game, all participants
rated Round 1 social pain. Two days later, participants rated
Round 2 anticipatory social anxiety and played Round 2 Cyberball
apparently with two different players, who were inclusive, that is,
passed participants the ball as many times as they did to each other.
Immediately after, participants rated Round 2 state social anxiety.
All procedures adhered to American Psychological Association
(APA) ethical principles and were approved by the University
Behavioral Research and Ethics Board. All manipulations and
dependent variables for the current research question were ana-
lyzed and reported.
Results
Descriptive statistics are shown in Table 1. Regarding our main
hypothesis, two separate mediation analyses were conducted using
the SPSS macro PROCESS (Hayes, 2012), entering effect-coded
condition variable (rejection 1, control 1) as the predictor,
Round 1 social pain as the mediator, and Round 2 anticipatory
 234 FUNG AND ALDEN
Table 1
Study 1 Descriptive Statistics
Rejection
Variable M (SD)
1. Round 1 social pain 7.70 (6.89)
2. Round 2 anticipatory social anxiety 9.18 (5.15)
3. Round 2 state social anxiety .44 (1.92)
Note. All between-condition differences were significant at p .05. All correlations were significant at p
.001.
social anxiety and Round 2 state social anxiety as the dependent
variables. To interpret effect sizes for condition, the effect of
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rejection on the mediator and dependent variables is twice the
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standardized regression coefficient. Point estimates and percentile
confidence intervals with 5,000 resamples for indirect effects of
Round 1 social pain are reported (Preacher & Hayes, 2008).
In each of the mediation analyses, first we reported whether pre-
dictor condition predicted mediator Round 1 social pain (i.e., Path a)
and whether Round 1 social pain predicted dependent variable Round
2 anticipatory social anxiety and Round 2 state social anxiety, con-
trolling for condition (i.e., Path b). The product of the effects of Path
a and Path b is the indirect effect. The indirect effect is significant at
p .05 if its 95% confidence interval (CI) does not overlap with zero.
Then, we reported the effect of condition on Round 2 anticipatory
social anxiety and Round 2 state social anxiety (i.e., Path c, total
effect), and the same effect after controlling for Round 1 social pain
(i.e., Path c=, direct effect).
Mediation 1: Condition Round 1 social pain Round 2
anticipatory social anxiety. As shown in Figure 1, the overall
model was significant, R2 .37, F(2, 85) 25.22, p .001.
Rejection predicted Round 1 social pain (i.e., Path a), .55,
t(86) 6.10, p .001, 95% CI [.37, .73], and Round 1 social pain
predicted Round 2 anticipatory social anxiety when condition was
held constant (i.e., Path b), .67, t(85) 6.54, p .001, 95% CI
[.47, .88]. The indirect effect was significant and was estimated to be
.37, 95% CI [.25, .51], which indicates that rejection caused an
estimated increase of .74 standard deviations of Round 2 anticipatory
social anxiety through Round 1 social pain. The effect of rejection on
Round 2 anticipatory social anxiety (i.e., Path c, total effect), .24,
t(86) 2.27, p .026, 95% CI [.03, .45], was negated when Round
1 social pain was held constant (i.e., Path c=, direct effect), = .13,
t(85) 1.28, p .20, 95% CI [.34, .07].
Mediation 2: Condition Round 1 social pain Round 2
state social anxiety. As shown in Figure 2, the overall model
was significant, R2 .27, F(2, 85) 15.92, p .001. Rejection
predicted Round 1 social pain (i.e., Path a), .55, t(86) 6.10,
Round 1 social pain
a .55*** .67*** b
Condition (rejection = 1; Round 2 anticipatory
c .13
control = 1) c 24* social anxiety
Figure 1. Standardized regression coefficients for Study 1 mediation
model condition Round 1 social pain Round 2 anticipatory social
anxiety. Indirect effect .37, 95% CI [.25, .51]. p .05. p .001. .001.
Control
M (SD) 1 2 3
1.07 (2.16)
6.68 (5.17) .60
.44 (1.50) .52 .54
p .001, 95% CI [.37, .73], and Round 1 social pain predicted
Round 2 state social anxiety when condition was held constant
(i.e., Path b), .55, t(85) 4.97, p .001, 95% CI [.33, .77].
The indirect effect was significant and was estimated to be .30,
95% CI [.13, .52], which indicates that rejection caused an esti-
mated increase of .60 standard deviations of Round 2 state social
anxiety through Round 1 social pain. The effect of rejection on
Round 2 state social anxiety (i.e., Path c, total effect), .25,
t(86) 2.37, p .020, 95% [.04, .46], was negated when Round
1 social pain was held constant (i.e., Path c=, direct effect),
= .05, t(85) .50, p .65, 95% [.28, .17], which again
is consistent with a full mediation model.
Discussion
As predicted, Study 1 demonstrated that participants who were
rejected experienced higher anticipatory and state social anxiety
when being exposed to a different group of inclusive peers 2 days
later. More importantly, these effects were fully mediated by social
pain. Our findings contribute to existing literature by showing that
rejection may cause social anxiety in young adults and suggested
that the effect may be dependent on the intensity of social pain (cf.
Gazelle & Druhen, 2009).
Study 2
Although results from Study 1 were consistent with the hypoth-
esis, the study design precluded us from making causal inferences
about the effect of the mediator, social pain, on subsequent antic-
ipatory and state social anxiety. To address this limitation, we
administered acetaminophen to alleviate social pain elicited by
rejection and examined whether this manipulation would also
reduce subsequent social anxiety.
In a previous study, participants were randomly assigned to take
daily doses of either 500-mg acetaminophen or a sugar placebo for
Round 1 social pain
a .55*** .55*** b
Condition (rejection = 1; c .05 Round 2 state social
control = 1) c .25* anxiety
Figure 2. Standardized regression coefficients for Study 1 mediation
model condition Round 1 social pain Round 2 state social anxiety.
Standardized indirect effect .30, 95% CI [.13, .52]. p .05. p
 SOCIAL PAIN AND SOCIAL ANXIETY
3 weeks (DeWall et al., 2010). Participants who took acetamino-
phen reported lower levels of daily social pain, and this effect
increased as time passed. When rejected via Cyberball, partici-
pants who ingested daily doses of acetaminophen showed lower
neural activity associated with social pain compared with those
who ingested placebo. In the current study, we administered one
single dose of 1,000-mg acetaminophen, which has also been
shown to be an effective manipulation (e.g., Randles et al., 2013).
In Study 2, all participants were rejected by one peer group and
were subsequently included by a second group. Participants were
randomly assigned to ingest either 1,000-mg acetaminophen (ex-
perimental group) or a sugar placebo (control group). Mediation
analyses were conducted to examine whether acetaminophen re-
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duced social anxiety before and during the second interaction, and
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if so, whether the effects could be explained by reduction in social
pain.
Method
Participants. Following previous studies, we estimated an
effect size of .50 standard deviations for one dose of 1,000-mg
acetaminophen (Randles et al., 2013). According to GPower, 126
participants across the two conditions were needed to detect two-
tailed significance at the level of .05, with a power of .80
(Faul et al., 2007). Data collection continued after achieving the
required sample size and stopped at the end of the university
school term when the online participant recruitment system closed.
The entire process lasted 3 months.
Accordingly, 144 undergraduate students participated in ex-
change for partial course credit. The sample consisted of 66%
females with a mean age of 20.60 years (SD 4.44). Of the
sample, 44% self-identified as East Asian or East Asian Canadian,
38% self-identified as North American, North American Euro-
pean, European, or White, and 17% self-identified as other cul-
tures. One participant in the placebo condition reported that he was
aware of Cyberball deception and the purpose of acetaminophen in
the middle of testing and was excluded from the study.
Materials and measures.
Cyberball 4.0 (Williams et al., 2012). Cyberball procedures
remained the same as those in Study 1. One exception was that
participants played with three other players (one male, two fe-
males) instead of two.
Acetaminophen and placebo pills. Participants in the acet-
aminophen condition ingested two Size 000 capsules, each con-
taining one Extra Strength Tylenol pill (500-mg acetaminophen)
and sugar, whereas those in the control condition ingested two Size
000 capsules filled with sugar. At the end of the study, participants
were asked to guess the content of their assigned pill (i.e., acet-
aminophen or sugar) even if they claimed that they did not know.
Fifty-six percent of participants correctly guessed the content of
their pills, which was not significantly different from randomly
guessing (p .45). The two types of pills were labeled with
meaningless letters and numbers (e.g., 1, 2, n, l) in order to keep
research assistants blind to the condition.
Round 1 social pain. Four items were used to measure social
pain after the first round of Cyberball (i.e., Other players were
hurtful, Other players made me feel bad, Other players made
me feel upset, Other players made me feel hurt). Participants
rated the degree to which each statement reflected their experience
235
with Cyberball on a nine-point scale ranging from 0 (not at all)
to 8 (very much so). The four items had excellent reliability
( .90).
Round 1 and 2 anticipatory social anxiety. Six items were
used to measure anticipatory social anxiety before Cyberball (i.e.,
I feel worried/stressed/nervous/uneasy about meeting other par-
ticipants, Other participants will judge me, Meeting other
participants makes me self-conscious). Participants rated each
statement on a nine-point scale ranging from 0 (not at all) to 8
(very much so). The six items showed excellent reliability for both
Round 1 and Round 2 (Round 1, .91; Round 2, .94).
Round 2 state social anxiety. State social anxiety symptoms
during Round 2 Cyberball were assessed immediately after the
game. As in Study 1, a global composite measure for cognitive and
physical symptoms of social anxiety was created by summing the
standardized scores of Round 2 cognitive anxiety and Round 2
BSAM. The two scales were intercorrelated but not isomorphic
(r .56, p .001). Reliability for the composite score calculated
using the formula provided by Nunnally and Bernstein (1994, p.
268) was .92.
Cognitive anxiety. Six items were used to measure cognitive
symptoms (i.e., Other participants made me feel worried/stressed/
nervous/uneasy/self-conscious/judged). These items reflect com-
mon cognitive symptoms associated with social anxiety, namely,
fear of negative evaluation. Participants rated the degree to which
each statement reflected their experience on a nine-point scale
ranging from 0 (not at all) to 8 (very much so). The six items had
excellent reliability ( .92).
Round 2 Brief State Anxiety Measure (BSAM; Berg et al.,
1998). The BSAM consists of six items measuring physical
symptoms (i.e., I felt relaxed/steady/strained/comfortable/wor-
ried/tense) and has been used to measure state social anxiety in
previous studies (e.g., Rodebaugh et al., 2010). Participants indi-
cated the degree to which they experienced each state on a 4-point
scale ranging 1 (not at all) to 4 (very much so). The scale dem-
onstrated good reliability ( .82).
Procedure. Participants were told the purpose of the study
was to examine how Tylenol affects personality, cognition, and
behavior, and were randomly assigned to consume either
1,000-mg acetaminophen (experimental condition; n 72) or a
sugar placebo (control condition; n 72). All participants com-
pleted personality questionnaires (e.g., the Big Five Inventory;
John & Srivastava, 1999) and sample questions from the Graduate
Record Examination as filler tasks for 45 min, which was the
maximum time required for acetaminophen to take effect, accord-
ing to manufacturer instructions.
After the delay, participants rated anticipatory social anxiety,
played the Round 1 Cyberball game in which they were rejected
(i.e., passed the ball few times), and rated social pain. Then,
research assistants asked participants to play Cyberball again with
another group with the rationale that they were not passed the ball,
and the second game might give them a chance to go through the
experimental procedure properly. Participants then rated their an-
ticipatory social anxiety, played Round 2 Cyberball apparently
with another group of peers who included them (i.e., passed the
ball to them as many times as to others), and rated state social
anxiety. All procedures adhered to APA ethical principles and
were approved by the University Behavioral Research and Ethics
 236
Board. All manipulations and dependent variables for the current
research question were analyzed and reported.
Results
Descriptive statistics are shown in Table 2. Two mediation
analyses were conducted using the SPSS macro PROCESS
(Hayes, 2012), entering an effect-coded condition variable (acet-
aminophen 1; placebo 1) as the predictor, Round 1 social
pain as the mediator, and Round 2 anticipatory social anxiety and
Round 2 state social anxiety as the dependent variables. To inter-
pret effect sizes for condition, the effect of acetaminophen on the
mediator and dependent variables is twice the standardized regres-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
sion coefficient. Point estimates and percentile confidence inter-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
vals with 5,000 resamples for indirect effects of Round 1 social
pain are reported (Preacher & Hayes, 2008). Results were analyzed
and reported using the same convention as in Study 1.
Mediation 1: Condition Round 1 hurt feelings Round
2 anticipatory social anxiety. As shown in Figure 3, the overall
model was significant, R2 .28, F(2, 141) 27.46, p .001. The
acetaminophen condition predicted lower Round 1 social pain (i.e.,
Path a), .22, t(142) 2.71, p .0075, 95% CI
[.38, .06], and Round 1 social pain predicted Round 2 antici-
patory social anxiety when condition was held constant (i.e., Path
b), .50, t(141) 6.87, p .001, 95% CI [.36, .65]. The
indirect effect was significant and was estimated to be .11, 95%
CI [.20, .03], which indicates that acetaminophen decreased .22
standard deviations of Round 2 anticipatory social anxiety through
Round 1 social pain. The effect of acetaminophen on Round 2
anticipatory social anxiety (i.e., Path c, total effect), .20,
t(142) 2.41, p .02, 95% CI [.36, .04], was diminished
when Round 1 social pain was held constant (i.e., Path c=, direct
effect), .09, t(141) 1.18, p .24, 95% CI [.23, .06].
Mediation 2: Condition Round 1 social pain Round 2
state social anxiety. As shown in Figure 4, the overall model was
significant, R2 .23, F(2, 141) 20.48, p .001. Acetaminophen
condition predicted lower Round 1 social pain (i.e., Path a),
.22, t(142) 2.71, p .001, 95% CI [.38, .06], and
Round 1 social pain predicted Round 2 state social anxiety when
condition was held constant (i.e., Path b), .45, t(141) 5.97, p
.001, 95% CI [.30, .60]. The indirect effect was significant and was
estimated to be .10, 95% CI [.19, .03], which indicates that
acetaminophen decreased .20 standard deviations of Round 2 state
social anxiety through Round 1 social pain. The effect of acetamin-
ophen on Round 2 state social anxiety (i.e., Path c, total effect),
.17, t(142) 2.06, p .04, 95% CI [.33, .01], was
Table 2
Study 2 Descriptive Statistics
Acetaminophen
Variable
1. Round 1 anticipatory social anxiety
2. Round 1 social pain
3. Round 2 anticipatory social anxiety
4. Round 2 state social anxiety
Note. All between-condition differences were significant at p .05. All correlations were significant at p .001.
FUNG AND ALDEN
Round 1 social pain
a -.22 *** .50*** b
Condition (acetaminophen c .09 Round 2 anticipatory
= 1; placebo = 1) c .20* social anxiety
Figure 3. Standardized regression coefficients for Study 2 mediation
model condition Round 1 social pain Round 2 anticipatory social
anxiety. Standardized indirect effect .11, 95% CI [.20, .03]. p
.05. p .001.
diminished when Round 1 social pain was held constant (i.e., Path c=,
direct effect), .07, t(141) .92, p .36, 95% CI [.22, .08].
Supplementary analysis: Did acetaminophen have anxiolytic
properties? The entire experiment took place within 2 hr, which
meant that acetaminophen remained active during the second
interaction (i.e., Round 2 Cyberball). The full range of acetamin-
ophens effect on affect has not been fully explored and it is not
known whether the drug reduces anxiety in addition to social pain.
Hence, one possibility for the current results is that acetamin-
ophens effect on Round 2 anxiety might not have been a conse-
quence of Round 1 social pain, but rather the drugs potential
anxiolytic properties per se. If acetaminophen possesses anxiolytic
properties in addition to pain-reducing properties, then it would
reduce anxiety even before social pain was elicited. To examine
this alternative hypothesis, we compared the two conditions on
Round 1 anticipatory social anxiety. As shown in Table 1, the
acetaminophen condition (M 10.58, SD 8.19) and the placebo
condition (M 11.60, SD 9.32) did not differ significantly on
Round 1 anticipatory social anxiety, t(142) .93, p .49. Taken
together with the previous main analyses, it appeared that acet-
aminophen reduced anxiety only after social pain was reduced and
was associated with the latter effect. This finding is inconsistent
with the alternative explanation that acetaminophen directly re-
duced Round 2 anticipatory social anxiety and state social anxiety.
Discussion
Results from Study 2 again supported our hypothesis that social
pain is a mechanism that contributes to the development of social
anxiety. Replicating past research, we found that participants who
took acetaminophen, compared with a sugar placebo, reported
lower social pain (DeWall et al., 2010). In addition, we found that
attenuating social pain resulted in lower anticipatory and state
social anxiety in a subsequent situation.
Placebo
M (SD) M (SD) 1 2 3 4
10.58 (8.19) 11.60 (9.32)
8.35 (6.35) 11.43 (7.23) .67
7.88 (8.46) 11.67 (10.31) .33 .52
.30 (1.69) .30 (1.80) .44 .58 .47
 SOCIAL PAIN AND SOCIAL ANXIETY
Round 1 social pain
a -.22 *** .45*** b
Condition (acetaminophen c .07 Round 2 state social
= 1; placebo = 1) c .17* anxiety
Figure 4. Standardized regression coefficients for Study 2 mediation
model condition Round 1 social pain Round 2 state social anxiety.
Standardized indirect effect .10, 95% CI [.19, .03]. p .05.
p .001.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Results were inconsistent with the alternative explanation that
This document is copyrighted by the American Psychological Association or one of its allied publishers.
acetaminophen had anxiolytic effects irrespective of social pain. If
the alternative explanation were true, social anxiety would be
reduced regardless of whether social pain was elicited. Contrary to
this explanation, we found no significant differences in social
anxiety between acetaminophen and placebo conditions prior to
rejection, and differences only emerged after rejection-induced
hurt feelings was elicited.
Since the current study was conducted, research was published
on the general effect of acetaminophen on reducing various neg-
ative states in addition to social pain (Durso, Luttrell, & Way,
2015). In the recently published study, acetaminophen reduced
negative affect in general in response to viewing upsetting pictures
of heterogeneous people and objects. Hence, it may be surprising
that acetaminophen did not reduce anticipatory social anxiety in
the current study. A closer look at other evidence suggests the
possibility that dACC unpleasantness, shared by physical and
social pain and alleviated by acetaminophen, is only elicited in
response to conflict or error detected in the external environment
(Eisenberger & Lieberman, 2004, Box 3). For example, a past
study has shown that acetaminophen took effect on participant
behavior only in the presence, but not in the absence, of meaning
threats (Randles et al., 2013). In the same vein, we found that
acetaminophen did not reduce anticipatory social anxiety in the
absence of external sources of conflict or error, and only did so
after rejection occurred.
General Discussion
Results from the two studies were consistent with our hypoth-
esis that social pain elicited by rejection promotes the development
of subsequent social anxiety. In Study 1, we found that social pain
fully mediated the effect of rejection on subsequent social anxiety.
In Study 2, we found that reducing social pain with acetaminophen
was associated with reductions in subsequent social anxiety. In a
broader perspective, we see the current findings as preliminary
support for the hypothesis, which bridges the gap between litera-
ture on social anxiety and social pain. However, as with many
other scientific hypotheses, more research is needed to further
refine the hypothesis.
The current findings were consistent with and reconcile research
on social anxiety and social pain. Replicating past research on
social anxiety, Study 1 showed that rejection facilitated subsequent
social anxiety, and the effect was mediated by the intensity of
negative emotions (Gazelle & Druhen, 2009; Levinson et al.,
2013). In addition, across both studies, social pain mediated the
237
effects of the manipulations and subsequent social anxiety, which
suggests that the emotion may be an important active mechanism
in social anxiety learning. As literature suggests, social pain, akin
to physical pain, alerts victims of undesirable stimuli by virtue of
shared neural pathways (Eisenberger & Lieberman, 2004; Mac-
Donald & Leary, 2005). One interesting finding in Study 2 is that
acetaminophen reduced social pain but not social anxiety, which
again highlights the partial distinctiveness of the two emotions
(e.g., Leary & Leder, 2009). Thus, it may be especially useful to
evaluate social pain sensitivity as a causal contributor in addition
to other variables such as anxiety proneness or conditionability
the ease with which individuals associate negative feelings with
stimuli (e.g., Lissek et al., 2008; Ollendick & Hirshfeld-Becker,
2002). Applications of the current hypothesis to treatment settings
could be exploredfor example, exploring whether attenuating
social pain, perhaps via social support or emotion regulation strat-
egies, is effective in preventing the development of debilitating
social anxiety (e.g., Masten, Telzer, Fuligni, Lieberman, & Eisen-
berger, 2012; Master et al., 2009). Given that rejection is an
inevitable part of life and can only be controlled to an extent, such
prevention strategies that target specific mechanisms underlying
social anxiety learning may have added benefit to strategies that
focus on reducing the occurrence of rejection.
Although the current findings are consistent with the hypothesis,
more research is needed to further clarify the specificity of social
pain as an active mechanism and the ecological validity of the
current results. To the extent that we attempted to precisely ma-
nipulate social pain without influencing other variables, the rela-
tive contributions of other factors on subsequent anxiety because
of acetaminophen remain relatively unknown. Acetaminophen was
chosen as a manipulation because of its documented effects on
social pain (DeWall et al., 2010). However, since the current
studies were conducted, recently published research suggests that
the drug may reduce negative affective states in general, which
creates ambiguity as to whether social pain was the specific
mechanism that contributed to social anxiety learning or was
merely a by-product (Durso et al., 2015). In light of the evidence,
it may not be social pain in itself, but dACC unpleasantness, which
is elicited in response to conflict and error and underlies experi-
ences other than physical and social pain, may be a specific,
overarching component that induces social anxiety. Another future
direction is to examine whether the current results generalize to
naturalistic settings. The current method was selected on the basis
of ethical considerations for participant well-being and the need
for a controlled social task. With appropriate precautions, future
research could examine the hypothesis using samples vulnerable to
developing social anxiety of clinical severity, and test whether
social anxiety learning generalizes to situations other than that
where rejection took place.
In sum, results from the two studies provide preliminary support
for the hypothesis that social pain underlies the relation between
rejection and subsequent development of social anxiety, which is
consistent with, and bridges the gap between, two bodies of
literature on social anxiety and social pain. Future studies could
refine the hypothesis by examining the specificity of social pain as
the active mechanism and the generalizability of the current results
to naturalistic settings. At the same time, applications of the
hypothesis could be explored, that is, integrating social pain ma-
nipulations as a prevention strategy for debilitating social anxiety.
 238 FUNG AND ALDEN
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Received October 18, 2015
Revision received July 4, 2016
Accepted July 24, 2016