Jurnal Social Anxiety Disorder

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Social Anxiety and Social Anxiety Disorder
Article in Annual Review of Clinical Psychology · March 2013

DOI: 10.1146/annurev-clinpsy-050212-185631 · Source: PubMed
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Annu. Rev. Clin. Psychol. 2013. 9:249–74 Keywords

The Annual Review of Clinical Psychology is online at social phobia, information processing biases, emotion regulation,
http://clinpsy.annualreviews.org
self-focused attention, safety behaviors, post-event processing
This article’s doi:
10.1146/annurev-clinpsy-050212-185631 Abstract
Copyright c 2013 by Annual Reviews. Research on social anxiety and social anxiety disorder has proliferated over
All rights reserved
the years since the explication of the disorder through cognitive-behavioral
models. This review highlights a recently updated model from our group and
details recent research stemming from the (a) information processing per-
spective, including attention bias, interpretation bias, implicit associations,
imagery and visual memories, and (b) emotion regulation perspective, includ-
ing positive emotionality and anger. In addition, we review recent studies
exploring the roles of self-focused attention, safety behaviors, and post-event
processing in the maintenance of social anxiety. Within each area, we detail
the ways in which these topics have implications for the treatment of social
anxiety and for future research. Finally, we conclude with a discussion of
how several of the areas reviewed contribute to our model of social anxiety
disorder.
249
Contents
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
The Heimberg et al. Model of SA/SAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
INFORMATION PROCESSING BIASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Attention Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Interpretation Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Implicit Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Imagery and Visual Memories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Interrelations Among Information Processing Biases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
SELF-FOCUSED ATTENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Treatment Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
EMOTION AND EMOTION REGULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Treatment Implications and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260

Atypical Responding to Positive Material and Experience of Positive Emotions . . . . 260

Anger Experience and Expression and Behavioral Disinhibition . . . . . . . . . . . . . . . . . . . 262
SAFETY BEHAVIORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Categories of Safety Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Causal Status: Safety Behavior Manipulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Future Directions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
POST-EVENT PROCESSING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Within-Situation Predictors of PEP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Self-Focus and PEP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Future Directions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
CONCLUDING COMMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
INTRODUCTION
Social anxiety (SA) is a common human experience characterized by an intense fear of evaluation
from others in social situations. When it reaches a pinnacle of severity such that functioning
is impaired, we refer to it as social anxiety disorder (SAD) or social phobia. The prevalence of
SAD and its chronicity, personal/economic/societal costs, and comorbidity with other disorders
have been well documented. Several researchers have proposed explanatory models; the most
widely cited and applied of these models have been those of Clark & Wells (1995) and Rapee
& Heimberg (1997) (see comparison of these models by Schultz & Heimberg 2008). Here, we
focus on our model of SA/SAD, which delineates the processes by which individuals with SA are
affected by their fear of evaluation in social situations.
The original model provided a framework for understanding factors that comprise and
maintain SA/SAD. Given the years of intervening research, however, we recently presented an
updated model (Heimberg et al. 2010). In this article, we briefly review that model. We then
examine several areas of research in SA/SAD and their implications for treatment and future
research and conclude with a brief summary of the implications of this research for the model.
Areas reviewed include information processing biases (including biases of attention, interpre-
tation, implicit association, imagery, and visual memory), self-focused attention, emotion and
250 Morrison · Heimberg

emotion regulation (including issues of anger and behavioral disinhibition), safety behaviors, and
post-event processing. A focus throughout the review, in addition to the typical focus on negative
affect and threatening stimuli, is the impact of SA on positive affect and reaction to positive
stimuli.
The Heimberg et al. Model of SA/SAD

The process begins with the perception of an audience, i.e., any person or persons who have the
potential to evaluate the person, whether they actually do so or not. The perception of an audience
stimulates a mental representation as seen by the audience, that is, a picture in the mind’s eye of
the person with SA of the audience’s picture of him or her, or as we often say, “your image of my
image of you.” Fed by negative self-imagery derived from a history of negative social experiences
and/or distorted self-perception, the person with SA concludes that the audience’s opinion of him
or her is poor. However, at the same time, he or she may believe that the audience holds very high,
and often unattainable, standards for his or her performance, creating what is essentially a problem
of arithmetic: Comparison of the mental representation of the self as seen by the audience and the
person’s appraisal of what the audience expects essentially leaves the person in negative numbers.
The threat of evaluation is palpable, and the likelihood that the person will be found lacking
appears to be very high. Anxiety is the inevitable consequence of the evaluative threat. However,
it also feeds into the vicious cycle as it feeds back into the mental representation of the self as
seen by the audience in a manner that further deflates it. Attention bias toward threat virtually
assures that visible or perceived displeasure on the part of the audience, visible signs of anxiety
(e.g., reduced eye contact or fidgety behavior; blushing), and aspects of anxiety knowable only by
the person (elevated heart rate or the sense that one’s mind is going blank, which may signal an
impending loss of control of behavior) are negatively applied to the mental representation of the
self as seen by the audience. This vicious cycle repeats as the person remains in the situation and
is carried forward in time as the person anticipates similar future situations.
INFORMATION PROCESSING BIASES
Attention Bias
Attention bias to threat. Recent meta-analyses clearly support the presence of biased attention
for threat across the anxiety disorders (e.g., Bar-Haim et al. 2007). This phenomenon has also
been well demonstrated in SA, and this literature has been extensively reviewed, so we begin by
considering its causal status in SA and then move on to other aspects of attention less directly
related to threat bias in SA.
Potential causal role of attention bias to threat. Although cognitive-behavioral models as-
sert that attention bias to threat plays a causal role in the maintenance of SAD, most research
has been correlational. In the past several years, however, researchers have manipulated atten-
tion bias using a variation of the attentional probe task to train attention either toward or away
from threat stimuli. Such “attention training” procedures have resulted in reductions in symp-
toms of SAD similar to those produced by more traditional therapies (e.g., Amir et al. 2009).
Because these studies manipulated attention bias and anxiety decreased thereafter, there is ev-
idence that attention bias to social threat plays a causal role in the maintenance of SA. How-
ever, the magnitude of this effect may be smaller than originally proposed (Hallion & Ruscio
2011).
www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 251

Attention bias away from positive stimuli. Attention bias toward social threat may be
accompanied by a bias away from positive social information (e.g., Chen et al. 2002). In addition,
the tendency to allocate attention away from positive social stimuli mediated the effect of SA
on change in state anxiety in response to a social stressor, implicating the role of diminished
processing of positive social information in the persistence of SA (Taylor et al. 2010). Recent
research provides initial support for the notion that training of attention toward positive
information may heighten positive emotional reactivity, thus implying a causal relationship
between attention toward positive information and positive affectivity in SA (Taylor et al. 2011).
Reduced attentional control. Mathews & MacLeod (1994) argued that the occasionally
contradictory findings in the attention bias literature suggest that normal individuals high in trait
anxiety may have the ability to effortfully compensate for their tendency to shift attention toward
threat-relevant stimuli. In contrast, clinically anxious individuals may be unable to effortfully
regulate their attention. Moreover, individuals vary in the ease with which they can be trained
to exhibit an attention bias toward threat (e.g., Clarke et al. 2008), which suggests that there may
also be differences in how easily attention bias toward threat develops naturalistically.
Research over the past few decades has consistently demonstrated an inverse relationship
between anxiety and attentional control (see theoretical accounts by Eysenck et al. 2007 and
Lonigan et al. 2004). Less evidence exists in SA, but it is generally supportive. SA was inversely re-
lated to self-reported attentional control after controlling for depression and state anxiety (Moriya
& Tanno 2008). There is also evidence of a relationship between SA and reduced attentional con-
trol using an antisaccade task in which participants are instructed to immediately look straight to
the opposite, mirror-image location on the screen of a peripherally presented cue, which requires
inhibition of a reflexive saccade as well as generation of a volitional saccade. In an emotional
antisaccade task in undergraduates low, moderate, and high in SA, Weiser et al. (2009) observed
significantly higher antisaccade error rates for individuals with high SA than for individuals with
moderate SA. There was no evidence of greater threat interference, however, implying the deficit
in attentional control was generalized. Indirect support for an association between SA and a gen-
eral deficit in attentional control also comes from a recent study by Amir & Bomyea (2011), who
used an operation span task, which involves attentional control processes. Finally, Simonds et al.
(2007) examined the relationship between various interpersonal behaviors and attentional control.
Children’s attentional control was inversely related to appropriate social responding. This finding
may hold particular relevance for SA in which anxiety-related impairments in self-regulatory
mechanisms such as attentional control may adversely affect interpersonal behavior, thereby
confirming the individual’s fears of poor social performance (Kashdan 2007, Kashdan et al. 2011).
Treatment implications and future directions. An important question is whether attention

biases can be mitigated by effective psychotherapy. Tobon et al. (2011) reviewed the literature
on the effects of cognitive-behavioral therapy (CBT) on attention bias toward threat and found
that 10 of 13 studies across various anxiety disorders demonstrated a treatment-related reduction
in bias. Further research on SAD in particular is warranted, but current findings suggest CBT
is effective at mitigating such biases. In contrast, much less is known about whether effective
psychotherapy modifies attention to positive stimuli. Additionally, research should consider
whether changes in attention bias to threat or positive stimuli mediate treatment outcome or
predict long-term treatment outcomes.
Translational relevance of research on attention bias to threat has been well demonstrated in
the early returns on cognitive bias modification procedures. However, there are other important
areas to examine, such as training attention toward positive stimuli (e.g., Taylor et al. 2011)

and training attentional control. Further research on individual differences in attention bias and
attentional control may also help with individualizing treatment packages.
Researchers have also investigated other therapeutic techniques targeting specific attention
mechanisms. Some examples include Bögels’s Task Concentration Training (e.g., Bögels 2006),
Rapee and colleagues’ attention retraining augmentation of CBT (Rapee et al. 2009), and
mindfulness-based interventions. Of these approaches, mindfulness-based interventions have
perhaps received the most empirical support. Several open trials have suggested the efficacy of
these interventions for SAD, mostly mindfulness-based stress reduction (MBSR; e.g., Goldin &
Gross 2010). Evidence to date also suggests MBSR results in increased activity in attention-related
brain areas (Goldin & Gross 2010). Therefore, MBSR, including its effects on attention bias
toward threat and away from positive information as well as attentional control deficits, appears
worthy of further investigation.
Interpretation Bias
Interpretation bias has been defined as the tendency to interpret ambiguous or neutral stimuli as
threatening. Most research on interpretation biases has utilized “offline” measures (i.e., measures
that permit sufficient time for engagement of relatively reflective cognitive processes) and found
consistent support for interpretation bias in SA (e.g., Amir et al. 2005). Studies of “online” measures
of interpretation bias (i.e., those that assess relatively automatic processes) typically find that
individuals with SA lack the nonthreat/positive bias typical of nonanxious individuals (e.g., Hirsch
& Mathews 2000).
Recent work has also examined interpretations of positive social information in SA. SA has
been associated with threat interpretations of positive social events (Alden et al. 2008) and failure
to accept others’ positive reactions at face value (Vassilopoulos & Banerjee 2010). Individuals
with SAD also endorsed more negative interpretations of positive events than individuals with
other anxiety disorders, including panic disorder and generalized anxiety disorder (GAD), but not
obsessive-compulsive disorder (Laposa et al. 2010). Laposa et al. (2010) also reported that, among
individuals with SAD, negative interpretation of positive events was correlated with perfectionism
and severity of interpersonal fears. These biases in interpretation of positive social information
may also contribute to diminished positive affect in SA, a topic discussed in more detail below.
Another line of research has examined whether SA is associated with biased interpretation
of emotional facial expressions. Studies have generally reported no difference in the accuracy of
detecting different facial emotions using static facial stimuli (e.g., Mullins & Duke 2004). However,
these studies did find evidence of variations in detection speed. For example, SA was associated with
quicker detection of high-intensity anger and fear under conditions of moderate threat (Mullins
& Duke 2004). In contrast, in the no-threat condition, SA was associated with slower detection
of low-intensity sadness and anger, suggesting the relationship between SA and facial emotion
detection may vary according to both state anxiety and intensity of the facial expression.
Two studies have attempted to extend the ecological validity of facial emotion decoding by
using a morphed-faces task, which more closely approximates the dynamic nature of facial expres-
sions exhibited in the real world by displaying expressions that change gradually from neutral to
full emotion. As with previous studies, Joormann & Gotlib (2006) found no evidence that SA was
associated with biases in interpretation accuracy, but there were differences in speed. Recently,
however, Heuer et al. (2010) demonstrated biased interpretation accuracy. In addition to using
the morphed faces task, they also increased the probability of misinterpretations by providing an
additional response option for categorizing the faces—contempt, an emotion strongly associated
with social rejection. Individuals with high SA were more likely than nonanxious individuals to

misinterpret disgust faces as exhibiting contempt. In contrast, nonanxious participants tended to

misinterpret disgust faces as happy. These biases were not shown when participants were provided
extended viewing time, suggesting the threat/lack of positive bias among the high-anxious partici-
pants was evident only when they were required to make interpretations quickly, much as in real life.
Potential causal role of interpretation bias. As with attention bias, emerging research supports
the hypothesis that interpretation biases play a causal role in SA. Repeated training to access
benign interpretations of ambiguous scenarios also modifies interpretation bias and has resulted
in the reduction of SA in adults high in SA (Beard & Amir 2008) and adults with generalized
SAD (Amir & Taylor 2012).
Treatment implications and future directions. As with research on attention biases, research
on interpretation biases has been translated into clinical intervention via cognitive bias modifi-
cation procedures. A recent meta-analysis suggests effect sizes may be larger for interpretation
than attention bias modification procedures (Hallion & Ruscio 2011). Additionally, participants
believe interpretation modification to be more helpful (Beard et al. 2011).

Negative interpretation bias is assigned theoretical importance in cognitive-behavioral models
of SAD. Indeed, CBT attempts to correct this bias by teaching clients to generate alternative
interpretations for ambiguous social situations. CBT is associated with reductions in probability
and cost estimates for negative social events, which may tap the same construct as interpretation
bias. However, only more recently have researchers studied the effect of CBT on interpretation
bias per se in SAD. Untreated clients with SAD showed greater negative interpretation bias on
a forced choice measure than treated clients or nonanxious controls, and the latter two groups
did not differ (Franklin et al. 2005). However, this outcome was not replicated with an open-
ended measure of interpretation bias. Future treatment outcome research is needed to examine
potential changes in interpretation bias, online interpretation biases, and interpretation of positive
information.
Implicit Associations
A recent extension of information processing research in SA has been to use the Implicit Association
Test (IAT; Greenwald et al. 1998), during which participants categorize four classes of items,
two representing a concept discrimination (e.g., self/other) and two representing an attribute
discrimination (e.g., anxious/calm). One concept and attribute are categorized together (e.g., self
and anxious), followed by the opposite pairing (e.g., self and calm together). Response latencies to
categorize items are interpreted in terms of relative association strength—responses are thought to
be more rapid when the concept and attribute mapped onto the same response are more strongly
associated. The IAT may be particularly useful in the assessment of SA given that it circumvents
problems of demand characteristics and self-presentation concerns. However, only a few studies
to date have studied implicit associations in SA using the IAT.
Studies using the IAT in SA have yielded consistent results despite methodological differences.
de Jong (2002) found that both low- and high-SA women were characterized by positive implicit
self-associations (i.e., greater associations of the self with high- versus low-esteem words), but this
effect was relatively weaker in the women with high SA. Likewise, individuals with high SA were
less likely than individuals with low SA to exhibit implicit associations between self and positive
social attributes following a speech threat (Tanner et al. 2006). More recent studies have extended
these findings to the attribute categories of anxious and calm. Individuals with high SA exhibited
smaller implicit self-calm associations than did low anxious controls (Gamer et al. 2008).

Treatment implications. Nilsson et al. (2011) demonstrated that audio feedback with cognitive
preparation related to a speech task successfully reduced negative implicit associations among
persons with SA. There is also preliminary support for the notion that training positive implicit
associations may have a causal effect on social behavior. Clerkin & Teachman (2010) examined
whether conditioning positive associations between the self and socially relevant feedback among
individuals with high SA would change implicit self-rejection associations and lead to lower SA in
a subsequent speech task. Participants in the active training condition did not report less anxiety
during the speech than did control participants; however, they were significantly more likely to
speak for the full duration of the speech task. Therefore, at least partial evidence was found in
support of a causal relationship between implicit associations and SA. Given the relative success
of other cognitive bias modification procedures, training of implicit associations as a stand-alone
or adjunctive treatment for SAD should continue to be explored. Future research should also
examine whether repeated training sessions results in reduced emotional vulnerability.
Future directions. Several questions remain regarding the utility of the IAT in assessing SA.
Studies to date have used only analogue samples. These studies also suggest convergence between
implicit and explicit measures of SA; however, several findings support the notion of separate
implicit and explicit self-concepts of anxiety/rejection. For example, change in explicit SA from
pre- to posttreatment was negatively correlated with change in implicit self-anxiety associations
(Gamer et al. 2008). Further study of this distinction could have implications for understanding
mechanisms of treatment response and improving the accuracy of assessment of SA.
Finally, one limitation to all research using the IAT, which may be particularly relevant to SA,
is the fact that the IAT assesses relative associations—the association of one concept category to
one attribute category can only be calculated with respect to the association of the other concept
category to the other attribute category. Within SA research, the “self” concept category has
been compared with “other,” so results of the IAT cannot speak to whether differential IAT
effects across groups are due to the self associations or the other associations. Future research
is needed to elucidate whether and under what circumstances self versus other associations drive
group differences observed on the IAT, perhaps using a one-category IAT.
Imagery and Visual Memories

Research on explicit, implicit, and autobiographical memory biases in SA has been equivocal and
was recently reviewed by Morrison et al. (2012). Therefore, we now turn to a discussion of research
on the related topics of self-imagery and visual memories, which have received more attention in
recent years.
Several phenomenological characteristics of imagery and visual memories in SAD have been
identified. Individuals with SAD are more likely than nonanxious individuals to imagine recent
social interactions as if looking at the self from an observer’s point of view (i.e., observer per-
spective; Wells et al. 1998). This stands in contrast to both SA and nonanxious individuals’ recall
of images of past nonsocial, anxiety-provoking situations, which are more likely to be “seen” as
if looking through one’s own eyes (i.e., field perspective). Research on perspective-taking in the
recall of social interactions also documents a predominance of observer perspective imagery in
SAD (e.g., Coles et al. 2002). Imagery in SAD is also reported to occur spontaneously during
anxiety-provoking situations, be negatively tinged, and remain relatively stable over time and
across situations (Hackmann et al. 2000). Moreover, many individuals with SAD report that the
onset of SAD was around the date of the reported memory (Hackmann et al. 2000). One recent
study suggests the rates of intrusive imagery experienced by individuals with SA may be lower

than previously reported (Moscovitch et al. 2011). Nevertheless, the negative images endorsed in
this study elicited more negative emotional and cognitive consequences in the high- compared to
low-SA group.
Potential causal role of negative self-imagery. In several studies, Hirsch and colleagues trained
participants to hold either a negative or benign self-image in mind while engaging in a social task.
Negative self-imagery elicited higher self-reported anxiety, more observable anxious behaviors,
and exaggerated negative self-appraisal of performance in individuals with SAD (Hirsch et al.
2003a), individuals high in SA (Hirsch et al. 2004), and nonanxious individuals (Hirsch et al.
2006b, Makkar & Grisham 2011b).
Benign or positive imagery. Researchers have also begun to investigate nonnegative imagery
in SA. Moscovitch et al. (2011) studied the accessibility and properties of mental images and
associated autobiographical memories for nonanxiety-provoking social situations. Individuals
with high SA retrieved a higher, more unbalanced ratio of negative-to-positive images and
memories than individuals with low SA. Moreover, the positive images accessed by individ-
uals with high SA were relatively impoverished, with significantly degraded episodic detail.
Related findings were recently reported by Amir et al. (2012). Individuals with SAD did not
differ from nonanxious controls in the speed of generating social threat images, but they
were relatively slower to generate images of neutral words. Individuals with SAD were also
slower to generate images of neutral stimuli (i.e., letters) in a well-validated behavioral task,
supporting Moscovitch et al.’s (2011) finding of relatively impoverished nonnegative imagery in
SA.
Treatment implications. In combination with research on self-imagery, the extant literature

on the tendency of individuals with SAD to grossly underestimate the quality of their social
performance (not reviewed here given space limitations; see Rapee & Lim 1992) has given
rise to two relevant therapeutic techniques—imagery rescripting and video feedback. Imagery
rescripting begins with a period of cognitive restructuring focusing on the negative belief reflected
in the spontaneous and recurring image reported by the client. Rescripting itself involves repeated
evocation of the memory, insertion of corrective information into the image, and a compassionate
stance toward the self in imagery. Imagery rescripting alone was associated with improvements
in clients’ negative social beliefs, the vividness and distress of their image and early memory, and
self-reported SA (Wild et al. 2007). Likewise, an imagery rescripting session was associated with
greater improvement in negative beliefs, image and memory distress and vividness, fear of negative
evaluation, and anxiety in feared social situations than a control imagery session (Wild et al. 2008).
Video feedback was initially intended to correct faulty self-perception by providing contrasting
evidence of the adequacy of one’s performance. However, several experiments with SA undergrad-
uates in public speaking situations demonstrated that the addition of a period of cognitive prepa-
ration was necessary (Harvey et al. 2000). Studies that added cognitive preparation demonstrated
robust effects on self-perceptions of performance, and the magnitude of the discrepancy between
self ratings and observer ratings predicted responses to video feedback (e.g., Rodebaugh & Rapee
2005). However, there was little impact on SA, confidence, or willingness to approach a subsequent
public speaking task. Rodebaugh et al. (2010) tested video feedback with cognitive preparation
among treatment-seeking participants with SAD. The intervention improved self-perceptions
of performance and reduced anticipatory anxiety in participants with high self-observer
discrepancy.

Future research. Hackmann et al. (2000) reported that the visual modality was the most
frequently reported modality of self-images in SAD, followed by imagery of bodily sensations
(e.g., sweating, feeling smaller, feeling fatter). Despite its high incidence, very little research
has targeted imagery of bodily sensations. Furthermore, no studies to our knowledge have
examined whether SAD is characterized by the use of voluntary imagery. Similar to the concept
of post-event processing (reviewed below), individuals with SAD may voluntarily conjure
self-images in an effort to appraise their appearance during a previous social interaction or
prepare for a future social interaction by rehearsing how they will posture themselves, make
facial expressions, sound, etc. If imagery in SAD includes both the voluntary and intrusive type,
we could investigate whether they have different emotional, cognitive, or behavioral sequelae.
For example, might voluntary imagery be reinforcing in the short term but ruminative in the
long term? Is intrusive imagery in SAD similar to that in posttraumatic stress disorder, in that it
is composed of fragmented memories of a socially traumatizing experience?
Interrelations Among Information Processing Biases

Hirsch et al. (2006a) assert that biases in information processing should be examined in con-
junction with one another, given that theoretical perspectives postulate systems of interacting
cognitive biases (e.g., Heimberg et al. 2010). Several studies have examined interactions of the
negative self-imagery typical of SAD with other cognitive biases. Negative self-imagery has
been shown to affect autobiographical memory. SA participants were faster to retrieve negative
autobiographical memories when they held a negative self-image in mind and faster to retrieve
positive autobiographical memories when they held a positive self-image in mind (Stopa &
Jenkins 2007). Participants in the negative imagery condition were also slower to retrieve positive
relative to both negative and neutral memories, suggesting an inhibitory effect of negative
self-imagery on positive autobiographical memories.
Other studies have documented the effect of self-imagery on interpretation of ambigu-
ous social information. In one study, nonanxious individuals trained to hold a negative
self-image in mind later lacked the nonthreatening interpretation bias shown by nonanxious
individuals who were not trained to use negative self-imagery (Hirsch et al. 2003b). Those
in the negative imagery group also experienced higher levels of state anxiety, supporting
the notion that these cognitive biases may interact to maintain anxiety. The effect of in-
terpretation bias on imagery has also been shown. Participants in a negative interpretation
bias induction condition produced more negative self-related images, rated their anticipated
anxiety for an imagined social situation higher, and rated their expected social performance
poorer compared to participants in a positive bias induction condition (Hirsch et al. 2007).
Therefore, research to date largely suggests that the negative self-imagery of individuals
with SA interacts with other cognitive processes to maintain excessive anxiety.
Preliminary research supports a link between interpretation and memory biases, but only
one study has examined this relationship in SA. Hertel et al. (2008) found that SA partici-
pants were more likely than controls to exhibit memory intrusions consistent with previously
made biased interpretations. Finally, studies support a relationship between attention and
interpretation biases. In one study, Amir et al. (2010) showed that an interpretation mod-
ification program, designed to facilitate more benign interpretations of ambiguous social
scenarios, facilitated attention disengagement from social threat cues in individuals with SA.
No studies to date have tested the reverse effect with participants or stimuli specific to SA.
Further research on the reciprocal effects of attention and interpretation biases in SA is
needed.

Future directions. Although this literature is in its infancy, there is already consistent support for
reciprocal relationships among information processing biases, including attention, interpretation,
imagery, and memory. Future research should extend research on these reciprocal relationships
to clinical samples. With regard to translational relevance, there is emerging evidence supporting
the combination of cognitive bias modification for attention and interpretation biases (Beard
et al. 2011), but further research is needed to compare these combined approaches with each
component and to more traditional therapies, such as CBT.
SELF-FOCUSED ATTENTION
Self-focused attention has been defined as “an awareness of self-referent, internally generated
information” (Ingram 1990, p. 156). The content of awareness can include bodily or physical
states, as well as thoughts and emotions, including beliefs, attitudes, and memories (Spurr &
Stopa 2002). Cognitive-behavioral models suggest that increased self-focused attention plays a
role in the maintenance of SAD. For example, Clark & Wells (1995) propose that individuals
with SAD are excessively self-focused during anxiety-provoking social situations, which precludes
them from attending to external information, thus preventing the opportunity for disconfirmation
of negative expectations. Instead, individuals with SAD use internal cues to evaluate their social
performance. There is ample evidence that individuals with SA report higher levels of self-focused
attention than do individuals without SA and that induction of self-focused attention increases
anxiety (e.g., Woody & Rodriguez 2000). However, one question arising from this type of research
is the directionality of this relationship. The majority of studies have attempted to manipulate the
focus of attention and found subsequent differences in anxiety. For instance, individuals with
high blushing fear reported higher SA in a self-focused versus task-focused attention condition,
whereas individuals with low blushing fear showed no differences across conditions (Zou et al.
2007). In contrast, Voncken et al. (2010) attempted to manipulate anxiety and examine its effect
on self-focused attention. Participants with high and low blushing fear wore a finger device that
vibrated with increasing intensity during a conversation task. Half the participants were told the
vibration indexed the intensity of their blushing, whereas the other half were told the vibration
did not correspond to any aspect of their performance. Immediately following the conversation,
participants rated their state SA and self-focused attention during the task, and confederates rated
participants’ performance. Participants in the blushing feedback condition reported higher self-
focused attention than those in the control condition, suggesting that an anxiety induction resulted
in increased self-focused attention. One limitation of this study, however, is that state SA and self-
focused attention were only assessed once, so the sequence of the causal relationships could not be
truly determined. In other words, it may be that the manipulation resulted in increased self-focused
attention, which then resulted in increased state SA, rather than vice versa.
Glick & Orsillo (2011) argue that it remains unclear whether self-focused attention is an au-
tomatic response to increased physiological arousal experienced during anxiety-provoking social
situations or if it is a more voluntary, deliberate coping strategy aimed at preventing embarrassment
and negative evaluation. They propose that self-focused attention may best be conceptualized as
the latter, and specifically, that it is an attempt to suppress, control, or alter uncomfortable internal
experiences (i.e., experiential avoidance). Indeed, in undergraduates, self-reported experiential
distress and avoidance mediated the relationship between SA and self-focused attention. Although
the results of this study should be considered preliminary given the cross-sectional design and
reliance on self-report measures, they highlight a need for further theoretical and empirical
consideration of the causal sequence in the relationship between self-focused attention and
SA.

In contrast to research documenting a relationship between self-focused attention and SA,

there is little empirical evidence showing that heightened self-focused attention has a detrimental
influence on social performance (e.g., Woody & Rodriguez 2000). In the study by Voncken et al.
(2010), reviewed above, in both high and low blushing-fearful individuals, state SA was related to
heightened self-focused attention and negative beliefs, but only negative beliefs were associated
with poorer social performance. The authors interpreted these findings as suggesting heightened
self-focused attention was a by-product of state SA rather than a mediator of the relationship
between SA and poorer social performance.
In other studies, modest support was found for a relationship between heightened self-focus
and poorer social performance. For example, in a study of women with low levels of self-efficacy,
women in a self-focused attention condition were quicker to withdraw from a social interaction
than were women in a control condition (Alden et al. 1992). However, this study could not disen-
tangle the effects of self-focused attention from the direct effects of state SA on behavior. McManus
et al. (2008, study 2) demonstrated support for the detrimental effect of induced self-focused
attention on behavior. In the experimental condition, however, participants were instructed to use
safety behaviors including self-focused attention, so the influence of self-focused attention per se
was potentially confounded by the effects of other safety behaviors. It is premature to draw firm
conclusions regarding the relationship between self-focused attention and social performance.
Treatment Implications
Several studies have found that self-focused attention was reduced after successful treatment of
SAD (for review, see Bögels & Mansell 2004). Hofmann (2000) also found that reduction of
attentional focus on negative aspects of the self correlated with reductions in SA. In addition,
reduction in self-focused attention during treatment was a significant predictor of long-term
change in SA and fears of blushing, trembling, and sweating (Bögels 2006).
A few therapeutic approaches have also been developed specifically targeting the reduction of
self-focused attention. Bögels (2006) developed an approach named Task Concentration Train-
ing, in which participants are taught to reduce self-focused attention by focusing on their task and
environment. Task Concentration Training was more effective than applied relaxation in treat-
ing individuals with SAD with fears of blushing, trembling, or sweating (Bögels 2006). Several
studies have also found that teaching individuals with SA to focus attention outward enhances
the effects of cognitive and/or behavioral treatments (for review, see Bögels & Mansell 2004).
Although understudied to date, acceptance and mindfulness-based approaches may also target the
detrimental effects of self-focused attention. These therapies have been developed to specifically
target experiential avoidance, which Glick & Orsillo (2011) found to mediate the link between SA
and self-focus, and the cultivation of a compassionate stance toward internal experiences.
EMOTION AND EMOTION REGULATION

Although difficulties with emotion regulation have been found in the majority of anxiety disorders,
research on strategies for regulation of anxiety and other emotions among persons with SA has
only just begun. Emotion regulation has been defined as the processes by which an individual
influences which emotions he or she experiences, when the emotions are experienced, and how
the emotions are experienced and expressed (Gross 1998).
SAD has been characterized by reduced emotionality, emotional hyperreactivity, and emotion
regulation deficits. In undergraduates with analogue SAD, GAD, and major depressive disorder,
SA was negatively predicted by heightened intensity of emotions (Mennin et al. 2007). SA also

remained significantly related to poor understanding of emotions after overlap with symptoms of
the other two disorders was considered. Negative reactivity to emotions was also associated with
SA, but not GAD. In another study, undergraduates with SA reported being less attentive to their
emotions and having more trouble describing emotions than an analogue GAD group or controls
(Turk et al. 2005). These results were also extended to a clinical sample, in which poor emotional
understanding best predicted a SAD diagnosis, regardless of GAD comorbidity (Mennin et al.
2009). SA has also been characterized by expressive suppression and maladaptive beliefs about
emotion regulation. Compared to controls, individuals with SA reported greater use of emotional
suppression and greater ambivalence about expressing emotions (Spokas et al. 2009). They also
reported more difficulties in emotional responding, more fears of emotional experiences, and
more negative beliefs about emotional expression. Individuals with SA endorsed the beliefs
that it is important to have control of emotional expression, that emotional expression may
lead to social rejection, and that expressing one’s emotions communicates weakness. Moreover,
these beliefs mediated the association between SA and expressive suppression (Spokas et al.
2009). Likewise, SA undergraduates reported engaging in more suppression of positive emotions
than an analogue GAD group or controls (Turk et al. 2005). Most recently, these results were
corroborated in a clinical sample. In an interview based on Gross’s (1998) process model of
emotion regulation, patients with SAD reported more frequent use of situation selection (i.e.,
avoidance) and suppression of emotional expression as well as less self-efficacy in engaging in
cognitive reappraisal and expressive suppression than controls reported (Werner et al. 2011).
Treatment Implications and Future Directions

Research on emotion dysregulation in SAD is relatively new; therefore, studies on the treatment
implications of these findings are few in number. Goldin et al. (2012) demonstrated that the
belief in one’s ability to effectively use the emotion regulation strategy of cognitive reappraisal
mediated the effect of CBT for SAD on social anxiety symptoms. This finding supports the
use of cognitive reappraisal in cognitive behavioral treatment packages and sufficient practice in
these skills to build one’s sense of self-efficacy, but it also raises the question of whether and
how emotion regulation deficits in SAD are remedied by treatments that do not use cognitive
reappraisal, such as Acceptance and Commitment Therapy. Another area that will likely guide
research in both experimental psychopathology and treatment development is the relationship
between comorbidity and emotion dysregulation.
Atypical Responding to Positive Material and Experience of Positive Emotions

A wealth of research concerns the distress and impairment associated with SA. Recently, how-
ever, researchers have begun to examine how individuals with SA/SAD respond to positive in-
formation and experience positive emotions, with accumulating evidence suggesting that SA is
associated with diminished response to positive stimuli or events. Research supports the distinc-
tion between positive and negative affect as two negatively correlated yet independent factors
(e.g., Watson et al. 2005). In addition, the most distinguishing characteristic of very happy peo-
ple is the existence of satisfying social interactions and relationships (Diener & Seligman 2002),
a domain known to be particularly impaired among individuals with SA. Therefore, further in-
vestigation of the phenomenology, extent, causes, and outcomes of reduced positive affect in SA
appears warranted and may have important implications for the functioning of individuals with
SAD.

Phenomenology. Anxiety disorders have not historically been tied to reduced positive affect.
However, several studies support the notion that SA, but not other types of anxiety, is associated
with reduced positive affect that cannot be solely attributed to co-occurring depressive symptoms.
SAD has been associated with diminished positive affect after statistically controlling for the con-
tribution of depressive symptoms (Brown et al. 1998). Similarly, in a study of the tripartite model
of anxiety and depression in individuals with SAD, SA was more closely related to a low positive
affect factor than a physiological hyperarousal factor (Hughes et al. 2006). A recent meta-analysis
also supported the findings of reduced positive affect across the SA spectrum after statistically
accounting for the variance contributed by depressive symptoms (Kashdan 2007).
Other evidence for diminished positive affect in SA comes from treatment studies and ecological
momentary sampling studies. From treatment outcome research, we know that posttreatment
quality of life of individuals with SAD fails to reach the normal range (e.g., Eng et al. 2005). In
recent studies using ecological momentary sampling, elevated trait SA in nonclinical samples was
related to reduced positive affect and fewer positive events in everyday life (e.g., Kashdan & Steger
2006). SA was associated with less time spent feeling happy and relaxed throughout the day, and
participants with relatively higher SA reported fewer and less intense positive emotions across
both social and nonsocial situations (Kashdan & Collins 2010).
Expectations about positive events and positive emotions. SAD is also associated with
maladaptive beliefs about positive events and positive emotions. Individuals with SAD estimate
positive events to be less likely to occur and anticipate experiencing more frequent and negative
reactions to positive social events than do nonanxious individuals (Gilboa-Schechtman et al.
2000). Perhaps then it comes as little surprise that SA has also been associated with fears of positive
evaluation, an outcome that psychologically healthy individuals would likely conceptualize as
a positive-affect-enhancing experience. Fear of positive evaluation is defined as “the sense of
dread associated with being evaluated favorably and publicly, which necessitates a direct social
comparison of the self to others and therefore causes an individual to feel conspicuous and ‘in the
spotlight’” (Weeks et al. 2010, p. 69). This perspective is in line with evidence that socially anxious
individuals worry that positive evaluation of their performance raises the social standards by which
they will be evaluated in the future, although they do not believe that their typical performance
will change for the better (Wallace & Alden 1997). As a result, they predict that positive evaluation
by others will ultimately result in failure. Nevertheless, fear of positive evaluation does not appear
to be only a delayed expression of the fear of negative evaluation (Weeks et al. 2008).
Positive emotion regulation. Whereas most individuals attempt to enhance and sustain
positive affective states, SA is associated with the down-regulation of positive emotional states.
SA has been associated with fear of positive emotions (Turk et al. 2005). Individuals with SA
tend to dampen positive affect, exhibit less savoring of it, and express it less than do nonanxious
individuals (Eisner et al. 2009, Turk et al. 2005). They also do not pursue activities that could
generate positive affect (Kashdan & Steger 2006). In sum, individuals with SA appear to fear
positive emotional states, avoid their onset, and quicken their offset, each of which likely serves
to maintain a relatively low level of overall positive affect, which likely reduces the quality of life
of individuals with SAD, directly as well as indirectly.
Given accumulating evidence supporting an inverse relationship between SA and positive
affect, researchers have turned to examining potential mechanisms. Kashdan (2007, Kashdan
et al. 2011) proposes a self-regulation depletion hypothesis. He proposes that there exists a
paradox in SA in which excessive attempts to make a positive impression, appear and feel less
anxious, and avoid rejection deplete the self-control resources necessary to effectively prevent

socially undesirable behaviors (e.g., inappropriately self-disclosing intimate details; Vohs et al.
2005). There follows a decreased likelihood of positive interpersonal outcomes and reduced
positive affect, given the centrality of satisfying social interactions and relationships necessary for
happiness (Diener & Seligman 2002).
From an information processing perspective, investigators have implicated both biased
attention and interpretation in diminished positive affect in SA. As reviewed above, some studies
suggest the biased attention toward threat in SA is accompanied by biased attention away from
positive information. Moreover, training of attention toward positive information heightened
positive emotional reactivity in SA (Taylor et al. 2011), thus providing preliminary support for
attention away from positive stimuli as a mediating factor between SA and reduced positive affect.
Furthermore, both threat interpretations of positive social events (Alden et al. 2008) and failure
to accept others’ positive reactions at face value (Vassilopoulos & Banerjee 2010) mediated the
relationship between SA and low positive affect.
Self-focused attention may also be related to reduced positive affect in SA. In one study,
undergraduates engaged in a reciprocal self-disclosure task with a trained confederate (Kashdan
& Roberts 2004). Individuals with high SA experienced less intense positive affect compared to
individuals with low SA both while answering questions with a camera directed at them (high
self-focus/social threat condition) and while asking questions and listening to the confederate’s
answers with the camera focused on the confederate (low self-focus/social threat condition).
However, group differences in positive affect were larger in the social threat/self-focus condition,
and self-focused attention partially accounted for this effect.
Treatment implications and future directions. Alden & Trew (2012) specifically examined the
effects of a positive-affect-enhancing treatment in SA. Undergraduates high in SA were randomly
assigned to one of three task conditions: (a) engaging in kind acts, (b) engaging in behavioral
experiments to observe the effects of eliminating their safety behaviors, or (c) monitoring life
details. Participants in the kind acts condition were asked to engage in three kind acts (i.e., acts
that benefit others or make others happy, typically at some cost to oneself ) for four weeks. Results
from both the pre- to posttreatment affect measures and from weekly mood monitoring revealed
that only engaging in kind acts resulted in significant increases in positive affect. Individuals in
the kind acts condition also reported greater satisfaction with their social relationships and less
concern with protecting themselves from negative social outcomes.
The study by Alden & Trew (2012) provides encouraging evidence that traditional CBT for
SAD could be augmented by integrating techniques specifically targeted at improving positive,
healthy functioning. Other interventions might also be considered. For example, loving-kindness
and compassion meditation (for review, see Hofmann et al. 2011) may have the potential
to enhance positive affect in SA, given that its primary focus is oriented toward enhancing
unconditional, positive emotional states of kindness and compassion.
Anger Experience and Expression and Behavioral Disinhibition

As has been the case for the study of positive affect in SA, little research to date has been devoted
to examining the potential roles of anger and aggression in SA/SAD. However, recent research
has paid more attention to this issue, and the results will likely improve assessment and treatment
of SAD.
Anger experience. Erwin et al. (2003) reported that individuals with SAD endorsed greater
anger than nonanxious controls. Individuals with SAD reported greater intensity of situationally

experienced anger (state anger), disposition to experience anger in a wide range of situations (trait
anger), inclination to express anger when criticized, evaluated negatively, or treated unfairly by
others (angry reaction), and tendency to experience and express anger without provocation (angry
temperament), as measured by the State-Trait Anger Expression Inventory (Spielberger 1988).
Breen & Kashdan (2011) replicated these findings in a sample of undergraduates and also found
that SA was positively correlated with anger in response to imagined rejection after listening to a
series of vignettes. In a study using ecological momentary sampling in community adults, Kashdan
& Collins (2010) found SA to be associated with more time spent feeling angry throughout the day.
Importantly, people with relatively higher levels of SA reported amplified anger episodes across
both social situations and time spent alone, suggesting that anger in SA may not be circumscribed
to social interactions.
Expression of anger. Erwin et al. (2003) also provided evidence that individuals with SAD en-
dorse poorer anger expression skills. Compared to controls, they were more likely to suppress
anger or direct it inward (anger-in). In contrast, groups did not differ in their likelihood to ag-
gressively direct anger toward other people or objects (anger-out) or to monitor and control
the expression of anger (anger control). In undergraduates, SA was also positively correlated with
anger-in scores and anger suppression in response to imagined rejection after listening to vignettes
(Breen & Kashdan 2011). Similarly, people with SAD were less likely to express anger than were
nonanxious controls, even after accounting for the effects of depressive symptoms (Moscovitch
et al. 2008).
The experience and expression of anger among individuals with SAD may also be associated
with poorer outcomes. Among individuals with SAD, the strongest correlations with indicators of
functioning were between higher state anger and increased depression and reduced quality of life
(Erwin et al. 2003). Also highly correlated were the tendency to suppress anger or direct it inward
(anger-in) and increased social interaction anxiety, reduced interpersonal trust, and lower quality
of life (Erwin et al. 2003).
Behavioral disinhibition in SAD. Despite a strong tendency to do so, not all individuals with
SAD habitually suppress anger and aggression. Emerging research suggests that some individuals
with SAD are prone to risky behaviors and aggression. Kachin et al. (2001) identified two subsets
of people with SAD with varying behavioral reactions to social threat. One group reported
the avoidant, unassertive, and submissive response style prototypical of individuals with SAD.
The other group reported angry, hostile, and mistrusting interpersonal styles. Following from
this, three recent studies examined whether there is a meaningful subgroup of individuals with
SA/SAD characterized by distinct patterns of approach/avoidance appraisals for social activities
and risk-taking behaviors.
Kashdan & Hofmann (2008) found that a subset of adults with SAD (41% of the sample)
made impulsive decisions to seek out novel information and experiences regardless of the danger
involved. The other subset comprised individuals who fit the prototype of SAD, endorsing little
to no interest in the new and unfamiliar. Whereas the former group showed substantially greater
novelty seeking compared with a large normative sample, the latter inhibited group showed
substantially lower novelty seeking. Of interest, the group higher in novelty seeking reported
more severe substance use problems.
In a second study, with college students, three distinct groups emerged—one low in SA, one
with moderate SA characterized by strong beliefs that risk-taking was dangerous but offered
opportunities to satisfy curiosity and enhance social status (i.e., SA-disinhibited), and one with
moderate SA and beliefs that risk-taking would be dangerous and offered few opportunities

to satisfy curiosity or enhance social status (i.e., prototypical SA-inhibited) (Kashdan et al.
2008). The SA-disinhibited group was less healthy than the SA-inhibited group, demonstrating
both greater suppression and greater outward expression of anger, as well as less psychological
flexibility and less social support and feelings of relatedness. The SA-disinhibited group also
reported a greater proportion of approach-avoidance conflicts and engaging in more frequent
aggression and substance use than the other two groups.
In a third study, of individuals with a current or lifetime diagnosis of SAD from the National
Comorbidity Survey-Replication dataset, a latent class analysis on impulsive, risk-prone behavior
revealed two SAD classes (Kashdan et al. 2009). Whereas the majority reported a typical pattern
of behavioral inhibition and risk aversion, a notable portion (21%) reported elevated anger and
aggression and moderate levels of sexual impulsivity. This disinhibited group also endorsed severe
substance use problems, had poorer general mental and physical health, had less education and
income, and had greater risk for several other mental health disorders, yet they were no more
likely to seek treatment for SAD.

Treatment implications. Preliminary evidence suggests issues related to anger may affect SAD
treatment outcomes. Erwin et al. (2003) found that patients who did not complete treatment
endorsed greater trait anger, angry temperament, and angry reaction compared to those who
completed treatment. Among those who completed treatment, there were reductions in trait
anger, angry reaction, and anger-in from pre- to posttreatment. Higher pretreatment scores on
anger-in, state anger, and angry reaction also predicted higher posttreatment scores on SA and
depression. Higher pretreatment scores on trait anger also predicted higher posttreatment de-
pression. Treatment implications for the SA-disinhibited group have yet to be examined.
SAFETY BEHAVIORS
A long line of research has documented difficulties with interpersonal functioning in SAD. Indi-
viduals with SA have fewer and less satisfying relationships and exhibit behaviors others interpret
as indicative of poor social skill (for review, see Alden & Taylor 2004). Although early inter-
pretations of these findings were that SA was indeed associated with social skill deficits, more
recent empirical evidence indicates that individuals with SA do not always exhibit maladaptive
social behavior; rather, they exhibit such behaviors when in socially ambiguous or threatening sit-
uations. Thus, cognitive-behavioral theorists suggested that the dysfunctional behavior patterns
exhibited by individuals with SA might reflect anxiety-related self-protective strategies (i.e., safety
behaviors) to prevent feared outcomes (e.g., Clark & Wells 1995, Heimberg et al. 2010). Safety
behaviors encompass a broad range of behaviors, such as low self-disclosure, avoidance of eye
contact, attempts to conceal anxiety, and over-rehearsal, that the person believes are necessary
to complete an interaction without harm. Safety behaviors typically do not have this hoped-for
effect, and they may contribute to the maintenance of SA via interference with the development
of new, nonthreat associations.
Individuals with high SA endorsed more frequent use of safety behaviors in potentially anxiety-
provoking social situations, a greater number of different safety behaviors, and use of these
behaviors in a greater number of social situations than did individuals with low SA (McManus
et al. 2008, study 1). People, including individuals with SA, tend to believe safety behavior use
will result in more negative outcomes, although SA also appears to be associated with a double
standard in which individuals with SA have relatively positive perceptions of their own, but not
others’, use of safety behaviors (Voncken et al. 2006). Beyond perceptions, safety behaviors appear
to be associated with negative interpersonal outcomes. Self-reported use of safety behaviors

partially mediated the relationship between diagnostic group (i.e., SAD, anxiety disorder controls,
nonanxious controls) and observer-rated negative behavior in both speech and conversation tasks
(Stangier et al. 2006). Avoidance behaviors such as low self-disclosure and avoiding eye contact
have also been shown to elicit negative responses from others (e.g., Sparrevohn & Rapee 2009).
Finally, self-protective communication (i.e., less self-disclosure) among women partially mediated
the relationship between SA and quality of romantic relationships (Cuming & Rapee 2010).
Categories of Safety Behaviors

Hirsch et al. (2004) suggested that SAD-related safety behaviors might be rationally grouped into
avoidance and impression-management subtypes. Whereas avoidance behaviors (e.g., avoiding eye
contact) were associated with negative perceptions by observers, impression-management behav-
iors (e.g., excessive self-monitoring and rehearsal) were not. More recently, Plasencia et al. (2011,
study 1) used factor-analytic techniques to uncover two factors that were consistent with these
subtypes. In a second study, Plasencia et al. (2011) extended these findings to a clinical sample of
individuals with SAD in a controlled social interaction. Avoidance and impression-management
safety behavior subtypes were associated with different social outcomes. Avoidance safety behav-
iors were associated with higher state anxiety during the interaction and more negative reactions
from interaction partners. In contrast, impression-management safety behaviors appeared to im-
pede corrections to negative predictions about subsequent interactions. Therefore, preliminary
evidence supports the distinction of safety behavior subtypes, suggesting it may be possible to
individualize treatment strategies depending on the client’s predominant type of safety behavior.
Causal Status: Safety Behavior Manipulations

A series of experimental studies provide support for a causal relationship between safety behaviors
and maintenance of SA. McManus et al. (2008, study 2) had high- and low-SA participants engage
in two conversations, once with instructions to focus on the self and use safety behaviors and
once with instructions to focus externally and refrain from using safety behaviors. Regardless of
SA level, instructions to use self-focus/safety behaviors resulted in higher anxiety, more negative
predictions about the outcome of the conversation, and poorer self-ratings of performance.
Partners also rated the conversation without safety behaviors/self-focus as more enjoyable and
rated the participants as less anxious, performing better, and more likeable.
Reduction of safety behaviors also appears linked with positive outcomes. Among individuals
with SAD, exposure combined with elimination of safety behaviors produced greater anxiety re-
duction compared to exposure alone (Kim 2005). Likewise, SA undergraduates and individuals
with SAD in a safety behavior reduction condition were less negative and more accurate in judg-
ments of their performance than were control participants (Taylor & Alden 2010). In addition,
participants with SAD who were instructed to reduce safety behaviors rated the likelihood of
negative outcomes as less than those who were not so instructed.
Most recently, Taylor & Alden (2011) examined whether safety behaviors influence judgments
individuals with SAD make about others’ reactions to them and how these compare to others’
actual reactions to them. Individuals with SAD who were instructed to reduce idiosyncratic safety
behaviors perceived and actually received more positive responses from an interaction partner than
did members of a control group who were not so instructed. Interestingly, different mechanisms
accounted for changes in self- versus partner-rated social outcomes. Participants in the safety
behavior reduction condition believed that their partner reacted more positively to them because
of reduced self-judgments about the visibility of anxiety-related behaviors. However, partners
reported they reacted more positively because of increases in participants’ social approach behavior.

Given that safety behaviors are central to cognitive models of SAD, they have become a primary
target in many exposure-based treatment regimens (e.g., Clark et al. 2006, Rapee et al. 2009). Re-
cently, Alden & Taylor (2011) integrated strategies based on relational and interpersonal research,
including reduction of safety behaviors, in a standard CBT intervention for SAD. Compared with
a wait-list control condition, clients who completed treatment exhibited increased frequency of
social approach behaviors and relationship satisfaction as well as reductions in SA.
Future Directions
Given that the majority of research in clinical samples of SAD has included individuals with the
generalized subtype, future studies should seek to understand whether safety behaviors function
similarly in the nongeneralized subtype, such as individuals with primary public speaking anxiety.
Relatedly, studies should examine whether the two categories of safety behaviors revealed by
the factor analytic study by Plasencia et al. (2011) function similarly in individuals with public
speaking anxiety. It may be that approach behaviors are more relevant in individuals with SA with
primary relational concerns as opposed to performance concerns. It may also be worthwhile to
examine whether the disinhibited behaviors of some individuals with SA described above can be
conceptualized as akin to safety behaviors: Can engaging in these kinds of behaviors lead a person
with SA to receive less negative evaluation from a deviant peer group?
POST-EVENT PROCESSING
Post-event processing (PEP) is defined as a thought process in which the individual reviews his
or her own actions and the reactions of the other individual(s) following a social event or in
anticipation of a similar upcoming event. Brozovich & Heimberg (2008) review research on PEP
and conclude that it is common in SA, often becomes negatively self-focused and perseverative
for individuals with high SA, maintains negative self-impressions, and leads to biased retrieval of
negative memories, thus perpetuating SA.
Within-Situation Predictors of PEP

Investigators have turned their attention to studying what characteristics of a social situation
predict later PEP. Makkar & Grisham (2011a) explored the predictors of PEP following a speech
task. SA predicted PEP over and above depression and trait anxiety, consistent with previous
studies. Negative beliefs and assumptions (e.g., excessively high standards for social performance)
were also predictive of PEP, accounting for unique variance in PEP over and above other within-
situation variables (e.g., self-focused attention, safety behaviors), depression, and trait anxiety.
Moreover, SA was no longer a significant predictor of PEP when these variables were included
in the model, suggesting that negative beliefs mediate the relationship between SA and PEP.
Laposa & Rector (2011) examined predictors of PEP following present, real, and idiographically
defined social events in the form of CBT exposure exercises. Baseline SA and state anxiety during
the videotaped exposures were unique predictors of PEP. Fear of causing discomfort to others,
negative interpretation of positive events, and trait anxious rumination were also associated with
PEP.

Self-Focus and PEP

Several studies have examined the implications of induced self-focus on the nature and conse-
quences of PEP. Makkar & Grisham (2011b) studied the effect of self-imagery on PEP. They
instructed participants high and low in SA to hold either a negative or control self-image in
mind while giving a speech. The following day, participants in the negative self-image condition
reported engaging in more negative and less positive PEP than those in the control condition,
regardless of SA level. Holding a negative self-image in mind also resulted in greater self-focused
attention. Although these results suggest negative self-imagery may encourage PEP, conclusions
about a causal relationship between focus of attention and PEP could not be established because
attention was directed toward the self in both conditions.
Brozovich & Heimberg (2011) instructed participants to engage in either self- or other-focused
PEP following a social interaction with a confederate. For individuals with SA, self-focused PEP
resulted in fewer positive feelings about their performance than other-focused PEP, whereas no
differences across condition emerged for control participants. Contrary to prediction, however,
there was not a significant interaction of SA group and PEP condition on negative perceptions of
performance; individuals with SA, regardless of PEP condition, evaluated their performance more
poorly than did controls both immediately and one week later. Interestingly, the latter effect was
moderated by trait PEP. Individuals with SA with high trait PEP generated more negative self-
judgments about their performance after one week than did those with lower trait PEP, whereas
this pattern was not observed in controls.
These results were extended by Gaydukevych & Kocovski (2012). Students with SA were in-
structed either to pay attention to their feelings, thoughts, actions, and body sensations (self-focus)
or to attend to their partner’s words and facial expressions (other-focus) during a conversation
with a confederate. The next day, individuals in the self-focused attention condition reported
more frequent negative PEP over the 24-hour period following the conversation than individuals
in the other-focused condition reported. However, this finding was observed for only one of the
two measures of PEP, suggesting that self-focused attention during a social situation increases
specifically negative self-relevant thoughts during PEP rather than increasing the repetitive na-
ture of PEP per se. Nevertheless, these results provide support for a causal relationship between
self-focused attention and PEP.
Treatment studies provide consistent evidence that PEP can be effectively reduced. For example,
Price & Anderson (2011) reported that PEP decreased as a result of both individual virtual reality
exposure-based therapy and exposure-based group therapy. However, PEP attenuated treatment
response. SA decreased at a slower rate for individuals reporting greater levels of PEP than for
those with lower levels of PEP.
Given the support for a causal relationship between self-focused attention and PEP, researchers
have suggested targeting this relationship to maximize therapy benefits. Cassin & Rector (2011)
compared the effects of brief mindfulness training (which may approximate training of the focus
of attention to be more flexible rather than self-focused), distraction training, or no training
(control). After training, participants underwent an experimental PEP induction, after which
they were instructed to apply the strategy they had just learned. Mindfulness reduced distress
significantly over the post-event period and resulted in significantly more positive affect compared
to the no-training condition. Distraction did not reduce distress and performed comparably to
the no-training condition. Future studies should examine the mechanisms involved in mindfulness
training that helped to alleviate the distress following PEP observed in this study.

Future Directions
Research on PEP has flourished in recent years, but many questions remain unanswered. For
example, we have yet to determine why individuals with SAD voluntarily engage in PEP. Could
they find PEP reinforcing or have positive beliefs about PEP? Alternatively, PEP may be expe-
rienced as a more intrusive or uncontrollable process. If this is the case, we might expect some
of the substance use of people with SAD to “shut off” PEP. With regard to treatment, we know
relatively little about which parts of the treatment package serve to reduce PEP. It would also be
helpful to better understand what mechanisms contribute to the attenuated treatment response
associated with PEP so this may be targeted more directly.
CONCLUDING COMMENTS
We have reviewed several areas important to SA/SAD, including information processing biases,
self-focused attention, emotion regulation, safety behaviors, and post-event processing. We
have highlighted treatment implications and directions for future research along the way. All
of these areas have implications for the cognitive-behavioral conceptualization of the etiology
and maintenance of SA/SAD as well as its treatment. Given space limitations, we can examine
only a few points in relation to our model. We focus briefly on self-focused attention, emotion
regulation, safety behaviors, and impaired response to positive stimuli in SA/SAD.
Self-focused attention has long been recognized as important in SA; however, there has been
less focus on what aspect of the self is the target of this attention. Consistent with Moscovitch
(2009), who asserts that the relevant aspects of the self are perceived flaws in social skills, behavior,
appearance, and personality, and the inability to conceal visible signs of anxiety (all areas that
have implications for evaluation by others), we hypothesize that it is the mental representation of
the self as seen by the audience as specified in our model. If so, self-focused attention, together
with focus on external indicators of evaluation and other factors, may well serve as an important
engine of the vicious cycle of anxiety that we describe. This line of thinking is supported by the
potentially directional links between self-focused attention and heightened anxiety and post-event
processing, which serve to bridge thought about the self in one situation to thought about the self
and the possibility of untoward negative outcomes in situations to come.
Difficulties with emotion regulation are a recent area of exploration in SA/SAD, but this is
an area of potentially great importance. Persons with SA/SAD suppress the expression of a range
of emotions, not just anxiety, and they further believe that the expression of emotion is a sign of
weakness, supporting the notion that expressive suppression may be the wiser course. How better
to get someone to negatively evaluate you than to react to them with uncontrolled and extreme
anger? However, expressive suppression is associated with less liking by the other person (Butler
et al. 2003). Of course, expressive suppression may also be considered a safety behavior.
Our review of safety behaviors reveals the wide range of behaviors that may serve this
function for persons with SA/SAD, from minimization of self-disclosure, to overpreparation,
to maintaining low levels of eye contact, and beyond. These behaviors are intended to increase
the person’s ability to safely transact a threatening social encounter but rarely have these effects,
although Hirsch et al. (2004) and Plasencia et al. (2011) suggest that different types of safety
behaviors may have different effects. Most importantly, safety behaviors appear to be a roadblock
to overcoming SA because they result in adverse rather than positive outcomes. Specifically, they
tend to block approach behavior, and as noted above for expressive suppression, lead the person
with whom the individual with SA interacts to evaluate him or her less positively than when
safety behaviors are not employed. Safety behaviors are an important part of understanding our

cognitive-behavioral conceptualization of SA/SAD, although they have been more explicitly

addressed in the model of Clark & Wells (1995), because they may hamper the person’s ability to
realistically compare the mental representation of the self as seen by the audience with a realistic
appraisal of the audience’s expectation, which should lead to an exaggerated judgment of the
likelihood and cost of evaluation by the audience.
Finally, we want to address the growing literature on positivity impairments in SA/SAD (see
Weeks & Heimberg 2012). In our review, we have seen, among other things, that persons with
SA/SAD avert their attention from positive stimuli, are more likely to come up with threat inter-
pretations of positive events, are more likely to suppress the experience and expression of positive
emotions, avoid activities that could generate positive affect, and, as touched on very briefly, fear
positive evaluation by others as much as they fear negative evaluation. These impaired reactions to
all things positive appear to down-regulate the quality of life of the person with SA and make him
or her less appealing to others, which most certainly has a further deflating effect on the mental
representation of the self as seen by the audience. This is an area of research that will be very
important moving forward in the development of newer and more effective treatments for SAD.
DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.
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45:2326–33

CP09-FrontMatter ARI 9 March 2013 1:0
Annual Review of
Clinical Psychology
Volume 9, 2013
Contents
Evidence-Based Psychological Treatments: An Update

and a Way Forward
David H. Barlow, Jacqueline R. Bullis, Jonathan S. Comer,
and Amantia A. Ametaj p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1

Quitting Drugs: Quantitative and Qualitative Features

Gene M. Heyman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p29
Integrative Data Analysis in Clinical Psychology Research
Andrea M. Hussong, Patrick J. Curran, and Daniel J. Bauer p p p p p p p p p p p p p p p p p p p p p p p p p p p p61
Network Analysis: An Integrative Approach to the Structure
of Psychopathology
Denny Borsboom and Angélique O.J. Cramer p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p91
Principles Underlying the Use of Multiple Informants’ Reports
Andres De Los Reyes, Sarah A. Thomas, Kimberly L. Goodman,
and Shannon M.A. Kundey p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 123
Ambulatory Assessment
Timothy J. Trull and Ulrich Ebner-Priemer p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 151
Endophenotypes in Psychopathology Research: Where Do We Stand?
Gregory A. Miller and Brigitte Rockstroh p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 177
Fear Extinction and Relapse: State of the Art
Bram Vervliet, Michelle G. Craske, and Dirk Hermans p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 215
Social Anxiety and Social Anxiety Disorder
Amanda S. Morrison and Richard G. Heimberg p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 249
Worry and Generalized Anxiety Disorder: A Review and
Theoretical Synthesis of Evidence on Nature, Etiology,
Mechanisms, and Treatment
Michelle G. Newman, Sandra J. Llera, Thane M. Erickson, Amy Przeworski,
and Louis G. Castonguay p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 275
Dissociative Disorders in DSM-5
David Spiegel, Roberto Lewis-Fernández, Ruth Lanius, Eric Vermetten,
Daphne Simeon, and Matthew Friedman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 299
viii
Depression and Cardiovascular Disorders

Mary A. Whooley and Jonathan M. Wong p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 327
Interpersonal Processes in Depression
Jennifer L. Hames, Christopher R. Hagan, and Thomas E. Joiner p p p p p p p p p p p p p p p p p p p p p 355
Postpartum Depression: Current Status and Future Directions
Michael W. O’Hara and Jennifer E. McCabe p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 379
Emotion Deficits in People with Schizophrenia
Ann M. Kring and Ori Elis p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 409
Cognitive Interventions Targeting Brain Plasticity in the Prodromal
and Early Phases of Schizophrenia
Melissa Fisher, Rachel Loewy, Kate Hardy, Danielle Schlosser,

and Sophia Vinogradov p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 435
Psychosocial Treatments for Schizophrenia

Kim T. Mueser, Frances Deavers, David L. Penn, and Jeffrey E. Cassisi p p p p p p p p p p p p p p 465
Stability and Change in Personality Disorders
Leslie C. Morey and Christopher J. Hopwood p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 499
The Relationship Between Personality Disorders and Axis I
Psychopathology: Deconstructing Comorbidity
Paul S. Links and Rahel Eynan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 529
Revisiting the Relationship Between Autism and Schizophrenia:
Toward an Integrated Neurobiology
Nina de Lacy and Bryan H. King p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 555
The Genetics of Eating Disorders
Sara E. Trace, Jessica H. Baker, Eva Peñas-Lledó, and Cynthia M. Bulik p p p p p p p p p p p p p 589
Neuroimaging and Other Biomarkers for Alzheimer’s Disease:
The Changing Landscape of Early Detection
Shannon L. Risacher and Andrew J. Saykin p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 621
How Can We Use Our Knowledge of Alcohol-Tobacco Interactions
to Reduce Alcohol Use?
Sherry A. McKee and Andrea H. Weinberger p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 649
Interventions for Tobacco Smoking
Tanya R. Schlam and Timothy B. Baker p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 675
Neurotoxic Effects of Alcohol in Adolescence
Joanna Jacobus and Susan F. Tapert p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 703
Socioeconomic Status and Health: Mediating and Moderating Factors
Edith Chen and Gregory E. Miller p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 723
Contents ix
School Bullying: Development and Some Important Challenges

Dan Olweus p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 751
The Manufacture of Recovery
Joel Tupper Braslow p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 781
Indexes
Cumulative Index of Contributing Authors, Volumes 1–9 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 811

Cumulative Index of Articles Titles, Volumes 1–9 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 815
Errata
An online log of corrections to Annual Review of Clinical Psychology articles may be

found at http://clinpsy.annualreviews.org
x Contents
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Social Anxiety and Social Anxiety Disorder

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Annu. Rev. Clin. Psychol. 2013. 9:249–74 Keywords

Treatment Implications and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260

Atypical Responding to Positive Material and Experience of Positive Emotions . . . . 260

250 Morrison · Heimberg

The Heimberg et al. Model of SA/SAD

INFORMATION PROCESSING BIASES

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 251

Treatment implications and future directions. An important question is whether attention

252 Morrison · Heimberg

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 253

misinterpret disgust faces as exhibiting contempt. In contrast, nonanxious participants tended to

believe interpretation modiﬁcation to be more helpful (Beard et al. 2011).

254 Morrison · Heimberg

Imagery and Visual Memories

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 255

Treatment implications. In combination with research on self-imagery, the extant literature

256 Morrison · Heimberg

Interrelations Among Information Processing Biases

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 257

258 Morrison · Heimberg

In contrast to research documenting a relationship between self-focused attention and SA,

EMOTION AND EMOTION REGULATION

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 259

Treatment Implications and Future Directions

Atypical Responding to Positive Material and Experience of Positive Emotions

260 Morrison · Heimberg

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 261

Anger Experience and Expression and Behavioral Disinhibition

262 Morrison · Heimberg

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 263

likely to seek treatment for SAD.

264 Morrison · Heimberg

Categories of Safety Behaviors

Causal Status: Safety Behavior Manipulations

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 265

Within-Situation Predictors of PEP

266 Morrison · Heimberg

Self-Focus and PEP

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 267

268 Morrison · Heimberg

cognitive-behavioral conceptualization of SA/SAD, although they have been more explicitly

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 269

experimental investigation. Cogn. Behav. Ther. 40:267–78

270 Morrison · Heimberg

PM DiBartolo, pp. 395–422. New York: Academic. 2nd ed.

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 271

272 Morrison · Heimberg

www.annualreviews.org • Social Anxiety and Social Anxiety Disorder 273

274 Morrison · Heimberg

Evidence-Based Psychological Treatments: An Update

and Amantia A. Ametaj p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1

Quitting Drugs: Quantitative and Qualitative Features

Depression and Cardiovascular Disorders

Melissa Fisher, Rachel Loewy, Kate Hardy, Danielle Schlosser,