Accepted Manuscript

Title: A meta-analysis and scoping review of social cognition

performance in social phobia, posttraumatic stress disorder
and other anxiety disorders

Author: India Plana Marie-Audrey Lavoie Marco Battaglia

Amélie M. Achim

PII: S0887-6185(13)00169-2
DOI: http://dx.doi.org/doi:10.1016/j.janxdis.2013.09.005
Reference: ANXDIS 1540

To appear in: Journal of Anxiety Disorders

Received date: 20-2-2013

Revised date: 15-7-2013
Accepted date: 12-9-2013

Please cite this article as: Plana, I., Lavoie, M.-A., Battaglia, M., & Achim, A. M.,
A meta-analysis and scoping review of social cognition performance in social phobia,
posttraumatic stress disorder and other anxiety disorders, Journal of Anxiety Disorders
(2013), http://dx.doi.org/10.1016/j.janxdis.2013.09.005

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Highlights_final.docx

 We used meta-analytic and scoping review techniques

 We targeted four domains of social cognition in anxiety disorders
 People with PTSD showed mentalizing and emotion recognition deficits
 Other anxiety disorders showed attributional biases
 We also identified several areas to further study

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*Manuscript

Word count: 4415

Abstract word count: 164

Number of table: 1

Number of figure: 2

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A meta-analysis and scoping review of social cognition performance in social phobia,

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posttraumatic stress disorder and other anxiety disorders

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India Planaa,b, Marie-Audrey Lavoieb,c, Marco Battagliaa,b & Amélie M. Achima,b*
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Affiliations:
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a) Département de Psychiatrie et neurosciences, Faculté de médecine, Université Laval

b) Centre de recherche de l’Institut universitaire en santé mentale de Québec
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c) École de psychologie, Université Laval

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Corresponding author

*Amélie Achim, Ph.D

Centre de recherche de l’Institut universitaire en santé mentale de Québec (F-4500)
2601, de la Canardière
Québec (Québec)
Canada, G1J 2G3
Tel. 418-663-5741 (4749)
amelie.achim@crulrg.ulaval.ca

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 Abstract

Social cognition deficits are observed in a variety of psychiatric illnesses. However, data

concerning anxiety disorders are sparse and difficult to interpret. This meta-analysis aims at

determining if social cognition is affected in social phobia (SP) or posttraumatic stress disorder

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(PTSD) compared to non-clinical controls and the specificity of such deficits relatively to other

anxiety disorders. The scoping review aims to identify research gaps in the field. Forty studies

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assessing mentalizing, emotion recognition, social perception/knowledge or attributional style in

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anxiety disorders were included, totalizing 1417 anxious patients and 1321 non-clinical controls.

Results indicate distinct patterns of social cognition impairments: people with PTSD show

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deficits in mentalizing (effect size d =-1.13) and emotion recognition (d=-1.6) while other anxiety

disorders including SP showed attributional biases (d=-.53 to d=-1.15). The scoping review
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identified several underinvestigated domains of social cognition in anxiety disorders. Some
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recommendations are expressed for future studies to explore the full range of social cognition in
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anxiety disorders and allow direct comparisons between different disorders.

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Keywords: Social cognition, Social phobia, Posttraumatic stress disorder, Mentalizing,

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Attributional style, Emotion recognition

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 1. Introduction

Social cognition is defined as the capacity to perceive, interpret and generate responses to

the intentions, dispositions and behavior of other people. It includes different specific cognitive

processes that underlie social interactions (Green et al., 2008). Four different but interrelated

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domains of social cognition are typically studied in the literature, namely mentalizing (also

known as Theory of Mind), emotion recognition, social perception/knowledge and attributional

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style (Pinkham et al., 2013). Mentalizing refers to the ability to attribute mental states, like

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beliefs, desires and intentions to other people (Green et al., 2008), typically based on multiple

pieces of information on the person and the context (Achim, Guitton, Jackson, Boutin, &

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Monetta, 2012). Emotion recognition is the ability to accurately perceive and identify emotions

from social stimuli, such as facial expressions or prosody. Social perception/knowledge refers to
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the awareness and recognition of social rules, norms, or goals in different social situations (Green
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et al., 2008). Finally, attributional style reflects how people typically infer the cause of different
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events (Green et al., 2008). Poor social cognition impacts on the global functioning and quality of

life (Fett et al., 2011; Maat, Fett, Derks, & Investigators, 2012). It thus has become an important
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study target in clinical populations such as schizophrenic and autistic patients since it predicts
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their current and future social functioning (Abdi & Sharma, 2004; Bora, Eryavuz, Kayahan,
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Sungu, & Veznedaroglu, 2006; Fett et al., 2011; Green et al., 2008; Mancuso, Horan, Kern, &

Green, 2011; Sparks, McDonald, Lino, O'Donnelle, & Green, 2010).

Anxiety disorders are the most prevalent psychiatric illnesses (Kessler, Berglund, Demler,

Jin, & Walters, 2005) with lifetime prevalence around 17% (Somers, Goldner, Waraich, & Hsu,

2006). In addition to suffering from important psychiatric comorbidity (Brown, Campbell,

Lehman, Grisham, & Mancill, 2001; Grant et al., 2004), people with anxiety disorders show

remarkable functional impairments and a poorer quality of life than non-clinical controls

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(Mendlowicz & Stein, 2000; Olatunji, Cisler, & Tolin, 2007; Stein et al., 2005). Even though the

link between social cognition and poor functioning has not yet been directly addressed in anxiety

disorders, an increasing number of studies report potential social cognition impairments

(Machado-de-Sousa et al., 2010; Mazza et al., 2012; O'Toole, Hougaard, & Mennin, 2012;

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Sripada et al., 2009) in these patient populations. Social cognition deficits could thus explain part

of the functional impairments and poorer quality of life in anxiety disorders. This may be

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especially true for those anxiety disorders where social abilities are known to be affected, such as

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social phobia (SP), where emotion recognition appears to be disturbed since childhood (Battaglia

et al., 2005; Battaglia et al., 2012; Simonian, Beidel, Turner, Berkes, & Long, 2001), and

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posttraumatic stress disorder (PTSD) where emotional numbing, a core symptom of the illness, is

known to impact interpersonal relationships (Cook, Riggs, Thompson, Coyne, & Sheikh, 2004;
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McFarlane & Bookless, 2001; Ruscio, Weathers, King, & King, 2002).
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The purpose of this study is to sum up what is known from the existing literature about
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social cognitive abilities of people with SP and PTSD by means of a meta-analysis, and to

compare their abilities to those found in other anxiety disorders. As SP and PTSD are often
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reported as particularly socially-impairing anxiety disorders (Antony, Roth, Swinson, Huta, &
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Devins, 1998; Liu, Zhu, Wu, & Hu, 2008; Mendlowicz & Stein, 2000; Schonfeld et al., 1997;
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Simon et al., 2002), it is expected that more important and pervasive social cognition deficits will

be found among people with these diagnoses. Concurrently, we performed a scoping review to

identify research gaps in the current literature on social cognition in anxiety disorders.

Accordingly, we summarized and quantified available data regarding four domains of social

cognition, namely mentalizing, emotion recognition, social perception/knowledge and

attributional style, in people with a primary diagnosis of social phobia (SP), posttraumatic stress

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disorder (PTSD), generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD) or

panic disorder with or without agoraphobia (PD).

2. Method

This study is based on Rosenthal et DiMatteo (2001) meta-analytic procedures and on

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Arksey et O'Malley (2005) methodological framework for scoping reviews, both of which share

similar methodologies to identify and select the relevant studies, but have different aims and

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analytic procedures, as scoping reviews are not centered on effect sizes.

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2.1. Literature Search

Relevant articles were identified through literature searches in PsycINFO, PubMed and

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Web of Knowledge databases using the keywords: social phobia, social anxiety disorder, panic

disorder, agoraphobia, post traumatic stress disorder, generalized anxiety disorder and
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obsessive compulsive disorder along with mentalizing, theory of mind, social cognition, emotion
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recognition, emotion perception, emotion processing, emotion identification, facial affect,

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emotion discrimination, attribution bias, attributional style, interpretation bias, social knowledge

and social cue. The titles and abstracts of the corresponding articles were examined for possible
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inclusion in the meta-analysis. Additional titles were obtained from the references cited in these
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articles.
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2.2. Inclusion and Exclusion Criteria

The inclusion criteria were: (a) inclusion of a group of adults (i.e. older than 18 years old)

with a primary diagnosis of an anxiety disorder (SP, PTSD, GAD, OCD or PD) according to

standard diagnostic criteria (i.e. DSM or ICD); (b) inclusion of a non-clinical comparison group

in which participants did not meet diagnostic criteria for the anxiety disorder assessed in the

study (note that in some studies, participants of the control group were not comprehensively

screened for disorders other than the one addressed in the study, leaving open the possibility that

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they may have presented with an undiagnosed condition); (c) report of a measure for at least one

social cognition construct (mentalizing, emotion recognition, social perception/knowledge,

attributional style), and (d) accessibility, whether in the paper or by contacting the author, of the

necessary data for the calculation of the effect size (r) of the difference between groups on the

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social cognition measures. Studies that were written in another language than English or

unpublished were excluded.

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2.3. Task classification criteria

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The boundaries of the different social cognition constructs are not always evident. For this

review, we used the conceptual definitions of Green et al. (2008) and the operational definitions

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proposed by Achim et al. (2012). For the purpose of this meta-analysis, classification of the tasks

into the different domains of social cognition was made by two of the authors (I.P. and AMA)
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who reached full agreement following the definitions presented below.
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2.3.1. Mentalizing. In mentalizing tasks, participants have to attribute mental states (e.g.
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emotions, intentions, beliefs, desires) to a specific agent in a specific context. Thus in those tasks,

both information about the agent and about the context are provided to the participant.
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2.3.2. Emotion recognition. In emotion recognition tasks, participants have to infer the
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emotional state of a specific agent by relying only on information about what is being expressed
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by this agent with no further contextual information. Tasks can be classified into two categories,

namely accuracy tasks (Etkin & Schatzberg, 2011; Fonzo et al., 2010; Mazza et al., 2012) and

sensibility tasks (Arrais et al., 2010; Kornreich et al., 2001; Palm, Elliott, McKie, Deakin, &

Anderson, 2011). In accuracy tasks, participants are asked either to identify the emotion

expressed in the stimuli, or to discriminate between emotional expressions (e.g. ‘which of 2 faces

is the most expressive’, or ‘which face matches the emotion of a target face’). When different

intensities of the same emotional face are presented, it is then possible to calculate a sensibility

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score that determines the minimal intensity level required to correctly identify the emotion. Those

tasks are considered sensibility tasks.

2.3.3. Social perception/knowledge. Social perception/knowledge tasks present

contextual information without presenting information about a specific agent, and participants are

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asked to identify what is normally expected in that situation (e.g. social rules or norms, expected

actions or reactions).

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2.3.4. Attributional style. Attribution style measures are easier to distinguish, as in these

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tasks there is no right or wrong answer. Rather, the aim is to determine which explanation the

participant will favor to explain the event. Explanations can be negative, positive or ambiguous.

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Consequently, different kinds of biases can be assessed depending on the type of event presented

in the task. For example, a negativity bias can be inferred based upon how often a participant
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favors negative causes for ambiguous events (Franklin, Huppert, Langner, Leiberg, & Foa, 2005).
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A depressive bias can be inferred when a person attributes a negative event to internal, stable and
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global causes (Peterson et al., 1982).

2.4. Meta-analysis Procedure

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Based on Rosenthal (1991), the effect size r (ESr) of the difference in performance
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between the clinical group and the comparison group was calculated for each measure of social
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cognition in each study, either from the means and standard deviations, or from the t or F

statistics. These ESrs were then transformed to Fisher’s Z (Zr) for subsequent analyses. For

studies in which data were reported for different clinical subgroups (Montagne et al., 2008), Zrs

were pooled between the groups before further analysis. Moreover, when a study reported data

for several measures targeting the same social cognition domain (e.g. accuracy and sensibility

task in Poljac, Montagne, & de Haan, 2011; or 3 different mentalizing tasks in Sayin, Oral, Utku,

Baysak, & Candansayar, 2010), these Zrs were also pooled before further analysis. For studies

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where more than 1 control group was assessed, our main analyses were performed using the Zrs

calculated from the control group to which the clinical group was most similar (e.g. military

officers who took part in the same mission, but did not develop PTSD in Mazza et al., 2012).

Based on the Zrs of the individual studies, mean Zrs weighted for the size of the samples

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(corresponding to a fixed-effect model) were calculated for each anxiety disorder and each

domain of social cognition. These mean weighted Zrs were then converted back to ESr and

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transformed into Cohen’s d for presentation of results. We chose to use r as a measure of effect

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size because it allows the calculation of effect sizes based on t or F statistics when the means and

standard deviations are not provided in a paper. We then converted r into Cohen’s d since more

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people are familiar with this metrics, also making comparisons with other meta-analyses more

obvious.
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A negative effect size in mentalizing, emotion recognition and social
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perception/knowledge implies that anxious patients scored lower than non-clinical controls. For
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attributional style, a negative effect size implies that anxious patients displayed more negative, or

depressive, attributional style than the non-clinical controls. For each anxiety disorder and each
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domain of social cognition, we calculated a homogeneity statistic (Rosenthal, 1991) and

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examined the presence of outliers using focused tests (Rosenthal, 1991). Finally, for each social
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cognition domain, we also compared the mean effect sizes of the different anxiety disorders using

Hedges (1982) procedure.

3. Results

Altogether, forty studies were included in our analyses for a total of 1417 patients

presenting with an anxiety disorder and 1321 non-clinical controls. The characteristics and effect

sizes of these studies are shown in Table 1. As can be seen from Table 1, all diagnoses put

together, the large majority of studies (97.5%) measured either emotion recognition or attribution

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biases, whereas fewer studies (10%) assessed social perception/knowledge or mentalizing

performance. For some domains of social cognition, very few studies or no study at all were

available for some of the diagnoses (see Figures 1 and 2 for the number of studies by domain and

by diagnosis).

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3.1. Meta-analysis Results

Figure 1 shows the meta-analytic results for the 2 domains for which there was a

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sufficient number of studies for the meta-analysis, namely emotion recognition and attributional

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style. Compared to the other anxiety disorders, people with PTSD present a distinct pattern of

performance for both emotion recognition and attributional style. For the other two social

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cognition domains, mentalizing and social perception/knowledge, the number of studies was

insufficient to conduct a meta-analysis. While we nonetheless present the available effect-sizes

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for these two domains (Figure 2), this figure should be interpreted with caution.
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3.1.1. Emotion recognition. PTSD showed a large weighted mean effect size (d=-1.60;
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number of studies (k) =4) while SP (d=0.12; k=11), GAD (d=-0.12; k=2), OCD (d=-0.16; k=12)

and PD (d=-0.25; k=2) showed small effects on emotion recognition tasks. The mean effect size
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in SP was however affected by the presence of an outlier with a d=0.84 (i.e. significantly higher
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than the mean d=-0.23 of the other studies of the category; d ranging from -0.65 to 0.38). All
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subjects in that study (Arrais et al., 2010) were high-functioning university students that were not

necessarily seeking treatment for their SP, which might explain why they showed a pattern of

performance distinct from the subjects of the other studies. When this study was removed from

the analysis, the mean weighted effect size for SP dropped to d= -0.23. After removing that

outlier, the effect size in PTSD differed significantly from the effect sizes of SP (X2= 37.46, p<

0.05), GAD (X2= 24.36, p< 0.05), OCD (X2= 42.61, p< 0.05) and PD (X2= 24.26, p< 0.05). The

other differences between the diagnoses did not reach statistical significance (all p’s > 0.63).

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With the outlier removed for SP, there was no evidence of heterogeneity between the effect sizes

of the different studies for each anxiety disorder (all p’s > .06).

3.1.2. Attributional style. Large weighted mean effect sizes were observed for SP

(d=-1.15; k=6), GAD (d=-0.97; k=2), and PD (d=-0.97, k=4), whereas PTSD and OCD

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respectively showed small (d=0.08; k=2) and medium (d=-0.53; k=1) weighted mean effect sizes.

Again, PTSD differed significantly from SP (X2= 53.34, p< 0.05), GAD (X2= 26.32, p< 0.05) and

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PD (X2= 32.76, p< 0.05). None of the other differences between the different anxiety disorders

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reached statistical difference (all p’s > 0.17). Heterogeneity only reached significance for GAD

(X2=16.34, p<.001), for which the only two available studies showed significantly different

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patterns of results (d= -1.78 in Clark et al., 1997 vs. -0.28 in Riskind, Castellon, & Beck, 1989).

These discrepant results may be attributed to the different types of attributional biases assessed
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by each study (i.e. a negative bias in Clark et al., 1997 and a depressive bias in Riskind et al.,
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1989).
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3.1.3. Mentalizing. The four studies assessing mentalizing together provided data only

for PTSD, SP and OCD. The analysis yielded a large effect size for PTSD (d=-1.13; k=1)
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whereas SP and OCD showed effect sizes that were respectively almost null (d=0.04; k=1) or
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small (d=-0.30; k=2). The effect size observed for PTSD was significantly larger than the effect

size in SP (X2 = 5.92, p< 0.05) and was marginally different from the effect size in OCD (X2=
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3.76, p= 0.05). The last two diagnoses did not significantly differ from each other (p= 0.34).

Homogeneity was respected in OCD. No homogeneity test was conducted for the other categories

(PTSD and SP) as they contained only one study.

3.1.4. Social perception/knowledge. The only study that reported results concerning

social perception/knowledge was in SP and showed a medium effect size (d=-0.48; k=1). As only

one study was included in the category, no further analysis was conducted.

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3.2. Scoping Review and target areas for future work

As can be seen in Table 1, the interest in studying social cognitive performance of people

with anxiety disorder is relatively recent. Except for attributional style that has been studied for

about 20 years, it is only in the last 10 years that publications have targeted other domains with

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approximately 65% of studies published within the last five years. Compared to attributional style

and emotion recognition, mentalizing and social perception/knowledge were given minimal

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attention, with respectively 2 and 1 studies. For the domains that were of greater general interest

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for the researchers (i.e. emotion recognition and attributional style), certain disorders have been

set aside. For example, of the 31 studies found regarding emotion recognition, GAD and PD were

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only addressed by 2 studies each and only 4 studies targeted PTSD. Furthermore, attributional

style was mainly assessed in SP (6 studies) while sparse studies could be retrieved for the other
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disorders. More generally, there is a lack of studies assessing social cognition in more than one
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disorder, restricting the possibility to compare the different diagnoses. To date, only 4 of the 40
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studies in this review (10%) have covered more than 1 anxiety disorder diagnosis. Furthermore,

only 3 studies out of 40 (7.5%) addressed more than one domain of social cognition in the same
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patients, and none assessed all 4 domains. Data are thus insufficient to allow a more global
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understanding of the complete range of social cognitive abilities in the different anxiety
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diagnoses.

3.2.1. Social phobia. SP was the most studied disorder (17 studies), representing more

than 42% of the studies listed in Table 1. Men (43%) and women (57%) were almost equally

represented. Emotion recognition was the most studied aspect with 11 studies that assessed either

accuracy (9 studies) and/or sensibility (4 studies; see section 2.3.2 for the definition of accuracy

and sensibility). Attributional style was assessed in 6 studies, 5 of which (83%) used a measure of

negative bias while only 1 (17%) used a measure of depressive bias. Mentalizing and social

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perception/knowledge were each addressed in only one study. The lack of data on those two

domains represents a gap in the existing literature.

3.2.2. Posttraumatic stress disorder. Overall, 6 studies were conducted in PTSD,

representing 15% of the reviewed studies. The majority of those studies were conducted in male

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samples (88% of the subjects). Three types of trauma were targeted: war participation (4 studies),

partner violence (1 study) and refugees (1 study), the overrepresentation of men being driven

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mainly by war participants.

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The most studied domain was emotion recognition, evaluated in 67% of the PTSD

studies, though only 1 study comprised a sensibility index. The other domains were scarcely

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studied, with 2 studies of attributional style both focused on the depressive bias, one mentalizing

study that included two different verbal tasks, i.e. Strange stories test (Happe, 1994) and Emotion
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attribution task (Blair & Cipolotti, 2000; Mazza et al., 2007), and no study assessing social
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knowledge/perception in people with PTSD.

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3.2.3. Obsessive-compulsive disorder. Fourteen studies were found in OCD, making it

the second most studied anxiety disorder. Both genders were almost equally represented in the
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total sample.
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Eighty-six percent (86%) of the studies assessed emotion recognition, making it by far the
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most studied domain in OCD. The majority of those studies (92%) assessed the accuracy to

correctly label facial emotions whereas only 8% of these studies assessed sensibility.

Interestingly, OCD is the only disorder in which emotion recognition was studied using stimuli

other than emotional facial expressions, i.e. emotional prosody (Bozikas et al., 2009). Again, the

other domains of social cognition were scarcely studied. Of the 2 mentalizing studies, one used 3

different classical tasks, i.e. False beliefs (Baron-Cohen, 1989; Frith & Corcoran, 1996), Strange

stories (Happe, 1994) and Hinting task (Corcoran, Mercer, & Frith, 1995), and the other used a

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non-verbal mentalizing task (Fantie, 1989). The only one study of attributional style assessed the

negative bias. No study could be found for social perception/knowledge, restricting the

possibility of drawing conclusions regarding the performance of OCD patients across social

cognition domains.

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3.2.4. Panic disorder with or without agoraphobia. Only 6 studies dealt with PD.

About 35% of participants in the overall sample suffered also from agoraphobia, with women

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being over-represented (70% of participants).

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The most studied domain in PD was attributional style with 4 studies, 3 of which

measured the negative bias while the remaining one assessed the depressive bias. Finally, a gap in

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knowledge was identified for mentalizing and social perception/knowledge as no study targeted

these domains in PD.

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3.2.5. Generalized anxiety disorder. GAD was the least studied disorder with only 4
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studies, i.e. 10% of all the studies included in our analyses. Men were slightly under-represented
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relatively to women, counting for about 31% of the total sample.

Only two domains were assessed in GAD, namely emotion recognition and attributional
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style. Both studies of emotion recognition assessed accuracy. For attributional style, one study
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assessed the depressive bias and the other targeted the negative bias. Here again, a gap in
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knowledge was identified for mentalizing and social perception/knowledge as no study targeted

these domains in GAD.

4. Discussion

This meta-analysis and scoping review covered social cognition abilities in PTSD and SP

and compared these abilities to those found in other anxiety disorders, namely GAD, OCD and

PD. The results of the meta-analysis confirmed that social cognition deficits are present in

anxiety disorders, although the affected domains differ among anxiety disorders. Results were

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more robust for emotion recognition and attributional style, where more data were available, at

least for PTSD and SP. A serious lack of research in other domains of social cognition was

however highlighted, in particular for social perception/knowledge and mentalizing. The results

for these two last domains must thus be interpreted with caution, as the number of published

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studies is limited. Also for the other domains, variations in the number of studies found for the

different disorders must be kept in mind when interpreting the results, some disorders having

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received little interest.

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However, studying social cognition is particularly relevant for disorders that are stemming

from social-interpersonal difficulties such as SP, and that are more socially impairing like SP and

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PTSD. However, gaining data on social cognition in the other anxiety disorders is also important

in order to understand which impairments are due to a specific disorder and which belong to the
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general presence of anxiety. The availability of data concerning the entire range of anxiety
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disorders is thus required to allow comparisons between the disorders. In the long term, if social
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cognition abilities appear to have different presentations across the different disorders, it could

become a distinctive clinical tool to help for differential diagnoses.

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Despite the small number of published studies, our meta-analysis provides important
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results. Overall, the meta-analysis suggested that people who suffer from PTSD show a different
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pattern of social cognition performance compared to other anxiety disorders, while people

suffering from SP seem to show social cognition abilities similar to what is found in GAD, OCD

and PD. More specifically, available results suggested that people with PTSD present large

impairments in mentalizing (effect size d=-1.13) and emotion recognition (d=-1.60) tasks in

comparison to controls, and that these deficits are significantly larger than in most other anxiety

disorders. In contrast, available studies suggested that patients with SP, GAD, OCD or PD

principally present attribution biases (respectively d=-1.15, -0.97, -0.53 and -0.97) whereas the

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other social cognition domains do not seem as affected (ranging from d=-.48 to d=0.04).

Mentalizing and emotion recognition impairments in PTSD can be partly related to the

symptomatology of the disorder. Emotional numbing, one of the core symptoms of PTSD, is

defined by emotional response deficits and contributes to the emotional processing deficits

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reported in the disorder (American Psychiatric Association, 1994; Lanius et al., 2010; Litz &

Gray, 2002). Apart from being linked to emotion recognition deficits, emotional numbing has

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been related to impairments in mentalizing (Mazza et al., 2012). Furthermore, aberrant activity of

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brain regions highly implicated in emotion processing and mentalizing, including a hyperactive

amygdala and a hypoactive medial prefrontal cortex, has also been observed in patients with

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PTSD (Etkin & Wager, 2007; Koenigs & Grafman, 2009). Results concerning attributional biases

(overall effect size of d=.08) are more surprising, as cognitive biases are part of most cognitive
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theories on PTSD (Brewin & Holmes, 2003). However, only 2 studies assessed attributional style
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in PTSD and these results might deserve replication and comparison with other disorders before
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firm conclusions can be drawn. It is also possible that cognitive biases are more apparent in

situations that concern the traumatic event.

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The scoping review revealed differences across domains of social cognition in anxiety
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disorders. Mentalizing and social perception/knowledge were largely neglected across all anxiety
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diagnoses. Given that the effect size of the mentalizing deficit was large at least in the one study

targeting this ability in PTSD (d=-1.13), it would certainly be interesting to learn more about

mentalizing in PTSD. As for social perception/knowledge, the only study was conducted in SP

and showed an effect size in the medium range (d=-.48), suggesting that this social cognition

domain could be of relevance for patients with anxiety disorders.

Moreover, very few studies have directly compared patients with different anxiety

diagnoses in terms of their social cognition performance, and the few studies that did so included

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only two or three diagnoses (Amir, Foa, & Coles, 1998; Clark et al., 1997; Corcoran, Woody, &

Tolin, 2008; Heimberg et al., 1989; Rosmarin, Bourque, Antony, & McCabe, 2009), not the full

range of diagnoses. One factor that might contribute to the difficulty in comparing the different

diagnoses is the frequent presence of comorbidities between the different disorders in the same

t
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patient. In most studies, groups were differentiated according to the primary diagnosis, but it is

possible that a patient with a primary diagnosis of GAD also presents with a secondary diagnosis

cr
of OCD or major depressive disorder. Relatedly, variations in the composition of the samples

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across studies and the resulting disadvantage for between-studies comparisons support the need

for studies that assess all domains of social cognition in the same sample.

an
In conclusion, this study leads to two major results. First, PTSD seems particularly

impaired in certain domains of social cognition, namely emotion recognition and mentalizing,
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compared to other anxiety disorders. This emphasizes the different nature of PTSD compared to
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other anxiety disorders by highlighting the implication of different cognitive processes involved
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in understanding the social world. The classification of PTSD among the other anxiety disorders

has long been debated (Resick & Miller, 2009) and this disorder is now part of a new psychiatric
p

spectrum called trauma- and stressor-related disorders in the DSM-V (American Psychiatric
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Association, 2013). Our results thus provide further evidence of a distinct pattern of social
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cognitive functioning of people with PTSD compared to the rest of the anxiety disorder spectrum

and contributes to support this new classification. Second, there is a lack of research across

several domains of social cognition in anxiety disorders, which is even more drastic for

mentalizing and social perception/knowledge. Well-conducted research in these domains could

help refine our comprehension of anxiety disorders and bring to light more differences in social

cognitive capacities of people presenting with different anxiety disorders, abilities which can

have an impact on these patients’ functional recovery.

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Acknowledgements

This work was supported by studentships from the Faculté de médecine de l’Université

Laval and from the Fondation Robert-Giffard to India Plana. The authors report no potential

conflict of interest.

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Yoon, K. Lira, Fitzgerald, Daniel A., Angstadt, Mike, McCarron, Rosemary A., & Phan, K.

t
Luan. (2007). Amygdala reactivity to emotional faces at high and low intensity in

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generalized social phobia: A 4-Tesla functional MRI study. Psychiatry Research-
Neuroimaging, 154(1), 93-98. doi: 10.1016/j.pscychresns.2006.05.004

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Figure

Figure 1. Mean weighted effect sizes for domains

with enough studies to perform a meta-analysis

Emotion recognition

t
ip
0.4

cr
-0.12 -0.16
-0.4 -0.2 -0.25
Effect size (d)

us
-0.8

-1.2

an
-1.6
-1.6

-2
SP
(k=10)
M
PTSD
(k=4)
GAD
(k=2)
OCD
(k=12)
PD
(k=2)

Anxiety disorder
ed

Attributional style
pt

0.4
0.08
0
ce

-0.4
Effect size (d)

-0.53
Ac

-0.8

-0.97 -0.97
-1.2
-1.15

-1.6

-2
SP PTSD GAD OCD PD
(k=6) (k=2) (k=2) (k=1) (k=4)

Anxiety disoder

SP=social phobia, PTSD= posttraumatic stress disorder,

GAD= generalized anxiety disorder, OCD=
obesessive-compulsive anxiety disorder, PD= panic
disorder with/without agoraphobia Page 26 of 29
 Figure 2. Effect sizes for the domains laking studies
for a meta-analysis

Mentalizing

t
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0.4
0.04
0

cr
-0.4
Effect size (d)
-0.3

us
-0.8

-1.2
-1.13

an
-1.6

-2
SP
(k=1)
M
PTSD
(k=1)
GAD
(k=0)
OCD
(k=2)
PD
(k=0)

Anxiety disorder
ed

Social perception/knowledge
pt

0.4

0
ce

-0.4
Effect size (d)

-0.48
Ac

-0.8

-1.2

-1.6

-2
SP PTSD GAD OCD PD
(k=1) (k=0) (k=0) (k=0) (k=0)

Anxiety disorder

SP=social phobia, PTSD= posttraumatic stress disorder,

GAD= generalized anxiety disorder, OCD=
obesessive-compulsive anxiety disorder, PD= panic
disorder with/without agoraphobia Page 27 of 29
Table

Table 1. Characteristics and effect sizes for each study included in the meta-analysis and scoping
review
 
Anxiety n n % men Mean age Effect size (d)
disorder Patients Controls (PT/CO) (PT/CO)
Mentalizing
Jacobs et al. (2008) SP 28 21* 54/52 32.4/36.0 0.04

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Mazza et al. (2012) PTSD 20 15 - 41.1/36.8 -1.13

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Bozikas et al. (2009) OCD 25 25* 40/56 32.7/33.4 0.00
Sayin et al. (2010) OCD 30 30* 33/33 34.3/33.0 -0.55
Emotion recognition

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Arrais et al. (2010) SP 78 153* 38/35 22.3/21.4 0.84
Campbell et al. (2009) SP 12 28* 42/64 31.9/30.4 -0.32
Garner et al. (2009) SP 16 17* 31/53 43.1/39.9 -0.65

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Gilboa-Schechtman et al. (2008) SP 54 65* 48/48 29.9/27.6 -0.08
Study 2
Jacobs et al. (2008) SP 28 21* 54/52 32.4/36.0 -0.36
Joormann et al. (2006) SP 26 25* 38/32 30.2/31.6 0.06

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Mohlman et al. (2007) SP 26 26 38/35 21.5/21.1 -0.26
Montagne et al. (2006) SP 24 26* 42/46 36.7/37.6 -0.44
Phan et al. (2006) SP 10 10* 50/50 26.7/26.6 0.00
Straube et al. (2004) SP 10 10* 40/40 25.0/23.2 0.38
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Yoon et al. (2007) SP 11 11* 45/45 27.0/26.9 -0.24
Fonzo et al. (2010) PTSD 12 12 0/0 35.4/37.0 -0.82
Mazza et al. (2012) PTSD 20 15 - 41.1/36.8 -2.61
Poljac et al. (2011) PTSD 20 20* 100/100 42.1/41.7 -1.20
d
Schmidt et al. (2009) PTSD 16 16 50/50 44.1/36.5 -1.75
Etkin et al. (2011) GAD 43 32* 39/28 31.3/35.6 -0.10
Palm et al. (2011) GAD 15 16* 0/0 34.0/34.0 -0.18
te

Aigner et al. (2007) OCD 40 40* 60/60 34.8/34.7 -0.18

Bozikas et al. (2009) OCD 25 25* 40/56 32.7/33.4 -0.06
Buhlmann et al. (2004) OCD 20 20* 40/35 31.0/32.9 -0.59
p

Cardoner et al. (2011) OCD 21 21* 48/48 28.5/26.2 -0.71

Corcoran et al. (2008) OCD 40 36* 36a 34.0a -0.12
ce

PD 36 36* 0.04
Kornreich et al. (2001) OCD 22 22* - 37.3/37.2 0.00
Jhung et al. (2010) OCD 41 37* 78/76 24.9/26.0 -0.12
Lawrence et al. (2007) OCD 17 19* 59/58 34.9/34.0 -0.10
Ac

Lochner et al. (2012) OCD 20 20* 55/45 34.1/34.8 -0.18

Montagne et al. (2008) OCD 21 47 43/51 34.2/40.6 0.22
Parker et al. (2004) OCD 15 15* 47/20 37.7/31.3 -0.34
Pertusa et al. (2012) OCD 31 55 61/49 39.0/37.4 -0.14
Kessler et al. (2007) PD 37 43* 22/30 37.8/36.4 -0.51
Social perception/knowledge
Jacobs et al. (2008) SP 28 21* 54/52 32.4/36.0 -0.48
Attributional style
Amir et al. (1998) SP 32 15* 66/40 35.5/33.5 -1.37
OCD 13 15* 62/40 -/33.5 -0.53
Clark et al. (1997) study 2 SP 73 45* 19/31 34.9/33.0 -1.78
GAD 33 45* 30/31 40.1/33.0 -1.13
PD 45 45* 31/31 33.0/33.0 -0.97

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Heimberg et al. (1989) SP 45 22 51/36 31.7/34.7 -1.13
PD 50 22 25/36 37.2/34.7 -0.80
Rosmarin et al. (2009) SP 13 12* 44/29 37.6/37.5 -0.97
PD 12 12* 48/29 41.0/37.5 -0.97
Franklin et al. (2005) SP 15 14* 40/14 34.0/29.0 -0.95
Stopa et al. (2000) SP 20 20* 40/35 33.5/35.5 -1.23
McCormick et al. (1989) PTSD 26 73 100/100 38.9a 0.26
Solomon et al. (1991) PTSD 144 73 - - 0.00

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Riskind et al. (1989) GAD 12 66 58/- 29.4/- -0.28

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Clark et al. (1997) study 1 PD 20 20* 30/40 32.5/35.5 -1.30

PT= patients, CO= controls, SP= social phobia, PTSD= posttraumatic stress disorder, GAD= generalized anxiety

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disorder, OCD= obsessive-compulsive anxiety disorder, PD= panic disorder with/without agoraphobia
a  Data were only available for all participants with no distinction between groups.
* Studies in which control participants were screened to exclude any current axis 1 psychiatric diagnosis.  

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