Philippe R. Goldin

Social anxiety disorder (SAD) is characterized by high prevalence (12.1%),¹ early onset,² and low rates of spontaneous remission.³ Social anxiety disorder is linked to significant impairment in social, educational, and occupational functioning^4,5 and represents a substantial problem for society.^6,7 Individuals with SAD experience distressing levels of social fear, humiliation, and embarrassment⁸ and distorted beliefs about the social self.⁹

Social anxiety disorder is thought to be characterized by maladaptive self-views. This study investigated whether (a) patients with social anxiety disorder (n = 75) differ at baseline from healthy controls (n = 43) in negative and positive self-views, (b) cognitive-behavioral therapy (CBT) for social anxiety disorder versus wait-list control produces statistically and clinically significant changes in negative and positive self-views, (c) changes in self-views mediate the effect of CBT on social anxiety symptoms, and (d) changes in self-views during CBT related to social anxiety symptoms at 1-year post-CBT. As expected, patients endorsed more negative and fewer positive self-views than healthy controls at baseline. Compared to wait-list control, CBT yielded statistically and clinically significant changes, specifically, fewer negative and more positive self-views. Mediational analysis indicated that increased positive (but not reduced negative) self-views mediated the effect of CBT on social anxiety reduction. Correlational analyses determined that increased positive self-views were associated with social anxiety symptom reduction at 1-year post-CBT.

Social anxiety disorder (SAD) is widely thought to be characterized by heightened behavioral and limbic reactivity to socio-emotional stimuli. However, although behavioral findings are clear, neural findings are surprisingly mixed.

Social anxiety disorder (SAD) is thought to involve deficits in emotion regulation, and more specifically, deficits in cognitive reappraisal. However, evidence for such deficits is mixed.

To examine whether changes in cognitive reappraisal self-efficacy (CR-SE) mediate the effects of individually administered cognitive-behavioral therapy (I-CBT) for social anxiety disorder (SAD) on severity of social anxiety symptoms. A randomized controlled trial in which 75 adult patients (21-55 years of age; 53% male; 57% Caucasian) with a principal diagnosis of generalized SAD were randomly assigned to 16 sessions of I-CBT (n = 38) or a wait-list control (WL) group (n = 37). All patients completed self-report inventories measuring CR-SE and social anxiety symptoms at baseline and post-I-CBT/post-WL, and I-CBT completers were also assessed at 1-year posttreatment. Compared with WL, I-CBT resulted in greater increases in CR-SE and greater decreases in social anxiety. Increases in CR-SE during I-CBT mediated the effect of I-CBT on social anxiety. Gains achieved by patients receiving I-CBT were maintained 1-year posttreatment, and I-CBT-related increases in CR-SE were also associated with reduction in social anxiety at the 1-year follow-up. Increasing CR-SE may be an important mechanism by which I-CBT for SAD produces both immediate and long-term reductions in social anxiety.

Mindfulness-based stress reduction (MBSR) is thought to reduce emotional reactivity and enhance emotion regulation in patients with social anxiety disorder (SAD). The goal of this study was to examine the neural correlates of deploying attention to regulate responses to negative self-beliefs using functional magnetic resonance imaging. Participants were 56 patients with generalized SAD in a randomized controlled trial who were assigned to MBSR or a comparison aerobic exercise (AE) stress reduction program. Compared to AE, MBSR yielded greater (i) reductions in negative emotion when implementing regulation and (ii) increases in attention-related parietal cortical regions. Meditation practice was associated with decreases in negative emotion and social anxiety symptom severity, and increases in attention-related parietal cortex neural responses when implementing attention regulation of negative self-beliefs. Changes in attention regulation during MBSR may be an important psychological factor that helps to explain how mindfulness meditation training benefits patients with anxiety disorders.

Mindfulness-based stress reduction (MBSR) is an established program shown to reduce symptoms of stress, anxiety, and depression. MBSR is believed to alter emotional responding by modifying cognitive-affective processes. Given that social anxiety disorder (SAD) is characterized by emotional and attentional biases as well as distorted negative self-beliefs, we examined MBSR-related changes in the brain-behavior indices of emotional reactivity and regulation of negative self-beliefs in patients with SAD. Sixteen patients underwent functional MRI while reacting to negative self-beliefs and while regulating negative emotions using 2 types of attention deployment emotion regulation-breath-focused attention and distraction-focused attention. Post-MBSR, 14 patients completed neuroimaging assessments. Compared with baseline, MBSR completers showed improvement in anxiety and depression symptoms and self-esteem. During the breath-focused attention task (but not the distraction-focused attention task), they also showed (a) decreased negative emotion experience, (b) reduced amygdala activity, and (c) increased activity in brain regions implicated in attentional deployment. MBSR training in patients with SAD may reduce emotional reactivity while enhancing emotion regulation. These changes might facilitate reduction in SAD-related avoidance behaviors, clinical symptoms, and automatic emotional reactivity to negative self-beliefs in adults with SAD.