Anger profiles in social anxiety disorder

Accepted Manuscript Title: Anger Profiles in Social Anxiety Disorder Author: Mark V. Versella Marilyn L. Piccirillo Carrie M. Potter Thomas M. Olino Richard G. Heimberg PII: DOI: Reference:

S0887-6185(15)30030-X http://dx.doi.org/doi:10.1016/j.janxdis.2015.10.008 ANXDIS 1782

To appear in:

Journal of Anxiety Disorders

Received date: Revised date: Accepted date:

2-7-2015 21-8-2015 31-10-2015

Please cite this article as: Versella, Mark V., Piccirillo, Marilyn L., Potter, Carrie M., Olino, Thomas M., & Heimberg, Richard G., Anger Profiles in Social Anxiety Disorder.Journal of Anxiety Disorders http://dx.doi.org/10.1016/j.janxdis.2015.10.008 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Anger Profiles In Social Anxiety

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Anger Profiles in Social Anxiety Disorder

Mark V. Versella, Marilyn L. Piccirillo, Carrie M. Potter, Thomas M. Olino, and Richard G. Heimberg

Temple University

Correspondence concerning this article should be addressed to Richard G. Heimberg, Adult Anxiety Clinic of Temple, Department of Psychology, Temple University, 1701 North 13th Street, Philadelphia, PA, 19122-6085, United States. Email: [email protected]. Tel: (215) 204-1575. Fax: (215) 204-5539.

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Highlights     

Individuals with social anxiety disorder (SAD) exhibit elevated levels of anger. There is variability in the experience/expression of anger among persons with SAD. Latent class analysis revealed four anger profiles in a sample of persons with SAD. Profiles differed on measures of distress and impairment. Findings have implications for the tailoring of interventions for persons with SAD.

Abstract Individuals with social anxiety disorder (SAD) exhibit elevated levels of anger and anger suppression, which are both associated with increased depression, diminished quality of life, and poorer treatment outcomes. However, little is known about how anger experiences differ among individuals with SAD and whether any heterogeneity might relate to negative outcomes. This investigation sought to empirically define anger profiles among 136 treatment-seeking individuals with SAD and to assess their association with distress and impairment. A latent class analysis was conducted utilizing the trait subscales of the State-Trait Anger Expression Inventory-2 as indicators of class membership. Analysis revealed four distinct anger profiles, with greatest distress and impairment generally demonstrated by individuals with elevated trait anger, a greater tendency to suppress the expression of anger, and diminished ability to adaptively control their anger expression. These results have implications for tailoring more effective interventions for socially anxious individuals.

Keywords: social anxiety disorder, social phobia, anger, anger expression, anger suppression, latent class analysis

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Social anxiety disorder (SAD) is characterized by an intense fear of being negatively evaluated by others (Diagnostic and Statistical Manual of Mental Disorders, 5th edition; DSM-5; American Psychiatric Association [APA], 2013). Individuals with SAD report experiencing greater impairments in friendships and romantic relationships than peers (Montesi et al., 2013; Rodebaugh, 2009) and experience greater academic and occupational dysfunction (Aderka et al., 2012; Bruch, Fallon, & Heimberg, 2003; Schneier et al., 1994). SAD typically has an early onset, is chronic, and displays a low recovery rate among affected individuals (Davidson, Hughes, George, & Blazer, 1993). SAD is associated with deficits in emotion regulation (Spokas, Luterek, & Heimberg, 2009), typically defined as the active role individuals play in influencing their experienced emotions, how they experience and express emotions, and in which situations they experience certain emotions (Dennis, 2007; Gross, 1998). Individuals with SAD report avoidance and suppression of emotional expression (Spokas et al., 2009; Werner, Goldin, Ball, Heimberg, & Gross, 2011). This may partially stem from the beliefs that emotional expression is a sign of weakness and that emotions should be controlled at all times (Spokas et al., 2009). Individuals with SAD experience difficulty regulating anger. Elevated anger is an important clinical indicator of symptom severity in psychopathology, as it is associated with a variety of impairments, including a higher incidence of depression (Tafrate, Kassinove, & Dundin, 2002), a greater risk for suicide (Hawkins & Cougle, 2013), and increased stress (Clay, Anderson, & Dixon, 1993). Individuals with SAD report elevated levels of anger relative to nonanxious peers, including a greater disposition towards experiencing anger in a variety of situations (i.e., trait anger) and more frequently expressing anger in response to criticism or negative evaluation (angry reaction) and without provocation (angry temperament) (Erwin,

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Heimberg, Schneier, & Liebowitz, 2003). Further work has demonstrated that individuals with SAD also spend more time throughout the day experiencing anger than their nonanxious peers (Kashdan & Collins, 2010). Despite high levels of anger experience, individuals with SAD have also been shown to suppress the expression of anger more frequently than their nonanxious peers (Erwin et al., 2003; Moscovitch, McCabe, Antony, Rocca, & Swinson, 2008). Few studies have examined the direct association between anger-related concerns and broader impairment in SAD. In one such investigation, treatment-seeking individuals with SAD who endorsed greater trait anger, angry reaction, and anger suppression exhibited greater social anxiety and depression and lower perceived quality of life (Erwin et al., 2003). In addition, greater pre-treatment anger suppression and angry reaction predicted higher post-treatment scores on indices of social anxiety and depression, and greater trait anger predicted early attrition from treatment. The association between SAD and elevated anger may be understood if one thinks of anger as a socially contingent emotion. Anger is predominantly experienced during interpersonal interactions (Averill, 1983) and is typically thought of as a response to an impeded interpersonal goal (Berkowitz & Harmon-Jones, 2004). In the context of SAD, in which the goal is to achieve social acceptance, the belief that one is being negatively evaluated in social situations may lead to fears of social rejection, which has been demonstrated to provoke anger in socially anxious individuals (Fitzgibbons, Franklin, Watlington, & Foa, 1997; Leary, Twenge, & Quinlivan, 2006). Thus, their angry response may be related to the perception that rejection is an obstacle to belonging. In support of this line of reasoning, elevated social anxiety is associated with greater state anger after listening to vignettes designed to elicit social rejection (Breen & Kashdan, 2011).

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The majority of individuals with SAD display passive interpersonal behavior theoretically consistent with the diagnosis (e.g., lack of assertiveness, submissive behavior, suppression of anger expression); however, there appears to be a subset of individuals with SAD who exhibit externalizing behavior, including outwardly directed anger expression, contrary to the prototypical presentation of SAD (Galbraith, Heimberg, Wang, Schneier, & Blanco, 2014; Kachin, Newman, & Pincus, 2001; Kashdan, Elhai, & Breen, 2008; Kashdan & Hofmann, 2008; Kashdan, McKnight, Richey, & Hoffman, 2009). This pattern was demonstrated in 21% of persons with SAD in a large community sample (Kashdan et al., 2009). This subgroup was also more likely to engage in problematic substance use and other high-risk behaviors. It is possible that these behaviors have multiple functions, including ingratiating oneself to a deviant peer group, but they may also represent an attempt to keep other people at a distance to reduce anxiety or the possibility of rejection. The current study sought to further elucidate the association between anger and SAD and to capture variations of anger presentations across individuals with SAD. To do so, we utilized latent class analysis (LCA) to examine whether there are distinct patterns of anger-related symptoms among individuals with SAD. We also assessed the external validity of anger profiles by evaluating their association with a range of clinical features related to SAD and anger expression (severity of social anxiety; fear of negative evaluation; interpersonal problems related to being vindictive, non-assertive, or socially inhibited; fearful reactions to one’s own anxious or angry emotions; shame; depression; and a history of childhood emotional abuse or neglect). We expected (1) that there would be distinct anger profiles among individuals with SAD, (2) that at least some of these classes would differ on the degree of anger experienced, the tendency to

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outwardly express anger, and the tendency to suppress the expression of angry feelings, and (3) that these classes would vary on indices of distress and impairment. Method Participants Participants (N = 136) were individuals with a principal diagnosis of SAD who sought treatment at the Adult Anxiety Clinic of Temple University (AACT) between 2004 and 2014. The mean age was 28.95 years (SD = 11.01, range 18-68 years), and 52.9% were male. A majority of the participants were Caucasian (n = 87, 64%) and similar percentages of individuals were employed full-time (n = 41, 30.1%) or full-time students (n = 40, 29.4%). The majority of individuals were single and had never been married (n = 102, 75%). All data were collected at baseline before the initiation of treatment, which was delivered as part of randomized controlled trials (RCTs) or open treatment. Because participants were drawn from both RCT and open treatment samples, there were no specific exclusion criteria for this study. Only those criteria that were related to a participant’s ability to complete the diagnostic interview and questionnaires or to give valid informed consent applied, e.g., active suicidality or self-harm, substance use, or cognitive impairment. All procedures of the original studies for which participants were recruited were conducted in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1964, as revised (World Medical Association, 2013). Informed consent was obtained from all participants, both for the use of their data in the original RCTs (if applicable) and for the use of their deidentified data in later research. Measures Diagnostic Interview

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Anxiety Disorders Interview Schedule for DSM-IV: Lifetime Version (ADIS-IV-L). The ADIS-IV-L (T. Brown, Di Nardo, & Barlow, 1994) is a semi-structured clinical interview assessing DSM-IV criteria for anxiety, depressive, somatoform, and substance use disorders. Each disorder is assigned a clinician’s severity rating (CSR) of symptom-related distress and impairment ranging from 0 (None) to 8 (Very Severe), and CSR scores of 4 or higher indicate distress and impairment sufficient to meet diagnostic thresholds. All clinicians using the ADISIV-L were doctoral students with the equivalent of master’s degree training, postdoctoral fellows in clinical psychology, or clinical psychologists who were trained to reliability standards put forth by the ADIS developers (T. Brown, Di Nardo, Lehman, & Campbell, 2001). The social anxiety module of the ADIS-IV-L has demonstrated excellent inter-rater reliability for the current principal diagnosis of SAD (к = .77; T. Brown et al., 2001). A random sampling of 20 ADIS-IV-L interviews from the AACT was reviewed by blind reliability coders. There was 100% (κ = 1.00) agreement with the original principal diagnosis. Indicators of Latent Class Membership State-Trait Anger Expression Inventory, 2nd edition (STAXI-2). The 57-item STAXI-2 (Spielberger, 1999) was used to determine latent classes of anger symptoms. The STAXI-2 measures anger both as an emotional state (state anger; not included in the present analyses) and dispositional trait, as well as how individuals express and control their angry feelings. Trait, but not state, subscales were used in the LCA, as we sought to examine the hypothesis that there would be distinct classes based on more-or-less enduring patterns of anger experience and expression. The trait anger-angry temperament (T-ANG/T), trait anger-angry reaction (T-ANG/R), anger expression-in (AX-I), anger expression-out (AX-O), anger control-in (AC-I), and anger control-out (AC-O) subscales were used in this study. Each of the trait anger

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subscales consists of 4 items. Items from the trait anger subscales use the stem “How I generally feel…” and examples include “Quick-tempered” (T-ANG/T) and “I get angry when I’m slowed down by others’ mistakes” (T-ANG/R). The anger expression and anger control subscales consist of 8 items. Items from the Anger Expression subscales use the stem “How I generally react or behave when angry or furious…” and examples include “I strike out at whatever infuriates me” (AX-O, an index of the tendency to express anger outwardly toward other people/objects in the environment) and “I boil inside, but I don't show it” (AX-I, an index of the tendency to suppress the expression of angry feelings). Items from the Anger Control subscales also use the stem “How I generally react or behave when angry or furious…” and examples include “I take a deep breath and relax” (AC-I, an index of generally adaptive attempts to control one’s angry feelings through calming down or cooling off), and “I am patient with others” (ACO, an index of generally adaptive attempts to control the expression of angry feelings). Subscales of the STAXI-2 (other than the state anger scale) use a 4-point Likert-type scale ranging from 1 (Almost never) to 4 (Almost always). Administrations of the STAXI-2 have demonstrated excellent reliability and good convergent validity with measures of hostility, neuroticism, and psychoticism as measured by the Eysenck Personality Questionnaire (EPQ; Eysenck & Eysenck, 1975), as well as systolic and diastolic blood pressure (Spielberger, 1999). Divergent validity has been demonstrated by a lack of correlation between the STAXI-2 subscales and the State-Trait Personality Inventory Curiosity subscale and the EPQ Extraversion subscale (Spielberger, 1999). Factor analysis supports the use of individual subscales (Spielberger, 1999; Spielberger & Reheiser, 2009). The subscales have also demonstrated adequate reliability and validity (Spielberger, 1999). The internal consistency of the subscales used in this study ranged from

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adequate to good, T-ANG/T (α = .83), T-ANG/R (α = .83), AX-I (α = .83), AX-O (α = .69), ACI (α = .88), and AC-O (α = .82). External Validators Social Interaction Anxiety Scale (SIAS). Social interaction anxiety was measured using the SIAS (Mattick & Clarke, 1998), a 20-item self-report measure that uses a Likert-type scale ranging from 0 (Not at all characteristic of me) to 4 (Extremely characteristic of me). The SIAS has been widely used in the assessment of social anxiety and has shown good reliability and validity in a number of studies (e.g., E. Brown et al., 1997; Mattick & Clarke, 1998; Rodebaugh, Woods, Heimberg, Liebowitz, & Schneier, 2006). Specifically, individuals with SAD score higher on the SIAS than individuals with other anxiety disorders and normal controls (E. Brown et al., 1997; Mattick & Clarke, 1998). SIAS scores are also more strongly correlated with other measures of social anxiety than measures of general distress and depression (Heimberg, Mueller, Holt, Hope, & Liebowitz, 1992; Mattick & Clarke, 1998). Recent studies have demonstrated that the three reverse-worded items do not contribute and potentially detract from the validity of the scale (e.g., Rodebaugh et al., 2011). Thus, only the straightforwardly worded items were summed to create a total score (SIAS-S; Rodebaugh, Woods, & Heimberg, 2007). Internal consistency of the SIAS-S was good (α = .90) in this sample. Brief Fear of Negative Evaluation Scale (BFNE). Fear of negative evaluation was measured using the BFNE (Leary, 1983), a 12-item self-report measure that uses a 5-point Likert-type scale ranging from 1 (Not at all characteristic of me) to 5 (Extremely characteristic of me). This measure has been shown to be psychometrically sound (Carleton, McCreary, & Norton, 2006); however, recent research supports the use of the straightforward items only

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(BFNE-S; Rodebaugh et al., 2004, 2011; Weeks et al., 2005), as was done in this study. Internal consistency of the BFNE-S in this sample was excellent (α = .94). Inventory of Interpersonal Problems – 64-item version (IIP-64). Interpersonal problems were measured using the IIP-64 (Alden, Wiggins, & Pincus, 1990), a 64-item selfreport measure that uses a 5-point Likert-type scale ranging from 0 (Not at all) to 4 (Extremely). The 64 items include eight 8-item subscales that measure different facets of interpersonal problems: Domineering-Controlling, Intrusive-Needy, Self-Sacrificing, Overly Accommodating, Non-Assertive, Socially Inhibited, Cold-Distant, and Vindictive-Self Centered. The VindictiveSelf Centered, Non-Assertive, and Socially Inhibited subscales were selected for use in this study on an a priori basis because we believed them to be the most relevant to the current thesis and to restrict the number of tests conducted. Reliabilities of the subscales range from α = .72 to .88 (Vittengl, Clark, & Jarrett, 2003). Internal consistency of the IIP-64 in this sample was adequate for the Vindictive Self-Centered subscale (α = .80) and for the Socially Inhibited subscale (α = .84) and good for the Non-Assertive subscale (α = .88). Affective Control Scale (ACS). Fear of one’s behavioral reactions to or loss of control over emotions was measured using the ACS (Williams, Chambless, & Ahrens, 1997), a 42-item self-report measure that uses a 7-point Likert-type scale ranging from 1 (Very Strongly Disagree) to 7 (Very Strongly Agree). The ACS has four subscales addressing Anger, Depressed Mood, Anxiety, and Positive Affect; the Anger and Anxiety subscales were selected for use in this study based on the reasoning expressed for the IIP-64. Higher scores indicate greater fear over behavioral reaction to emotions or losing control over emotions (Williams et al., 1997). Previous administrations of the ACS have repeatedly demonstrated its validity (Sexton & Dugas, 2009; Spokas et al., 2009). Further research has shown empirical support for use of the subscales

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(Melka, Lancaster, Bryant, Rodriguez, & Weston, 2011). The internal consistency of the Anger subscale (α = .80) and the Anxiety subscale (α = .86) was good in this sample. Internalized Shame Scale (ISS). Internalized shame was measured using the ISS (Cook, 1987), a 30-item self-report scale that uses a 5-point Likert-type scale ranging from, 0 (Never) to 4 (Almost always). The ISS contains two subscales measuring internalized shame and selfesteem/response set bias, respectively. This study utilized only the 24-item internalized shame score (Del Rosario & White, 2006). Previous administrations of the ISS have demonstrated good reliability (Cooke, 1993; Del Rosario & White, 2006). Internal consistency of the ISS in this sample was excellent (α = .96). Beck Depression Inventory – II (BDI-II). Depressive symptoms were assessed using the BDI-II (Beck, Steer, & Brown, 1996). The BDI-II is a 21-item self-report measure that uses a 4-point scale to assess thoughts and feelings associated with depression. Previous administrations of the BDI-II have demonstrated strong test-retest reliability and validity (convergent and divergent) (Beck et al., 1996; Riskind, Beck, Berchick, Brown, & Steer, 1987). Scores from 14 to 19 indicate mild depression, 20-28 indicate moderate depression, and above 29 suggest severe depression (Beck et al., 1996). Administration of the BDI-II in this sample demonstrated excellent internal consistency (α = .93). Childhood Trauma Questionnaire – Short Form (CTQ-SF). History of childhood maltreatment was assessed using the CTQ-SF (Bernstein et al., 2003). The CTQ-SF is a 28-item self-report measure divided into 5 subscales measuring sexual abuse, physical abuse, physical neglect, emotional abuse, and emotional neglect (plus 3 filler items). The emotional abuse and emotional neglect subscales were selected for use in this study on an a priori basis to restrict the number of tests conducted. Our previous research on the effects of childhood trauma on clinical

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presentation, and response to both pharmacotherapy and cognitive behavioral therapy for SAD (Bruce, Heimberg, Blanco, Schneier, & Liebowitz, 2012; Bruce, Heimberg, Goldin, & Gross, 2013) suggested that these aspects of childhood trauma were the most relevant. Each item is rated from 1 (Never true) to 5 (Very often true). Clinically significant emotional abuse is indexed by scores ≥ 10 and clinically significant emotional neglect by scores ≥ 15 (Walker et al., 1999). The CTQ-SF and its subscales have been shown to have strong reliability and validity in previous studies (Bernstein et al., 2003; Scher, Stein, Asmundson, McCreary, & Forde, 2001). The internal consistency of the emotional abuse subscale in this sample was excellent (α = .91); the internal consistency for the emotional neglect subscale was adequate (α = .81). Data Analysis All statistical analyses were performed with MPlus Version 7.31 (Muthen & Muthen, 1998-2015) and SPSS Version 21.0 (IBM Corp., 2012). Latent class analysis (LCA) was used to identify anger profiles among individuals with SAD. As opposed to variable-centered approaches (e.g., factor analysis, structural equation modeling), LCA considers relations among individuals to classify them into homogeneous “classes” that differ in terms of the frequency, severity, and/or quality of their anger symptoms (Muthén & Muthén, 2000). LCA does not require pre-determined assumptions about the structure of these classes (Beauchaine, 2003). In the present LCA, six subscales of the STAXI, treated as continuous variables, were entered as indicators of class membership. MPlus uses Full Information Maximum Likelihood estimation to handle missing data, and all participants were included in all analyses. The LCA procedure began with a one-class unconditional model, and the number of classes was increased until there was no significant improvement to model fit (Nylund, Asparouhov, et al., 2007; Nylund, Bellmore, et al., 2007). First, the Akaike Information Criterion

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(AIC; Akaike, 1987), Bayesian Information Criterion (BIC; Schwartz, 1978), and sample-size adjusted BIC (ABIC; Sclove, 1987) were examined. The model that produced the smallest values on these indices was considered to have the best fit. Second, the Bootstrap Likelihood Ratio Test (BLRT) was examined to determine whether a model with k classes significantly improved model fit over a model with k – 1 classes (Nylund, Asparouhov, et al., 2007; Nylund, Bellmore, et al., 2007). Third, models were examined to determine if they were theoretically sound and clinically meaningful. Fourth, the size of the smallest class was considered. Any classes composed of approximately 5% or less of the total sample would suggest over-fitting of the data and that the classes might be difficult to replicate in other samples. Further, power to detect differences on classes of this size (n = ~7 cases) would be quite limited. Following the identification of latent classes, we tested whether classes differed on a range of demographic characteristics as well as clinical features related to SAD, including social anxiety and fear of negative evaluation, interpersonal problems, fear of anxiety and anger, shame, depressive symptoms, and a history of childhood emotional trauma. The test of equality of means holds class membership constant and provides omnibus and pairwise comparisons across latent classes in the form of χ2 analyses for continuous variables and logistic regression analyses for categorical variables. These analyses were conducted using the AUXILIARY command and BCH option (Asparouhov, & Muthén, 2014) for continuous outcomes and DCATEGORICAL for categorical outcomes. Pairwise comparisons were interpreted if the omnibus tests were significant (p < .05).

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Descriptive Statistics (see Table 1) Individuals in the sample had high levels of social anxiety as measured by the SIAS-S. Most individuals in the sample experienced mild levels of depressive symptoms. Levels of TANG/T, T-ANG/R, AX-I, AX-O, AC-I, and AC-O varied but, for the sample as a whole, were roughly consistent with scores of the STAXI-2 development sample (Spielberger, 1999).

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Table 1. Descriptive statistics for STAXI-2 subscale scores, and external validators

M

SD

Range

% Missing

Trait Anger Angry Temperament

6.08

2.24

4 - 14

0.00 %

Trait Anger Angry Reaction

8.83

3.06

4 – 16

0.00 %

Anger Expression-Out

13.78

3.32

8 – 24

0.00 %

Anger Expression-In

20.34

5.05

8 – 32

0.00 %

Anger Control-Out

23.29

4.62

13 – 32

0.00 %

Anger Control-In

20.56

4.82

10 – 32

0.00 %

SIAS-S

43.46

11.55

5 – 62

0.08 %

BFNE-S

49.37

8.15

21 – 60

0.07 %

IIP Socially Inhibited

21.59

6.59

0 – 32

27.2 %

IIP Non-Assertive

19.56

6.85

1 – 32

25.0 %

IIP Vindictive-Self Centered

9.09

6.01

0 – 26

25.7 %

ACS Anger

28.65

8.40

12 – 49

29.4 %

ACS Anxiety

62.48

11.94

34 – 87

30.9 %

ISS

64.17

22.30

1 – 120

24.3 %

BDI-II

17.37

11.03

0 – 51

15.4 %

CTQ Emotional Abuse

7.30

5.42

0 – 23

0.04 %

CTQ Emotional Neglect

14.21

4.38

5 – 22

0.07 %

STAXI-2 Subscale Scores

External Validators

Note. SIAS-S = Social Interaction Anxiety Scale-Sum of Straightforwardly Scored Items; BFNE-S = Brief Fear of Negative Evaluation-Sum of Straightforwardly Scored Items; IIP = Inventory of Interpersonal Problems; ACS = Affective Control Scale; ISS = Internalized Shame Scale; BDI-II = Beck Depression Inventory – II; CTQ = Childhood Trauma Questionnaire.

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Latent Class Analysis LCA models indicated that the lowest BIC was found in the five-class model, and the lowest AIC and ABIC were found in the six-class model (Table 2). However, the five and sixclass models each produced small classes that were composed of only 5.8% (n = 8) of the sample. These small classes suggest that the five and six-class models were unlikely to be replicated; therefore, they were not considered further. Of the remaining models, the four-class model produced the lowest BIC, AIC, and ABIC, and the BLRT indicated that it provided an improvement in fit over the other models. Therefore, the four-class model appeared to be the most statistically sound. Mean STAXI-2 subscale scores across the four classes are displayed in Figure 1. Item means are presented in Figure 1 for ease of interpretation; however, unstandardized scores were entered into the LCA.1 Consistent with LCA conventions, we named the classes based on the frequency and quality of the profiles of responses regarding individuals’ anger symptoms. The Low Anger/High Control class (n = 28) displayed the lowest trait anger scores and anger expression scores and the highest anger control scores, suggesting the least problems with angry feelings and the most adaptive tools for dealing with them. The Moderate Anger/Low Control class (n = 21) displayed trait anger scores intermediate to the other classes but scored the lowest on the anger control subscales, suggesting that they were less equipped to adaptively deal with their anger. The Low Anger/Moderate Control class (n = 69) exhibited lower scores on trait anger and anger expression outward relative to the Moderate Anger/Low Control and High Anger/High Suppression classes. This class exhibited moderate scores on the anger control subscales that fell between the other three classes. The High Anger/High Suppression class (n =

1

A version of Figure 1 that includes unstandardized STAXI-2 scores is available upon request from the corresponding author.

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Table 2. Fit indices for latent class analysis models with 1-6 classes Number of classes

Number of free parameters

Log likelihood

AIC

BIC

ABIC

Smallest

BLRT Entropy

Class Size

1

12

-2222.288

4468.576

4503.528

4465.567

136(100%) N/A

2

19

-2116.226

4270.452

4325.792

4265.686

34(25%)

<.001

0.890

3

26

-2091.243

4234.485

4310.214

4227.965

16(12%)

<.001

0.894

4

33

-2073.113

4212.226

4308.343

4203.949

18(13%)

<.001

0.868

5

40

-2054.213

4188.426

4304.932 a

4178.394

8(6%)

<.001

0.882

6

47

-2039.506

4173.012 a

4309.907

4161.225 a

8(6%)

<.001

0.884

Note. AIC = Akaike Information Criterion; BIC = Bayesian Information Criterion; ABIC = sample-size Adjusted BIC; BLRT = Bootstrap likelihood ratio test. a

Indicates best fitting model according to each index.

-

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4 3.75 3.5 3.25 3 2.75 2.5 2.25 2 1.75 1.5 1.25 1 Trait Anger - Trait Anger Anger Anger Anger Control Anger Control Angry Angry Reaction Expression Out Expression In Out In Temperament High Anger/High Suppression Low Anger/Moderate Control Moderate Anger/Low Control Low Anger/High Control

Figure 1. Average STAXI-2 subscale scores for each class in the four-class model. Note: Item means for STAXI-2 subscale scores are presented here for ease of interpretation.

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18) exhibited the highest trait anger and anger suppression scores of all classes and demonstrated lower scores on the anger control subscales than the Low Anger/High Control class, suggesting that they have the greatest challenges in several anger domains, as they are the most angry, the most likely to suppress the expression of those feelings, and among the least equipped to deal with their anger adaptively. Comparisons of Demographic Characteristics among Classes Classes did not differ on age (2 ≥ 0.53, p = .913), gender (2 (3) = 2.33, p = .51), marital status (single/never married, married, divorced/separated); 2 (6) = 8.98, p = .175), race (Caucasian, other); 2 (3) = 4.00, p = .26), or employment status (full time worker, part time worker, other); 2 (6) = 7.28, p = .29). Comparisons of Symptom Severity and Impairment among Classes (see Table 3) Omnibus χ2 analyses revealed significant between-class differences on fear of negative evaluation; vindictive/self-centered interpersonal problems; concerns about behavioral expression and control of anger and anxiety; internalized shame; depressive symptoms; and childhood emotional abuse. Follow-up pairwise comparisons indicated that the High Anger/High Suppression and Moderate Anger/Low Control classes endorsed higher levels of vindictive/selfcentered interpersonal problems than the Low Anger/High Control and Low Anger/Moderate Control classes (2s ≥ 4.00, ps ≤ .045) and greater childhood emotional abuse and shame than the Low Anger/Moderate Control class (2s ≥ 4.42, ps ≤ .035). The High Anger/High Suppression and Moderate Anger/Low Control classes also endorsed higher levels of depressive symptoms than the Low Anger/Moderate Control Class (2s ≥ 7.67, ps ≤ .006). The High Anger/High

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Table 3. Comparisons of external validators in the four-class model Class 1:

Class 2:

Class 3:

Class 4:

Low Anger/

Moderate Anger/ Low Control (n = 21)

Low Anger/ Moderate Control

High Anger/ High Suppression

(n = 69)

(n = 18)

High Control (n = 28)

Omnibus χ2 test

Pairwise Comparisons

M

SE

M

SE

M

SE

M

SE

2

p

SIAS-S

44.38

2.90

44.47

2.45

41.92

1.60

46.20

2.07

2.77

.429

-

BFNE-S

29.07

1.85

32.26

1.61

31.35

0.79

34.31

1.11

7.97

.047

4>3,1

IIP – Socially Inhibited

21.62

1.81

21.27

1.90

21.13

0.97

23.57

1.11

3.05

.384

-

IIP – Non-Assertive

20.11

2.00

20.91

1.80

18.60

1.00

20.52

1.61

1.79

.616

-

IIP – Vindictive/Self-centered

6.73

1.24

12.01

1.57

7.59

0.75

14.27

1.78

19.66

<.001

4,2>3,1

ACS - Anger

24.67

1.69

32.31

1.72

26.32

1.23

37.95

1.75

43.00

<.001

4>2>3,1

ACS - Anxiety

60.24

2.57

68.80

1.83

60.34

2.08

64.58

3.84

12.53

.006

2>3,1

Internalized Shame Scale

64.93

5.63

74.65

4.32

57.55

3.29

73.32

5.89

11.85

.008

4,2>3

Beck Depression Inventory - II

16.03

2.68

22.69

2.41

14.51

1.35

23.94

3.12

14.16

.003

4,2>3

CTQ – Emotional abuse

6.67

0.91

9.20

1.31

5.89

0.64

11.05

1.65

12.09

.007

4,2>3, 4>1

Anger Profiles In Social Anxiety CTQ – Emotional neglect

13.63

22 0.92

14.50

1.05

13.99

0.58

15.86

1.13

2.83

.419

-

Note. SIAS-S = Social Interaction Anxiety Scale-Sum of Straightforwardly Scored Items; BFNE-S = Brief Fear of Negative Evaluation-Sum of Straightforwardly Scored Items; IIP = Inventory of Interpersonal Problems; ACS = Affective Control Scale; CTQ = Childhood Trauma Questionnaire. All pairwise comparisons are significant at the p < .05 level. Significant findings are marked in bold print.

Anger Profiles In Social Anxiety

23

Suppression class reported greater childhood emotional abuse than the Low Anger/High Control class (2s ≥ 5.59, ps ≤ .018) and greater fear of negative evaluation than both the Low Anger/High Control and Low Anger/Moderate Control classes (2s ≥ 4.65, ps ≤ .031). The High Anger/High Suppression class also exhibited greater concerns about behavioral expression and control of anger (but not anxiety) than all of the other classes (2s ≥ 5.77, ps ≤ .016), whereas the Moderate Anger/Low Control class exhibited greater concerns about behavioral expression and control of both anger and anxiety than the Low Anger/High Control and the Low Anger/Moderate Control classes (2s ≥ 4.79, ps ≤ .029). Omnibus χ2 analyses revealed no significant between-class differences on social anxiety, IIP-Socially Inhibited, IIP-Non-Assertive, or childhood emotional neglect. Discussion The investigation revealed four distinct anger profiles among individuals with SAD. Consistent with previous literature examining affective expression in SAD (e.g., Kachin et al., 2001; Kashdan et al., 2009), these profiles revealed heterogeneity in anger experience and expression across classes of individuals with SAD and were differentially associated with indices of distress and impairment. These findings suggest that anger in SAD is experienced and expressed differently across individuals with this disorder. The High Anger/High Suppression class exhibited elevated scores on both trait anger subscales relative to the other groups. In addition, this class exhibited elevations on both anger expression subscales, with especially high scores for anger suppression. Furthermore, this class displayed poorer ability to control their anger compared to the Low Anger/High Control and Low Anger/Moderate Control classes. This suggests a class of individuals that is highly prone to experiencing anger and which has little ability to adaptively control their anger when it arises.

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24

Furthermore, their scores on trait anger-angry reaction were higher than their scores on trait anger-angry temperament, suggesting that provocation by others plays an important role in their experience of anger. However, they may find themselves in a complex approach-avoidance conflict regarding their anger – their high scores on trait anger and anger expression are surpassed by their still higher scores on anger suppression. The Moderate Anger/Low Control class exhibited the least adaptive control of anger and the highest outward anger expression of the four classes (although similar on the latter to the High Anger/High Suppression class). This class includes individuals who experience anger at a normative frequency but who have trouble controlling their outward anger expression and utilizing adaptive anger control strategies. A majority of the sample fell in the Low Anger/Moderate Control class. Trait anger scores for this class were the second lowest among the four classes. Furthermore, this class displayed lower scores on outward anger expression relative to other classes and did not exhibit impairment in controlling outwardly directed anger. Thus, it appears that most individuals in this class do not experience pervasive anger problems, but when anger does occur, they tend to suppress the expression of these feelings. The Low Anger/High Control class displayed the lowest scores on all trait anger and anger expression scales and highest scores on anger control scales relative to other classes. This class demonstrates few anger-related issues and appears to be relatively able to manage their anger when it does arise. Results of the between-class comparisons of external validators support our expectation that the classes would have different clinical features. Importantly, classes did not differ in severity of social interaction anxiety. This may be due to the nature of our treatment-seeking sample, which was generally high in social anxiety. However, Erwin et al. (2003) reported a

Anger Profiles In Social Anxiety

25

correlation of .49 (p < .001), between anger suppression and social interaction anxiety in a clinical sample of patients with SAD, which might lead to the expectation that the High Anger/High Suppression class would have had higher SIAS-S scores than the other classes. Although this was not the case, the High Anger/High Suppression class did score higher than the two Low Anger classes on fear of negative evaluation, a central feature of SAD (APA, 2013). This class also scored higher than all other classes on the measure of fear of the consequences of failure to control their anger (ACS Anger). Previous research (Leary et al., 2006) has suggested that fear of being negatively evaluated or rejected may provoke anger in socially anxious individuals. Our findings suggest that this may be accompanied by fear of the consequences of expressing that anger and the tendency to suppress rather than express. A clear pattern of impairment emerged, with the High Anger/High Suppression and Moderate Anger/Low Control classes displaying greater general impairment across external outcomes than the Low Anger/Moderate Control and Low Anger/High Control classes, consistent with previous research linking elevated anger in SAD to greater global impairment (Erwin et al., 2003). These classes demonstrated elevated feelings of inferiority and worthlessness, as measured by the ISS, and higher scores on the vindictiveness/self-centered scale of the IIP-64, indicating problems with hostile dominance and irritability. This is consistent with these classes’ elevated outward anger expression and lends support to existing research demonstrating the existence of a subgroup of socially anxious individuals who exhibit externalizing, aggressive behavior (e.g., Kachin et al., 2001; Kashdan, Elhai, & Breen, 2008). In addition, the same pattern of differences among classes was found in reported childhood emotional abuse. The High Anger/High Suppression and Moderate Anger/Low Control classes displayed the poorest ability to adaptively control their anger. It is possible that childhood

Anger Profiles In Social Anxiety

26

emotional abuse gave rise to greater experience of anger and vindictiveness, which in turn, may have fueled feelings of worthlessness and shame. However, the causal chain suggested here is speculative, and future studies should explore the mechanisms behind these relationships within the context of SAD. Following with this pattern, the High Anger/High Suppression and Moderate Anger/Low Control classes displayed greater levels of self-reported depressive symptoms. Depressive symptoms are very common among persons with SAD, and depressive disorders and SAD are often comorbid (e.g., T. Brown, Campbell, Lehman, Grisham, & Mancill, 2001; Kessler, Stang, Wittchen, Stein, & Walters, 1999). Previous research has demonstrated a relationship between anger and depressive symptoms among individuals with SAD (Erwin et al., 2003) and that the magnitude of the relationship between SAD and anger is attenuated when controlling for depressive symptom levels. These findings suggest a complex, potentially reciprocal, relationship between anger and depression in SAD, and this is a fertile topic for future research. The present study has several limitations. First, the anger classes were derived from a single self-report measure of anger. Future studies including other objective types of anger measurements (e.g., clinician-administered assessments, behavioral observations, physiological measures) are necessary to examine how anger experience and expression/suppression manifest across individuals with SAD. Second, the present analyses were exploratory in nature, which increases the chance of Type-1 error. In addition, the sample was relatively small, potentially limiting the likelihood that the class structure found here would replicate. Further, the sample contained a low proportion of ethnic and racial minority participants. Although evidence for different patterns of anger experience and expression among ethnic minorities is mixed (Carter & Reynolds, 2011; Consedine, Magai, Horton, & Brown, 2012; Rosenthal & Shreiner, 2000),

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27

future studies should examine anger profiles among a more heterogeneous sample to understand if ethnic, racial, and cultural differences influence the composition of these classes. Finally, an important limitation is that we examined a sample comprised exclusively of individuals with SAD, and we cannot say that the findings are at all specific to that disorder. In fact, Moscovitch et al. (2008), in a study comparing individuals with a number of anxiety disorders on measures of anger experience and expression, demonstrated that patients with panic disorder and obsessivecompulsive disorder, as well as those with SAD, showed a greater propensity to experience anger than control participants. Follow-up research with more diverse anxiety disorder samples or samples of patients with other disorders is warranted. The present findings suggest that assessing anger experience and expression in SAD may help improve diagnostic assessment and may prove useful in treatment planning. Although there is strong support for the efficacy of CBT in ameliorating anger problems (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; Kulesza & Copeland, 2009), individuals with elevated anger seeking treatment for SAD are less responsive to cognitive-behavioral intervention (Erwin et al., 2003), suggesting the need to consider anger in planning more effective treatments for these individuals. This investigation highlights the different patterns of anger experience and expression in untreated individuals with SAD and how these profiles relate to both interpersonal and intrapersonal impairment. Future investigations should examine whether these classes respond differently to treatment, and whether the incorporation of techniques drawn from other evidence-based interventions such as Dialectical Behavior Therapy (Frazier & Vela, 2014) would enhance treatment efficacy for SAD individuals who possess elevated anger, above and beyond the demonstrated efficacy of traditional CBT (Gordon, Wong, & Heimberg, 2014;

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28

Heimberg & Magee, 2014). This knowledge may increase our ability to personalize treatment and provide effective and empirically-supported treatment.

Authorship Notes M.V.V., M.L.P., and R.G.H. developed the study concept and design. Data analysis was conducted by M.V.V., M.L.P., and C.M.P. M.V.V., M.L.P., and C.M.P. drafted the paper, and R.G.H. and T.O. provided critical revisions. All authors approved the final version of the paper for submission. None of the authors have any conflict of interest or financial disclosures to report.

Acknowledgements Portions of this paper were presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, Philadelphia, PA, November, 2014. The authors would like to thank all of the graduate students, past and present, of the Temple Adult Anxiety clinic for their contributions to the collection and management of the data for this project. Furthermore, we would like to thank Dr. Deborah Drabick for her assistance and tutelage in data analysis.

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