Direct and indirect predictors of social anxiety: The role of anxiety sensitivity, behavioral inhibition, experiential avoidance and self-consciousness

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ScienceDirect Comprehensive Psychiatry xx (2014) xxx – xxx www.elsevier.com/locate/comppsych

Direct and indirect predictors of social anxiety: The role of anxiety sensitivity, behavioral inhibition, experiential avoidance and self-consciousness Georgia Panayiotou⁎, Maria Karekla, Margarita Panayiotou University of Cyprus, Nicosia, Cyprus

Abstract Using mediated and moderated regression, this study examined the hypothesis that anxiety sensitivity, the tendency to be concerned about anxiety symptoms, and behavioral inhibition, the tendency to withdraw from novel and potentially dangerous stimuli, predict social anxiety indirectly through experiential avoidance as measured by the Acceptance and Action Questionnaire-II and self-consciousness, as measured by the Self-Consciousness Scale. Behavioral inhibition and anxiety sensitivity are operationalized as temperamental traits, while experiential avoidance and self-consciousness are seen as learned emotion regulation strategies. Study 1 included college student groups from Cyprus scoring high and low on social anxiety (N = 64 and N = 63) as measured by the Social Phobia and Anxiety Inventory. Study 2 examined a random community sample aged 18–65 (N = 324) treating variables as continuous and using the Psychiatric Disorders Screening Questionnaire to screen for social anxiety. Results suggest that experiential avoidance, but not self-consciousness mediates the effects of anxiety sensitivity on predicting social anxiety status, but that behavioral inhibition predicts social anxiety directly and not through the proposed mediators. Moderation effects were not supported. Overall, the study finds that social anxiety symptomatology is predicted not only by behavioral inhibition, but also anxiety sensitivity, when individuals take actions to avoid anxious experiences. Modifying such avoidant coping approaches may be more beneficial for psychological treatments than attempts to change long-standing, temperamental personality traits. © 2014 Elsevier Inc. All rights reserved.

Social anxiety disorder (SAD), the clinical manifestation of trait social anxiety [1] has a prevalence of 3–13% [2]. Central in SAD is the fear of failing at tasks such as public speaking, of receiving criticism and of anxiety symptoms (e.g. trembling, blushing) being obvious and causing embarrassment [e.g. 3]. The belief that anxiety is publically visible is exaggerated because of attention biases inherent in SAD, such as self-consciousness (SC) [4]. Socially anxious individuals overtly avoid social situations or use subtle avoidance to regulate their emotions, including standing at the margins of social gatherings, averting eye contact [5], and intentionally or unintentionally turning attention away from the situation [6]. Avoidance interferes with fear extinction, so that symptoms persist despite the inevitability of social interactions. Although the pathogenic role of avoidance in anxiety disorders is well⁎ Corresponding author. E-mail address: [email protected] (G. Panayiotou). http://dx.doi.org/10.1016/j.comppsych.2014.08.045 0010-440X/© 2014 Elsevier Inc. All rights reserved.

established, it is less clear how it interacts with individual differences, which is the goal of the present studies. Diathesis factors for SAD include genetic predisposition and temperamental traits like fearfulness, neuroticism and behavioral inhibition (BI) [7,8]. BI, the tendency to show fear, reservation and withdrawal toward unfamiliar situations and persons, is considered an intermediate phenotype for phobic disorders [e.g. 9] with a specific longitudinal association with SAD [e.g. 10], and is related to one of the fundamental neurobiological motivation systems proposed by Gray [11]. Because not all high BI children develop anxiety disorders, however [12] it is important to identify mediators and moderators of this link, especially regarding traits and behaviors acquired later in life that can be modified to prevent anxiety development. Interacting and intervening variables may include the ability to regulate emotion and flexibly control attention [13]. This study examines whether such mediators include the avoidant coping and attention refocusing common in high SAD individuals.

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Anxiety sensitivity (AS), another diathesis factor for SAD and other disorders [e.g. 14–18], is the fear of anxiety-related sensations, which are believed to have negative consequences [19–21]. It is considered temperamental, since it develops early, is genetically influenced [22] and is associated with other temperamental characteristics such as BI, introversion and neuroticism [23,24]. A possible link between temperament (e.g. BI, ASI) and SAD may be through the mediation of coping approaches such as the degree to which one has learned to avoid unpleasant experiences. This tendency has been called “experiential avoidance” (EA) by researchers in the domain of acceptance and commitment therapy [25]. EA is the tendency to negatively evaluate feelings and thoughts and expend effort to avoid or alter them [26,27], which apparently plays a significant role in maintaining psychopathology, including PTSD [e.g. 28], OCD [25] and SAD [6,27]. Avoidance inherent in these conditions, such as thought suppression or concealment, has paradoxical effects, increasing the frequency, severity, and accessibility of unwanted experiences [e.g. 29–34]. EA is typically viewed as a learned coping strategy, acquired and reinforced by its outcome of lowering distress in the moment. It results from the bidirectional nature of language, the cultural and family context of using thoughts and emotions as acceptable causes of behavior, the inappropriate generalization of rules about the controllability of thoughts or emotions and the observation of others exhibiting avoidance [35,25]. Here, EA is examined as a potential mediator between AS and SAD. Moderation rather than mediation models have also been previously tested [36,37,28], where level of EA was hypothesized to moderate the effect of BI or AS on anxiety disorders. These studies suggested that these are significant predictors of anxiety mostly among individuals high in EA. Moderation by EA is also examined in this study as an alternative model. The second proposed mediator of the effects of AS and BI on SAD, examined in this study, is SC, i.e. the tendency to turn attention away from the environment and toward internal experiences and self-evaluation [38,39]. SC has been conceptualized by some authors as a safety behavior used to momentarily escape from a threatening social environment [6], though such attention biases may operate automatically and without intention [40]. SC plays a crucial role in ‘vigilance-avoidance’ models of SAD, which suggest that initial attention toward threatening information is followed by attentional avoidance [39]. Glick and Orsillo [6, p. 2] and others [41,42] conceptualize self-focused attention, the momentary state of SC, as quite similar to EA, as “an attempt to suppress, control, or alter uncomfortable internal experiences,” acquired through exposure to stressors. Though SC may be non-deliberate, it may still become conditioned to occur automatically in social contexts, if it offers momentary comfort. However, like EA, SC is ultimately unsuccessful since it typically increases rather than decreases anxiety [43]. SC can be broken down

into private SC (focus on internal experiences and emotions) and public SC (examination of the self as a public object) [e.g. 4,42,43]. The aspect of private SC that best captures maladaptive self-focus in SAD is a sub-factor as measured by the Self-Consciousness Scale, termed self-reflectiveness (SR), which includes items like “I think a lot about myself” and “I'm always trying to understand myself.” In sum, this study examines the hypothesis that AS and BI are linked to SAD through EA and SC (specifically SR), in an effort to link personality and psychopathology by looking into potential mediators, such as emotion regulation [43]. AS and BI are viewed as temperamental characteristics, whereas EA and SC are seen as learned coping strategies. Similar models have been proposed for borderline personality [14], depression [44], drinking alcohol [45] and other types of pathology, where EA has been shown to mediate the predictive role of AS for each respective condition. Because the use of mediation with cross-sectional data has been criticized on the grounds that the temporal order of variables cannot be easily established [46], it has been suggested [47] that order should be defined at least on the basis of when variables appear developmentally. Here, based on theory, AS and BI are conceptualized as temperamental and are entered in the model first as predictors [10]. Proposed mediators are considered as learned behaviors [41] believed to appear later in life. Finally, SAD typically occurs in adolescence and early adulthood and is therefore entered last as the dependent variable. Two studies were conducted in Cyprus. The first predicts membership in high and low social anxiety groups, addressing the question if EA and SR mediate the association between AS and SAD, and BI and SAD respectively in predicting SAD group membership. An alternative moderation model, where levels of EA moderate the effect of AS and BI on SAD was also tested [28,36]. The 2nd study examined similar mediation and moderation models, in a community sample, treating all variables as continuous. Both studies were approved by the National Bioethics Committee and included informed consent.

1. Study 1 1.1. Method 1.1.1. Participants Participants were 253 (40 male) students, all Greek Cypriot Caucasian from two universities in the Republic of Cyprus who took part in exchange for extra credit. The gender distribution of the study reflects the population of the two universities. Mean age was 21.22, SD = 3.99. These were all full-time students (i.e. not employed full-time outside of college), mainly unmarried (single or in a romantic relationship, but not married or engaged; 94.10%). Seventy-three percent lived in the city, while the rest lived in smaller towns or villages. Those in the top and bottom 25% of the distribution of scores from the Social Phobia and

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Anxiety Inventory (SPAI; Social Phobia Score) were selected to form the high and low SAD groups (N = 64 and N = 63 respectively). Mean social phobia score for the high SAD group was M = 91.00, SD = 14.70, which was very close to the mean for clinic social phobic patients [48], indicating that the symptomatology of the high SAD group was at clinical levels. For the low SAD group M = 12.37, SD = 10.21, which was lower than that reported in the same study for non-SAD students, since the lowest end of the distribution was selected. 1.1.2. Measures The abbreviated version of the Anxiety Sensitivity Index [49], the ASI-16, measures the fear of anxiety-related sensations and concerns about the negative consequences of anxiety (e.g. “It scares me when I am nervous”), using a 5-point scale (“very little” to “very much” [50]). This tool demonstrated high internal consistency among Greek-speaking Cypriots [51] and English-speaking samples [52] with Cronbach's alphas of .89 and .88, respectively. The Greek ASI-16 has adequate convergent validity with a panic disorder measure (r = .40, p b .01), in line with earlier findings [17]. The total ASI-16 score was used in this study, as the higher order dimension of AS (alpha in this sample = .87). The Acceptance and Action Questionnaire-II [AAQ-II; 53] is a 7 item measure of experiential avoidance rated on a 7-point Likert-type scale. Based on seven samples totaling 3280 participants [53,54] it has adequate structure, reliability and validity (Malpha = .83). In this sample alpha = .93. The Social Phobia and Anxiety Inventory (SPAI) is a well-established measure of SAD [48], consisting of three subscales: social phobia, agoraphobia, and a difference (between these) subscale, used here, which is considered a purer measure of SAD. It has high test–retest reliability, (difference score: r = .86) internal consistency for the subscales α = .85–.96 and discriminant validity [7,48]. In its Greek translation the SPAI is psychometrically solid and maintains its structure [55]; in the current sample alpha = .99. The 23 item Self-Consciousness Scale was used to assess chronic self-reflection (SR) [56]. It is answered on a 5-point scale (from does not describe me at all, to describes me exactly) and has 3 subscales, public and private selfconsciousness and social anxiety. SR, which is a 5-item sub-scale of private SC, assesses monitoring of thinking processes that pertain to the self and has been characterized as the most pathogenic aspect of SC [57]. The full scale has shown good psychometric properties both in the original standardization study and its Greek translation [57,58]. Alpha for SR is this sample was .65. The 48-item Sensitivity to Punishment/Sensitivity to Reward Questionnaire (SPSRQ) was used to assess BI [59]. It was converted in its Greek version from a YES/NO format to a 6-point Likert-type scale [60] (not at all to very much). It measures the behavioral manifestations of Gray's behavioral inhibition and behavioral activation systems, and has shown good internal consistency in the initial standard-

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ization studies (α N .75) and good test–retest reliability (r N .87). In its Greek translation it has shown good psychometric properties (alphas N .90) and factor structure [61]. For sensitivity to punishment in the current sample, α = .84. A sample sensitivity to punishment item is “Whenever possible do you avoid showing your abilities because you are afraid you will be embarrassed”; a sensitivity to reward item is “Do you often do things in order to be praised?” 1.2. Results Means and SDs of the variables of interest for study 1 were as follows: SPAI total score, M = 50.81, SD = 30.52; AAQ-II, M = 27, SD = 9.32; ASI-16 total, M = 20.94, SD = 11.77; sensitivity to punishment, M = 55.88, SD =21.22; SR, M = 1.99, SD = .74. One-way ANOVAs showed significant between group differences, with high SAD individuals scoring higher than low SAD individuals: For AS, F (1, 125) = 47.41, p b .001. For EA F (1, 125) = 47.41, p b .001, for BI (sensitivity to punishment) F (1, 120) = 111.30, p b .001, and for SR F (1, 125) = 13.18, p b .001. Zero order correlations (see Table 1) demonstrated that, although all constructs were related, no multicollinearity between them could be claimed (all r b 0.8). The strongest correlate of SAD was sensitivity to punishment (i.e. BI). 1.2.1. Prediction of social anxiety status using the mediation model Before proceeding to test all models, linear regression assumptions (homoscedasticity, linearity, normality of errors) were tested and verified in SPSS. According to recent research [62], the bootstrapping approach to mediation is advantageous over the traditional [63] approach and has become the method of choice. Using logistic regression in the Process procedure and 5000 iterations, we examined whether AS and BI, entered in separate regressions, predicted SAD group membership and whether these associations were mediated first by EA or by SR. For AS as predictor, there was partial mediation by EA whereas SR was not a significant mediator. Both the indirect effect of EA on SAD, b = .04, bias corrected CI [.02–.07], and the total effect of AS on SAD (p b .001) with b = .09 were Table 1 Bivariate correlations between variables in Study 1. ASI total

Sensitivity to AAQ Private Public SR punishment total SC SC SC

SPAI Social Phobia .35⁎⁎ .60⁎⁎ ASItotal .48⁎⁎ Sensitivity to Punishment AAQ_total PrivateSC PublicSC ⁎ p b .05. ⁎⁎ p b .01.

.46⁎⁎ .15⁎ .46⁎⁎ .41⁎⁎ .59⁎⁎ .39⁎⁎

.35⁎⁎ .41⁎⁎ .55⁎⁎

.22⁎⁎ .48⁎⁎ .39⁎⁎

.32⁎⁎

.40⁎⁎ .68⁎⁎

.59⁎⁎ .79⁎⁎ .62⁎⁎

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significant (see Fig. 1). The mediation effects of EA and SR on SAD group membership, with BI as the predictor, were non-significant: BI predicted SAD directly. 1.2.2. Alternative moderation model The alternative moderation model tested through logistic regression was that AS and BI predicted SAD group membership depending on levels of EA and SR. For AS and BI separately, the predictor (AS or BI) was entered in step 1, EA or SR in the 2nd step, while in the 3rd step the interactions, EA × AS, SR × AS, EA × BI, or SR × BI, computed with all variables centered, were entered (one in each model). In all cases, SAD group was the dependent variable. In none of the cases were the interaction terms significant predictors of SAD group, indicating that moderation by EA or SR was not supported.

2. Study 2 2.1. Method 2.1.1. Participants Participants were 324 Caucasian Greek-Cypriot adults, (189 female, Mage = 44.87, SD = 11.79), recruited as part of an epidemiological study. Most were working full time (68.8%), were married and/or engaged (58% married, 20.1% engaged, 10.8% single, 3.7% divorced, and the rest were either in a relationship or widowed) and lived with their own family (79.9%). Regarding education, 46.3% were college graduates (including graduate degrees), 11.4% completed some college, 23.1% high-school graduates, 11.4% completed less than high-school education, and 7.7% did not specify. Eighty-three percent lived in the city, and the rest in smaller towns of villages. They were selected from telephone directories, using random stratified sampling, so that numbers were representative of the geographic distribution of the population while genders and age groups were about equally represented.

2.1.2. Measures The questionnaire package included the Psychiatric Diagnostic Screening Questionnaire (PDSQ) to assess SAD symptomatology (mean = 1.80 for present study; SD = 2.92; reliability for SAD subscale, α = .90), the ASI-16 (mean = 17.01; SD = 10.97; α = .89) and AAQ-II (mean = 17.13; SD = 8.26; α = .90). The PDSQ [64] is a self-report screener for DSM-IV disorders, answered in a yes/no format. The eight item SAD subscale was used here. Its authors reported high mean internal consistency (alpha = .86), mean test–retest reliability and convergent validity (r = .83 and .66 respectively) and adequate mean divergent validity (r = .25) [64]. In the Greek language the PDSQ demonstrated adequate internal reliability (mean alpha = .78) and factor structure [65]. 2.1.3. Procedure Selected participants were contacted over the phone by trained research assistants. Those who met participation criteria and consented orally were sent questionnaires by mail. Completed questionnaires were returned by post in a pre-stamped envelope. 2.2. Results 2.2.1. Zero-order correlations between variables Pearson correlations between SAD scores on the PDSQ, EA (total AAQ-II score), and AS (total ASI score) were as follows: both EA and AS were significantly correlated with SAD (r = .45, p b .01 and r = .39, p b .001 respectively), and related at r = .46 p b .01 to each other. These correlations were substantial but not suggestive of multicollinearity (r b .8). 2.2.2. Examination of mediation role of experiential avoidance on the full sample Similar to study 1, linear regression assumptions were tested and verified in SPSS. Bootstrapping [62] was used treating all variables as continuous to examine if AS predicted SAD through the mediation of EA. AS significantly predicted

AAQ-II b=.11, p<.001

b=.35, p<.001

AS

SAD group

Direct effect, b=.05, p<.05 Indirect effect, b=.04, CI [.02, .07] Fig. 1. Mediation effects of AAQ-11 on SAD group membership for AS as predictor.

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EA (b = .34, p b .001) and EA significantly predicted SAD (b = .12, p b .001). There was partial mediation by EA on SAD. The indirect effect was significant, b = .04, bias corrected CI [.02–.06] and the total effect of AS on SAD was also significant (p b .001) with b = .11. 2.2.3. Examination of the alternative moderation model As in study 1, the alternative hypothesis that EA moderated the effects of AS on SAD symptoms was tested: AS was entered in step one of linear regression, followed by EA at step two, their interaction term (centered variables) in step three and SAD score as the dependent variable. The interaction was not significant, indicating that moderation was not supported. 2.3. Discussion This study examined the hypothesis that AS and BI, both considered as temperamental, become part of the mechanism that maintains SAD through the learned tendency to avoid unwanted experiences. Results of both studies support this model for AS as the predictor and EA as the mediator, converging on the idea that a potential path of the association between AS and SAD is through EA. Results are consistent with recent evidence that SAD, like other anxiety disorders, is characterized by the perception that anxiety itself is fearful (high AS [e.g. 17,21]) and the tendency toward unacceptance and avoidance of unwanted experiences [66]. High SAD individuals also tend to turn their attention inward as evidenced by the correlation of SAD scores with SC. In support of the recent assertion of some authors that self-focused attention/self-consciousness is a form of avoidance of unpleasant experiences [6,41] current correlations (Table 1) show a moderate association between SC and EA. SR was not a significant mediator of AS: It appears that it is the tendency to avoid unpleasant experiences (EA) but NOT through turning attention to the self (SR) that represents the path through which AS predicts SAD. This suggests that the hypothesis that SC is an emotion avoidance behavior may need to be reconsidered; SC may not be a coping strategy but an automatic cognitive process involving bias away from fearful situations [40], which serves purposes other than the down-regulation of emotion (e.g. selfregulation; [67]). Alternatively, SC in SAD may not be related to AS but to other aspects of anxious experiences, which future research needs to clarify. Consistent with the findings of previous research [10] BI was the strongest, direct predictor of SAD. Hence, although our findings agree with accumulating evidence that both AS and EA are pathogenic for anxiety disorders [e.g. 16], their role may be less significant for SAD compared to BI, a direct predictor. Longitudinal studies are required to demonstrate the developmental stage at which each trait actually appears and the full array of mechanisms through which these correlates operate synergistically to produce and maintain SAD.

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Results are overall comparable to what has been found by studies examining the mediation role of EA between AS and disorders, like Borderline Personality Disorder, Depression and stress related drinking. Present and previous findings indicate that the learned tendency to avoid contact with unpleasant experiences is an important correlate for much psychopathology, especially in interaction with high sensitivity to unpleasant affect (e.g. AS). To the degree that EA is learned, it seems to be a good target for behavioral treatment. The alternative moderation model examined [28] was not supported. Moderation is not mutually exclusive to mediation and in much larger sample sizes as in the case of Pickett, Bardeen & Orcutt [28] it may be the case that those high in EA are more likely to show association between BI and SAD, for example. An alternative model tested by Pickett, Lodis, Parkhill & Orcutt [68], where BI predicts EA through AS is also compatible with current findings: It is likely that BI is a more “fundamental” temperamental trait, appearing very early in development, whereas AS may be a later and more proximal characteristic. This chain of events can only be tested in longitudinal studies of early childhood to late adolescence, needed to test these alternative models. Current results concur with findings that interventions with anxious patients, which incorporate acceptance and tolerance of aversive experiences, with a parallel reduction in avoidance are effective [69] and may need to become part of how anxiety disorders are conceptualized and treated. Protocols for SAD that specifically target EA [e.g., 70,71] have shown significant promise, departing from traditional CBT by de-emphasizing the challenging of dysfunctional cognitions while emphasizing emotional flexibility, anxiety tolerance and acceptance of negative experiences. By being more tolerant of their experiences, SAD patients can resort less to experiential avoidance and escape [36,69]. In such protocols the futility of EA is recognized and reduced by techniques such as cognitive defusion, mindfulness and values clarification [25]. Limitations of the current investigation include the fact that samples were derived from the community and did not meet formal SAD diagnosis. Hence the model needs to be replicated in a formally diagnosed population. However, study 1 included extreme groups using the SPAI, a well-documented instrument for its ability to select socially phobic individuals. This provides some assurance that findings are relevant to clinical populations for whom there are no theoretical reasons to expect different results. Another limitation is the relatively low reliability (.65) of the SR scale, which however is similar to previous studies [57]. The third limitation is the cross-sectional nature of the analyses. Future research should address mediation using longitudinal designs, where an early evaluation of temperamental characteristics and later assessment of mediators can verify the model proposed here. In sum, this investigation verifies that BI and AS are important diathesis factors for SAD as for much other psychopathology. It also contributes to the idea, that the

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learned tendency to avoid unpleasant experiences is a mediator between AS and psychopathology. Although BI was the most significant predictor of SAD, one needs to consider that temperament and personality are difficult to change in therapy. The value of documenting the intervening role of EA is that this may be more amenable to change. A reduction in avoidance, through acceptance of the unpleasantness of inevitable experiences may provide the necessary context for exposure and increase social activation. These can encourage fear habituation and permit for the learning of new, corrective information that can alter the behavioral repertoire and ultimately the quality of life of socially anxious individuals.

[11] [12]

[13]

[14]

[15]

Acknowledgment The authors wish to thank Dora Georgiou, Margarita Kapsou, and several undergraduate research assistants for their help with data collection. This research was partially funded by grants ΥΓΕΙΑ/0506/18 and ΝΕΑΥΠΟΔΟΜΗ/ ΣΤΡΑΤΗ/0309/37 both granted by the Cyprus Research Promotion Foundation, the Republic of Cyprus and EU Structural Funds. The funding agencies had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report or in the decision to submit the article for publication.

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