Interpersonal processes in social phobia

Clinical Psychology Review 24 (2004) 857 – 882

Interpersonal processes in social phobia Lynn E. Alden*, Charles T. Taylor University of British Columbia, Canada Received 30 October 2003; accepted 12 July 2004

Abstract Social phobia is a condition in which anxiety impairs the person’s ability to relate to others. Here, we draw on concepts from interpersonal theory to examine the literature on the role of interpersonal processes in creating and maintaining this disorder. Studies that examine interpersonal interactions with significant others and strangers are reviewed. We next consider topics of particular relevance to relationship impairment, such as the effect of anxiety on cognitive processing of social information, and the social developmental pathways to social phobia. The impact of interpersonal factors on the process and outcome of cognitive-behavioral treatment is also discussed. Finally, we identify emerging themes in the research literature and consider directions for future work. Throughout the paper we highlight topics central to the interpersonal perspective, such as the self-perpetuating interpersonal cycle, interpersonal variability in social phobia, and the relational nature of self-related information. D 2004 Elsevier Ltd. All rights reserved. Keywords: Social phobia; Anxiety; Interpersonal cycle

Social Phobia (Social Anxiety Disorder) involves more than anxiety-related symptoms. It is also an interpersonal disorder, a condition in which anxiety disrupts the individual’s relationships with other people. Over the past decade, researchers have increasingly documented how social anxiety impairs interpersonal relationships and conversely, how interpersonal processes shape and perpetuate social fears. Our goal here is to review those studies to determine what is known about the interpersonal aspects of social anxiety with an eye toward understanding how social phobia affects the development of social relationships.

* Corresponding author. Tel.: +1 6048222198; fax: +1 6048226923. E-mail address: [email protected] (L.E. Alden). 0272-7358/$ - see front matter D 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2004.07.006

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Research on interpersonal factors and social anxiety is distributed across a variety of research areas, including developmental, personality, social, and clinical psychology. Each literature provides insights into different aspects of the social processes that shape and maintain social phobia. To present a comprehensive picture, our review includes studies from each domain. To integrate the various literatures, we draw on concepts from interpersonal theory. This perspective incorporates developmental experiences, social cognition, motivation, and social behavior in a cohesive model and can therefore provide a structural framework for the review. It is important to note that social anxiety is conceptualized and measured in somewhat different ways across the various domains. Developmental researchers study the temperaments of behavioral inhibition and social timidity; personality and social psychologists study shyness and social anxiety, both as situational-induced states and personality traits; clinical researchers study the diagnostic categories of social phobia and avoidant personality disorder. These various concepts are related but not interchangeable. For example, shyness has been shown to be more prevalent, associated with a broader range of negative emotions, and to characterize a more heterogeneous group of people than social phobia (Turner, Beidel, & Townsley, 1990). Therefore, as studies are discussed, we note the concept being addressed so readers can take such differences into account. We begin the paper with a brief overview of the interpersonal framework, highlighting several key tenets of this perspective. The empirical literature is then reviewed, beginning with studies on social relationships and going on to consider the behavioral and cognitive processes that contribute to relationship impairment. To reduce overlap with other papers in this volume, this part of the review focuses on topics that arise from interpersonal theory, such as how other people respond to socially anxious people and the way in which social relationships shape one’s sense of self and interpretation of social events. Finally, we discuss nascent themes in the research literature and identify unresolved issues for future research.

1. Interpersonal perspective Interpersonal models of psychopathology have emerged in a variety of contexts, each with its own domain of interest, theoretical viewpoints, and research methods (e.g., Segrin, 2001). Despite some differences, these models share the common assumption that good social relationships are intimately tied to an individual’s psychological well-being and conversely that poor social relationships contribute to psychopathology. A central feature of the interpersonal perspective is the concept of the self-perpetuating interpersonal cycle. We tend to expect people in the present to treat us in the same way that people have in the past, and we tend to repeat the behavioral strategies we learned to handle those earlier events. Furthermore, our behavior exerts a bpullQ on other people that tends to evoke responses that maintain our social assumptions, expectations, and behavioral patterns (e.g., Benjamin, 1993; Blatt & Zuroff, 1992; Coyne, 1976; Kiesler, 1983; Strupp & Binder, 1984). Thus, people who expect others to respond positively to them engage in social behaviors that tend to elicit favorable responses, whereas people who anticipate negative responses adopt self-protective strategies that increase the likelihood of negative responses from previously neutral people (e.g., Curtis & Miller, 1986). Interpersonal models also posit that dysfunctional interpersonal patterns are the result of an ongoing interaction between the individual and the social environment, a social developmental

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process that begins early and continues throughout the lifespan. Our relationships shape not only our habitual social behavior, but also our sense of self and others (see Alden, 2001). As we review the literature, we will come back to the concept of the self-perpetuating interpersonal cycle and the role of social developmental experiences in creating and maintaining social phobia. We begin our review with the first interpersonal tenet that social phobia is associated with dysfunctional social relationships.

2. Social anxiety disorder and social relationships There is little doubt that people with social phobia have fewer social relationships than other people. They have been shown to have fewer friends, fewer dating and sexual relationships, and to be less likely to marry than people in the general population or even patients with other anxiety disorders (e.g., Hart, Turk, Heimberg, & Liebowitz, 1999; Sanderson, DiNardo, Rapee, & Barlow, 1990; Schneier et al., 1994; Turner, Beidel, Dancu, & Keys, 1986). The same patterns are found in children with social phobia and among nonclinical socially anxious populations. For example, children with social phobia engage in fewer social interactions with classmates (Beidel, Turner, & Morris, 1999; Spence, Donovan, & Brechman-Toussaint, 1999). Socially anxious college students have fewer heterosexual interactions and sexual experiences than other students (Dodge, Heimberg, Nyman, & O’Brian, 1987; Leary & Dobbins, 1983), and socially anxious adolescents have fewer and less intimate friendships than their nonanxious peers (La Greca & Lopez, 1998; Vernberg, Abwender, Ewell, & Beery, 1992). That being said, we know relatively little about how socially anxious people function in the close relationships they do develop. To address that issue, Heinrichs (2003) examined marital relationships (intimate partnerships) in patients with social phobia and found that patients with partners reported greater life satisfaction than those without partners. While more satisfied than non-partnered patients, however, they reported more marital distress than a comparison group of people with panic disorder. In a similar vein, Wenzel (2002) compared a small group of patients with social phobia to nonanxious controls on a variety of relationship measures. Social phobic patients reported lower levels of emotional and social intimacy and were more likely to display fearful or preoccupied adult attachment styles. Interestingly, they were also more likely to attribute the cause of negative relationship events to some stable characteristic of their spouse, which suggested they were more negative and blaming toward their partners (Wenzel, 2002). Davila and Beck (2002) used structured interviews to assess university students’ relationships with friends, acquaintances, family, and romantic partners. Social anxiety was associated with a variety of dysfunctional strategies in those relationships, including the expected strategies of nonassertiveness and avoidance of emotional expression and conflict. One interesting finding to emerge was that socially anxious people also reported over-reliance on others, a result the authors suggested reflects their dependence on the few relationships they have. Moreover, over-reliance (and nonassertiveness) were found to mediate the relationship between social anxiety and chronic interpersonal stress. Socially anxious people who were excessively dependent on others and unable to assert their own needs apparently experienced more persistent social stress. Together, the three studies indicate that even when people with social anxiety develop relationships, they view those relationships as less intimate, functional, and satisfying than do people without social anxiety.

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2.1. Summary In light of the importance of close relationships to psychological well-being and quality of life, surprisingly few studies have examined those relationships in any detail. It would be useful for future research to determine whether the marital discord and low intimacy described by people with social phobia are also reported by their partners. If so, it would be valuable to determine what behaviors lead to partner dissatisfaction so they can be addressed in treatment. Although several studies found that shy people were viewed negatively by their spouses and friends (see Others’ Reactions below), work is needed to learn if those findings extend to clinical populations. Another question is whether relationship impairment is found in all people with social phobia. For example, do people with nongeneralized social phobia also have difficulty establishing intimate relationships or is this a distinguishing feature of generalized social phobia? In short, extant findings suggest that more work is needed to understand what goes wrong for people with social phobia in developing close relationships and how they might improve the relationships they are able to establish. Some insights into the source of relationship impairment may be provided by research that examines the characteristic social behaviors displayed by socially anxious people. We turn now to these studies.

3. Self-perpetuating interpersonal cycles Writers from many theoretical perspectives have observed that socially anxious people behave in ways that lead to negative social outcomes (e.g., Clark, 2001; Arkin, Lake, & Baumgardner, 1986; Rapee & Heimberg, 1997). Such observations suggest that people with social phobia may establish negative interpersonal cycles between themselves and others in which they adopt behavioral strategies that evoke negative reactions. To explore this possibility, we first look at the behavioral patterns associated with social anxiety and social phobia and then consider the social outcomes those behavioral strategies engender. We devote particular attention to identifying the specific behaviors that elicit negative outcomes. 3.1. Behavioral patterns The behaviors most commonly associated with social anxiety in the empirical literature are low social skill, nonassertiveness, and visible anxiousness, as measured through observer ratings and Q-sort techniques (e.g., Beidel, Turner, and Dancu, 1985; Creed & Funder, 1998). Some studies also found differences between socially anxious and nonanxious people on specific anxiety-related micro behaviors, such as poor eye contact, short speech duration, conversational pauses, low self-disclosure, trembling, blushing, and other anxious mannerisms (e.g., Amies, Gelder, & Shaw, 1983; Glass & Arnkoff, 1989; Glass & Furlong, 1990; Fydrich, Chambless, Perry, Buergener, & Beazley, 1998; Meleshko & Alden, 1993; Snell, 1989; Spence et al., 1999; Turner et al., 1986). Thus, the extant literature suggests that socially anxious individuals can appear less skillful and more anxious than other people, and provides some suggestions as to the specific behaviors that contribute to this impression. An emerging theme over the last decade is the suggestion that there is variability in the behavioral patterns found in socially anxious populations. Several studies found that patients with social phobia and avoidant personality disorder report a variety of focal interpersonal problems (Alden & Capreol, 1993;

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Kachin,Newman, & Pincus, 2001). Consistent with the behavioral findings above, some patients did describe their primary problems in terms of nonassertiveness, anxiety, and social withdrawal. Other patients, however, reported that their social problems were due to emotional distancing, even vindictiveness. Still others described problems arising from overly dependent and submissive behavior (Alden & Capreol, 1993; Kachin et al., 2001), results that are reminiscent of the Davila and Beck (2002) study of close relationships. Although the extent to which self-reported problems are expressed in overt behavior remains to be established, those findings point to individual differences in how socially anxious patients experience their interpersonal problems. Other researchers report evidence of critical or angry behavior in socially anxious samples. Jones et al. found that shy people reported feeling critical and non-affectionate toward their friends and others (Jones & Briggs, 1984; Jones & Carpenter, 1986; see also Henderson & Zimbardo, 2001). Erwin, Heimberg, Schneier, & Liebowitz (2003) found that relative to nonanxious controls, patients with social phobia reported more state and trait anger, as well as a tendency to express anger when criticized or treated unfairly, or even without provocation. Another set of studies examined social anxiety in domestic violence. This work revealed that approximately 35% of wife batterers scored above the clinical cutoff on avoidant personality disorder, a condition marked by severe social anxiety and avoidance (Hart, Dutton, & Newlove, 1993; Dutton, Bodnarchuk, Kropp, Hart, & Ogloff, 1997). Interestingly, avoidant personality traits predicted not only assault, but also spousal murder (Dutton & Kerry, 1999). In contrast, several laboratory studies found no evidence of critical behavior, as measured by social phobic patients’ ratings of others during social tasks (Alden & Wallace, 1995; Rapee & Lim, 1992; Stopa & Clark, 1993). The latter studies, however, examined behavior during brief social events, and there may have been insufficient time or motive for anger expression in that context. 3.2. Others’ reactions A central tenet of the interpersonal perspective is that people with psychological problems often elicit negative responses from other people. Empirical studies support this idea in shy and socially anxious students. Shy individuals were rated more negatively on a variety of interpersonal dimensions (e.g., warmth, relational competence, as well as likeability) by both objective interviewers and their best friends (e.g., Gough & Thorne, 1986; Jones & Briggs, 1984). Even more persuasive are several studies indicating that shy individuals are seen as less intelligent than non-shy people by peers during initial interactions, even though there is no actual association between social anxiety and intelligence (Gough & Thorne, 1986; Paulhus & Morgan, 1997). That finding suggests the presence of a global negative halo in others’ judgments of these people. Interestingly, spouses and long-term acquaintances rated shy people more positively than did strangers or recent acquaintances, suggesting that with longer exposure, others may become more positive about them (e.g., Gough & Thorne, 1986; Paulhus & Morgan, 1997). Research on social anxiety paints a similar picture of negative social outcomes. Several studies found that following a bgetting acquaintedQ discussion, others were less likely to desire future interactions with socially anxious as opposed to nonanxious students (e.g., Meleshko & Alden, 1993; Papsdorf & Alden, 1998). The authors concluded that the social behavior of the anxious students led their partners to disengage from relationship development. An attempt was made to identify the exact behaviors that precipitated disengagement. Anxiety-related behavior (e.g., observer-rated low eye contact, anxious mannerisms) was one factor, although this behavior displayed a relatively modest negative correlation

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with desire for future interaction. More significant was failing to reciprocate others’ self-disclosures, a strategy that led others to perceive targets as dissimilar to themselves and disinterested in them, factors that weigh heavily in relationship formation (Alden & Bieling, 1998; Meleshko & Alden, 1993; Papsdorf & Alden, 1998). Creed and Funder (1998) used the Q-sort technique to examine how socially anxious students were perceived by their college friends. Friends’ Q-sort ratings indicated that they viewed anxious students as, among other things, sensitive to demands, having brittle ego defenses, moody, and self-pitying. An important contribution of the study was to examine how unacquainted students behaved during interactions with socially anxious targets. Partners of socially anxious individuals were rated by objective observers as trying to dominate and control the interaction, talking at rather than with them, and displaying irritability. The authors concluded that not only were socially anxious students rated negatively by their friends, they irritated and alienated strangers very rapidly. Research on other people’s reactions to people with a clinical diagnosis of social phobia is sparse. One recent study provided evidence for negative social outcomes in children with social phobia. Spence et al. (1999) found that when these children initiated social interactions with their schoolmates, they were less likely than other children to receive positive social outcomes. It is notable that the phobic children did not evoke negative outcomes, they simply failed to garner positive reactions. Another study examined an adult clinical sample with Generalized Social Phobia (GSP). Alden and Wallace (1995) compared the GSP group to a group of matched community controls in laboratory bgetting acquaintedQ discussions. The phobic group was rated by observers and by their conversational partners as conveying less warmth and interest and emitting fewer positive verbal behaviors during the interaction than controls. Importantly, both partners and observers were less likely to desire future interaction with social phobic than with control participants (Alden & Wallace, 1995). 3.3. Summary The extant literature suggests that people with social anxiety and with social phobia display distinctive and less functional social behavior than people without those conditions. A nascent trend in the literature is the emergence of empirical support for interpersonal variability in the behavior of socially anxious people, particularly for the existence of anger and aggression. There are also hints in the literature that some people with social phobia feel overly dependent on others. An important direction for future research is to determine whether such interpersonal differences have an effect on relationship development and on treatment outcome, factors we will return to later. Consistent with the notion of dysfunctional interpersonal cycles, people with social anxiety and social phobia appear to evoke less positive reactions from other people, even in brief initial encounters. Moreover, at least one study suggested that others may overtly express those negative reactions. It is notable that several studies suggested that the absence of prosocial behavior (nonverbal warmth and interest, reciprocal self-disclosure) is as important, if not more so, to others’ reactions than visible signs of anxiety. These findings, if replicated, would appear to have clinical implications. Socially anxious individuals often worry about displaying anxiety-related symptoms, when in fact the use of prosocial behaviors (friendly nonverbals and reciprocal self-disclosure) may be more critical to developing close relationships. In short, it may be okay to be anxious as long as you’re friendly. Relatively few studies of interpersonal behavior have included psychopathology comparison groups. An important direction for future research is to determine whether the behavioral patterns and social

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responses found in social phobic populations are specific to social phobia or are shared with other psychological disorders (Alden, Bieling, & Meleshko, 1995). A related possibility is that the dysfunctional interpersonal cycles observed in patients with social phobia arise from comorbid conditions rather than from social phobia per se. Depression, for example, is often found in conjunction with social phobia and is also associated with negative social responses (Alden et al., 1995). We return to this point later. Existing studies are limited by their analogue nature; for example, some studies used confederates’ judgments as the standard for others’ responses. Research personnel are trained to be sensitive and often critical observers of behavior, and naturalistic studies are needed to examine the generalizability of laboratory findings. In addition, relatively few studies have addressed clinical samples, and more work is needed to identify the specific behaviors that elicit negative interpersonal reactions to these individuals. Finally, it would be valuable to determine whether the different patterns of interpersonal behavior discussed earlier (anger, dependency) elicit different social responses. For example, one might expect that anger and criticism would be particularly toxic to relationship formation.

4. Social skill deficit or self-protective strategy If, as the research literature suggests, people with social anxiety and social phobia behave in ways that disrupt relationship development, the next question is why they do so. The traditional explanation for the dysfunctional behavior described above is that socially anxious individuals have social skill deficits; they failed to learn effective social behavior and their anxiety is in part a reaction to those deficits and the resulting negative responses (e.g., Segrin, 2001; Segrin & Flora, 2000). Research findings over the last decade paint a somewhat more complex picture. For one thing, it is increasingly recognized that socially anxious people do not always display avoidant or maladaptive social behavior (e.g., Leary & Kowalski, 1995; Pilkonis, 1977; Rapee & Lim, 1992, see also Rapee, 1995). Maladaptive behavior appears to rely on the social context, with such factors as impending evaluation and ambiguity serving to trigger selfprotective behavior (e.g., Depaulo, Epstein, & LeMay, 1990). Those findings led cognitive-behavioral theorists to speculate that dysfunctional behavior is the result of cognitive and emotional processes that are activated by social cues. According to these writers, dysfunctional behavior reflects anxiety-related behavioral inhibition or is a cue activated self-protective strategy adopted to prevent feared outcomes (e.g., Arkin et al., 1986; Clark & Wells, 1995; Rapee, 1995; Rapee & Heimberg, 1997). One corollary of those theories is that we would expect dysfunctional social behavior to emerge only when particular contextual cues (i.e., social threat) are present. Several studies used interpersonal manipulations to examine that proposition. Consistent with situational control explanations, Depaulo et al. (1990) found that socially anxious students wrote less self-disclosive essays when they were led to expect social evaluation than when they were not, a pattern not found in nonanxious students. In another study, Alden and Bieling (1998) used experimental instructions that led participants to appraise their interaction partners as potentially critical or accepting. Although the partner behaved the same in each condition, in the negative appraisal condition, socially anxious participants displayed more safety behaviors (e.g., low self-disclosure) than nonanxious controls. In the positive appraisal condition, on the other hand, their behavior was the same as that of the controls (Alden & Bieling, 1998). A third study examined social cues in a clinical sample. People with and without Generalized Social Phobia participated in conversations with partners who provided either positive or ambiguous social cues. Although the social phobia group displayed fewer

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positive behaviors than controls in both conditions, they engaged in more positive verbal and nonverbal behaviors in response to friendly than to ambiguous social cues (Alden & Wallace, 1995). Interestingly, in the friendly cue condition, the patients not only displayed more positive social behavior, they were better liked by their conversational partners than in the ambiguous condition, where they appeared less warm and interested. Thus, when social conditions are right, people with social phobia appear to be capable of behavior that elicits a positive interpersonal response. 4.1. Summary There appears to be some flexibility in the behavioral strategies used by socially anxious people to manage social events. In particular, the literature suggests that self-protective behaviors are elicited by social cues signaling potential criticism and rejection. That flexibility appears inconsistent with the concept of a social skill deficit, which implies a chronic behavioral deficiency. Ironically, in light of the evidence discussed earlier, self-protective behavior only increases the likelihood of the negative interpersonal outcomes they are trying to avoid. We note, however, that the one study to examine a clinical sample found that social phobic patients displayed less effective behavior than controls even when others provided positive cues. Thus, more work is needed to determine whether there are limits on behavioral flexibility in people with social phobia.

5. Cognitive processing of social information Our next issue pertains to the process through which social cues influence behavior. Cognitive theorists propose that social cues set in motion a cognitive process that ultimately triggers social anxiety and dysfunctional social behavior. According to this view, social cues activate negative beliefs and assumptions about self and others (negative social schema), which leads to selective processing of threatrelated information and biased interpretation of social events. Selective attention and biased interpretation heighten anxiety and lead to the use of self-protective behavioral strategies to prevent negative outcomes (Clark, 2001; Clark & Wells, 1995; Rapee & Heimberg, 1997). Research on cognitive models has addressed three topics of interpersonal relevance. First, some researchers argue that the critical aspect of negative social schema is relational information, i.e., concerns self in relation to significant others. Second, researchers have asked whether people with social phobia display selective processing of negative interpersonal cues. Finally, some work has studied whether people with social phobia display negative biases in their interpretation of other people as well as their judgments of themselves. Each of these topics is considered below. 5.1. Social schema and the self Researchers in social cognition posit that social anxiety arises from the activation of what they call relational schema, or knowledge structures based on experiences with significant others. These writers also argue that relational information forms a key part of our sense of self, or self-structure, and therefore the activation of information about others affects our subjective experience of ourselves (e.g. Baldwin, 1992; Higgins, Klein, & Strauman, 1985; Leary & Kowalski, 1995; Rapee & Heimberg, 1997; Schlenker & Leary, 1982). Higgins and his colleagues, for example, posit that social anxiety arises when

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the person becomes aware of a discrepancy between knowledge structures representing the actual-self and the ought-other self, or the self one believes others think one ought to be (e.g., Higgins et al., 1985). The ought-other self is based on parental expectations and can therefore be seen as an internal store of information derived from past experiences with significant others. Baldwin postulated that because socially anxious individuals have extensive experience with disapproving others, they develop elaborated negative schema about self in relation to others, which are readily activated by social cues (Baldwin, 1992; Baldwin & Main, 2001). Once activated, those schema result in negative expectations for social events and hence social anxiety (Baldwin & Main, 2001). Support for these ideas was provided by several studies conducted by Higgins and Strauman, who demonstrated that priming procedures that increased awareness of discrepancies between the actual self and the ought:other self produced arousal (e.g., Higgins et al., 1985; Strauman & Higgins, 1987). Further work by Strauman indicated that patients with social phobia were characterized by larger discrepancies between the actual and ought:other self structures than were depressed patients (Strauman, 1989, 1992). The authors concluded that it is the activation of relational information that is critical to the onset of social anxiety. These findings are also relevant to the identification of social factors specific to social phobia as opposed to those shared with depression. Baldwin went a step further to examine how the activation of information about others affected a person’s subjective experience of self. In a series of studies, experimental participants were asked to envision either an accepting or critical significant other or to complete measures in the presence of photographs depicting smiling or disapproving significant others (Baldwin, 1994, 1995; Baldwin, Carrell, & Lopez, 1990). Subjects who envisioned the critical other or who were exposed to a critical picture displayed a drop in mood and self-esteem. Particularly relevant here is a study that assessed social anxiety (Baldwin & Main, 2001). Participants first completed a task for which they received social approval or disapproval paired with different tones. They then participated in a social task while one or the other tone played in the background. Socially anxious subjects who heard the disapproval-linked tone reported more social anxiety and lower self-esteem than socially anxious subjects in the approvallinked tone condition (Baldwin & Main, 2001). The authors concluded that the tone-activated negative social information not only heightened social anxiety but also altered participants’ evaluations of their self-worth. Baldwin concluded from these studies that information about others is intertwined in memory with information about self and that activating one type of information automatically affects the other. In particular, he argues that for socially anxious people, the activation of negative social information activates negative self-information as well. 5.2. Selective attention to social cues Cognitive models suggest that socially anxious people selectively process threat-related information. In theory, threat information can be internal (e.g., anxiety) or external (e.g., cues from other people). Most studies to address selective processing have used traditional cognitive tasks (see Bo¨gels & Mansell, 2004). Here, we consider what little is known about selective processing of external (i.e., social) cues in social situations. In support of selective processing, Veljaca and Rapee (1998) found that people with social phobia displayed selective attention to negative social cues in a public speaking task. In contrast, two studies found that people with social phobia displayed memory omissions for partner-related information in social interactions (Hope, Heimberg, & Klein, 1990; Mellings & Alden, 2000). The

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latter studies suggested that social cues were ignored in favor of other types of information. However, Veljaca and Rapee (1998) deliberately presented subjects with positive and negative social cues, whereas the latter studies involved neutral to positive interactions. It may be that there were few social threat cues to be detected in those studies, a possibility that requires study. In addition, some research suggests that people with social phobia display an attentional bias toward threat information followed by immediate avoidance (e.g., Amir, Foa, & Coles, 1998; Mogg & Bradley, 2002, see Bo¨gels & Mansell, 2004). Future research might address whether the attentionavoidance pattern is also found in social situations. 5.3. Interpretation of social cues According to cognitive writers, selective processing of threat cues leads to biased interpretation of social events. Interpretation biases have been studied in three contexts: judgments of self, judgments of others’ reactions to self, and interpretations of other peoples’ behavior and characteristics quite apart from their reactions to oneself. The strongest evidence of interpretation bias is found in self-related judgments pertaining to subjects’ own behavior and others’ responses to them (see Hirsch & Clark, 2004). It is less clear whether people with social phobia display biases in their interpretations of other people’s behavior and characteristics per se, i.e., apart from perceived reactions to oneself. Social interpretation bias has been studied in a variety of contexts, including response to vignettes, perceptions of others in laboratory interactions, and in relationships. Results are inconsistent. In support of social interpretation bias, socially anxious subjects were found to believe that people depicted in social scenarios would evaluate both themselves and other students negatively, a pattern the researchers interpreted as reflecting a generalized view of others as inherently critical (Leary, Kowalski, & Campbell, 1988). In a second study, shyness was associated with negative ratings of other group members’ warmth and friendliness in a group discussion task (Jones & Briggs, 1984). There was no control, however, for the possibility that others were indeed less friendly toward shy individuals (Creed & Funder, 1998; Paulhus & Morgan, 1997). In a study of close relationships, Jones et al. found that shy students rated their friends more negatively, i.e., as less considerate and courteous, than did non-shy students (Jones & Briggs, 1984). To determine whether this was due to biased interpretation or to the selection of friends who actually had negative characteristics, a second study asked students and their best friends to rate themselves and each other. Although the shy students rated their friends negatively on attributes important to relational competence, the friends themselves did not, a finding the researchers interpreted as indicative of a negative bias in the social judgments of shy people (Jones & Carpenter, 1986). Another possibility, of course, is that the friends had a positive bias in their self-ratings. In contrast to those findings, two laboratory studies of patients with social phobia failed to find negative biases in patients’ interpretations of others’ characteristics in getting acquainted discussions (Stopa & Clark, 1993; Alden & Wallace, 1995). Finally, the results of one recent study suggested that negative interpretation bias may be confined to people with particular social developmental histories. Taylor and Alden (In press) found that patient-reported parental emotional and physical abuse was associated with negative interpretation of an ambiguous partner, whereas other social developmental experiences were not. Interestingly, social interpretation bias was not significantly influenced by severity of social anxiety, suggesting that the interpretation pattern was more the result of the nature of patients’

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social learning experiences than their anxiety-related symptoms per se. Those findings are consistent with recent work demonstrating that individuals with abuse backgrounds display distinctive cognitive and emotional responses to interpersonal cues (e.g., Pollak & Tolley-Schell, 2003). 5.4. Summary The literature supports the idea that activation of relational information may play a key role in triggering social anxiety. One interesting possibility suggested by Baldwin’s work, is that relational information activation exerts its effect by altering the person’s subjective sense of self. However, studies have yet to examine the effects of priming relational information in clinical samples, and more work is needed to extend current findings. At present, the literature provides greater support for the existence of negative interpretation biases in judgments of self and others-in-relation-to-self than for biases in interpretations of other people’s general characteristics. Recent work suggesting that patients with particularly traumatic learning histories may be prone to negative interpretations of other people’s behavior indicates that interpretation biases may be specific to some patients with social phobia and that interpersonal learning experiences may shape perceptions of contemporary events. However, that finding emerged from a single study, and replication is required before definitive conclusions can be drawn. Having reviewed the literature suggesting that socially anxious people establish negative interpersonal cycles between themselves and others, and that these interpersonal cycles may arise from the activation of negative social schema, our next consideration is to examine how those patterns get started. Interpersonal writers propose that habitual interpersonal patterns are the result of a social development process that begins in childhood interactions with significant others and continues through peer relationships in adolescence (e.g., Benjamin, 1993; Sullivan, 1953). To address this social developmental process, we turn to the literature on social anxiety in children and adolescents. Because this literature is discussed in depth elsewhere (Rapee & Spence, 2004), our focus here is on topics central to interpersonal theory.

6. Social pathogenesis The research literature provides persuasive evidence that there are heritable, biological processes that increase vulnerability to social anxiety (Kagan, Reznick, Snidman, Gibbons, & Johnson, 1988; see also, Kendler, Karkowski, & Prescott, 1999; Kendler, Neale, Kessler, Heath,& Eaves, 1992). In particular, Kagan’s seminal developmental studies demonstrated that, even within their first year, some children display autonomic hypersensitivity to environmental change that operates to inhibit behavior. The presence of behavioral inhibition (BI) early in life has been repeatedly shown to predict social timidity in childhood and adolescence (e.g., Kagan et al., 1988). For their part, interpersonal writers have been interested in the way in which the social environment shapes the expression of such innate dispositions. The first evidence that BI is moderated by social factors comes from Kagan’s original studies. Approximately twenty-five percent of children who were extremely timid at 21 months of age were no longer so at age 6, while about the same proportion of children who were not inhibited at 21 months became inhibited by 6 years of age (Kagan et al., 1988; see also, Asendorpf, 1990, 1994; Fordham & Stevenson-Hinde, 1999; Goldsmith & Lemery, 2000; Scarpa,

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Raine, Venables, & Mednick, 1995). Kagan concluded that BI is binfluenced in a major way by environmental conditions existing during the early years of lifeQ (Kagan, 1998, p. 668). Developmental researchers have identified a number of early social learning experiences that are associated with behavioral inhibition, shyness, and social anxiety (e.g., Burgess, Rubin, Cheach, & Nelson, 2001; see Rapee & Spence, 2004). For example, parental encouragement of open communication and social involvement was associated with less shyness at both 12- and 24-months (Plomin & Daniels, 1986), and reductions in social inhibition were observed in temperamentally reactive infants whose mothers were not overly responsive to fretting and crying (Arcus, 1991). On the other end of the spectrum, patients with late-onset shyness were more likely to report parental abuse than patients with early-onset shyness, who were more likely to report having shy parents (Alden & Cappe, 1988). One explanation for that finding is that social anxiety can be produced by adverse social experiences even in children who are not initially inhibited (e.g., Dinwiddie et al., 2000; Saunders, Villeponteaux, Lipovsky, Kilpatrick, & Veronen, 1992; see also, Johnson, Smailes, Cohen, Brown, & Bernstein, 2000). Beyond the general association between negative early experiences and social anxiety, the interpersonal perspective draws our attention to two emerging themes in the literature. The first theme is the growing recognition that behavior between children and their parents is interactive with each party influencing the other. The second theme is that there is variability in the interpersonal environments that are associated with social phobia. Let us consider each emergent theme in turn.

7. Self-perpetuating cycles The association between BI and dysfunctional child-rearing styles begs the question of whether parental behaviors are causal factors in the development of social fears or responses to the child’s temperament. In support of the latter possibility, research by Rubin et al. demonstrated that an inhibited temperament can elicit less effective parenting styles (Mills & Rubin, 1993; Rubin, Nelson, Hastings, & Asendorpf, 1999, see also Hudson & Rapee, 2000). Not only does parenting affect the child’s social anxiety, the child’s social anxiety evokes distinct parental behavior. Several researchers specifically addressed bi-directional models of parent–child relationships. In a longitudinal investigation, Rubin et al. (1999) found that parents’ perceptions of their child’s social wariness predicted their preference for socialization strategies that limited opportunities for the child to develop independence. In turn, those parenting styles were found to predict social reticence in middle childhood over and above initial levels reticence at age four (Burgess et al., 2001). Rubin, Burgess, and Hastings (2002) conducted longitudinal assessments of children at ages 2 and 4. They found that an interaction of child inhibition and maternal behavior at age 2 predicted reticence at age 4. Specifically, in the high maternal intrusion/overprotection group, toddlers’ level of inhibition at age 2 was strongly correlated with reticence at age 4, whereas there was no relationship in the low to moderate maternal intrusion/overprotection group. A similar interaction pattern was found for derisive maternal behavior; namely when mothers were highly derisive, toddler inhibition at age 2 was correlated with social reticence at age 4. Those results suggest that maternal behavior played a significant role in perpetuating social reticence. Other research demonstrated that the physiological correlates of behavioral inhibition were moderated by the security of the attachment bond between mother and child (Nachmias, Gunnar, Mangelsdorf, Parritz, & Buss, 1996). Inhibited children who were insecurely attached exhibited greater autonomic

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arousal to strangers than inhibited children who were securely attached or low BI children. Conversely, insecure attachment has been found to predict social inhibition (e.g., Calkins & Fox, 1992). In short, research over the last decade increasingly supports a bi-directional relationship in which inhibited and anxious children and their parents display a cyclical interaction pattern that perpetuates social anxiety (e.g., Rapee, 2001; Rubin & Mills, 1991). The clinical implication of those findings is that early interventions that help parents understand how their child’s timidity bpullsQ them into ineffective parenting strategies and teach parents new strategies (e.g., how to encourage independent social exploration) might help to prevent social phobia.

8. Variability in social learning experiences The second nascent theme in the social developmental literature pertains to variability in the dysfunctional interpersonal environments associated with BI, shyness, and social phobia. The literature points to at least three dimensions that characterize early social experiences in these individuals, parental over-protection and control, parental hostility and abuse, and lack of family socializing. Of these, overprotective, intrusive parental behavior has received the greatest research attention (e.g., Rapee, 1997; Rubin & Mills, 1991). Developmental studies revealed that mothers of extremely anxious-withdrawn children responded to their children’s shy, unskilled behavior with attempts to direct and control how the child behaved (Mills & Rubin, 1998; Rubin & Mills, 1990). During a laboratory task intended to elicit collaborative behavior between mothers and their child, mothers of anxious children displayed the greatest degree of aversive control compared to mothers of nonanxious and aggressive children (Dumas, LaFreniere, & Serketich, 1995). Interestingly, anxious children displayed the highest degree of noncompliance during the interactions, a pattern of behavior that may perpetuate dysfunctional transactions between mothers and their children. Hudson and Rapee (2001) found that mothers of anxious children, some of whom had social phobia, displayed more intrusive involvement during a laboratory problem-solving task compared to mothers of nonanxious children (see also Bo¨gels, Van Oosten, Muris, & Smulders, 2001). Finally, retrospective reports of adults with social phobia confirm developmental findings; these patients described their parents as overprotective and more controlling compared to controls (Arrindell, Emmelkamp, Monsma, & Brilman, 1983; Arrindell et al., 1989; Parker, 1979; Rapee & Melville, 1997). Although the primary focus of the extant literature has been on parental overprotection, some patients with social phobia report histories of physical and sexual abuse (Chartier, Walker, & Stein, 2001; David, Giron, & Mellman, 1995; Mancini, Van Ameringen, & Macmillian, 1995; Stein et al., 1996). In an analysis of a representative sample from the National Comorbidity Survey, Magee (1999) found that sexual assault by a relative, and exposure to verbal aggressiveness between parents, had unique effects on social phobia onset in women. Moreover, the presence of sexual abuse before the age of 18 was found to increase the risk for developing social phobia two to four-fold (Dinwiddie et al., 2000; Saunders et al., 1992; see also, Johnson et al., 2000). Interestingly, some studies found that sexual and/or physical abuse histories were more specific to patients with social phobia than to those with panic disorder with agoraphobia (David et al., 1995), although other researchers have either found no difference in childhood trauma among anxiety disorders (Mancini et al., 1995), or more abuse in patients with other anxiety disorders (Safren, Gershuny, Marzol, Otto, & Pollack, 2002; Stein et al., 1996). Regardless of

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the specificity of those findings, childhood physical and sexual abuse appears to pose a significant risk for the later development of social phobia. Patients with social phobia also report significantly more emotional abuse and neglect in their childhoods (Alden, Mellings, Taylor, & Laposa, in preparation). Those individuals described their parents as less affectionate and caring, more rejecting, and more likely to use shame as a form of discipline compared to nonphobic controls (Bruch & Heimberg, 1994; Bruch, Heimberg, Berger, & Collins, 1989). In a similar vein, behavioral inhibition in 7–12-year olds was associated with maternal criticism and dissatisfaction, but only when mothers had a lifetime history of an anxiety disorder (Hirshfeld, Biederman, Brody, Faraone, & Rosenbaum, 1997; see also Lieb et al., 2000). Observational studies confirm self-report findings in that mothers of extremely anxious-withdrawn children tended to use nonresponsiveness, statements of devaluation (Mills & Rubin, 1998; Rubin & Mills, 1990), or criticism and punishment (Dumas et al., 1995) in response to their child’s behavior during a laboratory task. Apart from negative parenting styles, some patients report having limited exposure to social interactions during their development (Alden et al., in preparation; Bo¨gels et al., 2001; Bruch & Heimberg, 1994; Bruch, Heimberg, Berger, & Collins, 1989; Caster, Inderbitzen, & Hope, 1999; Taylor & Alden, submitted for publication). Furthermore, parents have been observed to encourage social avoidance in their anxiety disordered children (Barrett, Rapee, Dadds, & Ryan, 1996; Dadds, Barrett, & Rapee, 1996). Restricted social exposure may exacerbate social fears by constraining the development of social skills or limiting opportunities to learn that social situations are not harmful (e.g., Hudson & Rapee, 2000, see also Asendorpf, 1994). Interestingly, the three social developmental dimensions, parental overprotection, emotional and physical abuse, and low family socializing, were found to be largely independent (Alden et al., in preparation). Developmental psychopathologists note that there can be multiple pathways through which psychological disorders develop, the principle of equifinality (Ollendick & Hirshfeld-Becker, 2002). Research on social developmental experiences suggests that different early social environments may create different developmental trajectories to social phobia. If, as developmental researchers argue, there are multiple pathways to social phobia, one might expect differences in the social beliefs and expectations, as well as the behavioral patterns, of patients with different learning histories. This topic has been largely unexplored in the literature. One recent study that did examine the effect of childhood experiences on the adult social behavior of patients with social phobia, found that childhood parental overprotection was associated with less self-disclosure in a laboratory interaction. Non-disclosure, in turn, led to social rejection when patients failed to reciprocate their partner’s level of openness (Taylor & Alden, submitted for publication). Those findings support the notion that contemporary behavioral patterns arise out of past learning experiences. However, replication is required before definitive conclusions can be drawn. As noted by interpersonal writers, social development continues beyond the family of origin. Consistent with this notion, social anxiety is associated with a variety of adverse peer social experiences in school situations, including bullying and harassment, rejection, and neglect (e.g., Gilmartin, 1987; Ishiyama, 1984; La Greca, Dandes, Wick, Shaw, & Stone, 1988; Ollendick, Weist, Borden, & Greene, 1992; Olewus, 1993; Strauss, Lahey, Frick, Frame, & Hynd, 1988). This is true in primary school (Ginsburg, La Greca, & Silverman, 1998), middle school (e.g., Strauss et al., 1988), and high school (La Greca & Lopez, 1998). Those results were corroborated by researchers who found that 7–14-year-old socially phobic children were less likely to receive positive outcomes from peers during behavioral observations (Spence et al., 1999). Additionally, peer-neglected and

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peer-rejected children report the highest levels of social anxiety in their peer group, and popularity is often negatively associated with social anxiety (Inderbitzen, Walters, & Bukowski, 1997; La Greca et al., 1988, Strauss et al., 1988; Walters & Inderbitzen, 1998). Similarly, many adults with social phobia are able to identify a traumatic social event (e.g., being humiliated) in adolescence that marked the onset or an increase in their social anxiety (Ost, 1985; Ost & Hugdahl, 1981; Stemberger, Turner, Beidel, & Calhoun, 1995). Most studies do not address whether negative peer interactions are the cause or outcome of social anxiety, or both. Some longitudinal research found that social withdrawal was increasingly associated with negative peer perceptions and peer-related difficulties from early to late elementary school, which suggests that social withdrawal leads to peer rejection (Hymel, Rubin, Rowden, & LeMare, 1990). Another longitudinal study painted a more complex picture (Vernberg et al., 1992). These researchers followed a group of early adolescents who had recently relocated and found that social anxiety predicted less intimacy and companionship, but not direct peer rejection. Peer rejection, on the other hand, produced increases in social anxiety and fear of negative evaluation. These writers concluded that shyness interferes with friendship formation, but does not evoke rejection, whereas rejection can exacerbate the cognitive aspects of shyness (Vernberg et al., 1992). Those findings support an interactive model of social anxiety and peer relationships. 8.1. Summary Social developmental factors and social anxiety have been addressed in numerous ways, direct of observation of parent–child interactions in laboratory settings, self-reports of inhibited children and their parents, and retrospective reports of adults with social phobia. Although each method of assessment is limited in its own way, taken as a whole, the literature supports the idea that the pathogenesis of social anxiety resides in an interaction of innate temperament with a family environment that either fails to help children overcome their innate timidity or exacerbates their fears through overprotection, control, abuse, isolation, or modeling. In addition, social anxiety appears to choke off the development of positive peer relationships that might temper these early experiences, while negative peer interactions intensify the child’s self-doubts and evaluative fears. Several social developmental issues remain to be resolved. First, if there are different developmental pathways to social phobia, how do those pathways affect the clinical picture and treatment response in adults with social phobia? Researchers are aware that there is considerable heterogeneity within social phobic populations in terms of the number and type of situations that elicit anxiety, as well as the safety behaviors adopted to reduce anxiety. A direction for future research is to determine whether differences in the social developmental histories of people with social phobia account for some of the variance in symptoms, and if so, whether such differences have treatment implications. We will return to this issue later. A second issue pertains to specificity of etiologic factors. It is notable that many of the negative social learning experiences discussed above are also implicated in other disorders, such as depression and aggression. In addition, clinical studies of parental overprotection generally include a cross-section of anxious children, which indicates that overprotective parenting is a risk factor shared with other anxiety disorders. Moreover, recent genetic studies suggest that people inherit a general tendency toward negative affectivity that increases their risk for a number of conditions in addition to social phobia. Together, these findings underscore the need to determine how some people develop social phobia

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whereas others with similar biological vulnerabilities and dysfunctional social backgrounds develop other conditions.

9. Interpersonal processes in treatment The literature reviewed above points to some interesting questions about the role of interpersonal factors in the treatment of social phobia. The first question is whether the interpersonal heterogeneity found in the developmental histories and social behavior of people with social phobia affects treatment response. Little research has addressed that question, but several studies indicate that some interpersonal patterns are associated with poor treatment outcome. For example, Alden and Capreol (1993) found that some patients with avoidant personality disorder reported interpersonal problems that fell into the warm, submissive quadrant of the interpersonal circle. So called bwarmQ problems, such as fear of offending or disagreeing with others, reflect a desire to maintain contact with others. In contrast, other patients reported problems related to emotional detachment and hostility (bcoldQ problems). Whereas the bwarmQ problem group benefited from a CBT regimen that taught relationship development skills, such as reciprocal self-disclosure, the bcoldQ problem group did not (Alden & Capreol, 1993). The warm-submissive patients appeared to be more motivated or capable of developing close relationships than the second group, who were either more dismissive of relationships or more fearful of emotional closeness. In a similar vein, Erwin et al. (2003) found that patients who reported greater trait anger or a tendency to express anger with or without provocation were more likely to drop out of treatment. Moreover, higher pretreatment scores on scales measuring state anger, expression of anger in response to negative evaluation, and the tendency to hold anger in responded less well to a group cognitive-behavioral regimen. Taken together, the two studies suggest that interpersonal behavior marked by anger or emotional distance bodes poorly for treatment outcome and requires particular attention when treating social phobia. A second question is whether the social anxiety and dysfunctional interpersonal behavior that characterizes social phobia impair patients’ ability to collaborate with therapists and therefore to benefit from treatment. The two studies that examined the patient–therapist alliance arrived at different conclusions. Woody and Adessky (2002) found that the working alliance between social phobic patients and their therapists was not correlated with response to a group CBT regimen. In contrast, Alden, Bieling, and Koch (submitted for publication) found that a positive working alliance in session 3 predicted significantly greater change in individual CBT. Interestingly, therapist perceptions of patient irritability were related to a poor working alliance, a finding that echoes those of Erwin et al. (2003) above. One possible explanation for the inconsistent findings is that individual and group therapy place different demands on patients. Individual therapy, where the patient is the sole focus of therapist attention, may involve more intense interpersonal contact and hence evoke greater reliance on interpersonal safety behaviors (e.g., irritability). If not addressed, those behaviors may impair the working alliance and treatment outcome. The inconsistent findings of the two studies may also arise from patient characteristics. The Woody and Adessky sample included a greater proportion of patients with nongeneralized social phobia. Alden et al. studied patients with Generalized Social Phobia referred to a working hospital clinic, nearly half of whom were on concurrent medication and had histories of

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previous treatment failure. There may be greater variability in therapeutic relationships in severely impaired, treatment nonresponsive samples. It is also possible that interpersonal relationships with therapists are more crucial to motivating those individuals. One recent study indicated that difficulties establishing a therapeutic alliance may be confined to some individuals. In a small sample of patients with Generalized Social Phobia, self-reported childhood parental abuse was associated with a weak therapeutic alliance and more negative patient–therapist interactions (Alden, Taylor, Laposa, & Mellings, In Press). Specifically, parental abuse was associated with less agreement with therapists on the tasks and goals of treatment and with therapist ratings of patient irritability and resistance. Parental abuse was also associated with somewhat less change on selfreported symptoms of social phobia and depression, which suggested that patients with histories of abuse benefited less from treatment. It is not clear from the study whether the negative treatment response was a direct function of the weak working alliance or due to some pre-existing characteristic of these patients, e.g, anger, unwillingness to cooperate, that not only affected their relationships with therapists but also produced more difficult interpersonal problems. In interpreting these results, it is useful to consider three models of the patient–therapist relationship. In dynamic interpersonal therapy, patient–therapist interactions are viewed as an opportunity for patients to experience how biases in their expectations and interpretations of others’ behavior lead them to engage in maladaptive behaviors in therapy sessions. Thus, exploration of in-session interactions is an experiential treatment strategy. Very little research has evaluated the effectiveness of dynamic interpersonal treatment for social anxiety. However, one study indicated that dynamic interpersonal therapy was less effective than cognitive therapy for avoidant personality disorder (Barber, Morse, Krakauer, Chittams, & Crits-Christoph, 1997). At present, there is little support for the contribution of dynamic interpretations of the patient–therapist relationship to treatment outcome. A second view of the therapeutic alliance is that it is an essential or at least facilitative factor in treatment (Horvath & Symonds, 1991). According to this view, treatment techniques are more likely to be effective if delivered by a supportive, empathic therapist. Most clinicians would agree that a hostile relationship between patient and therapist is likely to increase treatment drop-out and failure (see Henry & Strupp, 1994; Binder & Strupp, 1997). The studies by Erwin et al. (2003) and Alden et al. (In Press) are consistent with the notion that irritability and anger between social phobic patients and their therapists increase the likelihood of poor treatment outcome. It is not clear from existing studies however, whether enhancing the working relationship beyond a cordial, professional level also enhances treatment response. The third view of the therapeutic relationship is that it is a marker of treatment progress. Therapist or patient dissatisfaction with the working alliance signals that treatment is not effectively addressing a key element of the patient’s problem. According to this view, therapists can use their observations and reactions to identify patients’ previously unrecognized social beliefs or interpersonal safety behaviors, and as a cue to reassess treatment focus. At a minimum, the studies reviewed above support the need for therapists to recognize negative interpersonal patterns early in treatment so they can be addressed. 9.1. Summary Studies of interpersonal factors in treatment, although few in number, suggest that interpersonal differences affect treatment response and that to be effective, treatment must be tailored to the specific

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interpersonal problems and safety behaviors displayed by the patient. In particular, the extant literature points to interpersonal anger, irritability, and resistance as behaviors that bode poorly for outcome and suggests that these particular factors must be recognized early and addressed for treatment to be successful. In light of our earlier discussion of close relationships and social phobia, another topic that requires consideration pertains to treatment goals. Specifically, to what extent do existing treatment protocols result in patients developing close relationships? It would be important to establish whether reduction in anxiety-related symptoms enables patients to form intimate relationships or whether treatment must specifically address relationship development. Finally, interpersonal therapy takes a variety of forms. It may be that interpersonal strategies that provide more structured, problem-solving interventions for interpersonal problems could be fruitfully combined with cognitive-behavioral regimens. That possibility remains to be formally evaluated.

10. General discussion As one might expect, social anxiety is associated with fewer and more negative social relationships at all stages of life. Socially anxious people’s interactions with their parents, schoolmates, friends, and partners are less satisfying and fraught with problems. At each level of development, we also find evidence that these people engage in behavior that elicits negative responses from others, including intrusive control and derision from parents, less intimacy from schoolmates, irritability from college peers, and disengagement from relationship development in adults. Although relatively few studies have addressed the issue, some research suggests that others’ negative responses perpetuate or exacerbate social anxiety. Overall, the literature suggests that people may enter the social developmental path to social anxiety at a variety of stages, for example, through inhibited temperament, parent–child interactions, or adolescent peer relationships. Once initiated however, social anxiety appears to be maintained by a self-perpetuating interpersonal cycle of events. In evoking the concept of a self-perpetuating cycle, we do not mean to suggest that people with social phobia are in any way motivated to maintain that cycle. Some writers have proposed that people engage in interpersonal behaviors that verify their negative self-views to prevent epistemological conflict arising from self-inconsistent social responses (e.g., Swann, 1983; Swann, Wenzlaff, Krull, & Pelham, 1992), or to maintain a sense of psychological connectedness to early significant others (e.g., Benjamin, 1993). The studies reviewed here point more to an underlying concern with protecting the self from negative social reactions than a need to maintain negative self-schema or unconscious connections to significant others. For example, when socially anxious people anticipate positive outcomes, they spontaneously become friendlier, a tendency that reveals an underlying motivation to connect with others rather than to maintain negative patterns (e.g., Alden & Bieling, 1998). An emerging theme in the literature is the recognition of interpersonal variability at all stages of life. Children with social anxiety experience a variety of social learning environments; adults with social phobia report a variety of interpersonal problems. Interpersonal differences among patients are related to treatment outcome. An important direction in future research is to determine whether different developmental experiences are related to contemporary social functioning, beliefs, and adult behavioral patterns. In addition, work is needed to more fully elucidate the range of social behavior found in social phobic populations. If, as several studies suggest, some people with social phobia are overly dependent,

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whereas others are critical and aggressive, and still others nonassertive and timid, where do those differences come from and how do they affect relationship functioning? One possibility is that interpersonal variability arises from different social developmental experiences; however, they may also reflect innate personality traits, such as agreeableness or aggressiveness. It would also be informative to determine which social cognitions and interpersonal behaviors are specific to social phobia and which are shared with other disorders, a topic that we did not have space to address in this paper. For example, depressed individuals also display less accurate social perceptions (Hollander & Hokanson, 1988), self-critical cognitions following social interactions (e.g., Anderson, Horowitz, & French, 1983), and underestimate their social behavior relative to objective observers (e.g., Gotlib & Meltzer, 1987). They are distinct, however, in their tendencies to express more negative emotions, self-preoccupied complaining and reassurance-seeking (e.g., Belsher & Costello, 1991; Blumberg & Hokanson, 1983; Gotlib & Robinson, 1982; Joiner & Metalsky, 1995; Joiner, Metalsky, Katz, & Beach, 1999; see Alden et al., 1995, for a review). Understanding how different interpersonal patterns come to be associated with various disorders would advance our understanding of the role of social processes in the onset and maintenance of those conditions. In addition, it would be informative to establish the effect of comorbidity on interpersonal functioning in patients with social phobia. Another path that might be fruitfully explored is to determine what behaviors lead others to disengage from developing relationships with people who have social phobia. Whether the behavior of the socially anxious person is conceptualized in terms of safety behaviors, anxiety-related inhibition, or social skill deficits, identifying the specific actions that elicit negative social responses would inform cognitive and behavioral treatments. Finally, research indicates that friendly nonverbal behavior and reciprocal selfdisclosure are key building blocks in relationship development. If so, are treatments that target these responses more likely to produce clinically significant improvements in patients’ quality of life than treatments than focus primarily on anxiety reduction? All of these issues represent interesting directions for future study. In closing, this review draws attention to the fact that in addition to suffering from anxiety-related symptoms, people with social phobia have a history of interpersonal experiences that shape their beliefs about themselves and others, their interpersonal strategies, and their response to treatment. They, like most people, want social acceptance and intimacy, but their beliefs and strategies trap them in an interpersonal cycle that prevents them from accomplishing those goals. We end the review where we began—the ultimate goal of treatment should be to enable people with social phobia to establish closer and more satisfying interpersonal relationships. References Alden, L. E. (2001). Interpersonal perspectives on social phobia. In R. Crozier, & L. E. Alden (Eds.), International handbook of social anxiety: Concepts, research and interventions relating to the self and shyness (pp. 381 – 404). United Kingdom7 John Wiley & Sons. Alden, L. E., & Bieling, P. J. (1998). The interpersonal consequences of the pursuit of safety. Behaviour Research and Therapy, 36, 1 – 9. Alden, L. E., Bieling, P. J., & Koch, W. J. (2003). Patient–therapist relationship and treatment response in generalized social phobia. Manuscript submitted for publication.

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