Article summary with Interpersonal processes in social phobia by Alden & Taylor - 2004

Social Phobia/Anxiety Disorder is an interpersonal disorder, a condition where anxiety disrupts a person’s relationship with others. This paper aims to determine what’s known about the interpersonal aspects of social anxiety and understand how it effects the development of relationships.

Interpersonal theory incorporates developmental experiences, social cognition, motivation, and social behaviour in a cohesive model and can therefore provide a structural framework for this review – using different research areas.

Social anxiety is conceptualized and measured differently across domains. The various concepts are related but not interchangeable. E.g. developmental researchers study temperaments of behavioural inhibition and social timidity, whereas personality/social psychologists study shyness and social anxiety (as situation-induced states) and personality disorder.

1. Interpersonal Perspective

Interpersonal models of psychopathology share the assumption that good social relationships are tied to a person’s psychological well-being and that poor social relationships contribute to psychopathology. Central feature of this perspective – self-perpetuating interpersonal cycle. We expect people to treat us the same way now that they have previously, and tend to repeat the behavioural strategies learned to handle earlier events. Furthermore, people expecting others to respond positively to them engage in behaviours eliciting favourable responses, vice versa those anticipating negative responses adopt self-protective strategies likely eliciting negative responses.

Interpersonal models also maintain that dysfunctional interpersonal patterns result from ongoing interaction between the individual and the social environment. Our relationships shape our habitual social behaviour as well as our sense of self and others.

2. Social Anxiety Disorder and Social Relationships

People with social phobia generally have fewer social relationships than others (fewer friends, dating and sexual relationships, less likely to marry). But we don’t know much about how they function in the relationships they do develop. E.g. study on marital relationships in social phobic patients found patients to report greater life satisfaction than those without partners but also more marital distress.

A study using structured interviews to assess university students’ relationships with friends, acquaintances etc. found social anxiety to be associated with various dysfunctional strategies in those relationships – expected strategies of nonassertiveness and avoidance of emotional expression/conflict. Socially anxious individuals reported over-reliance on others – result of dependence on the few relationships they have. Over-reliance (and nonassertiveness) was found to mediate the relationship between social anxiety and chronic interpersonal stress. Together these findings indicate that even when socially anxious people develop relationships, they view them as less intimate, functional, and satisfying than those without social anxiety.

3. Self-Perpetuating Interpersonal Cycles

Writers from different perspectives have observed that socially anxious people behave in ways that lead to negative social outcomes. Suggests that people with social phobia may establish negative interpersonal cycles between themselves and others in which they adopt behavioural strategies evoking negative reactions.

3.1. Behavioural Patterns

Behaviours commonly associated with social anxiety are low social skill, nonassertiveness, and visible anxiousness. Differences between socially anxious and nonanxious people on specific anxiety-related micro behaviours (poor eye contact, trembling, low self-disclosure etc.) have also been found. Research suggests socially anxious individuals to appear less skillful and anxious than others, providing suggestions as to behaviours that contribute to this impression.

Variability in behavioural patterns have been found in socially anxious populations – findings point to individual differences in how socially anxious people experience their interpersonal issues.

Other researchers report evidence of critical or angry behaviour in socially anxious samples. One study found that shy people reported feeling critical and non-affectionate towards their friends/others. Another found that social phobic patients reported more state/trait anger, and a tendency to express anger when criticized or treated unfairly, or even without provocation. Studies in the context of domestic violence found that 35% of wife batterers scored above the clinical cutoff on avoidant personality disorder. Avoidant personality traits predicted not only assault, but also spousal murder.

3.2. Others’ reactions

The interpersonal perspective posits that people with psychological problems often elicit negative responses form others. Shy individuals generally rate negatively on interpersonal dimensions (warmth, likeability etc.) by objective interviewers and close friends. Research indicates shy people to be seen as less intelligent by peers though there’s no actual association between social anxiety and intelligence. Conversely, long-term acquaintances rate shy people more positively than recent ones, suggesting other may become more positive about them with longer exposure.

Several studies found others less likely to want future interactions with socially anxious students after an initial discussion. It’s concluded that the social behaviour of anxious students led their partners to disengage from relationship development. Anxiety-related behaviour was one main factor precipitating disengagement, as well as failing to reciprocate others’ self-disclosures.

Authors concluded that socially anxious students were rated negatively by their friends, and they irritated/alienated strangers quickly.

3.3. Summary

Research suggests socially phobic people to show distinctive and less functional social behaviour than others. There’s an increase in empirical support for interpersonal variability in the behaviour of socially anxious people. They seem to evoke less positive reactions from others, even in brief encounters and studies suggest that the absence of prosocial behaviour is as important to others’ reactions as visible signs of anxiety.

These findings could have clinical implications. Socially anxious people worry about displaying anxiety-related symptoms, when the use of prosocial behaviours could be more important in developing relationships. Important for future research is determining if behavioural patterns and social responses found in social phobic individuals are specific to social phobia or shared with other psychological disorders – could arise form comorbid conditions rather than just social phobia, e.g. depression.

4. Social Skill Deficit or Self-Protective Strategy

If people with social anxiety behave in ways that disrupt relationship development, the next question is why. Traditional explanation for this is that they have social skill deficit’s, and failed to learn effective social behaviour – anxiety is partially a reaction to those deficits and negative responses. However, it seems to depend on the social context whether they will display avoidant/maladaptive social behaviour. Speculation that dysfunctional behaviour results from cognitive and emotional processes activated through social cues – leading to self-protective behaviour.

4.1. Summary

There’s some flexibility in the strategies used by socially anxious people to deal with social events. Self-protective behaviours elicited by social cues is inconsistent with the concept of a social skill deficit – which implies a chronic behavioural deficiency. More researched is needed to determine if there are limits on behavioural flexibility in social phobic people.

5. Cognitive Processing of Social Information

Cognitive theorists propose that social cues activate negative beliefs and assumptions about the self and others, leading to selective processing of threat information and biased interpretation of events – heightens anxiety and leads to the use of self-protective behavioural strategies.

Three topics of interpersonal relevance in cognitive model research:

1. Critical aspect of negative social schema is relational information
2. Whether people with social phobia show selective processing of negative interpersonal cues
3. Whether people with social phobia show negative biases in their interpretation of other people

5.1. Social Schema and the Self

Researchers in social cognition posit that social anxiety arises from the activation of a relational schema – knowledge structures based on experience with significant others. It’s argued relational information forms a key part of our sense of self. Some suggest that social anxiety arises when someone becomes aware of a discrepancy between knowledge about the actual- and ought-self (the self one believes others things one ought to be). Baldwin (1992) suspected that socially anxious people develop negative schema about the self in relation to others, which are readily activated by social cues. Schema result in negative expectations for social events -> anxiety.

Research has demonstrated priming procedures to increase awareness of discrepancies between the actual and ought-self. Authors concluded that activating relational information is critical to the onset of social anxiety.

Baldwin went further to examine how activation of information about others affects someone’s subjective experience of the self. He concluded that information about others is intertwined in memory with information about self, and activating one type of information affects the other.

5.2. Selective Attention to Social Cues

Cognitive models suggest socially anxious people to selectively process threat-related information. Threat information can be internal or external.

In support of selective processing, a study found that socially phobic people showed selective attention to negative social cues in a public speaking task. Other studies found them to display memory omissions for partner-related information in social interactions.

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: 1) judgments of self, 2) judgments of others’ reactions to self, 3) interpretations of other people’s behaviour/characteristics apart from their reactions to oneself.

Not as clear if social phobic people display biases in their interpretations of other people’s behaviour and characteristics. Studies on social interpretation yield inconsistent results.

Two lab studies of patients with social phobia weren’t able to find negative biases in patients’ interpretations of others’ characteristics in getting acquainted discussions. A recent study suggested that negative interpretation bias may be confined to people with particular social developmental histories.

5.4. Summary

The literature supports the idea that activation of relational information may play a key role in triggering social anxiety. One possibility is that relational information activation exerts its effect by altering the person’s subjective sense of self.

Right now, findings provide 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.

Interpersonal writers propose that habitual interpersonal patterns are the result of a social development process that begins in childhood interactions and with significant others and continues through peer relationships in adolescence.

6. Social Pathogenesis

Research gives persuasive evidence that there are heritable, biological processes that increase vulnerability to social anxiety. Particularly, the presence of behavioural inhibition (BI) early in life is shown to predict social timidity in childhood and adolescence. Kagan concluded that BI is “influenced in a major way by environmental conditions existing during the early years of life.

Developmental researchers have identified a number of early social learning experiences that are associated with behavioural inhibition, shyness, and social anxiety. For example, parental encouragement of open communication and social involvement is associated with less shyness at 12- and 24- months, and reductions in social inhibition were observed in temperamentally active infants whose mothers weren’t too responsive to fretting and crying. Conversely, patients with late-onset shyness are more likely to report parental abuse than those with early-onset shyness, who were most likely to have shy parents. Social anxiety can be produced by adverse social experiences even in children who aren’t initially inhibited.

Two themes: 1) behaviour between children and parents is interactive with each party influencing the other, 2) there’s variability in the interpersonal environments associated with social phobia.

7. Self-Perpetuating Cycles

Association between Bi and dysfunctional child-rearing styles begs the question of whether parental behaviours are causal factors in the development of social fears or responses to the child’s temperament.

Several researchers address bi-directional models of parent-child relationships. Other research has demonstrated that the physiological correlates of behavioural inhibition were moderated by the security of the attachment bond between mother and child.

Research over the last decade increasingly supports a bi-directional relationship where inhibited/anxious children and their parents display a cyclical interaction pattern, perpetuating social anxiety.

8. Variability in Social Learning Experiences

Research points to at least three dimensions that characterize early social experiences in these individuals: 1) parental over-protection and control, 2) parental hostility and abuse, and 3) lack of family socializing. Over protective, intrusive parental behaviour has received greatest research attention.

Developmental studies revealed that mothers of anxious-withdrawn children responded to their children’s shy behaviour with attempts to direct and control how the child behaved. Anxious children also displayed the highest degree of noncompliance, a pattern that may perpetuate dysfunctional transactions between mothers and their children.

But some patients with social phobia also report histories of physical and sexual abuse. An analysis found that sexual assault by a relative and exposure to verbal aggressiveness between parents had unique effects on social phobia onset in women. Childhood physical and sexual abuse seems to pose a risk for later development of social phobia.

Social phobic patients also report more emotional abuse and neglect in their childhoods. Observational studies confirm self-report findings, mothers of extremely anxious-withdrawn children tended to use non-responsiveness, statements of devaluation, or criticism and punishment in response to their child’s behaviour in a lab task.

Some patients report having limited exposure to social interactions during their development with parents encouraging this. Restricted social exposure may exacerbate social fears by constraining the development of social skills or limiting opportunities to learn that social situations can be harmless.

Interestingly, the three social development dimensions mentioned before were found to be largely independent. Principle of equifinality – there can be multiple pathways through which psychological disorders develop.

Most studies don’t address whether negative peer interactions are the cause or outcome of social anxiety, or both. It’s been concluded that shyness interferes with friendship formation, but doesn’t evoke rejection, whereas rejection can exacerbate the cognitive aspects of shyness. Supports an interactive model of social anxiety and peer relationships.

8.1. Summary

Social developmental factors and social anxiety have been addressed in numerous ways. Each method of assessment is limited in its own way, but taken as a whole the research 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 fails to help children overcome their innate timidity or exacerbates their fears through overprotection, control, abuse, isolation, or modeling.

9. Interpersonal Processes in Treatment

First question is whether interpersonal heterogeneity found in developmental histories and social behaviour of social phobic people affects treatment response. There’s little research on this, but studies indicate that some interpersonal patterns associate with poor treatment outcome. Example: studies on avoidant personality reported people with ‘warm’ problems (fear of offending/disagreeing with others) reflects a desire to maintain contact with others – more likely to benefit from CBT teaching relationship development skills. Those with ‘cold’ problems (emotional detachment/hostility) – less likely to benefit from treatment.

Second question is whether social anxiety and dysfunctional interpersonal behaviour characterizing social phobia impairs patients’ ability to collaborate with therapists and benefit from treatment. Different conclusions reported. One explanation for inconsistent findings could be that individual and group therapy place different demands on patients. It’s also possible that interpersonal relationships with therapists are crucial to motivating those individuals.

One study showed that difficulties establishing therapeutic alliance may be confined to some individuals. E.g. self-reported childhood parental abuse was associated with weak therapeutic alliance and more negative patient-therapist interactions. It’s unclear if negative treatment response was a direct function of weak working alliance or due to some pre-existing characteristic of patients that affect their relationships with therapists as well as producing difficult interpersonal problems.

Three models of patient-therapist relationship:

1) Dynamic interpersonal therapy: patient-therapist interactions are viewed as an opportunity for patients to experience how biases in their expectations and interpretations of others’ behaviour lead them to engage in maladaptive behaviours in therapy sessions.

2) Second view is that it is an essential or at least facilitative factor in treatment. Treatment techniques are more likely to be effective if delivered by a supportive, empathic therapist.

3) Third view is that it is a marker of treatment progress. Therapist or patient dissatisfaction with the working alliance signals that treatment isn’t effectively addressing a key element of the patient’s problem.

10. General Discussion

Social anxiety is associated with fewer and more negative social relationships at all stages of life. To close, 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. Their beliefs and strategies trap them in an interpersonal cycle that prevents them from accomplishing those goals. The ultimate goal of treatment should be enabling social phobic people to establish closer and more satisfying interpersonal relationships.