Article summary of Social emotions and social cognition in the development of social anxiety disorder by M. Nikolic et al. - Chapter

Humans have a social nature: they value others’ opinions and share norms of the groups they belong to. Some people are so extremely and often worried about others’ opinion of themselves that it highly affects their social life. They suffer from social anxiety disorder (SAD), a very common disorder in Western countries. Approximately 1 in 10 people receive this diagnosis. SAD is related to loneliness, low quality of life, societal costs and comorbidity with other mental issues. It has an early onset (average age 10-13 years), but the first symptoms of social anxiety can emerge earlier (preschool age). Once developed, SAD often has a lifelong course while treatment outcomes are poor. This emphasizes the relevance of examining the factors influencing the development of SAD. A better understanding of these risk factors may help improving current treatments.

Dysregulated emotions are seen as a symptom of SAD, but they may also play a key role in the development of SAD. The feelings experienced by children in social situations may influence their behavior in those situations, for instance avoiding the situation. Avoiding social situations leads to social anxiety and the development of SAD. A disturbed social cognition (how children think about others and themselves in social situations) may also be of relevance.

What is the role of social emotions in the development of SAD?

Social emotions are the emotions that emerge in social situations: in relation to social norms or other people. These emotions are disturbed in individuals with SAD: they are excessively afraid of others’ opinions and are highly self-conscious. So far, it has been not clear whether these dysregulated emotions are a risk factor for SAD. This study is aimed at examining whether shyness and fear exist in young children with elevated levels of social anxiety and whether they influence the development of SAD.

How is social fear related to social anxiety?

Social fear is the fear of potentially being negatively evaluated by others in social situations, for example when being the centre of attention or during interaction with strangers. Fear is mostly shown through bodily and facial signs. Responding with fearful behaviors is also known as ‘behavioral inhibition’, which includes avoidance and withdrawal in social situations. Previous research indicates that behavioral inhibition in infants and young children is a predictor of the onset of SAD in late childhood and adolescence. However, it is unknown when and how behavioral inhibition influences the development of SAD. This knowledge could be helpful in the prevention and treatment of SAD.

In this study, social behavioral inhibition in social situations was examined in young children aged between 2.5 and 4.5 years. One situation involved a conversation with a stranger. Early social anxiety symptoms were measured by using parent reports, SAD symptoms in children aged 7.5 years were diagnosed by a clinician and reported by parents. It was found that social behavioral inhibition at the age of 2.5 and 4.5 years is a predictor of early onset of social anxiety symptoms at 7.5 years. Conclusion: social behavioral inhibition during toddler- and childhood is a risk factor for a later SAD diagnosis.

From a physiological perspective, fear often goes together with hyperarousal, since it activates the sympathetic system (measured through EDA: electrodermal activity) and withdrawals the parasympathetic autonomic nervous system (measured through HR: heart rate and HF-HRV: high-frequency heart rate variability). In this study, it was examined whether physiological hyperarousal in social situations is related to elevated social anxiety levels in early childhood (before a SAD-diagnosis), by measuring the participating children’s EDA, HR and HRV while singing a song in front of others. The findings show that physiological hyperarousal (reduced HRV and increased sweating) was related to higher social anxiety levels.

It was also examined whether physiological hyperarousal influences the development of SAD symptoms. The findings show that children exhibiting reduced HRV and increased HR during their interaction with a stranger displayed more SAD symptoms at a later age.

How is shyness related to social anxiety?

Shyness is an expression of self-consciousness. Although shy children want to interact, they are anxious and afraid of rejection. Shyness can be exhibited through positive shy expressions (approach-dominant) or through negative shy expressions (avoidant-dominant). A child displaying numerous negative shy expressions is considered more socially anxious, due to avoiding and withdrawing from social situations.

In this study, the relation between negative and positive shyness in social situations and social anxiety was examined. The findings show that negative shy expressions were positively associated with social anxiety symptoms, while positive shy expressions were negatively associated with social anxiety symptoms. How children exhibit their shyness can thus be predictive of their development.

From a physiological perspective, shyness is often exhibited through blushing. Individuals with SAD are considered to blush more often and easily in social situations. The findings of this study prove that individuals with SAD blush more in social settings. In children aged 4.5 years, more blushing was associated with more social anxiety symptoms. Also, blushing was found predictive of the development of SAD symptoms at the age of 7.5-12 years. There are two possible explanations. Being self-conscious about blushing may result into distress and avoidance and eventually into SAD. Another explication might be that blushing is the result of experiencing social stress due to continuous social exposure, which leads to the avoidance of future social situations and increased social anxiety.

What is the role of social cognition in the development of SAD?

Previous research showed that impairments in socio-cognitive abilities are related to elevated social anxiety levels in children aged 4-11 years. The findings of this study indicate a negative association between social anxiety and ToM (Theory of Mind, the capacity to comprehend and predict someone else’s behavior based on their emotions) in children aged 4.5 years. Also, impairments in understanding emotions are associated with elevated social anxiety levels.

Previous studies found high or low levels of socio-cognitive abilities in social anxiety. It is possible that both levels are associated with SAD symptoms in children. This notion was analysed in this study through mindreading: detecting one’s mental state through facial expressions. Children with SAD often express rejection or disapproval. The findings show that both high and low levels of mindreading are associated with elevated social anxiety symptoms in children aged 8-12.

What are the conclusions?

The results of this study indicate two possible pathways to the development of SAD: one through elevated self-consciousness and one through fearful temperament. Fearful responses in social situations are especially important in early childhood (2.5-4.5 years), because it could be predictive of developing SAD at a later moment in life.

Dysregulated social emotions and elevated levels of socio-cognitive skills may be risk factors for SAD, so the treatment of SAD during childhood should focus on socio-cognitive abilities and emotional experiences. For instance, task concentration training trains children to concentrate on the task rather than on themselves.