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Social Anxiety and Fear of Causing Discomfort to Others: Diagnostic Specificity, Symptom Correlates and CBT Treatment Outcome

  • Yasunori Nishikawa (a1), Judith M. Laposa (a2), Rotem Regev (a3) and Neil A. Rector (a1)

Background: Patients with social anxiety disorder (SAD) report fear content relating to the perceived aversive consequences of their anxiety for others in their social environment. However, no studies to date have examined the diagnostic specificity of these fears to SAD as well as predictors to treatment response of these fears. Aims: To examine relative specificity of fears related to causing discomfort to others, as measured by Social Anxiety–Fear of Causing Discomfort to Others (SA-DOS), among patients with anxiety disorders, obsessive compulsive disorder (OCD) and major depressive disorder (MDD), in addition to relation between dysfunctional attitudes and treatment response among patients with SAD. Method: In study 1, a large (n=745) sample of DSM diagnosed OCD, MDD and anxiety disorder participants completed the SA-DOS. In study 2, patient participants with SAD (n=186) participated in cognitive behavioural group therapy (CBGT) and completed measures of social anxiety symptoms and dysfunctional attitudes. Results: In study 1, the SAD group demonstrated significantly elevated SA-DOS scores compared with participants with generalized anxiety disorder (GAD), OCD and panic disorder with or without agoraphobia (PD/A), but not the MDD group. In study 2, CBGT treatment was found to lead to significant reductions in SA-DOS scores. Need for approval (NFA) but not perfectionism, predicted treatment response to fears related to causing discomfort to others, with greater change in NFA relating to greater change in SA-DOS scores. Conclusions: These findings extend previous research linking allocentric fears to the phenomenology and treatment of SAD.

Corresponding author
Correspondence to Neil A. Rector, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada. E-mail:
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Acarturk, C., Cuijpers, P., Van Straten, A. and De Graaf, R. (2009). Psychological treatment of social anxiety disorder: a meta-analysis. Psychological Medicine, 39, 241254. doi:10.1017/S0033291708003590
Alden, L. E. (2001). Interpersonal perspectives on social phobia. In Crozier, W. R. and Alden, L. E. (eds), International Handbook of Social Anxiety: Concepts, Research and Interventions Relating to the Self and Shyness (pp. 381404). New York: John Wiley and Sons.
Alden, L. E. and Taylor, C. T. (2004). Interpersonal processes in social phobia. Clinical Psychology Review, 24, 857882. doi:10.1016/j.cpr.2004.07.006
American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders (4th edn, text revision). Washington, DC.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders (5th edn). Washington, DC.
Antony, M. M., Purdon, C. L., Huta, V. and Swinson, R. P. (1998). Dimensions of perfectionism across the anxiety disorders. Behaviour Research and Therapy, 36, 11431154. doi:10.1016/S0005-7967(98)00083-7
Ashbaugh, A., Antony, M. M., Liss, A., Summerfeldt, L. J., McCabe, R. E. and Swinson, R. P. (2007). Changes in perfectionism following cognitive-behavioral treatment for social phobia. Depression and Anxiety, 24, 169177. doi:10.1002/da.20219
Bagby, R. M., Gilchrist, E. J., Rector, N. A., Dickens, S. E., Joffe, R. T., Levitt, A. et al. (2001). The stability and validity of the sociotropy and autonomy personality dimensions as measured by the Revised Personal Style Inventory. Cognitive Therapy and Research, 25, 765779. doi:10.1023/A:1012975524455
Beck, A. T., Steer, R. A. and Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.
Blaney, P. H. and Kutcher, G. S. (1991). Measures of depressive dimensions: Are they interchangeable? Journal of Personality Assessment, 56, 502512. doi: 10.1207/s15327752jpa5603_11
Blatt, S. J., Quinlan, D. M., Pilkonis, P. A. and Shea, M. T. (1995). Impact of perfectionism and need for approval on the brief treatment of depression: the National Institute of Mental Health Treatment of Depression Collaborative Research Program revisited. Journal of Consulting and Clinical Psychology, 63, 125132. doi:10.1037/0022-006X.63.1.125
Blatt, S. J., D'Afflitti, J. P. and Quinlan, D. M. (1976). Experiences of depression in normal young adults. Journal of Abnormal Psychology, 85, 383389. doi:10.1037/0021-843X.85.4.383
Blatt, S. J. and Zuroff, D. C. (1992). Interpersonal relatedness and self-definition: Two prototypes for depression. Clinical Psychology Review, 12, 527562. doi:10.1016/0272-7358(92)90070-O
Burns, D. D. and Spangler, D. L. (2001). Do changes in dysfunctional attitudes mediate changes in depression and anxiety in cognitive behavioral therapy? Behavior Therapy, 32, 337369. doi:10.1016/S0005-7894(01)80008-3
Cane, D. B., Olinger, L. J., Gotlib, I. H. and Kuiper, N. A. (1986). Factor structure of the Dysfunctional Attitude Scale in a student population. Journal of Clinical Psychology, 42, 307309. doi:10.1016/j.brat.2012.02.007.
Canton, J., Scott, K. M. and Glue, P. (2012). Optimal treatment of social phobia: systematic review and meta-analysis. Neuropsychiatric Disease and Treatment, 8, 203215. doi: 10.2147/NDT.S23317
Choy, Y., Schneier, F. R., Heimberg, R. G., Oh, K. S. and Liebowitz, M. R. (2008). Features of the offensive subtype of Taijin-Kyofu-Sho in US and Korean patients with DSM-IV social anxiety disorder. Depression and Anxiety, 25, 230240. doi:10.1002/da.20295
Clark, D. M. and Wells, A. (1995). A cognitive model of social phobia. In Heimberg, R. G., Liebowitz, M., Hope, D. and Schneier, F. (eds), Social Phobia: Diagnosis, Assessment and Treatment (pp. 6993). New York: Guilford Press.
Clark, L. A. and Watson, D. (1991). Tripartite model of anxiety and depression: psychometric evidence and taxonomic implications. Journal of Abnormal Psychology, 100, 316336. doi:10.1037/0021-843X.100.3.316
Cohen, J. (1988). Set correlation and contingency tables. Applied Psychological Measurement, 12, 425434. doi:10.1177/014662168801200410
Cox, B. J., Rector, N. A., Bagby, R. M., Swinson, R. P., Levitt, A. J. and Joffe, R. T. (2000). Is self-criticism unique for depression? A comparison with social phobia. Journal of Affective Disorders, 57, 223228. doi:10.1016/S0165-0327(99)00043-9
Cox, B. J., Ross, L., Swinson, R. P. and Direnfeld, D. M. (1998). A comparison of social phobia outcome measures in cognitive-behavioral group therapy. Behavior Modification, 22, 285297. doi:10.1177/01454455980223004
Cox, B. J., Walker, J. R., Enns, M. W. and Karpinski, D. C. (2002). Self-criticism in generalized social phobia and response to cognitive-behavioral treatment. Behavior Therapy, 33, 479491. doi:10.1016/S0005-7894(02)80012-0
Coyne, J. C. (1976). Toward an interactional description of depression. Psychiatry, 39, 2840. doi:10.1521/00332747.1976.11023874
Darcy, K., Davila, J. and Beck, J. G. (2005). Is social anxiety associated with both interpersonal avoidance and interpersonal dependence? Cognitive Therapy and Research, 29, 171186. doi:10.1007/s10608-005-3163-4
Davila, J. and Beck, J. G. (2002). Is social anxiety associated with impairment in close relationships? A preliminary investigation. Behavior Therapy, 33, 427446. doi:10.1016/S0005-7894(02)80037-5
Dinnel, D. L., Kleinknecht, R. A. and Tanaka-Matsumi, J. (2002). A cross-cultural comparison of social phobia symptoms. Journal of Psychopathology and Behavioral Assessment, 24, 7584. doi:10.1002/da.20759
Dunkley, D. M., Blankstein, K. R. and Flett, G. L. (1997). Specific cognitive-personality vulnerability styles in depression and the five-factor model of personality. Personality and Individual Differences, 23, 10411053. doi:10.1016/S0191-8869(97)00079-2
First, M. B., Gibbon, M., Spitzer, R. L. and Williams, J. B. W. (1996). User's Guide for the Structured Clinical Interview for DSM-IV Axis I Disorders – Research Version (SCID-I, version 2.0, February 1996). New York: Biometrics Research.
Gilbert, P. and Trower, P. (2001). Evolution and process in social anxiety. In Crozier, W. R. and Alden, L. E. (eds), International Handbook of Social Anxiety: Concepts, Research and Interventions Relating to Self and Shyness, pp. 259279. Chichester, England: J. Wiley & Sons.
Garratt, G., Ingram, R. E., Rand, K. L. and Sawalani, G. (2007). Cognitive processes in cognitive therapy: Evaluation of the mechanisms of change in the treatment of depression. Clinical Psychology: Science and Practice, 14, 224239. doi:10.1111/j.1468-2850.2007.00081.x
Grant, D. M., Gayle Beck, J., Farrow, S. M. and Davila, J. (2007). Do interpersonal features of social anxiety influence the development of depressive symptoms? Cognition and Emotion, 21, 646663. doi:10.1080/02699930600713036
Hamilton, E. W. and Abramson, L. Y. (1983). Cognitive patterns and major depressive disorder: a longitudinal study in a hospital setting. Journal of Abnormal Psychology, 92, 173184. doi:10.1037/0021-843X.92.2.173
Hawley, L. L., Rector, N. A. and Laposa, J. M. (2016). Examining the dynamic relationships between exposure tasks and cognitive restructuring in CBT for SAD: Outcomes and moderating influences. Journal of Anxiety Disorders, 39, 1020. doi: 10.1016/j.janxdis.2016.01.010
Heimberg, R. G. and Becker, R. E. (2002). Cognitive-Behavioral Group Therapy for Social Phobia: Basic Mechanisms and Clinical Strategies. Guilford Press.
Heimberg, R. G., Liebowitz, M. R., Hope, D. A., Schneier, F. R., Holt, C. S., Welkowitz, L. et al. (1998). Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome. Archives of General Psychiatry, 55, 11331141. doi:10.1001/archpsyc.55.12.1133
Imber, S. D., Pilkonis, P. A., Sotsky, S. M., Elkin, I., Watkins, J. T., Collins, J. F. et al. (1990). Mode-specific effects among three treatments for depression. Journal of Consulting and Clinical Psychology, 58, 352359. doi:10.1037//0022-006X.58.3.352
Iwamasa, G. Y. (1997). Asian Americans. In Fredman, S. (eds), Cultural Issues in the Treatment of Anxiety (pp. 99129). New York: The Guilford Press.
Kashdan, T. B. (2007). Social anxiety spectrum and diminished positive experiences: Theoretical synthesis and meta-analysis. Clinical Psychology Review, 27, 348365. doi: 10.1016/j.cpr.2006.12. 003.
Kashdan, T. B., Elhai, J. D. and Breen, W. E. (2008). Social anxiety and disinhibition: an analysis of curiosity and social rank appraisals, approach–avoidance conflicts, and disruptive risk-taking behavior. Journal of Anxiety Disorders, 22, 925939. doi:10.1016/j.janxdis.2007.09.009
Kleinknecht, R. A., Dinnel, D. L., Kleinknecht, E. E., Hiruma, N. and Harada, N. (1997). Cultural factors in social anxiety: A comparison of social phobia symptoms and Taijin Kyofusho. Journal of Anxiety Disorders, 11, 157177. doi:10.1016/S0887-6185(97)00004-2
Kopala-Sibley, D. C., Zuroff, D. C., Russell, J. J. and Moskowitz, D. S. (2014). Understanding heterogeneity in social anxiety disorder: Dependency and self-criticism moderate fear responses to interpersonal cues. British Journal of Clinical Psychology, 53, 141156. doi: 10.1111/bjc. 12032
Lancu, I., Bodner, E. and Ben-Zion, I. Z. (2015). Self-esteem, dependency, self-efficacy and self-criticism in social anxiety disorder. Comprehensive Psychiatry, 58, 165171. doi: 10.1016/j.comppsych.2014.11.018
Laposa, J. M., Cassin, S. E. and Rector, N. A. (2010). Interpretation of positive social events in social phobia: an examination of cognitive correlates and diagnostic distinction. Journal of Anxiety Disorders, 24, 203210. doi:10.1016/j.janxdis.2009.10.009
Laposa, J. M. and Rector, N. A. (2011). A prospective examination of predictors of post-event processing following videotaped exposures in group cognitive behavioural therapy for individuals with social phobia. Journal of Anxiety Disorders, 25, 568573. doi: 10.1016/j.janxdis.2011.01. 004
Leary, M. R. (1983). Understanding Social Anxiety: Social, Personality and Clinical Perspectives (vol. 153). Sage Publications, Inc.
Leary, M. R. and Kowalski, R. M. (1995). The self-presentation model of social phobia. In Heimberg, R.G. and Liebowitz, M.R. (eds), Social Phobia: Diagnosis, Assessment, and Treatment, pp. 94112. New York: Guilford Press.
Lewis-Fernández, R., Hinton, D. E., Laria, A. J., Patterson, E. H., Hofmann, S. G., Craske, M. G. and Liao, B. (2010). Culture and the anxiety disorders: recommendations for DSM-V. Depression and Anxiety, 27, 212229. doi:10.1002/da.20647
Marques, L., Robinaugh, D. J., LeBlanc, N. J. and Hinton, D. (2011). Cross-cultural variations in the prevalence and presentation of anxiety disorders. Expert Review of Neurotherapeutics, 11, 313322. doi:10.1586/ern.10.122
Mattick, R. P. and Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455470. doi:10.1016/S0005-7967(97)10031-6
Mennin, D. S., Heimberg, R. G. and Jack, M. S. (2000). Comorbid generalized anxiety disorder in primary social phobia: symptom severity, functional impairment, and treatment response. Journal of Anxiety Disorders, 14, 325343. doi:10.1016/S0887-6185(00)00026-8
Morris, S. B. and DeShon, R. P. (2002). Combining effect size estimates in meta-analysis with repeated measures and independent-groups designs. Psychological Methods, 7, 105125. doi:10.1037/1082-989X.7.1.105
Musa, C. Z. and Lépine, J. P. (2000). Cognitive aspects of social phobia: A review of theories and experimental research. European Psychiatry, 15, 5966. doi:10.1016/S0924-9338(00)00210-8
Osman, A., Gutierrez, P. M., Barrios, F. X., Kopper, B. A. and Chiros, C. E. (1998). The social phobia and social interaction anxiety scales: Evaluation of psychometric – properties. Journal of Psychopathology and Behavioral Assessment, 20, 249264. doi: 10.1023/A:1023067302227
Padesky, C. A. (1994). Schema change processes in cognitive therapy. Clinical Psychology and Psychotherapy, 1, 267278. doi:10.1002/cpp.5640010502
Rapee, R. M. and Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35, 741756. doi:10.1016/S0005-7967(97)00022-3
Rector, N. A., Bagby, R. M., Huta, V. and Ayearst, L. (2012). Examination of the trait facets of the five-factor model in discriminating specific mood and anxiety disorders. Psychiatry Research, 199, 131139.
Rector, N. A., Bagby, R. M., Segal, Z. V., Joffe, R. T. and Levitt, A. (2000). Self-criticism and dependency in depressed patients treated with cognitive therapy or pharmacotherapy. Cognitive Therapy and Research, 24, 571584. doi:10.1023/A:1005566112869
Rector, N. A., Kocovski, N. L. and Ryder, A. G. (2006a). Social anxiety and the fear of causing discomfort to others. Cognitive Therapy and Research, 30, 279296. doi: 10.1007/s10608-006-9050-9
Rector, N. A., Kocovski, N. L. and Ryder, A. G. (2006b). Social anxiety and the fear of causing discomfort to others: Conceptualization and treatment. Journal of Social and Clinical Psychology, 25, 906918. doi:10.1521/jscp.2006.25.8.906
Regev, R., Shahar, G. and Lipsitz, J. D. (2012). Is Social Self-Criticism a Unique Vulnerability Dimension for Social Anxiety and Depression? International Journal of Cognitive Therapy, 5, 211218. doi:10.1521/ijct.2012.5.2.211
Robins, C. J., Bagby, R. M., Rector, N. A., Lynch, T. R. and Kennedy, S. H. (1997). Sociotropy, autonomy, and patterns of symptoms in patients with major depression: A comparison of dimensional and categorical approaches. Cognitive Therapy and Research, 21, 285300. doi:10.1023/A:1021874415967
Rosser, S., Issakidis, C. and Peters, L. (2003). Perfectionism and social phobia: Relationship between the constructs and impact on cognitive behavior therapy. Cognitive Therapy and Research, 27, 143151. doi:10.1023/A:1023505108426
Saboonchi, F., Lundh, L. G. and Öst, L. G. (1999). Perfectionism and self-consciousness in social phobia and panic disorder with agoraphobia. Behaviour Research and Therapy, 37, 799808. doi:10.1016/S0005-7967(98)00183-1
Sanz, J. and Avia, M. D. (1994). Cognitive specificity in social anxiety and depression: Self- statements, self-focused attention, and dysfunctional attitudes. Journal of Social and Clinical Psychology, 13, 105137. doi:10.1521/jscp.1994.13.2.105
Schlenker, B. R. and Leary, M. R. (1982). Social anxiety and self-presentation: A conceptualization model. Psychological Bulletin, 92, 641669. doi:10.1037/0033- 2909.92.3.641
Shadick, R. N., Roemer, L., Hopkins, M. B. and Borkovec, T. D. (1991). The Nature of Worrisome Thoughts. Paper presented at the annual meeting of the Association for Advancement of Behavior Therapy, New York, NY.
Tabachnick, B. G. and Fidell, L. S. (1996). Using Multivariate Statistics (3rd edn). New York: Harper Collins.
Takahashi, T. (1989). Social phobia syndrome in Japan. Comprehensive Psychiatry, 30, 4552. doi:10.4236/ojpsych.2013.34042
Toothaker, L. E. (1993). Multiple Comparison Procedures (no. 89). Newbury Park, CA: Sage Publications, Inc.
Tryon, W. (2014). Cognitive Neuroscience and Psychotherapy: Network Principles for a Unified Theory. New York, NY: Academic Press.
Uziel, L. (2010). Rethinking social desirability scales from impression management to interpersonally oriented self-control. Perspectives on Psychological Science, 5, 243262. doi: 10.1177/1745691610369465
Weissman, A. and Beck, A. T. (1978). Development and validation of the Dysfunctional Attitude Scale. Paper presented at the annual convention of the Association for Advancement of Behavior Therapy, Chicago, IL.
Wells, A. (1997). Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide. Chichester, UK: Wiley.
Zhu, X., Yao, S., Dere, J., Zhou, B., Yang, J. and Ryder, A. G. (2014). The cultural shaping of social anxiety: Concerns about causing distress to others in Han Chinese and Euro- Canadian outpatients. Journal of Social and Clinical Psychology, 33, 906917. doi: 10.1521/jscp.2014.33.10.906
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