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Assessing Gaze Avoidance in Social Anxiety Disorder Via Covert Eye

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Assessing Gaze Avoidance in Social Anxiety Disorder Via Covert Eye Journal of Anxiety Disorders 65 (2019) 56–63 Contents lists available at ScienceDirect Journal of Anxiety Disorders journal homepage: www.elsevier.com/locate/janxdis “Fear guides the eyes of the beholder”: Assessing gaze avoidance in social ⋆ T anxiety disorder via covert eye tracking of dynamic social stimuli ⁎ Justin W. Weeksa,1, , Ashley N. Howella,2, Akanksha Srivastava,3, Philippe R. Goldinb a Center for Evaluation and Treatment of Anxiety, Department of Psychology, Porter Hall 200, Ohio University, Athens, OH, 45701, United States b Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, 95817, United States ARTICLE INFO ABSTRACT Keywords: Gaze avoidance is an important feature of social anxiety disorder (SAD) and may serve as a biobehavioral marker Social anxiety disorder of SAD. The purpose of the present study was to replicate and extend findings on gaze avoidance in SAD viaeye Social phobia tracking during a computerized social simulation. Patients with SAD (n = 27) and a (sub)sample of demo- Gaze avoidance graphically-matched healthy controls (HC; n = 22) completed a computerized, dynamic social simulation task Eye tracking involving video clips of actors giving positive and negative social feedback to the participant. All participants Submissive gestures were unknowingly eye tracked during the simulation, and post-study consent was obtained to examine re- sponses. Consistent with the bivalent fear of evaluation (BFOE) model of social anxiety, fear of positive evaluation related systematically to state anxiety in response to positive social feedback, and fear of negative evaluation related systematically to state anxiety in response to negative social feedback. Moreover, compared to HCs, SAD patients exhibited significantly greater global gaze avoidance in response to both the positive and negative video clips. Our results provide strong additional support for gaze avoidance as a biobehavioral marker of SAD, as well as additional support for the BFOE model. Implications for the assessment and treatment of SAD are discussed. 1. Introduction Eye gaze in particular is considered a threat signal in humans and an- imals (e.g., see Ellsworth, Carlsmith, & Hensen, 1972; Gilbert, 2001). In Social anxiety disorder (SAD; social phobia) is characterized by parallel, gaze avoidance serves as a submissive signal (Gilbert, 2001; excessive fear of social or performance situations and is the fourth most Horley, Williams, Gonsalvez, & Gordon, 2004) in that avoiding gaze common mental disorder, with an estimated lifetime prevalence rate of signals one’s lower social status and sense of threat. Similar to non- 12.1% (Kessler et al., 2005). Patients seeking treatment for SAD report human primates (de Waal, 1988), humans can appease others with impairment across numerous life domains (Schneier et al., 1994; Stein, submissive nonverbal displays which include eye gaze avoidance McQuaid, Laffaye, & McCahill, 1999). Moreover, SAD is highly co- (Ellyson & Dovidio, 1985; Kaminer & Stein, 2005). morbid with other debilitating disorders, including depression and Eye tracking is an objective measure that can be used to determine substance use disorders (Kessler, Stang, Wittchen, Stein, & Walters, the direction of an individual’s gaze in real time. Previous studies have 1999; Schneier et al., 1994). utilized eye tracking to examine “eye contact” tendencies of socially The link between social anxiety-related symptoms (e.g., fears of anxious individuals with experimental stimuli, and results have high- evaluation) and submissive behaviors in general has been supported by lighted gaze avoidance as a biobehavioral indicator of SAD. For ex- a number of studies (e.g., see Galili, Amir, & Gilboa-Schechtman, 2013; ample, a model which has informed eye tracking research with respect Gilboa-Schechtman, Galili, Sahar, & Amir, 2014; Weeks, Heimberg, & to social anxiety (Weeks, Howell, & Goldin, 2013) is the bivalent fear of Heuer, 2011; Weeks, Rodebaugh, Heimberg, Norton, & Jakatdar, 2009). evaluation (BFOE) model (Weeks & Howell, 2012, 2014). According to ⋆ This work was supported by Ohio University funds awarded to JWW; additionally, the writing of this manuscript was supported in part by T32MHO18869 awarded to ANH. ⁎ Corresponding author. E-mail address: [email protected] (J.W. Weeks). 1 Justin Weeks is now at Nebraska Medicine, Department of Psychology, and the University of Nebraska Medical Center, Department of Psychiatry, Omaha, NE 68198-4185, United States. 2 Ashley Howell is now at the Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Charleston, SC, 29425, United States. 3 Akanksha Srivastav is now at Counseling and Psychological Services, San Jose State University, San Jose, CA, 95192, United States. https://doi.org/10.1016/j.janxdis.2019.05.005 Received 2 October 2018; Received in revised form 23 May 2019; Accepted 25 May 2019 Available online 28 May 2019 0887-6185/ © 2019 Elsevier Ltd. All rights reserved. J.W. Weeks, et al. Journal of Anxiety Disorders 65 (2019) 56–63 the BFOE model, fear of evaluation in general, including fear of positive principal diagnosis of SAD (generalized subtype, per DSM-IV criteria evaluation (FPE) as well as fear of negative evaluation (FNE), is im- (APA, 1994)) and demographically-matched healthy control (HC) par- portant in social anxiety (e.g., see Weeks, Heimberg, & Rodebaugh, ticipants were asked to view twenty-six 12 s dynamic videos of actors 2008). FPE consists of dread that others may evaluate one positive- delivering either positive (13 videos) or negative (13 videos) statements ly—resulting in increased attention and potential reprisal from per- (concordant with emotional expressions), as if “to the participant”. All ceived socially dominant others (see Reichenberger & Blechert, 2018, participants were unknowingly eye tracked during the experiment for a review). In contrast, FNE pertains to the sense of dread associated (post-study consent was obtained to examine responses; see Proce- with being evaluated unfavorably, and social anxiety pertains to af- dures), and were asked to provide state anxiety ratings in response to fective reactions to social situations. FPE, FNE, and social anxiety have each of the videos. all been shown to relate strongly and positively to one another. More- We tested four hypotheses. (Hypothesis 1) [1a] SAD patients would over, FPE and FNE account for unique variance in social anxiety endorse elevated state anxiety relative to HCs in response to social in- symptom severity (e.g., see Fergus et al., 2009; Weeks, Heimberg, teraction video stimuli involving receipt of [i] positive and [ii] negative Rodebaugh, 2008; Weeks, Heimberg, Rodebaugh, & Norton, 2008). feedback; [1b] state anxiety in response to the distinctly valenced social Essentially, the BFOE model suggests that these two fears cause socially simulation task videos would relate positively to fear of the respective anxious individuals to feel compelled to be as inconspicuous as possible valence of evaluation (i.e., state anxiety experienced in response to at all times within feared social situations (e.g., see Weeks & Howell, positive videos would relate positively and uniquely to FPE, whereas 2014). responses to negative videos would relate positively and uniquely to FNE); (Hypotheses 2-4) with regard to gazing at the eyes of the actors 1.1. Convergence between BFOE model and eye tracking findings in both the positive and negative social stimuli, SAD patients would exhibit increased gaze avoidance overall in comparison to the healthy Given the focus of the present study upon eye contact, previous controls, as indexed by [2] total time holding eye contact (i.e., gazing findings involving attention to faces in general (e.g., utilizing dot-probe within designated eye regions); [3] total number of eye fixations; and tasks, or eye tracking pertaining to faces in general rather than eye regions [4] total fixation durations. specifically) are beyond the scope of this paper, and so will notbere- viewed here. Given the above, and relevant to the foci of the BFOE model upon distinct valences of socio-evaluative cues, four studies have speci- 2. Methods fically examined social anxiety and gaze avoidance in response toposi- tive and negative social stimuli (in contrast to either attention to faces in 2.1. Participants general or gaze tendencies in response to only neutral facial images). Two of these studies included treatment-seeking adults diagnosed with Participants were 27 SAD patients and 22 HCs who were demo- SAD and demographically-matched healthy controls who viewed still- graphically-matched to a subset (n = 22) of the SAD patients on age, images of happy, angry or sad, and/or neutral faces for a period 10 s sex, and racial/ethnic background. No eligible matched HCs were able (Horley, Williams, Gonsalvez, & Gordon, 2003, 2004). Convergent to be recruited for 5 of the eligible SAD patients. These 5 unmatched findings across the studies by Horley et al. (2003, 2004) showed that SAD SAD patients were retained to maximize the external validity of the patients exhibited fewer total fixations in the eye regions of the negative obtained effects. When excluding the 5 unmatched SAD patients, results facial photographs in comparison to healthy control participants (Horley were substantively identical to results obtained from the full sample (N et al., 2003, 2004). In addition, consistent with the BFOE model, SAD = 49). symptom severity related negatively
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