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Social Anxiety Disorder: a Critical Overview of Neurocognitive Research Henk R Overview Social anxiety disorder: a critical overview of neurocognitive research Henk R. Cremers1,2* and Karin Roelofs3,4 Social anxiety is a common disorder characterized by a persistent and excessive fear of one or more social or performance situations. Behavioral inhibition is one of the early indicators of social anxiety, which later in life may advance into a certain personality structure (low extraversion and high neuroticism) and the development of maladaptive cognitive biases. While there are several effective psycho- and pharmacotherapy options, a large number of patients benefit insufficiently from these therapies. Brain and neuroendocrine research can help uncover both the biological basis of social anxiety and potentially provide indicators, ‘biomarkers,’ that may be informative for early disease detection or treatment response, above and beyond self-report data. Several large-scale brain networks related to emotion, motivation, cognitive control, and self- referential processing have been identified, and are affected in social anxiety. Social anxiety is further characterized by increased cortisol response and lower testosterone levels. These neuroendocrine systems are also related to altered connectivity patterns, such as reduced amygdala–prefrontal coupling. Much work is needed however to further elucidate such interactions between neuro- endocrine functioning and large-scale brain networks. Despite the great prom- ise of brain research in uncovering the neurobiological basis of social anxiety, several methodological and conceptual issues also need to be considered. © 2016 Wiley Periodicals, Inc. How to cite this article: WIREs Cogn Sci 2016, 7:218–232. doi: 10.1002/wcs.1390 INTRODUCTION feared situations almost invariably provokes anxiety, which can take the form of panic attacks.2 Social ocial anxiety disorder (SAD) is characterized by a situations are either avoided or endured with intense Spersistent fear of one or more social or perfor- anxiety or distress.2 Imagine for instance being nerv- mance situations with exposure to unfamiliar people 1 ous, days in advance, about a meeting at work or to possible scrutiny by others. A person with because of what colleagues think about how you SAD fears that he or she will act in a way that will look or what you say, and eventually calling in sick be humiliating or embarrassing, and exposure to the to avoid the meeting altogether. Such behavior, when repeated, will be unfavorable to actual performance reviews at work, and perhaps lead to gossiping, *Correspondence to: [email protected] which in turn reinforces the social fears that led to 1Department of Clinical Psychology, University of Amsterdam, the avoidance behavior to begin with. Here we will Amsterdam, Netherlands provide a critical overview of neurocognitive and 2 Department of Psychiatry, The University of Chicago, Chicago, neuroendocrine research on social anxiety. Our goal IL, USA is to focus on a selection of important findings on the 3Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, Netherlands brain (focussing on functional Magnetic Resonance 4Donders Institute for Brain Cognition and Behaviour, Radboud Imaging research) and neuroendocrine systems in University Nijmegen, Nijmegen, Netherlands adult SAD, rather than providing an exhaustive over- fl fl view; for this, the interested reader is referred to Con ict of interest: The authors have declared no con icts of inter- 3–6 est for this article. references. We will start by briefly covering 218 ©2016WileyPeriodicals,Inc. Volume7,July/August2016 WIREs Cognitive Science Social anxiety disorder developmental, cognitive and therapeutic perspec- Another line of research aims to uncover the tives, to first sketch a broader context, before we underlying or latent factors of social anxiety. Two move to the brain and neuroendocrine research. We independent studies found a similar three-factor solu- will also highlight several limitations of brain ima- tion for social anxiety, one consisting of social inter- ging studies. action fears, observation fears, and public speaking fears15 and the other of public performance, close scrutiny, and social interaction.16 This work on DEVELOPMENT, COGNITION, AND latent models of social anxiety may be helpful while ‘ ’ TREATMENT dissecting subtypes of social anxiety. When discuss- ing the basic structure and personality characteristic The diagnosis of SAD requires that the condition of social anxiety in the population it is important to interferes substantially with the person’s normal rou- emphasize that such factors indeed just pertain to the tine.2 Hence, while almost everyone will get nervous population, not the individual.17 That is, for any when speaking in public, in order to ‘qualify’ as a individual, the development and variation in social disorder, this fear must be present in one or several anxiety severity over time may be related to a single different situations and lead to substantial distress. cognitive factor (e.g., the fear of negative evaluation) The lifetime prevalence rates are estimated between or to multiple factors. Research into such processes 5 and 12%.7,8 A classical discussion on psychiatric obviously requires longitudinal data. In the next sec- disorders is whether they should be regarded as an tion, we will briefly discuss the development and cog- extreme form of ‘normal’ behavior (i.e., simply a nitive processes and treatment of social anxiety. more extreme level of social anxiety) or as categori- 9 10 cally different. Work by Ruscio et al. provided Developmental and Cognitive Models converging evidence for the dimensional nature of social anxiety. Hence we will incorporate both social Behavioral inhibition (BI), a temperamental trait anxiety (as an individual differences trait) and SAD referring to reactions of a child when confronted with novel situations or unfamiliar people,18 is one (or social phobia; i.e., the set of symptoms that fulfill DSM criteria) in our discussion, since this distinction of the earliest developmental indications of social is unlikely to be respected by underlying brain anxiety. For example, research has shown a moder- ate relation between BI at 21 months, 31 months, mechanisms. and 4 years old,19,20 and stable BI is a risk factor for Research on personality traits and the develop- 18 ment of social anxiety stresses the dimensional nature social and other anxiety disorders. During the course of a child’s development, social anxiety may of social anxiety. Traits related to emotional proces- sing, such as neuroticism (a temperamental sensitivity progress from such initial behavioral indicators, to to painful or negative stimuli, and experiencing nega- increasing levels of self-consciousness and preoccupa- tion with peer feedback and exclusion.21 Several cog- tive affect more frequently and/or intensely) and extraversion (a temperamental sensitivity to pleasura- nitive models have been proposed that describe this ble stimuli (rewards) and experiencing positive effect, social information processing and, importantly, maintaining cognitive biases in social anxiety.22,23 A pride, and self-confidence more frequently and/or intensely)11 are critical. Neuroticism is regarded as a detailed comparison of such models is beyond the ‘vulnerability’ marker, and extraversion a ‘protective’ scope of the article, but there are important overlap- 12,13 ping elements including low perceived emotional con- factor in the development of SAD. Moreover, it has been found that the heritability of social anxiety trol, post-event rumination, avoidance and the use of can, to a large extend, be explained by the heritabil- safety behaviors. Hofmann (2007) eloquently sum- 13 marized a cascade of maladaptive cognition: ity of these personality traits. Note that this rela- tion between personality factors and (social) anxiety development may be interpreted in a merely probabi- When confronted with challenging social situations, listic manner: on average, someone who scores high individuals with SAD shift their attention toward on extraversion and low on neuroticism is less likely their anxiety, view themselves negatively as a social object, overestimate the negative consequences of a to develop social anxiety later in life. Personality social encounter, believe that they have little control traits may simply capture some aspects of (social) over their emotional response, and view their social anxiety, such as a low stress threshold in the case of skills as inadequate to effectively cope with the social neuroticism, and therefore naturally show covaria- situation. In order to avoid social mishaps, indivi- tion, which makes such explanations somewhat duals with SAD revert to maladaptive coping strate- circular.14 gies, including avoidance and safety behaviors, Volume7,July/August2016 ©2016WileyPeriodicals,Inc. 219 Overview wires.wiley.com/cogsci followed by post-event rumination, which leads to studies on the neurobiology of extinction learning 24 further social apprehension in the future. resulted in pharmacological enhancement (D-cycloser- ine) of exposure training.41 SAD is a heterogeneous condition, and natu- rally there are many different possible ‘routes’ to the development of similar social anxiety symptoms NEUROBIOLOGY fi (principle of equi nality), while comparable predis- There has been a steady increase of functional mag- posing factors (e.g., childhood trauma) may lead to netic resonance imaging (fMRI) research into the very different symptom outcomes (principle of multi- neural
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