Becoming the Center of Attention in Social Anxiety Disorder

Abstract

Objective A detailed understanding of how individuals diagnosed with social anxiety disorder (SAD) respond physiologically under social-evaluative threat is lacking. We aimed to isolate the specific components of public speaking that trigger fear in vulnerable individuals and best discriminate among SAD and healthy individuals. Method Sixteen individuals diagnosed with SAD and 16 healthy individuals were asked to prepare and deliver a short speech in a virtual reality (VR) environment. The VR environment simulated standing center stage before a live audience and allowed us to gradually introduce social cues during speech anticipation. Startle eye-blink responses were elicited periodically by white noise bursts presented during anticipation, speech delivery, and recovery in VR, as well as outside VR during an initial habituation phase. Results SAD individuals reported greater distress and state anxiety than healthy individuals across the entire procedure (ps < .005). Analyses of startle reactivity revealed a robust group difference during speech anticipation in VR, specifically as audience members directed their eye gaze and turned their attention toward participants (p < .05, Bonferroni corrected). Conclusions The VR environment is sufficiently realistic to provoke fear and anxiety in individuals highly vulnerable to socially threatening situations. SAD individuals showed potentiated startle, indicative of a strong phasic fear response, specifically when they perceived themselves as occupying the focus of others' attention as speech time approached. Potentiated startle under social-evaluative threat indexes SAD-related fear of negative evaluation.

Anxiety and Depression Symptom Dimensions Demonstrate Unique Relationships with the Startle Reflex in Anticipation of Unpredictable Threat in 8 to 14 Year-Old Girls

“…The present study examined more specific variation in anxiety phenomenology, and results indicated that social phobia symptoms specifically were associated with heightened startle potentiation in anticipation of unpredictable threat. Social phobia has previously been associated with an increased startle reflex during fearful imagery (McTeague et al, 2009), anticipation of public speaking (Cornwell et al, 2011, 2006), and across an entire task (Larsen, Norton, Walker, & Stein, 2002). However, the present study is the first to demonstrate an association between social phobia symptoms and startle potentiation as a function of the predictability of threat.…”

“…The age range of the sample spanned late childhood and early adolescence, a period during which there is a marked increase in social phobia (Beesdo et al, 2009; Merikangas et al, 2010). Importantly, social phobia has been previously linked to intolerance of uncertainty (Boelen & Reijntjes, 2009; Carleton, Collimore, & Asmundson, 2010; Whiting et al, 2014) and an increased startle reflex in anticipation of public speaking (Cornwell, Heller, Biggs, Pine, & Grillon, 2011; Cornwell, Johnson, Berardi, & Grillon, 2006), an uncertain and unpredictable threat. Therefore, it was hypothesized that greater social phobia symptoms would be associated with increased startle and self-reported anxiety in anticipation of unpredictable (but not predictable) threat.…”

Exaggerated neurobiological sensitivity to threat as a mechanism linking anxiety with increased risk for diseases of aging

“…In the subsequent appraisal stage, anxious individuals are likely to regard ambiguous and threatening stimuli (e.g., mild electric shocks in the laboratory and motor vehicle accidents in real life) as more threatening than they actually are (Boddez et al, 2012; Britton et al, 2011; Dash and Davey, 2012; Lazarus and Folkman, 1984; Meiser-Stedman et al, 2009). This may contribute to the tendency for anxious individuals to show greater neurobiological reactivity to standardized threatening stimuli such as a virtual audience for a public speaking task or angry and fearful human faces (Cornwell et al, 2011; Eldar et al, 2011; Robinson et al, 2012a). Finally, following such reactions, anxious individuals engage in cognitive-behavioral avoidance of perceived threats, which limits their ability to challenge inappropriate threat perception, confront and resolve threatening situations, and reshape expectations for the future (Cisler and Koster, 2010; Koster et al, 2006).…”

New Directions in Virtual Reality-Based Therapy for Anxiety Disorders

“…What is perhaps more relevant in this context is the fact that the VR environment have been shown to have a specific effect on clinical subjects (i.e., those that had a social anxiety disorder diagnosis) as compared to healthy controls. In a recent study, subjects with social anxiety showed higher overall state anxiety during the entire procedure (entering VR environment, performing a speech and existing the environment) and higher startle responses in the anticipation phase in which the virtual audience turned towards the subjects (Cornwell, Heller, Biggs, Pine, & Grillon, 2011). Given these findings, we believe that the use of VR could overcome potential limitations of the emotion regulation paradigm.…”