مقیاس های منفی خودتجسمی: توسعه، اعتبار سنجی و برنامه برای اضطراب اجتماعی

Abstract The Negative Self-Portrayal Scale (NSPS) is a new questionnaire designed to assess the extent to which individuals are concerned that specific self-attributes they view as being deficient will be exposed to scrutiny and evaluation by critical others in social situations. These concerns have been proposed to drive symptoms of social anxiety and account for individual differences in social fears and avoidance behaviors (Moscovitch, 2009). Here, we introduce the NSPS and examine its factor structure and psychometric properties across two large samples of North American undergraduate students with normally distributed symptoms of social anxiety. Exploratory and confirmatory factor analyses supported a 3-factor solution representing concerns about (a) social competence; (b) physical appearance; and (c) signs of anxiety. The NSPS was found to have good internal consistency and test-retest reliability, strong convergent validity, and adequate discriminant validity. In addition, NSPS total scores accounted for a significant proportion of unique variance in self-concealment (i.e., safety) behaviors over and above established symptom measures of social interaction anxiety, social performance anxiety, and depression. Results are discussed in relation to theoretical models of social anxiety and the potential utility of the NSPS for both clinical research and practice.

According to cognitive-behavioral models of social anxiety disorder (SAD; Clark & Wells, 1995; Hofmann, 2007; Moscovitch, 2009; Rapee & Heimberg, 1997), individual differences in social anxiety (SA) and SA-related emotions and behaviors are driven by the cognitions – specifically, the beliefs and appraisals – that individuals hold about themselves in relation to others within social situations. Studies have shown that both individuals with a diagnosis of SAD and nonclinical participants with high levels of trait SA are more likely than nonanxious controls to view themselves as being socially inept or undesirable (e.g., Ashbaugh, Antony, McCabe, Schmidt, & Swinson, 2005; Moscovitch, Orr, Rowa, Gehring Reimer, & Antony, 2009), and to perceive others as being critical evaluators who hold unreachable or overly rigid standards for social performance (e.g., Bielak & Moscovitch, 2013; Moscovitch & Hofmann, 2007; Moscovitch, Rodebaugh, & Hesch, 2012; Wallace & Alden, 1991). Socially anxious individuals engage in frequent upward social comparisons in which they evaluate themselves unfavorably relative to others across various domains (Antony, Rowa, Liss, Swallow, & Swinson, 2005; Weisman, Aderka, Marom, Hermesh, & Gilboa-Schechtman, 2011). As such, they enter social situations expecting interaction partners or audience observers to criticize or reject them (Bielak & Moscovitch, 2012, 2013; Foa, Franklin, Perry, & Herbert, 1996; Gilboa-Schechtman, Franklin, & Foa, 2000; Rodebaugh, 2009). Indeed, for individuals with SAD or high trait SA, the perceived discrepancy between their own social abilities and self-worth, on one hand, and their beliefs about how they ought to present themselves in social situations (as embodied in perceived social norms and expectations of social partners or observers), on the other, is thought to lie at the core of their problems (Leary & Kowalski, 1995; Schlenker & Leary, 1982; Strauman & Higgins, 1987). When this set of negative beliefs about self and others is activated during social situations, it alters individuals' allocation of cognitive resources toward or away from perceived threat (Schultz & Heimberg, 2008) and changes the way they process social information (see Clark & McManus, 2002; Hirsch & Clark, 2004). Moreover, these beliefs generate elevations in autonomic arousal and corresponding increases in negative affect and reductions in positive affect (e.g., Moscovitch, Suvak, & Hofmann, 2010), while also promoting submissive withdrawal from social situations (Weeks, Rodebaugh, Heimberg, Norton, & Jakatdar, 2009), including outright avoidance or escape, or the more subtle use of safety behaviors (e.g., Alden & Bieling, 1998; Cuming et al., 2009; McManus, Sacadura, & Clark, 2008; Plasencia, Alden, & Taylor, 2011; Wells et al., 1995). These behaviors, in turn, diminish opportunities for positive emotional rewards from social engagement (Kashdan, 2007) and make socially anxious individuals appear less warm and friendly, thereby increasing the likelihood of interpersonal rejection from others (Alden & Taylor, 2004). Based on clinical observation, Moscovitch (2009) recently proposed that socially anxious individuals are fundamentally concerned about particular self-attributes that they believe are flawed and likely to be exposed for public scrutiny and evaluation in social situations. Moscovitch argued that the types of self-attributes about which such individuals are generally concerned tend to encompass four correlated dimensions: social skills, personality, signs of anxiety, and physical appearance. According to Moscovitch, these self-attribute concerns represent the core threat stimuli in SAD and it is their activation in anticipation of, or during social encounters that lead to emotional distress and maladaptive behavioral responses, including the use of specific safety behaviors designed to conceal perceived self-attribute flaws. Further, Moscovitch theorized that differences between socially anxious individuals in the nature and constellation of such concerns across the four dimensions are meaningful in so far as such differences might help to account for the considerable degree of heterogeneity that has been observed in both SA symptom expression and SAD treatment outcomes ( Hofmann, Heinrichs, & Moscovitch, 2004; see also Kashdan, Weeks, & Savostyanova, 2011; Moscovitch, Gavric, et al., 2012). In this vein, although cognitive behavioral therapy (CBT) has shown clear efficacy in treating SAD across numerous randomized controlled trials (RCTs; e.g., Clark et al., 2006; Rapee, Gaston, & Abbott. 2009; see also Norton & Price, 2007), many patients with SAD – both within the context of such RCTs and in community-based practice settings that offer empirically-supported CBT protocols for SAD – commonly drop out of therapy early or remain significantly symptomatic by the end of treatment (see Eskildsen, Hougaard, & Rosenberg, 2010; Moscovitch, Gavric, et al., 2012). It is possible that refinements to the conceptualization of SAD based on Moscovitch's model may ultimately lead to improvements in CBT delivery and outcomes for those patients who are not responding adequately to existing treatment packages. In order to test Moscovitch's hypothesized model, we developed and validated the Negative Self-Portrayal Scale (NSPS; Moscovitch & Huyder, 2011), a new self-report measure designed to assess individuals' concerns about revealing particular self-attributes in social situations across the four proposed dimensions. Exploratory and confirmatory factor analyses of the NSPS supported a nonorthogonal 3-factor solution in which concerns about signs of anxiety and concerns about physical appearance each loaded onto their own respective factors, while concerns about social skills and concerns about personality loaded onto a single factor that was labeled concerns about social competence ( Moscovitch & Huyder, 2011). These two proposed dimensions may have loaded onto one common factor because NSPS respondents likely considered social skills to be observable indices of personality. Indeed, it is reasonable to suppose that exhibiting flaws in social skills or flaws in personality would lead essentially to the same concern: appearing socially incompetent. Initial studies of the NSPS in undergraduate samples have shown that it demonstrates strong concurrent and construct validity, internal consistency, and test-retest reliability, and that NSPS total scores account for a significant proportion of unique variance in self-concealment behaviors over and above established measures of social interaction anxiety, social performance anxiety, and dysphoria (see Moscovitch & Huyder, 2011). Moreover, we have found that NSPS self-attribute concerns are represented in the negative mental self-images that individuals report experiencing in anxiety-provoking social situations, and that the images endorsed by high SA participants are more significantly imbued with themes related to the NSPS dimensions – in particular, appearing socially incompetent and anxious (and to a lesser extent, physically unattractive) – than the corresponding negative images of low SA participants (Moscovitch, Gavric, Merrifield, Bielak, & Moscovitch, 2011). These images, which are often linked to autobiographical memories of past negative experiences, tend to contain negatively distorted sensory representations which are appraised by socially anxious individuals as being accurate, personally meaningful, and intrusive (Chiupka, Moscovitch, & Bielak, 2012; Hackmann, Clark, & McManus, 2000). While the preliminary validation of the NSPS and our initial studies on the nature of self-portrayal concerns in undergraduate samples certainly help to sharpen our understanding of SA and the measurement of its cognitive underpinnings, they also illuminate new research questions and the need for experimental studies to address them. For example, it remains unknown whether the types of self-relevant concerns assessed by the NSPS are uniquely associated with SA and a clinical diagnosis of SAD. Given that NSPS scores in our initial validation study correlated robustly with both measures of SA and depression (Moscovitch & Huyder, 2011), it is possible that the NSPS captures self-critical cognitions that serve as a common diathesis underlying both syndromes (see Dozois & Frewen, 2006; Ingram, Ramel, Chavira, & Scher, 2005). In the same vein, it has not yet been clearly established that self-portrayal concerns are more relevant to SAD than they are to other anxiety disorders. In addition, little is known about how self-portrayal concerns across the dimensions of social competence, signs of anxiety, and physical appearance function in relation to emotional and behavioral symptoms of SA within both experimental and naturalistic social settings. Are specific self-portrayal concerns triggered by the demands of in-vivo social encounters and do elevations in such concerns lead to corresponding increases in state negative affect and use of safety behaviors, as proposed by Moscovitch (2009)? Here, as elsewhere ( Moscovitch, 2009), we conceptualize SA-related safety behaviors as strategic responses designed to suppress or conceal perceived self-flaws within anxiety-provoking social contexts. Following this premise, it might be reasonable to expect that the use of safety behaviors during social encounters would mediate the relation between heightened self-portrayal concerns and elevated levels of negative affect. From this perspective, it is possible that safety behaviors in SA might function in much the same way as expressive suppression (see Gross & John, 2003; Kashdan & Steger, 2006; Spokas, Luterek, & Heimberg, 2009), which has been shown in previous studies to amplify arousal and prolong negative affect when used as an emotion regulation strategy by individuals with various anxiety and mood disorders (e.g., Campbell-Sills, Barlow, Brown, & Hofmann, 2006). No previous studies have examined these issues and questions, but investigating them is important not only for the sake of further testing and potentially validating Moscovitch's (2009) theoretical model, but also to help pave the way toward increasing the efficacy of psychological treatments for SAD via the continued refinement of evidence-based, idiosyncratically-tailored interventions that target core symptoms. In the present multiphase study, a community-based sample consisting of adults with a principal diagnosis of SAD (both with and without an additional depressive disorder), a principal anxiety diagnosis other than SAD (both with and without an additional diagnosis of SAD), or no history of psychological problems completed trait questionnaires, 1-week of daily diaries in naturalistic social situations, and a standardized social performance task in the lab. Participants' self-portrayal concerns, use of safety behaviors, and affective reactions to social stress were measured across phases of the study. We hypothesized, first, that self-portrayal concerns across the 3 NSPS subscales would be significantly elevated among participants with a diagnosis of SAD but not among those without SAD, irrespective of comorbid depression. Second, we expected that the activation of specific self-portrayal concerns within both naturalistic and laboratory-based social contexts would predict significant use of in-vivo safety behaviors, even after controlling for associated increases in general negative affect. Finally, we hypothesized that safety behavior use during the laboratory speech task would mediate the relation between participants' self-portrayal concerns in anticipation of the task and their reported levels of negative affect after the task was completed.