حافظه شرح حال منفی در اختلال اضطراب اجتماعی: مقایسه افراد مبتلا به اختلال ترس و افراد سالم

Abstract Background and objectives Empirical interest in mental imagery in social anxiety disorder (SAD) has grown over the past years but still little is known about the specificity to SAD. The present study therefore examines negative autobiographical memories in participants with social anxiety disorder (SAD), compared to patients with panic disorder (PD), and healthy controls (HCs). Methods A total of 107 participants retrieved four memories cued by verbal phrases associated with either social anxiety (SA) or panic anxiety (PA), with two memories for each cue category. Results PA-cued memories were experienced with stronger imagery and as more traumatic. They were also rated as more central to identity than SA-cued memories, but not among participants with SAD, who perceived SA-cued memories as equally central to their identity. When between-group effects were detected, participants with anxiety disorders differed from HCs, but not from each other. Limitations Central limitations include reliance on self-report measures, comorbidity in the anxiety disorder groups, and lack of a neutrally cued memory comparison. Conclusions The findings align with models of SAD suggesting that past negative social events play a central role in this disorder. Future research is suggested to further explore the function of negative memories, not only in SAD, but also in other anxiety disorders.

Introduction Empirical interest in mental imagery in social anxiety disorder (SAD) has grown over the past years, and studies have shown that individuals high in self-reported social anxiety experience negative imagery more so than individuals low in self-reported social anxiety (Hackmann, Suraway, & Clark, 1998). In addition, studies have indicated that negative self-imagery has a causal role in maintaining SAD by increasing state anxiety, enhancing negative self-judgments, and having a detrimental effect on performance (Hirsch et al., 2003 and Hirsch and Holmes, 2007). Correspondingly, recent intervention approaches have been targeting past negative social events and related imagery with promising results (Frets et al., 2014 and Wild et al., 2007). 1.1. Autobiographical memories and related imagery in SAD Individuals high in self-reported social anxiety and individuals with SAD differ from individuals low in self-reported social anxiety and healthy controls (HCs) on a number of phenomenological characteristics of their memory imagery (for a review, see Morgan, 2010). Socially anxious individuals may experience mental images related to autobiographical memories as more negative (Hinrichsen & Clark, 2003), vivid, detailed in quality (Wild et al., 2007), and to a larger extent view them from an observer's perspective (Coles et al., 2001, D'Argembeau et al., 2006, Hinrichsen and Clark, 2003, Wells and Papageorgiou, 1999 and Wells et al., 1998). Imagery in SAD may be linked in time with negative, self-defining autobiographical memories (Hackmann et al., 2000, Morgan, 2010 and Moscovitch et al., 2011), a notion that was first introduced by Singer and Salovey (1993). In general, autobiographical memories differ in the degree to which they are perceived as central to the person's identity or life story (Berntsen and Rubin, 2006 and Berntsen and Rubin, 2007). To perceive some, but not all, memories as central has been argued to help give meaning and structure to our life narratives, providing anchors for and stabilizing conceptions of ourselves (e.g., Baerger and McAdams, 1999, Pillemer, 1998, Pillemer, 2003, Robinson, 1992, Robinson and Taylor, 1998 and Shum, 1998). However, these anchors may become fixed reference points and bring about rigidity in negative self-assumptions in case a highly negative event takes this role (Berntsen and Rubin, 2006 and Berntsen et al., 2003). For instance, an individual with SAD who has experienced humiliation when speaking in front of others may avoid public speaking in order to prevent similar, future failures. Autobiographical memories can be retrieved either voluntarily, that is by a deliberate effort to recall an episodic event, or involuntarily, referring to spontaneously occurring retrieval that takes place with no preceding retrieval attemtpts, typically when situational cues map onto episodic events from the past (Berntsen, 1996 and Berntsen, 2009). Individuals with SAD may ruminate about past social events (Clark & McManus, 2002), thereby engaging in voluntary retrieval of anxious memories. Regarding involuntary retrieval, individuals with SAD have been found to experience spontaneously occurring retrieval of past events in anxiety provoking situations (Hackmann et al., 1998 and Hackmann et al., 2000). Such spontaneously occurring recall of negative events may be experienced as having an intrusive character, a notion that is supported by a study showing that socially anxious individuals experience having poor control over their images (Moscivitch, Chiupka, & Gavric, 2013). In fact, individuals with SAD have been shown to react to socially stressful memories with PTSD-symptoms (Erwin, Heimberg, Marx, & Franklin, 2006). Finally, retrieved events differ in specificity, that is, the degree to which the memories concern a specific episodic event. Non-specific, overgeneral memories are a common phenomenon in major depressive disorder (e.g., Watson et al., 2012 and Williams et al., 2007) and prevalent in PTSD (e.g., McNally, Lasko, Macklin, and Pitman, 1995; Moore & Zoellner, 2007), but likely not so in other anxiety disorders (Wessel, Meeren, Peeters, Arntz, & Merckelbach, 2001) including SAD (Heidenreich, Junghanns-Royack, & Stangier, 2007). 1.2. Disorder and content specificity in SAD Most research to date on autobiographical memories and imagery in SAD has not included an anxiety control group, which calls the specificity of the findings into question. First, specificity may concern disorder specificity, understood as the extent to which there are SAD-specific characteristics that apply across types of retrieved memories. Second, the cognitive specificity hypothesis ( Beck, 1987 and Clark and Beck, 2010) concerns disorder specific biases and addresses what may be termed content specificity. This concerns the question of whether imagery in SAD is different for events characterized by social anxiety compared with content non-specific to social anxiety. These two types of specificity have been sparsely studied comparing SAD and other anxiety disorders. Wells & Papageorgiou, 1999 found that only individuals with SAD, not individuals with blood/injury phobia, agoraphobia, or HCs, shifted their recall perspective depending on the content of the recalled situation. They recalled social situations from an observer perspective and neutral situations from a field perspective. Harvey, Ehlers, and Clark (2005) found that in the recall of social situations, individuals with SAD and PTSD did not differ from each other, but differed from HCs, in their rating of the extent to which they looked embarrassed in the event. However, individuals with SAD claimed that the events had a higher impact on their future than individuals with PTSD. Wenzel and Cochran (2006) investigated retrieval of autobiographical memories prompted by automatic thoughts prototypical of SAD or panic disorder (PD) or neutral sentences in individuals with SAD, PD and HCs. Only one difference emerged between the anxiety groups, where individuals with PD were faster at generating memories when prompted by PD-related thoughts than both individuals with SAD and HCs. This pattern was not found for SAD and SAD-related thoughts. Finally, a study by Witheridge, Cabral, and Rector (2010) investigated cued autobiographical memory content in individuals with SAD, PD, and major depressive disorder. The SAD group did not report more social evaluation memory content than the depressed or PD group and no overall between-group differences in cognitive vulnerability characteristics were observed. Taken together, the studies have revealed mixed findings, and our knowledge about which characteristics of autobiographical memory recall are specific to the type of memory and/or to SAD is generally an under-investigated area. This is unfortunate as it would seem crucial to understand which characteristics of the imagery are disorder and/or content specific in order to appropriately and effectively target current and new treatments. 1.3. Aims and hypotheses The present study is an examination of autobiographical memories of negative events and related imagery in SAD, PD and HCs, investigating two types of autobiographical memories across groups; one cued by social anxiety (SA)-related words and one by panic anxiety (PA)-related words. Individuals with PD were chosen as a comparison group for three reasons: 1) The two diagnoses are comparable in that they are associated with anxiety in a variety of situations. However, 2) the focal points of anxiety differ between the disorders in that individuals with SAD mainly fear the negative evaluation of others and individuals with PD mainly fear the occurrence of internal anxious sensations. Finally, 3) individuals with SAD have most often been compared with individuals with PD. Regarding content specificity, we expected SAD participants' memories cued by SA-related phrases to be experienced as more negative and vivid, and viewed from an observer's perspective, when compared with their memories cued by PA-related phrases. Concerning disorder specificity, we hypothesized that, compared with HCs, participants with SAD would report more voluntary and involuntary recall of anxious events, and perceive the events as having a greater traumatic impact and playing a more central role in relation to their identity. Given the sparse research comparing SAD to other anxiety disorders, we did not formulate any a priori hypotheses regarding differences between the anxiety disorders, and analyses concerning this issue are exploratory.

Conclusions PA-cued memories were generally rated higher than SA-cued memories on a number of autobiographical memory properties, and participants experienced these events as more central to their identity and having a higher traumatic impact. Participants with SAD were more likely to hold SA-cued memories central to their identity, but overall, participants with anxiety disorders differed from HCs but not from each other. Therapeutically addressing past negative events may be an important component in understanding the functionality of present distorted cognitions in anxiety disorders such as SAD and PD.