BackgroundSocial anxiety disorder (SAD) is characterized by fear and avoidance in social situations where one perceives being in danger of scrutiny by others. Low self-esteem, low self-efficacy, high self-criticism and high dependency are additional potential features of SAD, and thus their examination is warranted, as is the elucidation of their inter-relationship.MethodThirty-two SAD subjects diagnosed with the Mini-International Neuropsychiatric Interview and 30 healthy controls, were administered the Liebowitz Social Anxiety Scale (LSAS), the Rosenberg Self Esteem Scale, the Depressive Experiences Questionnaire (DEQ) that assesses self-criticism, dependency and self-efficacy, and a socio-demographic questionnaire. We hypothesized that the SAD group would present higher scores of dependency and self-criticism and lower self-esteem and self-efficacy. We also hypothesized that low self-esteem, low self-efficacy, high self-criticism and high dependency will predict the severity of SAD.ResultsIn line with the hypotheses, SAD patients had higher scores of self-criticism and dependency and lower scores of self-esteem. The social anxiety score correlated negatively with self-esteem and self-efficacy, and positively with dependency and self-criticism. Self-criticism, but not the other measures, predicted the total LSAS score.ConclusionsSelf-esteem, self-criticism, dependency and self-efficacy are related to SAD and their relations should be examined in future studies that will employ larger samples. It is suggested to search for ways to affect these factors through cognitive-behavioral interventions and additional psychotherapeutic treatments. Research should also focus on the specific role of self-criticism in SAD.
1. Introduction
Social anxiety disorder (SAD) is a common anxiety disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations [1], [2] and [3]. People with SAD have a persistent, intense, and chronic fear of being judged by others and of being embarrassed by their own actions. Their fear may be so severe that it interferes with work, school, or other activities. SAD is frequently accompanied by comorbid mental disorders, such as depression and substance abuse [2]. Cognitive factors may play a part in the etiology or maintenance of the disorder [3]. SAD subjects display thoughts and beliefs that are dysfunctional and lead to anxiety and avoidance, and experience the environment as threatening and dangerous [3]. SAD persons tend to dwell on the point of view of the other person and believe that others' gazes indicate criticism and rejection. Their mental image is usually negative; they believe that they are failing and that the results of their behavior will be disastrous. These thoughts strengthen their negative feelings, creating a vicious cycle. Following these inclinations, potential features in SAD individuals and possible etiological factors, may be low self-esteem, low self-efficacy, high dependency and high self-criticism. The jointly role of these psychological traits in SAD and their inter-relationship has not yet been examined, and this was the target of our study.
Self-esteem refers to how persons evaluate themselves and is defined as “the extent to which one prizes, values, approves of, or likes oneself” ([4], page 115). Persons with low self-esteem tend to dwell on unfavorable attributes, rather than focusing on their strengths [5]. This evaluation can have a huge impact on the person's psychological well-being, leading to disorders like SAD [6] and [7]. Indeed, highly socially anxious children exhibited low levels of self-esteem [8] and adolescents with anxiety disorder had lower self-esteem compared with healthy adolescents, with SAD having the greatest relative impact on self-esteem [9]. de Jong and colleagues [10] demonstrated that self-evaluative thoughts and actions can originate from an adolescent's self-esteem level and suggested that one's self-esteem can be an important factor for the development of SAD, and in turn, can further deflate self-esteem. Finally, SAD patients showed low implicit self-esteem compared to healthy controls, whereas panic disorder patients scored in between these groups [11].
Another important facet of SAD is self-criticism. This is the inner negative voice that attacks and judges the individual and his/her actions [12] and [13]. Self-criticism contributes to the vulnerability of an individual as he/she could view actions as failures, feel a failure as a whole and expect only very high and unachievable standards, and thus might withdraw from social networks [14]. This individual will not appreciate his/her efforts and the failure circle will expand, with evolving depression, despair and guilt. The National Comorbidity Survey (NCS) suggested already in 2004 that self-criticism is robustly associated with SAD and that it may represent an important core psychological process in SAD [13]. Self-criticism was elevated in SAD, even in cases of only past history of SAD, as compared to individuals with no psychiatric disorder [13]. The highest levels of self-criticism were reported by people with the complex subtype of SAD (generalized type in DSM-4), both with and without comorbid major depression. These levels were significantly greater compared to those observed in panic disorder, the pure speaking subtype SAD, and cases of major depression alone. In a regression analysis that controlled for current emotional distress, neuroticism, and lifetime histories of mood, anxiety, and substance use disorders, self-criticism remained significantly associated with lifetime prevalence of SAD [13]. Recently, Kopala-Sibley and colleagues [15] also reported increased self-criticism in SAD, with self-criticism moderating the fear-inducing effects of situational self-consciousness.
Perceived self-efficacy describes the individual's belief in his/her resources and capabilities, according to goal-oriented strivings, in various life domains, including the social domain [16]. Self-efficacy beliefs have been linked to motivation and behavioral change and to enhanced affect regulation and psychosocial functioning [17]. They are strongly connected to SAD both among children [18] and adults [19]. Furthermore, general self-efficacy has been reported to mediate the link between negative self-statements and SAD [18]. In a similar manner, low self-efficacy was associated with the severity of social anxiety and related impairment, and this relationship was partly mediated by dysfunctional coping strategies [20]. Low self-efficacy may increase an individual's tendency to rely on dysfunctional coping strategies for dealing with anxiety in social situations [20]. In turn, these dysfunctional coping strategies exacerbate the experience of impairment from social anxiety.
SAD patients are more dependent and dependent individuals are characterized by both excessive preoccupations with the possibility that they are not loved or cared for, as well as by feelings of helplessness, weakness, and abandonment fears [15]. SAD persons fear rejection, and might be dependent on their families. Kopala-Sibley et al [15] reported that highly dependent SAD patients are more likely to feel fear during interpersonal situations when they feel less emotionally secure. Additional studies demonstrated that people who report high levels of social anxiety have only few social connections and therefore exhibit a tendency for overdependence on these relations [21], [22], [23] and [24].
In the present study, we examined the relationship between social anxiety, self-criticism, self-esteem, self-efficacy and dependency among SAD subjects and healthy controls, with the Depressive Experiences Questionnaire that comprises of three factors: dependency, self-criticism and self-efficacy. Our study is the first study to examine the jointly role of these psychological traits in SAD and their inter-relationship, aiming to elucidate which of the variables contributes the most to social anxiety scores.
6. Conclusions
Our study may enhance the understanding of cognitive and emotional processes that underlie SAD. It is important to raise self-esteem and to lower self-criticism in subjects with SAD. Cox et al [36] reported that over the course of treatment, self-criticism was significantly associated with improvement in SAD symptoms, even after controlling for baseline symptoms severity and change in depression. We recommend that therapists use questionnaires that examine these psychological traits, in addition to SAD questionnaires [40]. Cognitive treatment and also psychodynamic therapy have been reported to similarly improve self-esteem in SAD [41], as well as to decrease SAD symptoms. Deliberate retrieval of positive self-images facilitates access to a healthy positive bias and improves self-esteem [42]. Targeting change in self-efficacy may increase confidence and lead to better treatment outcomes [18]. Finally, it can also be useful to enhance self-esteem among patients with low self-esteem who had not as yet developed SAD, as low self-esteem may function as a possible precursor of SAD.
