by Michael D. Anestis, M.S.
I was very excited when I came across the article I will discuss today, as it covers a topic I had never considered before but which makes a lot of sense: understanding a subset of individuals with social anxiety disorder (SAD) who exhibit aggressive, impulsive, risk-prone behaviors. SAD is one of the most common diagnoses in the DSM-IV-TR, impacting approximately 12% of the population (Kessler, Chiu, Dernier, & Walters, 2005). The disorder is primarily characterized by a fear of negative evaluation by others and includes two subtypes: generalized and not generalized. The generalized subtype involves a fear of all situations that could result in negative evaluations, whether that means a presentation at work or a conversation at a party. The not generalized subtype involves evaluation fears specific to a specific situation such as public speaking (test anxiety would be another example of this). Cognitive behavioral therapy (CBT), whether in group or individual format, has been shown to be an empirically supported treatment for SAD and Lora Rose Hunter contributed a valuable guest article to PBB that explained this therapeutic approach. I highly recommend reading that description if you believe you or somebody you know suffers from this condition.
Generally speaking, individuals diagnosed with SAD exhibit a high level of avoidance behaviors. For instance, they might avoid class when they think they might have to speak in front of others or avoid going out with a friend when they believe they will be forced to encounter large groups of other people. Although these behaviors are impairing in their own right, they make functional sense, as they allow the individual temporary and immediate relief from anxiety provoking situations that they believe could result in unacceptable consequences. In a paper published in Behaviour Research and Therapy, Todd Kashdan, Patrick McKnight, Tony Richey, and Stefan Hofmann (2009) investigated a small subset of individuals with SAD who present with an entirely different set of behavioral characteristics. These individuals have the same types of fears, but they tend to engage in risk-prone behaviors, approaching feared situations instead of avoiding them and taking on a more domineering, aggressive, and angry interpersonal style that allows them to avoid their feared rejections by maintaining a particular brand of control over the situation. Their behavior can be characterized by hostile impulses, unsafe sexual practices, and novelty seeking (Erwin, Heimberg, Schneier, & Liebowitz, 2003; Kashdan, & Hofmann, 2008). In this study, which utilized data from the magnificent National Comorbidity Survey - Replication, Kashdan and colleagues (2009) sought to provide evidence that this subgroup truly exists and that they do not simply reflect a greater number of fears or a more severe level of SAD.
Before going any further on describing the study itself, I want to make a couple of quick side comments. Todd Kashdan, the primary author of the study and a professor at George Mason University, is a strong presence on Twitter (@ToddKashdan) and provides frequent, valuable mental health updates throughout the day. I highly recommend following his "tweets" if you would like to be exposed to some interesting research and thoughts on mental health. Additionally, Tony Richey is a former grad school colleague of mine and Joye's, so I was thrilled to see his name attached to such a strong study.
Back to the point. Kashdan and colleagues (2009) premised their work by providing a substantial review of prior research on the matter, but perhaps even more compelling was their description of two different individuals with SAD and how their goals impacted their presentation. One hypothetical individual they referred to as Alexis, decided to stay home rather than attend a party and to avoid the phone in order to keep from being pressured to attend. This is fairly commonplace in SAD, as such individuals fear that they will be rejected unilaterally or behave in an embarrassing manner if they engage in social interactions. The second hypothetical individual, who Kashdan and colleagues (2009) referred to as Jessica, made a different decision. She decided to go to the party and to take on an active role. She initiated and dominated conversations, ending them when she chose and changing topics at will. She openly expressed judgmental opinions of others and asked questions when she was curious. Jessica thus took it upon herself to judge and reject others before they had the chance to do the same to her. Behind these actions was the same overwhelming sense of anxiety that led Alexis to avoid the situation altogether, but Jessica's response to the anxiety was quite obviously very different.
The authors based their belief in these two distinct subtypes of SAD upon prior research, including work they had done on their own, that statistically established distinct clusters of SAD individuals who either exhibit habitual avoidance behaviors or habitually impulsive and risk-prone behaviors. In one such study, Kashdan et al (2008) found that risk-prone individuals with SAD exhibited greater difficulties with emotion regulation, fewer social resources, less psychological flexibility, more unsafe sexual practices, greater aggression, and a higher level of substance abuse. Importantly, prior work has also shown that individuals with SAD who exhibit higher levels of anger and aggression do not respond as well to cognitive behavioral group therapy (CBGT). The different response to treatments indicates that it is pivotal for researchers and clinicians to identify such individuals and develop alternative treatment approaches.
So what exactly did the authors discover in their study? Using a statistical procedure referred to as "latent class analysis," the authors, in fact, identified exactly what they anticipated finding: two distinct subgroups of individuals with SAD differentiated by behavioral profiles. Group 1, which represented 79% of the sample, was characterized by low levels of aggression, anger, sexual impulsivity, and substance use. Group 2, on the other hand (21% of the sample), was marked by moderate-to-high aggression, high anger, low-to-moderate sexual impulsivity, and low-to-moderate substance use. Nearly 4 out of every 5 individual in this sample fit the standard image of SAD - avoidant, non-confrontational, unlikely to take risks - but 1 in 5 fit the atypical pattern.
The authors also examined severity of SAD in this sample and found that two groups again emerged, one of higher severity and one of lower severity. Importantly, however, the typical versus atypical groups mentioned above did not map onto the severity groups. In other words, although there was a small significant relationship indicating that individuals with the atypical presentation were more likely to be severely impaired by SAD, 37% of individuals classified as atypical were also classified as not severe (as compared to 58% of the typical presentation). As such, the atypical presentation does not simply represent more severe or numerous fears. That being said, individuals classified as atypical did report a younger age at the time of the diagnostic interview, poorer overall health and lower income and were more likely to be male than were individuals classified as typical.
Having provided compelling evidence that a minority of individuals diagnosed with SAD actually fit this atypical, aggressive, risk-prone profile, Kashdan and colleagues (2009) concluded their article by hypothesizing why this pattern emerges. They presented five distinct possibilities:
- As research suggests that frequent attempts at self-control reduce our capacity to control our behaviors (Muraven & Baumeister, 2000), it might be that some individuals with SAD expend massive amounts of effort at controlling their impulses, ultimately weakening their ability to do so and resulting in the above mentioned behavioral outcomes.
- Impulsivity has biological underpinnings and it might simply be that individuals predisposed to impulsive behaviors who develop SAD are more likely to present in this atypical fashion.
- Impulsivity might lead to SAD. The consequences of impulsive behavior (e.g., losing control while intoxicated) might lead to extreme embarrassment and enhanced fears of evaluation by others
- Individuals with the atypical presentation might simply be characterized by greater levels of distress
- Individuals with the atypical presentation might develop such behaviors due to their position in society.
More research is needed in order to understand why a minority of individuals with SAD present in such a different manner, but Kashdan et al's (2009) study provided us with valuable data that help clarify the point that SAD does not always look the same.
Before signing off for the day, I'd like to make two points and I would be interested in hearing your thoughts on either or both of them:
First, as much of my research is based on the influence of emotions on behavioral outcomes, particularly the role of distress tolerance and negative urgency, I wonder to what degree stable personality variables influence whether an individual who meets criteria for SAD presents as typical or atypical in their behavioral profile. In other words, I wonder if a general tendency not to be able to handle distress and an increased motivation to behaviorally regulate such emotions plays an important role in causing some individuals with SAD to take more proactive and potentially hostile and dangerous approaches to managing their anxiety.
Second, I have heard many individuals skeptical of research in general and psychological diagnoses in particular say something along the lines of "this information is not useful because people are all different and might not look the way the DSM or your research says that they will. I treat individuals, not group data." This is, of course, a valid point and I hope that you will read a prior PBB article on the utility of group data for more information about this, but either way, Kashdan and colleagues (2009) performed a valuable service directly related to the concerns expressed in that quote. Rather than simply assuming, based on experience or belief, that some individuals with SAD appear very different from the standard pattern, they designed a study and empirically investigated the question. In other words, they tested their hypothesis and provided us with evidence that is significantly more compelling than their own beliefs or experiences. If more people would do this, our understanding of such phenomena would be greatly enhanced.
If you would like to learn more about social anxiety disorder and its treatment, we recommend the following resources, all of which are available through our online store:
- Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach Client Workbook by Debra Hope, Richard Heimberg, Harlan Juster, and Cynthia Turk
Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach Therapist Guide
by Debra Hope, Richard Heimberg, and Cynthia Turk
- Cognitive-Behavioral Group Therapy for Social Phobia: Basic Mechanisms and Clinical Strategies
by Richard Heimberg and Robert Becker
- Social Phobia: Diagnosis, Assessment, and Treatment by Richard Heimberg, Michael Liebowitz, Debra Hope, and Franklin Schneier