Interpretations for anxiety symptoms in social phobia

Abstract

This study explored the ways in which people interpret visible physical symptoms of anxiety. A group of participants with social phobia (SP) and a nonclinical control (NCC) group completed either the Actor version or the Observer version of the Symptom Interpretation Scale (SIS), designed for the purposes of this study. The SIS asks participants to rate the extent to which each of eight interpretations is a likely explanation for a number of visible symptoms of anxiety. On the Actor version of the SIS, participants are asked to judge how their own anxiety symptoms are interpreted by others. On the Observer version of the SIS, participants are asked how they typically interpret anxiety symptoms that they notice in others. When participants were asked about anxiety symptoms that they themselves exhibit, people with social phobia were more likely than nonclinical controls to think that others interpreted these symptoms as being indicative of intense anxiety or a psychiatric condition and were less likely to think that others interpreted these symptoms as being indicative of a normal physical state. Data also suggested that people with social phobia have a more flexible cognitive style when asked to interpret anxiety symptoms exhibited by others than when asked about how others view their own anxiety symptoms. These findings are discussed in the context of recent psychological models of social anxiety and social phobia.

Introduction

Social phobia is characterized by a “marked and persistent fear of one or more social or performance situations…” in which the individual is fearful that he or she “will act in a way (or show signs of anxiety) that will be humiliating or embarrassing” (American Psychiatric Association, 1994, p. 411). In other words, in addition to fearing the possibility of making a mistake, looking unattractive or seeming incompetent, people with social phobia are often fearful of exhibiting symptoms that may be interpreted as signs of anxiety, such as sweating, shaking or blushing. People with social phobia hold this concern not only because they assume that other people will notice these symptoms, but also because others may use these symptoms to draw negative characterological conclusions about them (see Clark & Wells, 1995). For instance, people with social phobia may believe that if others notice them blushing, it will be assumed that they are anxious, weak or stupid.

Thinking in this manner is detrimental for many people with social phobia. As Clark and Wells (1995, p. 70) point out, “social phobics become preoccupied with their somatic responses and negative social-evaluative thoughts, and this preoccupation interferes with their ability to process social cues”. This inattentiveness to social cues can result in poor social performance, which in turn elicits negative reactions from others, thus confirming the fears held by people with social phobia (e.g. that they are incompetent in social situations). In other words, the cognitive style of people with social phobia not only serves to exacerbate social anxiety, but may also play a role in the maintenance of the disorder.

A number of studies have examined the ways in which people with social phobia interpret their own social behavior, keeping in mind that the process of making interpretations and the quality of those interpretations can have an important influence on social performance. Amir, Foa and Coles (1998) examined interpretation biases in people with generalized social phobia by presenting ambiguous scenarios of either a social nature or a nonsocial nature and asking participants to rank order how likely a negative, positive and neutral interpretation would be for each scenario were it to happen to themselves (self-relevant version) and were it to happen to others (other-relevant version). As compared to an anxious control group and a nonclinical control group, people with social phobia ranked negative interpretations as more likely only for social scenarios that were self-relevant and ranked positive interpretations as more likely only for social situations that were other-relevant.

Other studies have focussed on how people with social phobia evaluate their behavior in actual social situations. Stopa and Clark (1993) found that people with social phobia had more negative self-evaluative thoughts (“I am boring”) during a ‘get acquainted task’ with a stranger than did anxious controls or nonclinical controls. Individuals with social phobia also rated their coping ability and social skills more negatively than did either comparison group. In the same study, subjects were asked to imagine themselves in various hypothetical situations. Again, people with social phobia reported that they would have more negative self-evaluative thoughts in these situations than did either comparison group. Alden and Wallace (1995) also used a ‘get-acquainted task’ and found that people with social phobia were more likely than nonclinical controls to overestimate the visibility of their anxiety and to underestimate how interesting and likable they were. In a follow-up study, Wallace and Alden (1997) found that even after a positive social interaction, people with social phobia still viewed their performance negatively.

In summary, research has demonstrated that people with social phobia (1) are more likely than people without social phobia to interpret ambiguous, self-relevant social scenarios in a negative way, (2) interpret their own social behavior more negatively than do people without social phobia and (3) tend to overestimate the extent to which their anxiety symptoms are visible to others. However, there have been no studies to date that have explored the relationship between the presence of social anxiety and the ways in which people interpret visible physical symptoms. Anecdotally, individuals with social phobia often appear to be overly concerned that others will interpret their physical symptoms as signs of a severe anxiety problem or a serious psychiatric disorder. This concern persists despite the fact that there are often many more benign explanations for why someone might show visible symptoms such as blushing, sweating and shaking. The present study was an attempt to examine how people with social phobia and nonanxious individuals interpret the occurrence of visible physical symptoms.

The current study examined the interpretations that people make for visible symptoms typically associated with social anxiety (e.g. sweating, blushing, shaking, shaky voice). Participants were asked to complete one of two versions of the Symptom Interpretation Scale (SIS; designed for the purposes of this study). The ‘Actor’ version (see Appendix A) of the questionnaire asked participants to judge how their own anxiety symptoms are interpreted by others (e.g. “What will other people think if your hands are shaking?”). The “Observer” version was similar to the “Actor” version except that participants were asked how they interpret anxiety symptoms that they notice in others (e.g. “What do you think about someone whose hands are shaking?”). Participants were presented with eight possible interpretations for each symptom (e.g. experiencing intense anxiety, has a medical condition, is experiencing a normal physical state like hunger or feeling cold) and were asked to rate how likely each interpretation was for a given symptom. Some of the interpretations could be construed as being relatively extreme (e.g. experiencing intense anxiety; having a psychiatric problem), while others could be viewed as being relatively benign (e.g. experiencing normal anxiety; experiencing some normal physical state).

Overall, we predicted that individuals with social phobia would more strongly endorse the extreme interpretations (the ‘intense anxiety’ and ‘psychiatric condition’ interpretations specifically) for anxiety symptoms as compared to individuals in the nonclinical control group. Two alternate competing hypotheses were proposed with respect to differences that might emerge between the two versions of the questionnaire. First it was possible that people with social phobia may only apply this negative interpretation bias to situations in which other people see them exhibiting signs of anxiety. Alternatively, they may apply this bias when others see them looking anxious and when they see others exhibiting signs of anxiety.

In order for the first prediction to garner support — that people with social phobia only apply a negative interpretation bias to symptoms that they themselves exhibit — the presence of a significant interaction between groups (social phobia group vs. a nonclinical control group) and questionnaire version (Actor version vs. Observer version of the SIS) would have to be observed. The social phobia group (SP) should endorse these extreme interpretations more strongly than the nonclinical control group (NCC), and should also endorse the interpretations more strongly in the Actor version of the SIS as compared to the Observer version. No between-version differences were predicted for the NCC group. In other words, the presence of a self-relevant bias would involve the SP group seeing the extreme interpretations (e.g. experiencing intense anxiety; having a psychiatric problem) as more likely overall as compared to the NCC group, but also endorsing the interpretations as far more likely on the Actor version of the SIS than on the Observer version of the SIS. Evidence of a bias would garner additional support if the SP group viewed more benign interpretations (e.g. experiencing normal anxiety, experiencing some normal physical state) as less likely in general than the NCC group and also as less likely on the Actor version than on the Observer version of the SIS.

As mentioned above, an alternative pattern of findings was also possible. People with social phobia could hold a more general bias such that they see negative interpretations as being viable both for symptoms exhibited by themselves and for symptoms exhibited by others. In clinical practice, we often ask patients about the judgments that they make about other people, particularly when they see someone else exhibiting symptoms of anxiety (e.g. blushing, shaking, etc.). This strategy is often meant to demonstrate that patients with social phobia hold higher standards for themselves than they do for others. It is also possible, however, that people with social phobia may actually hold others to the same strict standards as they think that others hold for them.

Two studies (both in nonclinical populations) have examined related issues. Purdon, Antony, Monteiro and Swinson (in press) asked individuals who scored high and low on measures of social anxiety to rate an anxious target person on a number of personal characteristics. Individuals who scored high on social anxiety were more likely than low scorers to rate the anxious target person as having less ‘strength of character’ and as being less attractive. Thus, socially anxious individuals in this study were more judgmental toward a target person who was described as being anxious than were nonsocially anxious individuals.

Marcus, Wilson and Miller (1996) asked female college students to perform either a highly embarrassing task or an innocuous task in front of a group of other subjects. Regardless of the nature of the task, observers who themselves were easily embarrassed perceived the performers to feel more embarrassed than did subjects who were not themselves easily embarrassed.

Together, these studies suggest that socially anxious people may perceive more nervousness in others (even if it is not truly there) and that they may form negative judgments of others based on visible signs of anxiety. How would this alternate prediction appear in our data? What we might expect is a simple main effect of group such that people with social phobia more strongly endorse negative interpretations both in the Actor and Observer versions of the questionnaire as compared to the NCC group. It is generally accepted that people with social phobia assume that others judge them using very strict standards. This pattern of findings would suggest that people with social phobia may also hold other people to the same strict standards as they expect that others use to judge them.