University of Groningen Adolescents at risk for social and test

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University of Groningen Adolescents at risk for social and test anxiety. Who are at risk and how can we help? Sportel, Bouwina Esther IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2013 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Sportel, B. E. (2013). Adolescents at risk for social and test anxiety. Who are at risk and how can we help?. s.n. Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license. More information can be found on the University of Groningen website: amendment. Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date: 27-06-2022 Adolescents at Risk for Social and Test Anxiety Who are at risk and how can we help? Esther Sportel 2013 © 2013 Esther Sportel, Groningen Cover: Rommie Schilstra ( Print: Ipskamp Drukkers Enschede ISBN (boek): 978-90-367-6057-7 ISBN (digitaal): 978-90-367-6056-0 RIJKSUNIVERSITEIT GRONINGEN Adolescents at Risk for Social and Test Anxiety Who are at risk and how can we help? Proefschrift ter verkrijging van het doctoraat in de Medische Wetenschappen aan de Rijksuniversiteit Groningen op gezag van de Rector Magnificus, dr. E. Sterken, in het openbaar te verdedigen op woensdag 29 mei 2013 om 14.30 uur door Bouwina Esther Sportel geboren op 19 november 1976 te Veendam Promotores: Prof. dr. R.B. Minderaa Prof. dr. P.J. de Jong Copromotor: Dr. M.H. Nauta Beoordelingscommissie: Prof. dr. S.M. Bögels Prof. dr. E. de Haan Prof. dr. A.J. Oldehinkel 5 Table of Contents Chapter 1 General Introduction 7 Chapter 2 Behavioral Inhibition and Attentional Control in Adolescents: Robust Relationships with Anxiety and Depression 23 Chapter 3 Predicting Internalizing Symptoms over a two year period by Behavioral Inhibition, the Fight-Flight-Freeze-system and Attentional Control 41 Chapter 4 Cognitive Bias Modification versus CBT in Reducing Adolescent Social Anxiety: A Randomized Controlled Trial 55 Chapter 5 Long term effects of Cognitive Bias Modification and CBT in the Reduction of Adolescent Social Anxiety and Test Anxiety: two year follow up of a Randomized Controlled Trial 79 Chapter 6 The Moderating Role of Behavioral Inhibition and Attentional Control on Intervention Success 109 Chapter 7 General Discussion 119 References 139 Nederlandse Samenvatting – Dutch Summary 153 Dankwoord 169 Curriculum Vitae 175 6 7 Chapter 1 General Introduction General introduction 8 General introduction 9 The Aim of Current Thesis Social and test anxiety are characterized by a chronic course and have an invalidating influence on the people who suffer from them. The comorbidity with other anxiety disorders and depression is high, and suffering from these disorders has been associated with social isolation, substance abuse, and lowered academic performance (Stein & Kean, 2000; Wittchen, Fuetsch, Sonntag, Müller, & Liebowitz, 2000). Therefore, it is of the utmost importance to work towards a situation in which people at risk of these disorders are detected at an early stage, and to intervene before the full effects of these disorders develop. In line with this, the focus of this thesis is twofold; the first focus is on risk factors for developing internalising disorders; can we determine factors that enhance the chance that an individual develops internalising disorders? The second focus is to test the effectiveness of early interventions in social and test anxiety, to prevent early symptoms becoming a full blown disorder. Since the age of onset of social anxiety is in adolescence (Wittchen, Nelson, & Lachner, 1998; Wittchen & Fehm, 2003), this research project focuses on early adolescents, firstly to identify risk factors for onset, secondly to be able to intervene before the full blown disorder occurs. Social and Test Anxiety Social anxiety is characterized by a marked and persistent fear of social or performance situations in which embarrassment may occur. When exposed to this social or performance situation an immediate anxiety response is provoked, which may take the form of panic. These social or performance situations are often avoided or endured with dread. Adolescents and adults with this disorder are aware of the fact that their fear is excessive (American Psychiatric Association, 2000). In daily life, adolescents with social anxiety are characterized by an extreme fear in social situations, such as introduction rounds, or oral examinations in classes when these adolescents are expected to speak out loud. They may also experience extreme fear during birthday parties with lots of new (unknown) people, and in public places, such as a shopping mall or busy streets with all kinds of people that might be looking at them and judging them. One could then choose to avoid these situations, and thus also avoid the feelings of fear and anxiety that come along with it. However, this avoidance behavior has all kinds of negative consequences, including positive General introduction 10 experiences with social interactions, as well as a lack of friendships, hobbies, or social isolation. In the short run the benefit for these adolescents is not feeling anxious, but in the long run a risk arises at for example social isolation. Test anxiety is related to social anxiety, however, with a focus more specifically on test situations, where judgment by others regarding performance is at hand (McDonald, 2001). Test anxious adolescents are specifically anxious to give talks in class or make exams, and also the moment of grades being made ‘public’ is often experienced as very anxiety provoking. They may suffer from or fear “black-outs” or “going blank” during exams. Some adolescents may do their utmost to prevent failure, become stressed and spend too much time on preparing for tests, while missing out on social events or spare time activities that are important for their social development. Other adolescents may avoid judgments and evaluations, by underachieving or by not showing up for tests or not fully prepared, thus missing school days and risking dropping out of school. It has been found that a consequence of avoiding school and school situations or enduring them with extreme fear can be lower grades, resulting ultimately in lower level of education or school drop-out (Wittchen et al., 1998). In their review Bögels and colleagues (2010) come to the conclusion that both in social anxiety and test anxiety the fear that anxiety may hinder performance plays an important role. In the case of fear of negative evaluation as core issue in test anxiety, test anxiety qualifies to belong to social anxiety disorder (Bögels et al., 2010). Social anxiety disorder is among the most prevalent anxiety disorders in adolescence and adulthood (Kessler, Chiu, Demler, & Walters, 2005; Merikangas et al., 2010). In adolescence, the prevalence of social anxiety disorder varies from 9.5% for girls and 4.9% for boys, whereas the lifetime prevalence of social anxiety disorder is estimated at about 3% up to 13% (American Psychiatric Association, 2000; Wittchen et al., 1998). For test anxiety specifically the lifetime estimates varying between 10% and 30% (McDonald, 2001), however, the absence of DSM-IV criteria for test anxiety make these prevalence rates less generalizable. Besides the high prevalence rates there are serious long term consequences of social anxiety: it may lead to other anxiety disorders or depression in adulthood (Wittchen, Stein, & Kessler, 1999), whereas it is also associated with alcohol and drug misuse, lowered academic and work performance, lower self esteem and General introduction 11 poorer development of social skills (Beidel & Turner, 2007; Stein & Kean, 2000; Wittchen et al., 1999). Models of Social and Test Anxiety Several models are developed during the past decades to explain the development and maintenance of social anxiety. The model of Clark and Wells (1995; see Figure 1.1) explains the maintenance of social anxiety as follows: when a person with social anxiety disorder enters a social situation, this will automatically activate various anxiety provoking assumptions concerning the situation, and as a results the person will experience/perceive social threats. In such a situation, a person with social anxiety disorder will direct his/her attention towards him or herself (processing of self as social object) and at the same time experience behavioral symptoms, such as avoidance behavior. Next to that, there are somatic and cognitive symptoms such as sweating and trembling. These various symptoms then again strengthen the self awareness and thus the perceived social danger. Since the negative beliefs are not disconfirmed, social situations will remain anxiety provoking, and people may enter a downward spiral. The same may hold for test anxiety, since social and test anxiety seem to share many underlying mechanisms (Bögels et al., 2010). More recent, so called vulnerability models of social anxiety emphasize cognitive processes that may set people at risk for developing symptoms of social anxiety (Ouimet, Gawronski, & Dozois, 2009). These models generally assume that disturbed cognitive information processing may be critically involved in the generation and/or maintenance of social anxiety. Individuals with social anxiety disorder have a distorted cognitive information processing. Not only do they interpret social situations in a threat confirming manner but they also focus their attention more towards negative social information. For example, when speaking in front of a group of people, a socially anxious person will immediately notice the single person in the crowd who is yawning (attention) and automatically interpret the yawning in a negative manner, e.g. “I must be giving the worst talk ever”, “I am extremely boring”, etc. In these models, the automatic negative thoughts are strengthened in encounter with social threat situations or test situations. Both models provide leads for treatment, as will further be described in part II of the introduction. General introduction 12 Figure 1.1 The model of social phobia by Clark & Wells From a developmental psychopathology perspective several factors have been identified that may predispose a child to develop an internalizing disorder and are associated with the maintenance of internalizing disorders (Vasey & Dadds, 2001). Within these factors, temperament is considered a major candidate. Within temperament, especially behavioral inhibition and negative affect are assumed to be important. High behavioral inhibition, low attentional control, and their combination are assumed to be specifically relevant for the development of internalizing disorders (Lonigan & Phillips, 2001). Part I – BIS/FFFS and Attentional Control as Risk Factors Reactive and Regulative Temperament Temperament can be described as “constitutionally based individual differences in reactivity and self-regulation, in the domains of affect, activity, and attention (Rothbart & Bates, 1998)”. Rothbart and Bates (1998) propose that temperament General introduction 13 has biological basis, which is, then influenced by experience, heredity, and maturation (constitutionally), is responsive to change in external and internal environment (reactive) and can modulate reactiveness (self-regulation). Reactive temperament thus refers to temperament components that are responsive to change, internal and external. Examples of reactive temperament components are feelings of fear, emotionality, or cardiac responses. Regulative temperament on the other hand refers to processes that modulate reactivity, like effortful control, and orienting. Within reactive as well as regulative temperament, several components are identified that may be linked to the development and maintenance of internalizing complaints. For reactive temperament, behavioral inhibition system (BIS) has been identified as an important component; while for regulative temperament attentional control seems a relevant component (e.g., Johnson, Turner, & Iwata, 2003). Gaining insight into risk factors for internalizing disorders not only contributes to further development of theory, but may also provide clues for early interventions in teenagers: children or adolescents can be screened at an early stage for the possible risk of developing disorders, thereby opening the way for early intervention and prevention. Reactive temperament: Behavioral Inhibition System and the Flight-Fight- Freeze System The Behavioral Inhibition System was first proposed by Gray (1982) within the context of his Reinforcement Sensitivity Theory (RST). In its original description the RST consisted of three subsystems: the behavioral inhibition system (BIS), the behavioral activation system (BAS), and the fight-flight system (FFS). In this theory BIS reflects people’s sensitivity towards punishment and proneness towards anxiety, BAS reflects one’s sensitivity towards reward and proneness towards impulsivity, and FFS reflects the sensitivity towards unconditioned aversive stimuli. With evidence from new experimental data in mind, the role of BIS and FFFS was reconsidered resulting in the renewed RST (Gray & McNaughton, 2000). In the new RST the FFS was replaced by the so-called flight-fight-freeze-system (FFFS), which is assumed to handle all aversive stimuli, conditioned as well as unconditioned. FFFS is related to fear, not anxiety and is responsible for avoidance and escape behaviours. People with a highly sensitive FFFS are supposed to have a proneness towards fear and have the tendency to react with avoidance. Following the revised General introduction 14 RST, the BIS is responsible for dealing with goal conflicts that can arise within the FFFS, within the BAS or between both systems. For example, BIS is activated when conflicting goals arise, such as approaching something rewarding (e.g., participating in a sports game and getting the chance to win by scoring the crucial penalty), while at the same time wanting to avoid something threatening (e.g., failing on scoring the crucial penalty). BIS is related to feelings of anxiety, not so much fear. People high on BIS are assumed to be vigilant for signs of danger and are often in a state of worry. The BAS remained largely unchanged compared to the original RST. The BAS mediates reactions to all appetitive stimuli and may generate feelings of anticipatory pleasure (Corr, 2008). Those high on BAS are associated with more impulsiveness and high risk behavior. In the light of the proposed functions BIS and FFFS seem most relevant for internalizing symptoms. Accordingly, BIS and FFFS have often been implied as being involved in the development and maintenance of internalizing symptoms (Corr, 2008). BIS and FFFS in internalizing disorders Although the revised theory of RST has already been published in 2000, a large part of current research still works with the former (originally formulated) concept of BIS, instead of the renewed concepts of BIS and FFFS. This might reflect a slowness to adopt, or the fact that various views on the RST are possible (Corr, 2008). Since both lines provide important leads for research, in the following I will discuss both research based on the original RST and research based on the renewed RST. BIS-FFFS has mostly been studied with respect to internalizing disorders, and is often measured by the BIS/BAS-scales (Carver & White, 1994). Its nature of sensitivity towards punishment leads to the hypothesis of an association with anxiety and depression. In line with this, it has been found that BIS-FFFS is positively related to higher general anxiety scores (Campbell-Sills, Liverant, & Brown, 2004; Johnson et al., 2003; Jorm et al., 1999). Research into specific anxiety symptoms has shown similar results (see Bijttebier, Beck, Claes, & Vandereycken, 2009 for a review), with BIS-FFFS being positively related to social anxiety (Coplan, Wilson, Frohlick, & Zelenski, 2006; Kimbrel, Cobb, Mitchell, Hundt, & Nelson-Gray, 2008) and symptoms of obsessive-compulsive disorder (Fullana et al., 2004). In a similar vein, several