Contents lists available at ScienceDirect Journal of Affec

Contents lists available at ScienceDirect
Journal of Affective Disorders
journal homepage: www.elsevier.com/locate/jad
Research paper
The role of expressive suppression and cognitive reappraisal in
cognitive
behavioral therapy for social anxiety disorder: A study of self-
report,
subjective, and electrocortical measures
Yogev Kivity⁎ ,1, Lior Cohen, Michal Weiss, Jonathan Elizur,
Jonathan D. Huppert
Department of Psychology, The Hebrew University of
Jerusalem, Jerusalem, Israel
A R T I C L E I N F O
Keywords:
Social Anxiety
Emotion Regulation
Cognitive Reappraisal
Expressive Suppression
Cognitive Behavioral Therapy
A B S T R A C T
Background: Contemporary models of cognitive behavioral
therapy (CBT) for social anxiety disorder (SAD)
emphasize emotion dysregulation as a core impairment whose

reduction may play a causal role in psy-
chotherapy. The current study examined changes in use of
emotion regulation strategies as possible mechanisms
of change in CBT for SAD. Specifically, we examined changes
in expressive suppression and cognitive reappraisal
during CBT and whether these changes predict treatment
outcome.
Methods: Patients (n = 34; 13 females; Mean age = 28.36
(6.97)) were allocated to 16-20 sessions of CBT. An
electrocortical measure of emotion regulation and a clinician-
rated measure of SAD were administered monthly.
Self-report measures of emotion regulation and social anxiety
were administered weekly. Multilevel models were
used to examine changes in emotion regulation during treatment
and cross-lagged associations between emotion
regulation and anxiety.
Results: CBT led to decreased suppression frequency, increased
reappraisal self-efficacy, and decreased un-
pleasantness for SAD-related pictures (ps < .05). At post-
treatment, patients were equivalent to healthy controls
in terms of suppression frequency and subjective reactivity to
SAD-related stimuli. Gains were maintained at 3-
months follow-up. Decreases in suppression frequency and
electrocortical reactivity to SAD-related pictures
predicted lower subsequent anxiety but not the other way
around (ps < .05). Lower anxiety predicted greater
subsequent increases in reappraisal self-efficacy.
Limitations: The lack of a control group precludes conclusions
regarding mechanisms specificity.
Conclusions: Decreased frequency of suppression is a potential
mechanism of change in CBT for SAD.
1. Introduction
Recent models of anxiety, including social anxiety disorder
(SAD),

emphasize impairments in emotion regulation (Hofmann,
Sawyer,
Fang, & Asnaani, 2012; Morrison & Heimberg, 2013). Two
regulation
strategies, cognitive reappraisal and expressive suppression,
may be
particularly relevant for SAD (Morrison & Heimberg, 2013). In
the
process model of emotion regulation (Gross, 2015), cognitive
re-
appraisal is generally considered an adaptive strategy that
involves
cognitive change to regulate one's emotion – for example,
attempts to
reinterpret emotional stimuli in less threatening ways (Gross,
2015). On
the other hand, expressive suppression is an attempt to inhibit
one's
expression of emotions and is generally considered maladaptive
(Gross, 2015).
In Heimberg's updated model (Morrison & Heimberg, 2013),
emotion dysregulation in SAD includes avoidance of anxiety
(e.g.
avoidance or escape from stressful situations) and expressive
suppres-
sion due to believing that expressing emotions will lead to
rejection or
to excessive focus on oneself. The model further proposes that
in-
dividuals with SAD are less effective in implementing
reappraisal. Ac-
cordingly, decreased suppression and increased effective use of
re-
appraisal are hypothesized to lead to symptom reduction, for

example,
by outward shifting of attention and by reducing exaggerated
prob-
ability and cost of rejection.
Recently, studies have examined suppression and reappraisal in
SAD
(reviewed in Dryman & Heimberg, 2018). Cross-sectional and
daily
diary studies typically focus on the frequency of use of a
strategy and
self-efficacy (perceived success in implementation). Individuals
with
SAD report an over-reliance on suppression and lower
frequency and
self-efficacy of reappraisal (e.g., Farmer & Kashdan, 2012;
https://doi.org/10.1016/j.jad.2020.10.021
Received 10 May 2020; Received in revised form 16 August
2020; Accepted 11 October 2020
⁎ Corresponding author: Yogev Kivity, Department of
Psychology, Bar Ilan University, Ramat Gan 5290002, Israel,
Telephone: +972-3-5318715
E-mail address: [email protected] (Y. Kivity).
1 Yogev Kivity is now in the Department of Psychology, Bar
Ilan University, Israel.
Journal of Affective Disorders 279 (2021) 334–342
Available online 14 October 2020
0165-0327/ © 2020 Elsevier B.V. All rights reserved.
T

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Gaebler, Daniels, Lamke, Fydrich, & Walter, 2014).
Impairments in
frequency seem to be larger than impairments in self-efficacy in
sup-
pression while the opposite is true for reappraisal (Kivity &
Huppert, 2018, 2019), thus supporting the Heimberg model.
In addition, studies have also utilized subjective ratings during
lab
tasks of emotion regulation to study reappraisal and suppression
abil-
ities in SAD. These studies typically present SAD-related
stimuli to
participants, such as pictures of rejecting faces (Goldin et al.,
2009a),
pictures portraying scenes of rejection and embarrassment
(Kivity &
Huppert, 2016, 2018, 2019) and idiographic statements of
negative
self-beliefs (Goldin et al., 2009b) while asking participants to
change
the way they interpret these stimuli in order to reduce the
distress they
evoke in them. However, compared to questionnaires and daily
diary
measures, these lab studies have shown intact emotion

regulation
abilities in SAD compared to controls, even under social stress
(e.g.,
Gaebler et al., 2014; Kivity & Huppert, 2016, 2018, 2019).
Thus, self-
reported impairments are not reflected in lab performance.
Among
other possibilities, this discrepancy may suggest a difficulty im-
plementing strategies in daily life despite an intact ability to
implement
them upon instruction in controlled circumstances, low
ecological va-
lidity of lab-based measures, or a bias in self-reports that does
not exist
in lab-based measures. Examining the role that each of these
aspects
(lab-based performance, self-reported frequency and self-
reported self-
efficacy) plays in treatments for SAD may shed light on their
relative
importance.
Several techniques of cognitive behavioral therapy (CBT) for
SAD
seem relevant for improving emotion regulation.
Psychoeducation and
exposures likely decrease suppression, as patients learn that
hiding
their anxiety is futile and likely to backfire. Outward shifting of
at-
tention (focusing on the task at hand instead of on how one is
per-
ceived) presumably decreases suppression by decreasing
patients’ pre-
occupation with their overt signs of anxiety. Furthermore,
cognitive

restructuring can potentially increase the use of reappraisal by
chan-
ging biased catastrophic cognitions. Finally, psychoeducation
and in-
vivo exposure challenge biased cognitions and are expected to
promote
reappraisal too.
Studies have shown that self-reported reappraisal (frequency
and
self-efficacy) increases in CBT (Goldin et al., 2014a; Goldin,
Morrison,
Jazaieri, Heimberg, & Gross, 2017; Kocovski, Fleming, Hawley,
Huta, &
Antony, 2013; Moscovitch et al., 2012). However, findings
regarding
self-reported suppression are inconclusive, with one study
reporting a
decrease in frequency (Goldin et al., 2014a) and another
reporting no
change (Moscovitch et al., 2012). Less is known regarding lab-
based
measures: one study found improvements in reappraisal of
negative
social evaluations and negative self-beliefs during CBT (Goldin
et al.,
2013, 2014b).
Importantly, the best test of the importance of emotion
regulation as
a treatment target for SAD is to examine its contribution to
symptom
improvement (Nock, 2007). Changes in reappraisal and
suppression
that predict treatment outcome would provide further support to
Heimberg's model. Several studies found that increases in self-

reported
frequency and self-efficacy of reappraisal predicted subsequent
symptom reduction (Goldin et al., 2017; Kocovski, Fleming,
Hawley,
Ho, & Antony, 2015; Moscovitch et al., 2012), although another
study
found that only self-efficacy (but not frequency) of reappraisal
pre-
dicted subsequent outcome (Goldin et al., 2014a). Decreases in
self-
reported suppression frequency predicted contemporaneous, but
not
subsequent, symptoms reduction in one study (Goldin et al.,
2014a) and
did not predict outcome at all in another (Moscovitch et al.,
2012). The
only examination of lab-based reappraisal (Goldin et al., 2014b)
found
that greater changes in fMRI measures of reappraisal predicted
greater
symptom change during CBT for SAD, although subjective task
per-
formance did not. Thus, the self-report findings suggest that
reappraisal
increases during CBT for SAD and may be driving symptom
change,
with more consistent findings regarding self-efficacy than
frequency.
Additional studies are needed regarding lab-based emotion
regulation.
The present study examines changes in suppression and
reappraisal
during CBT for SAD and their role in treatment outcome using
data
from a previously completed study (Huppert, Kivity, Cohen,

Strauss,
Elizur & Weiss, 2018). We collected weekly self-reports of the
frequency
and self-efficacy of reappraisal and suppression, and monthly
lab-based
measures of reappraisal and suppression in response to SAD-
related
pictures. Given past findings, our primary focus was self-
reported self-
efficacy of reappraisal and frequency of suppression. Frequency
of re-
appraisal and self-efficacy of suppression were of secondary
interest.
For the lab-based task, we focused on unpleasantness and event-
related potentials (ERP) during reappraisal and suppression of
SAD-
related pictures. We focused on the late positive potential
(LPP), an ERP
with a posterior midline distribution and an onset of 300 ms
post-sti-
mulus (Proudfit, Dunning, Foti, & Weinberg, 2013). Larger LPP
reflect
sustained attention to stimuli and elaborative engagement in
order to
regulate the emotion (Proudfit et al., 2013). The LPP is
sensitive to
emotional intensity and to emotion regulation, with higher
amplitudes
for highly arousing stimuli that are reduced following
instructions to
regulate, including reappraisal and suppression, even within
several
seconds from the presentation of the stimuli (Proudfit et al.,
2013). The
LPP shows less habituation over repeated exposure to stimuli

compared
to other psychophysiological measures (Proudfit et al., 2013),
which
allows for repetition of stimuli and attribution of changes in
LPPs to the
same stimuli as due to regulation. The LPP has been utilized in
SAD
(Kinney, Burkhouse, & Klump, 2019; Kivity & Huppert, 2018,
2019;
Yuan et al., 2014) but we are unaware of studies examining it
during
CBT for SAD.
We examined these hypotheses: 1) CBT will result in significant
improvements in suppression and reappraisal, including reduced
fre-
quency of suppression and increased self-efficacy, frequency,
and suc-
cessful lab implementation of reappraisal. 2) Improvements in
sup-
pression and reappraisal will play a potentially causal role in
CBT:
improvements will predict subsequent improvements in anxiety
and not
vice versa. 3) We examined whether patients reached an
equivalent
level of emotion regulation to healthy controls (HCs) at post-
treatment,
and whether gains were maintained at 3-months follow-up
without an
a-priori hypothesis.
2. Method
2.1. Participants

Data were drawn from the CBT arm of a study of treatments for
SAD
(Huppert et al., 2018)2. Patients were recruited via
advertisements and
referrals. Participants were 34 patients who met DSM-IV-TR
(American Psychiatric Association, 2000) criteria for SAD and
40 HCs
with no history of psychiatric disorders, matched to patients on
sex, age
and education. One patient decided not to enter treatment and 5
HCs
were removed because they did not have a continued low social
anxiety
score between screening and participation. The final sample
included
33 patients (13 females, Age: 18-53, M = 28.36, SD = 6.97) and
35
HCs (15 females, Age: 19-45, M = 28.49, SD = 6.28).
Participants were
Hebrew speaking and family status was: single: CBT = 59%,
HC = 61%; in a relationship: CBT = 41%, HC = 35%; divorced:
CBT = 0%, HC = 4%. Education levels were: high school: CBT
= 15%,
HC = 29%; post-high school: CBT = 21%, HC = 9%;
undergraduate
degree/student: CBT = 42%, HC = 27%; graduate
degree/student:
2 The original study also included participants receiving a
computerized
treatment for SAD called Attention Bias Modification. This
treatment was of
shorter duration compared to CBT, of a smaller sample size and
only included
three measurements of lab-based emotion regulation. In
addition, group as-

signment was random only for a subset of the CBT patients. Due
to these rea-
sons, we decided not to include data from this treatment in the
current study,
which a priori was designed to examine the role of ER in CBT.
Y. Kivity, et al. Journal of Affective Disorders 279 (2021)
334–342
335
CBT = 21%, HC = 26%. Groups did not differ on demographics
(ps >
.05). Ten SAD participants (29.41%) had one comorbid disorder
and
two (5.88%) had more than one. The most common comorbid
disorders
were depression (n = 9; 26.47%) or other anxiety disorders (n =
4;
11.76%).
2.2. Measures
Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987). A 24-
item interviewer-rated measure of fear and avoidance of social
inter-
actions and social performance. The Hebrew version (Levin,
Marom,
Gur, Wechter, & Hermesh, 2002) was administered by trained
clinical
psychology doctoral students, blind to hypotheses. Internal
consistency
in all assessments was α = .90 – .96; interrater reliability for 15
ran-

domly chosen interviews was r = .94.
Social Phobia Inventory (SPIN; Connor et al., 2000). A valid
and
reliable 17-item self-report measure of social anxiety
symptoms,
translated and back translated to Hebrew for previous studies.
Internal
consistency in all assessments was: α = .78 – .95.
Emotion Regulation Questionnaire – Self-Efficacy and
Frequency (ERQ; Gross & John, 2003). We used the reliable
and valid
Hebrew version (Carthy, Horesh, Apter, Edge, & Gross, 2010).
Fol-
lowing Goldin et al. (2009b), we measured both the frequency
(ERQ-F)
and self-efficacy (ERQ-SE) in social situations instead of
frequency only
(internal consistency of all subscales: α = .73 – .97). Items tap
into
reappraisal (e.g., “When I want to feel less negative emotion, I
change
the way I'm thinking about the situation”) and suppression (e.g.,
“I
control my emotions by not expressing them”) which
participants en-
dorse using a 1 ("Seldom"/"Ineffectively") to 7
("Often"/"Effectively")
scale.
Emotion Regulation Task. Full details are provided in supple-
mental material, section 1. We used a task that was developed
by
Hajcak and Nieuwenhuis (2006) who presented emotionally-
salient

pictures to participants and instructed them to either passively
view the
picture or to reappraise the emotion it evokes in them while
ERP ac-
tivity was recorded and unpleasantness ratings were collected.
Hajcak
and Nieuwenhuis found that the amplitude of the LPP and the
level of
subjective unpleasantness were decreased during reappraisal
compared
to passive viewing. Thus, the task is validated and suitable for
studying
the effects of emotion regulation on electrocortical activity and
sub-
jective unpleasantness. In the current study, we adapted the task
to
measure suppression in addition to reappraisal and used SAD-
related
pictures rather than general pictures (Kivity & Huppert, 2018,
2019). In
selecting the stimuli for the task, we chose to focus on shame,
embar-
rassment and rejection because these experiences are central in
SAD
(Goldin et al., 2009b; Morrison & Heimberg, 2013; Moscovitch,
2009)3.
Twenty trials of each condition were included: viewing of SAD-
related
pictures, viewing of neutral pictures, reappraisal of SAD-related
pic-
tures and suppression of SAD-related pictures.
When viewing SAD-related pictures, participants imagined
them-
selves as the character that is the focus of shame, rejection, and
em-

barrassment. When viewing neutral pictures, participants
responded
naturally. When reappraising, participants first imagined
themselves as
the character and then changed the way they think of the picture
to
decrease their unpleasantness (e.g., "This guy is not laughing at
me, but
at someone else"). When suppressing, participants first
imagined
themselves as the character and then concealed any expression
of
emotions. To enhance the effect of the suppression
manipulation, a web
camera was placed above the computer screen and participants
were
told that a member of the research team would review the
recordings.
Participants were instructed to avoid any expression of their
emotions
such that it would be impossible to tell whether they were
viewing
neutral pictures or concealing their emotions4.
After each trial, participants rated their unpleasantness on a
Self-
Assessment Manikin (SAM; Lang, Bradley, & Cuthbert, 2008)
scale (1
through 9; 5 being neutral; transformed such that higher ratings
express
greater unpleasantness). We focused on unpleasantness ratings
in order
to complement the LPP data (which is mostly correlated with
arousal)
and arrive at a more complete picture of the participants’

emotional
experience that takes into account the two basic dimensions of
emo-
tions – valence and arousal. After providing unpleasantness
ratings,
participants were asked to indicate the instructions they
followed
during that trial. In the reappraisal condition, participants were
also
asked to record the new interpretation they came up with for the
pic-
ture (results not reported here).
Ratings were averaged for each condition and a regulation score
(view – regulate; calculated on the transformed scores) was
calculated
to capture the amount of reduction in unpleasantness. Higher
scores
indicate larger regulation effects.
SAD-related pictures were collected from the internet5, normed
and
shown to evoke moderate shame, embarrassment, rejection and
un-
pleasantness (Kivity & Huppert, 2018, 2019). These depicted
situations
of shame, rejection, and/or embarrassment such as scenes of
people
pointed and laughed at, anxious people during a public speech,
and
facial expressions of contempt. Neutral pictures were taken
from the
International Affective Picture System (IAPS) database (Lang et
al.,
2008).

Psychophysiological Recording, Data Reduction, and Analysis.
Full details are provided in section 2 of the supplement. ERPs
were
constructed by averaging trials in each condition (view,
suppression,
reappraisal and view neutral). Following Moser, Hartwig,
Moran,
Jendrusina, & Kross (2014), the LPP was quantified as the
average
voltage in 5 parietal electrodes (CPz, P1, Pz, P2, POz) in the
entire
segment (400-2000 ms). A regulation change score (view –
regulate)
was calculated to capture the amount of reduction in the LPP.
Higher
scores indicate larger regulation effects. Trials in which
participants
failed to use the instructed strategy were excluded (4.57% on
average,
no group differences). Studies have shown that the LPP can be
reliably
measured with as little as 8 trials and that it varies little beyond
12
trials (Moran, Jendrusina, & Moser, 2013). Assessments with
fewer than
12 valid trials in each condition were removed from analyses
(5%
across groups, no group differences).
2.3. Treatment and therapists
Individual CBT was delivered for up to 20 sessions using a
manual
by Roth-Ledley, Foa, & Huppert (2006), based on Clark's
(2005) CBT for
SAD. Components such as building an idiographic model,

outward
shifting of attention, safety behaviors experiment, video
feedback, be-
havioral experiments and exposures, and optional use of
imaginal ex-
posure, assertiveness training, or social skills training are
included.
Therapists were four clinical psychology doctoral students with
2-4
years of CBT experience. Videorecordings of sessions were
used in
group supervision by the last author.
3 Shame, embarrassment and rejection are likely separate, but
related, ex-
periences. Similar to previous studies (e.g., Goldin et al., 2009),
when designing
and validating the task (Kivity & Huppert, 2018, 2019) we were
not able to
examine these experiences separately due to a small number of
stimuli that
purely fall into one of these categories. It remains for future
studies to examine
these experiences separately.
4 It should be noted that although the view condition is not
entirely a passive
one (as it includes perspective taking), it is still possible that i t
requires less
cognitive effort than the reappraisal and suppression conditions.
However,
studies have shown that cognitive effort alone does not explain
the down-reg-
ulatory effects of reappraisal (Foti & Hajack, 2008).
5 See a sample picture at

https://tinyurl.com/ShameArousingPicture.
334–342
336
https://tinyurl.com/ShameArousingPicture
2.4. Procedure
The institutional review board approved the study. After
providing
informed consent, participants were evaluated by trained
independent
evaluators (blind to hypotheses) using the Mini-International
Neuropsychiatric Interview (Sheehan et al., 1998) and the
LSAS. Par-
ticipants completed a baseline assessment and entered
treatment. Pa-
tients completed the ERQ before and after each session (post-
session
ratings were of secondary interest and are only reported in
Supple-
mental Material, Section 4). Patients also completed in-lab
assessments
at pre-treatment, every four sessions during treatment, at post-
treat-
ment and at 3-months follow-up which included the LSAS,
SPIN, ERQ,
and the lab task. Thus, each patient had up to seven assessments
(pre-
treatment, sessions 4, 8, 12 and 16, post-treatment, and follow-
up). HCs
only completed a single assessment and were not followed long-

itudinally. Thus, HCs were included only in analyses of
equivalency.
2.5. Data Analyses
We used intent-to-treat linear multi-level models (assessments
at
level 1 repeated within patients at level 2) implemented in R
package
'nlme' (Pinheiro, Bates, DebRoy, Sarkar, & R Core Team,
2016). In-
cluding therapists as a third level showed negligible and non-
significant
effects (ICCs: Med = .00, range: 0 – 0.049) and therefore this
level was
removed. We used restricted maximum likelihood estimation, a
first-
order autoregressive level 1 covariance structure and random
intercepts
and slopes at level 2. For H1, linear rates of change were
examined by
including session/assessment number as a level 1 predictor
(centered at
pre-treatment). Intercepts represent estimated levels of the
dependent
variable at pre-treatment and slopes represent estimated changes
in the
dependent variable between two assessment points (one/four
sessions,
depending on the measure). To examine changes from post-
treatment to
follow-up we fitted a piece-wise model that examines changes
during
treatment and from post-treatment to follow-up separately. This
was
done by adding the follow-up data to the abovementioned model

and
adding a dummy coded variable that captures post-treatment to
follow-
up changes (coded “1” for follow-up assessment and “0” for all
other
assessment). The fixed effect of the dummy variable expresses
the
amount and significance of the change from post-treatment to
follow-
up.
H2 was examined by modeling within-patient variation in the
pre-
dictor following recommended procedures (Wang & Maxwell,
2015).
Monthly scores of the predictor (patient mean-centered) served
as
within-patient scores in a cross-lagged (1-month) model.
Within-subject
effects represent cross-lagged associations between the
predictor and
the outcome. Per Wang and Maxwell (2015) we did not control
for
linear time effects as we wished to model and explain these very
effects.
Following Falkenström, Finkel, Sandell, Rubel, and Holmqvist
(2017),
we did not include the lagged dependent variable as a predictor
because
it introduces a dependency between the dependent variable and
the
error, thus violating assumptions. However, the first auto-
regressive
residual structure partly accounts for the effects of prior on
current
levels of the outcome. For consistency, we only analyzed

monthly
scores of the SPIN and ERQ. A cross-lagged association was
interpreted
as significant only if effects were significant for clinician-rated
and self-
reported anxiety.
For H3, comparisons were conducted using clinical equivalency
procedures (Kendall, Marrs-Garcia, Nath, & Sheldrick, 1999)
through t
tests examining non-inferiority (i.e., < 1 SD difference) of post-
treat-
ment scores compared to HCs. A significant effect in
noninferiority tests
suggests that patients are non-inferior to HCs.
Effect sizes were calculated as semi-partial r (rs; Jaeger,
Edwards,
Das, & Sen, 2016; Nakagawa & Schielzeth, 2013) using package
'r2glmm' in R (Jaeger & R Core Team, 2016). These represent
the un-
ique contribution above and beyond the contribution of other
pre-
dictors in the model and are presented in absolute values.
3. Results
3.1. Changes in regulation (H1) and equivalency to HCs (H3)
3.1.1. Change in self-reports
Descriptive statistics for all study variables are presented in
sup-
plemental material, section 3. Changes are shown in Fig. 1.
Suppression. Consistent with hypotheses, the frequency of sup-

pression decreased during treatment (t467 = -3.98, p < .01, rs =
.22
[.14, .30]) and did not change from post-treatment to follow-up
(b = -.10, t490 = -.62, p = .53, rs = .01 [.00, .10]). In contrast to
hypotheses, self-efficacy of suppression decreased during
treatment
(t467 = -2.85, p < .01, rs = .14 [.05, .22]) and did not change
from
post-treatment to follow-up (b = -.09, t490 = -.64, p = .52, rs =
.01
[.00, .10]).
Reappraisal. Consistent with hypotheses, self-efficacy of
reappraisal
increased during treatment (t467 = 3.67, p < .01, rs = .17 [.08,
.25])
and did not change from post-treatment to follow-up (b = -.02,
t490 = -.10, p = .92, rs = .00 [.00, .10]). In contrast to
hypotheses, no
changes in frequency of reappraisal were observed (t467 = .04,
p = .97,
rs = .00 [.00, .10]) nor did they change from post-treatment to
follow-
up (b = .08, t490 = .33, p = .74, rs = .01 [.00, .10]).
3.1.2. Change in lab-based measures
Changes are shown in Fig. 2 and Fig. 3.
View SAD-related pictures. As hypothesized, unpleasantness
ratings
decreased during treatment (t115 = 4.49, p < .01, rs = .28 [.13,
.42])
and did not change from post-treatment to follow-up (b = .08,
t138 = .70, p = .49, rs = .03 [.00, .18]). The LPP while viewing
SAD-
related pictures did not change significantly during treatment (b

= -.46,
t103 = -1.80, p = .07, rs = .14 [.01, .30]) or from post-treatment
to
Fig. 1. Change in frequency and self-efficacy of reappraisal (top
panel) and
suppression (bottom panel) during Cognitive Behavioral
Therapy (CBT). Error
bars represent estimated standard errors. Only data from
sessions 1-16 are
presented because only 5 patients received more than 16
sessions. b = esti-
mated weekly change in emotion regulation. ** p < .01
334–342
337
follow-up (b = 1.73, t126 = 1.11, p = .27, rs = .05 [.00, .20]).
View neutral pictures. Supporting our hypotheses, we found no
change in unpleasantness ratings during CBT or from post-
treatment to
follow-up (during: t115 = -.43, p = .67, rs = .04 [.00, .20]; post-
treatment to follow-up: b = -.05, t138 = -.26, p = .79, rs = .02
[.00,
.17]) and in the LPP (during: b = -.29, t103 = -1.04, p = .30, rs
= .09
[.00, .25]; post-treatment to follow-up: b = 1.86, t126 = 1.09, p
= .28,
rs = .05 [.00, .20]) while viewing neutral pictures.
Suppression. Examining suppression-related reductions in un-

pleasantness (compared to viewing pictures) we found that
reductions
were significantly different from zero at pre-treatment (b = .25,
t115 = 3.84, p < .01), indicating that suppression was effective
in
down-regulating negativity. Consistent with hypotheses,
regulation
scores did not change during treatment (t115 = -1.77, p = .08, rs
= .16
[.02, .31]) or from post-treatment to follow-up (b = .03, t138 =
.29,
p = .78, rs = .02 [.00, .18]). Reductions in LPP via suppression
were
not different from zero at pre-treatment (b = .69, t103 = 1.00, p
= .32),
suggesting that suppression was not effective in down
regulating the
LPP. Also consistent with hypotheses, regulation scores did not
change
during treatment (b = -.10, t103 = -.36, p = .72, rs = .03 [.00,
.20])
and from post-treatment to follow-up (b = -.68, t126 = -.50, p =
.61,
rs = .03 [.00, .19]).
Reappraisal. Reappraisal-related reductions in unpleasantness
were
significantly different from zero at pre-treatment (b = 1.41,
t115 = 10.33, p < .01) indicating that reappraisal was indeed
effective
in down-regulating negativity. However, in contrast to
hypotheses, we
also found significant decreases in regulation scores during
CBT (t115 = -
3.98, p < .01, rs = .26 [.11, .41] and no change from post-
treatment to

follow-up (b = -.16, t138 = -1.25, p = .21, rs = .06 [.00, .21]).
Additional analyses showed that raw unpleasantness ratings
during
reappraisal did not change (b = .02, t115 = .60, p = .55, rs = .03
[.00,
.20]) which suggests that the decrease in regulation scores of re-
appraisal was driven by a decrease in unpleasantness whi le
simply
viewing SAD-related pictures and not by a decrease in
unpleasantness
ratings during reappraisal.
Fig. 2. Mean unpleasantness ratings while viewing neutral
pictures and while
viewing (top panel), suppressing, and reappraising (bottom
panel) SAD-related
pictures during Cognitive Behavioral Therapy. Higher scores
indicate greater
unpleasantness. Error bars represent estimated standard errors.
Only data from
sessions 1-16 are presented because only 5 patients received
more than 16
sessions. b = estimated change in unpleasantness every four
session. ** p < .01
Fig. 3. Picture-locked Event Related Potentials in the emotion
regulation task pooled at parietal sites (CPz, P1, Pz, P2, POz),
shown separately at pre- (top panel) and
post- (bottom panel) cognitive behavioral therapy. Green, blue,
red, and black lines represent amplitudes in the view neutral,
reappraisal, suppression and view
conditions, respectively.
334–342

338
When examining reappraisal-related reductions in the LPP, we
found that reductions were not different from zero at pre-
treatment
(b = .52, t103 = .71, p = .48), indicating that reappraisal was not
effective in down-regulating the LPP. Also, inconsistent with
hy-
potheses, regulation scores did not change during treatment (b =
-.06,
t103 = -.20, p = .84, rs = .02 [.00, .19]) and from post-treatment
to
follow-up (b = -1.66, t126 = -1.21, p = .23, rs = .10 [.01, .25]).
3.1.3. Equivalency to HCs
Equivalency tests were only carried out for measures in which
pa-
tients showed impairments compared to HCs at baseline: self-
report
measures of emotion regulation and subjective unpleasantness
while
viewing SAD-related pictures (Kivity & Huppert, 2019). In
terms of self-
reported emotion regulation, at post-treatment, patients reached
equivalency to HCs in terms of frequency and self-efficacy of
suppres-
sion (p < .01) but continued to show lower frequency and self-
efficacy
of reappraisal (ps > .05). In addition, patients reached
equivalency to
HCs in terms of unpleasantness while viewing SAD-related
pictures (p
< .02).

3.2. Cross-lagged associations between emotion regulation and
anxiety
(Hypothesis 2)
A summary of estimated cross-lagged fixed-effects are
presented in
Table 1.
3.2.1. Self-reported emotion regulation
Frequency of suppression. Consistent with hypotheses, lower
sup-
pression frequency predicted lower subsequent clinician-rated
(t81 = 2.11, p = .04, rs = .11 [.01, .29]) and self-reported
anxiety
(t86 = 2.41, p = .02, rs = .18 [.02, .35]). Thus, lower
suppression
frequency predicted lower anxiety four sessions later.
Furthermore,
neither clinician-rated (t81 = 1.46, p = .15, rs = .08 [.00, .26])
nor self-
reported anxiety (t86 = 1.68, p = .10, rs = .08 [.00, .26])
predicted
subsequent suppression frequency. These results suggest a
unidirec-
tional association whereby suppression frequency predicts
subsequent
anxiety and not the other way around.
Frequency of reappraisal. In contrast to hypotheses, no
significant
cross-lagged associations were found between reappraisal
frequency
and anxiety (reappraisal→clinician-rated anxiety: t81 = -.39, p
= .70,

rs = .02 [.00, .22]; reappraisal→self-reported anxiety: t86 = -
.45,
p = .65, rs = .02 [.00, .21]; clinician-rated anxiety →
reappraisal:
t81 = -.91, p = .37, rs = .07 [.00, .25]; self-reported anxiety →
re-
appraisal: t86 = -.55, p = .58, rs = .04 [.00, .22]).
Self-efficacy of suppression. In partial support of hypotheses,
greater suppression self-efficacy predicted lower subsequent
self-re-
ported (t86 = 2.25, p = .03, rs = .17 [.02, .34]) but not clinician-
rated
anxiety (t81 = 1.90, p = .06, rs = .09 [.00, .27]). In addition,
neither
clinician-rated (t81 = .97, p = .34, rs = .04 [.00, .23]) nor self-
reported
anxiety (t86 = 1.82, p = .07, rs = .07 [.00, .25]) predicted
subsequent
suppression self-efficacy.
Self-efficacy of reappraisal. In partial support of hypotheses,
greater reappraisal self-efficacy predicted lower subsequent
self-re-
ported (t86 = -2.09, p = .04, rs = .12 [.01, .30]) but not
clinician-rated
anxiety (t81 = -1.45, p = .15, rs = .06 [.00, .25]). Furthermore,
in
contrast to hypotheses, lower clinician-rated (t81 = 2.11, p =
.04,
rs = .11 [.01, .29]) and self-reported anxiety (t86 = -2.77, p <
.01,
rs = .11 [.01, .29]) predicted greater subsequent reappraisal
self-effi-
cacy. These results are more supportive of a unidirectional

relationship
such that anxiety predicts subsequent reappraisal self-efficacy
and not
vice-versa.6
3.2. 2. Lab-based emotion regulation
Unpleasantness ratings and electrocortical responses while
viewing
SAD-related pictures. Lower unpleasantness ratings while
viewing
SAD-related pictures predicted subsequent self-reported (t85 = -
2.50,
p = .01, rs = .18 [.02, .35]), but not clinician-rated, anxiety (t80
= -
1.46, p = .15, rs = .09 [.00, .27]). However, lower clinician-
rated
(t80 = -2.39, p = .02, rs = .14 [.01, .32]) and lower self-reported
an-
xiety (t85 = -2.46, p = .02, rs = .14 [.01, .31]) predicted lower
sub-
sequent unpleasantness ratings.
For electrocortical responses, smaller LPPs while viewing SAD-
re-
lated pictures predicted lower subsequent clinician-rated (t70 =
2.30,
p = .02, rs = .12 [.01, .31]) and self-reported anxiety (t75 =
2.73, p <
.01, rs = .17 [.01, .35]). In addition, anxiety did not predict
subsequent
LPPs while viewing SAD-related pictures (clinician-rated
anxiety:
b = -.02, t69 = -.36, p = .72, rs = .03 [.00, .24]; self-reported:
t74 = -.72, p = .47, rs = .08 [.00, .27]). This suggests a
unidirectional

association whereby lower electrocortical reactivity to SAD-
related
stimuli predicts lower anxiety four sessions later and not the
other way
around.
Table 1
Estimated multi-level fixed effects and 95% confidence
intervals for cross-lagged associations between emotion
regulation and social anxiety.
Emotion Regulation → Anxiety Anxiety → Emotion Regulation
Emotion regulation variable Clinician-rated anxiety Self-
reported anxiety Clinician-rated anxiety Self-reported anxiety
ERQ
Suppression frequency 2.92 [0.16, 5.67]* 2.34 [0.41, 4.28]*
0.01 [0.00, 0.02] 0.01 [0.00, 0.03]
Reappraisal self-efficacy -2.55 [-6.05, 0.96] -2.46 [-4.80, -
0.12]* -0.01 [-0.02, 0.00]* -0.02 [-0.03, 0.00]**
Suppression self-efficacy 2.72 [-0.12, 5.57] 2.49 [0.29, 4.69]*
0.00 [-0.01, 0.01] 0.01 [0.00, 0.03]
Reappraisal frequency -0.62 [-3.80, 2.56] -0.44 [-2.38, 1.50] -
0.01 [-0.02, 0.01] -0.01 [-0.03, 0.01]
Lab-based (ratings)
View -4.22 [-9.96, 1.53] -4.41 [-7.92, -0.90]* -0.01 [-0.02,
0.00]* -0.01 [-0.02, 0.00]*
Suppression -6.74 [-16.82, 3.35] 0.60 [-5.41, 6.61] 0.00 [0.00,
0.01] 0.00 [-0.01, 0.01]
Reappraisal -0.30 [-5.77, 5.18] 1.99 [-1.00, 4.98] 0.01 [0.00,
0.01] 0.01 [0.00, 0.02]
Lab-based (LPP)
View 0.70 [0.09, 1.30]* 0.49 [0.13, 0.85]** -0.02 [-0.11, 0.08] -
0.06 [-0.21, 0.10]
Suppression 0.28 [-0.25, 0.81] 0.00 [-0.32, 0.31] -0.04 [-0.13,
0.05] -0.03 [-0.15, 0.09]

Reappraisal -0.03 [-0.47, 0.42] 0.12 [-0.14, 0.38] 0.04 [-0.05,
0.13] -0.04 [-0.18, 0.10]
Notes. ERQ = Emotion regulation questionnaire; LPP = Late
positive potential. Clinician-rated and self-reported anxiety was
measured using the Liebowitz Social
Anxiety Scale and the Social Phobia Inventory, respectively.
Lab-based reappraisal and suppression represent regulation
change scores (view – regulate) with higher
scores indicating larger regulation effects. */** significantly
different from zero at p < .05/.01.
6 We also examined whether our findings are sensitive to the
time lag between
the measurement of emotion regulation and anxiety (one vs.
four weeks) by
refitting cross-lagged models of self-reported emotion
regulation and self-re-
ported anxiety with all weekly data. Lab-based emotion
regulation and clin-
ician-rated anxiety were only measured every four weeks and
were not included
in these analyses. We found that lower anxiety predicted lower
subsequent
suppression frequency and greater subsequent reappraisal self-
efficacy, and not
the other way around. The findings are reported in full in
Supplemental
Material, Section 5.
334–342
339

Lab-based reappraisal and suppression. Reappraisal- and
suppres-
sion-related reductions in unpleasantness and electrocortical
responses
did not predict and were not predicted from clinician-rated and
self-
reported anxiety (ts = -1.33 – 1.88; ps = .06 – .98; rss = .00 –
.12).
4. Discussion
We utilized a multi-method design to examine the role of
emotion
regulation in CBT for SAD. CBT led to decreased self-reported
frequency
and self-efficacy of suppression, increased self-reported self-
efficacy of
reappraisal, decreased unpleasantness while viewing SAD-
related pic-
tures, and smaller reappraisal-related reductions in
unpleasantness
while viewing SAD-related pictures. Gains were maintained at
3-
months follow-up. Lower suppression frequency and smaller
electro-
cortical reactivity predicted lower subsequent anxiety, but not
vice
versa. In contrast, self-efficacy of reappraisal and subjective
reactivity
to SAD-related pictures were predicted by previous levels of
anxiety,
but not vice versa.
4.1. Changes in emotion-regulation during treatment

Self-report findings are consistent with the literature regarding
in-
creases in reappraisal (Goldin et al., 2014a, 2017; Kocovski et
al., 2013;
Moscovitch et al., 2012), and partly consistent regarding
decreases in
suppression (Goldin et al., 2014a). Moscovitch et al. (2012)
found no
changes in suppression, which could be due to a number of
reasons
(e.g., different CBT protocols, insufficient power). Our study is
novel in
showing that patients reached normal levels of suppression, but
not
reappraisal. Thus, CBT seems to eliminate the initial
overreliance on
suppression among individuals with SAD – an impairment that
has been
shown to be large (e.g., g = 0.96 in Kivity & Huppert, 2019).
Im-
plementation of reappraisal seems to take more time to develop,
pos-
sibly due to its complexity.
In terms of lab-based emotion regulation, we found decreased
sub-
jective reactivity to SAD-related pictures. Goldin et al. (2013)
found
similar reductions in reactivity that were specific to CBT
compared with
waitlist controls, and that only CBT patients reported an
increase in
automatic use of reappraisal during view. These findings, along
with
the finding that decreased subjective reactivity predicted lower
sub-

sequent self-reported anxiety suggest that the reduction is
unlikely to be
due to practice effects (i.e., habituation due to the mere
repeated ex-
posure to the stimuli). Rather, it is possible that as treatment
progresses,
patients' automatic regulation increases even when passively
viewing.
This is consistent with our findings that the decrease in
unpleasantness
during reappraisal was mostly driven by reduction in
unpleasantness
while viewing pictures, and not by changes in unpleasantness in
the
reappraisal condition. It is noteworthy that floor effects could
not be
ruled out because unpleasantness was low at pre-treatment.
However,
even at post-treatment, unpleasantness while viewing SAD-
related
pictures did not reach the level of neutral pictures (see
supplemental
material, section 3, for descriptive statistics) making floor
effect a less
likely explanation. Finally, the LPP during lab-based regulation
did not
change, which is consistent with other studies reporting that the
LPP is
not larger among participants with social anxiety (Kivity &
Huppert, 2018. 2019; Yuan et al., 2014, but see Kinney et al.,
2019 for
an exception).
4.2. The association between emotion-regulation and anxiety
Lower frequency of suppression predicted lower subsequent

anxiety,
but not the other way around. This supports a unidirectional
association
such that as patients make less attempts to hide their anxiety,
their
anxiety level decreases. This is consistent with the emphasis in
CBT on
reducing attempts to hide anxiety which is conveyed in several
ways
throughout treatment, such as in the psychoeducation module,
outward
shifting of attention (instead of on one's overt signs of anxiety)
and in
vivo exposures (patients are exposed to anxiety provoking
situations
while dropping safety behaviors that are intended to hide their
an-
xiety). Together with the finding that patients reached a normal
level of
suppression frequency, our findings point to a unique role of
suppres-
sion in CBT for SAD.
Surprisingly, suppression did not predict subsequent anxiety in
previous studies (Goldin et al., 2014a; Moscovitch et al., 2012).
This
divergence in findings could be due to the specific CBT
protocol used in
the current study that uniquely emphasizes outward shifting of
atten-
tion (Clark, 2005; Roth-Ledley et al., 2006). Our findings are
consistent
with a recent study showing that suppression, and not
reappraisal,
predicts subsequent anxiety in CBT for panic disorder (Strauss,

Kivity, &
Huppert, 2019). In addition, in our sensitivity analyses, anxiety
pre-
dicted suppression in a one-week lag, but not vice versa. Thus,
the exact
time lag that determines the association between suppression
and an-
xiety needs to be further understood (c.f., Cole & Maxwell,
2003) and
more studies examining the role of suppression in various CBT
protocols
are needed.
Self-reported reappraisal did not reliably predict subsequent
anxiety
but rather was predicted by it. This is in contrast to previous
studies
showing that reappraisal predicted subsequent anxiety (Goldin
et al.,
2014a, 2017; Kocovski et al., 2015; Moscovitch et al., 2012).
Together
with our findings regarding suppression, it seems like the
association
between habitual emotion regulation and anxiety in CBT is
dynamic,
includes bidirectional influences between regulation and anxiety
(c.f.
Hofmann, Curtiss, & Hayes, 2020) and depends on the specific
CBT
protocol being used.
Lower electrocortical reactivity to SAD-related stimuli
predicted
lower subsequent anxiety, but not vice versa. This
unidirectional as-
sociation was unique to electrocortical reactivity whereas

subjective
reactivity seemed to be predicted by anxiety and not vice versa.
Thus,
while reductions in LPPs during treatment were not significant,
they did
predict outcome. This may suggest that some CBT patients
become less
reactive to SAD-related stimuli and that decreased reactivity is
related
to subsequent symptom reduction. The mechanism underlying
this re-
duction remains to be examined. For example, the decreased
reactivity
could be related to use of automatic reappraisal (that is not
captured by
the lab-based task) or to improvements in other regulation
strategies
that are known to be impaired in SAD such as rumination
(Kashdan &
Roberts, 2007) and avoidance (Heur, Rinck, & Becker, 2007).
Other than the abovementioned findings, lab-based regulation
did
not improve and was unrelated to outcome. This is consistent
with the
lack of impairments in social anxiety compared to controls in
lab-based
tasks (Gaebler et al., 2014; Goldin et al., 2009b; Kinney et al.,
2019;
Kivity & Huppert, 2018, 2019; Yuan et al., 2014; but see Ziv,
Goldin,
Jazaieri, Hahn, & Gross, 2013 for a significant finding in one
out of
three tasks). Along with daily diaries studies showing impaired
emotion
regulation (e.g., Kivity & Huppert, 2016), our findings suggest

that
individuals with SAD are able to regulate upon instruction, but
have
difficulties implementing their abilities in daily life. However,
one
study found specific CBT-related decreases in emotion intensity
ratings
and modulation of fMRI activity during reappraisal of negative
social
evaluations (Goldin et al., 2013, 2014b). These differences
could either
stem from the different tasks used, the measure of brain activity
(ERPs
vs. fMRI), or the materials used (standardized pictures vs.
idiographic
self-referential social evaluations).
Taken together, our findings suggest that CBT eliminates the
over-
reliance on suppression and that this reduction in suppression
fre-
quency plays an important role in CBT for SAD whereas
reappraisal
does not. This is only partly consistent with the Heimberg
model
(Morrison & Heimberg, 2013) which attributes a role to both
suppres-
sion and reappraisal in CBT for SAD. Thus, as more findings
accrue, the
model could be modified to put a larger emphasis on
suppression re-
lative to reappraisal. Furthermore, models should explicitly
articulate
the ways in which CBT is hypothesized to reduce suppression
(e.g.,
outward shifting of attention, dropping safety behaviors). Future

334–342
340
studies could empirically examine these propositions and
potentially
improve existing protocols. Finally, at least one other route for
anxiety
reduction exist in CBT that occurs through diminished
reactivity to
SAD-related stimuli. This remains to be further understood in
future
studies.
5. Limitations
Despite the multiple assessment points, our sample was
moderate in
size. Relatedly, unbiased crossed-lagged estimates an accurate
time lag
between cause and outcome (Cole & Maxwell, 2003). Such
information
is available for emotion regulation-social anxiety associations,
and we
mostly focused on four-weeks lags. Additional studies with
intensive
measurements are needed to determine the most accurate time
lags.
Finally, without a treatment control group, it is difficult to rule
out that
the observed changes were not due to the mere passage of time.
However, the finding that changes in emotion regulation were

only
observed during treatment but not from post-treatment to
follow-up
reduce the likelihood of changes due to the passage of time
only. Still,
the lack of a control group makes it impossible to determine the
spe-
cificity of the findings to CBT compared to other treatments.
6. Conclusions
CBT for SAD reduced emotion dysregulation as revealed by
self-
reports and subjective emotional reactivity. Most notably,
patients
reached a normal level of suppression frequency. In addition,
sup-
pression frequency and electrocortical reactivity emerged as
unidirec-
tional predictors of subsequent anxiety while the role of other
types of
emotion regulation was less clear. This suggests that emotion
regula-
tion, and especially suppression, may play a complex, causal
role in CBT
for SAD.
If these findings are replicated, they might have important
theore-
tical and clinical implications for models of CBT for SAD.
Models and
protocols may need to assign a greater role to suppression and a
lesser
role to reappraisal. Our study also highlights the importance of
multi-
method designs when examining emotion regulation during

treatment
while specifying the exact nature of emotion dysregulation and
focusing
on the possible difficulties in implementing otherwise intact
regulation
abilities in daily life.
Author Contributions
Y.K. developed the concept, performed the data analysis and in-
terpretation and drafted the paper for the current report under
the
supervision of J.D.H. J.D.H developed the overall study concept
and
design. All authors contributed to data collection, provided
critical re-
visions and approved the final manuscript for submission.
Declaration of Competing Interest
The authors declare that they have no known competing
financial
interests or personal relationships that could have appeared to
influ-
ence the work reported in this paper.
Acknowledgements
The authors would like to thank Roni Pener-Tessler, Ariela
Friedman, Asher Strauss, Yael Milgram, Shai Avishay, Michal
Kovacs,
and Maayan Langmass for their help in data collection and
Jason Moser
and members of the clinical psychophysiology lab for their help
in
analyses of the ERP data. Preparation of this manuscript was

supported
by a grant from the Israel Science Foundation (grant #332/09)
to the
last author, the Sam and Helen Beber Chair of Clinical
Psychology at
The Hebrew University. The funding sources did not have any
in-
volvement in conducting the study and preparing the
manuscript.
Supplementary materials
Supplementary material associated with this article can be
found, in
the online version, at doi:10.1016/j.jad.2020.10.021.
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http://refhub.elsevi er.com/S0165-0327(20)32865-2/sbref0051
http://refhub.elsevier.com/S0165-0327(20)32865-
2/sbref0054The role of expressive suppression and cognitive
reappraisal in cognitive behavioral therapy for social anxiety
disorder: A study of self-report, subjective, and electrocortical
measures1 Introduction2 Method2.1 Participants2.2
Measures2.3 Treatment and therapists2.4 Procedure2.5 Data
Analyses3 Results3.1 Changes in regulation (H1) and
equivalency to HCs (H3)3.1.1 Change in self-reports3.1.2
Change in lab-based measures3.1.3 Equivalency to HCs3.2
Cross-lagged associations between emotion regulation and
anxiety (Hypothesis 2)3.2.1 Self-reported emotion regulation3.2
2. Lab-based emotion regulation4 Discussion4.1 Changes in
emotion-regulation during treatment4.2 The association between
emotion-regulation and anxiety5 Limitations6
ConclusionsAuthor ContributionsDeclaration of Competing
InterestAcknowledgementsSupplementary materialsReferences

Cultural Aspects of Social Anxiety Disorder: A Qualitative
Analysis of Anxiety Experiences and Interpretation
Abolafzl Mohammadi
1
, Imaneh Abasi
2
*, Mehdi Soleimani
1
, Seyed Tayeb Moradian
3
, Taha Yahyavi
4
,
Mostafa Zarean
5
Abstract
Objective: Anxiety is a complex phenomenon on which culture
has a prominent influence. The present study aimed to
investigate the cultural aspects of social anxiety disorder (SAD)
in an Iranian population.
Method: A qualitative content analysis research was done to

answer the study question. A total of 16 individuals with
social anxiety disorder (six men and 10 women) were selected
using purposeful sampling method (M = 24.43, SD =
4.56). The study was conducted in Tehran, Urmia, and
Sanandaj- Iran. Participants were from different ethnic
backgrounds (LOR, FARS, TURK, and KURD). Data were
analyzed by thematic analysis using an inductive method.
Results: Analysis of participants’ records yielded five distinct
categories with some subcategories, which are as follow:
(1) anxiety experiences; (2) core beliefs; (3) reasons of being
anxious; (4) effects of SAD on life aspects; and (5) coping
strategies.
Conclusion: It seems that symptoms of social anxiety and its
underlying beliefs, causes and effects and coping
strategies are almost experienced and interpreted in a way that
could be the same as DSM-5 clinical presentation of
social anxiety, with the exception that somatic symptoms are
experienced by almost all participants.
Key words: Anxiety; Culture; Qualitative Research; Social
Anxiety Disorder
Anxiety disorders are the most prevalent psychiatric
disorders (1). They affect various aspects of life,
including social, financial, educational, relationship, and
quality of life. Anxiety disorders are the result of
genetic, environmental, familial, mental, and cultural

factors (2, 3). Anxiety disorders are affected by cultural
features (4, 5); and symptoms and variation in
prevalence of anxiety disorders could be transformed
across ethnicities and cultures (6, 7).
Cultural values and beliefs may put individuals at risk
and they may also act as a buffer against anxiety
problems (8). Culture plays an important role in
awareness toward problem severity and its consequences
and health care searching behaviors (9).
In line with cultural influences on anxiety disorders, a
review showed that unexpectedness and 10-minute

crescendo criteria in panic disorder, definition of social
anxiety and social reference group in social anxiety
disorder, and the preference given to psychological
symptoms of worry in generalized anxiety disorder are
phenomenological expressions in different cultures (10).
Individualism vs. collectivism nature of countries may
be related to social anxiety differently (11). Furthermore,
khyâl cap (wind attacks), taijin kyofusho, and ataques de
nervios are three main examples of culture-specific
expressions of anxiety disorders, which have been
included in DSM-V as distress concepts (12).
Iran J Psychiatry 2019; 14: 1: 33-39

Original Article
1. Department of Psychiatry, School of Medicine, Tehran
University of Medical Sciences, Tehran, Iran.
2. Department of Clinical Psychology, University of Social
Welfare and Rehabilitation Sciences, Tehran, Iran.
3. Atherosclerosis Research Center, Baqiyatallah University of
Medical Sciences, Tehran, Iran.
4. Department of Psychiatry, School of Medicine, Tehran
University of Medical Sciences, Tehran, Iran.
5. Department of Psychology, School of Education and
Psychology, Tabriz University, Tabriz, Iran.
*Corresponding Author:
Address: Department of Clinical Psychology, University of
Social Welfare and Rehabilitation Sciences, kodakyar Avenue,
Daneshjo
Boulevard, Evin, Tehran, Iran. Postal Code: 1985713834
Tel: 98-2122180045, Fax: 98-2122180045, Email:
[email protected]
Article Information:
Received Date: 2018/04/11, Revised Date: 2018/08/18,
Accepted Date: 2018/09/16

Mohammadi, Abasi, Soleimani, et al.
Iranian J Psychiatry 14: 1, January 2019 ijps.tums.ac.ir 34
A study on anxiety and its cultural complexities in Iran
showed that individuals with Azeri ethnicity (one of
several Iranian ethnicities) suffering from emotional
disorders reported 11 main themes as avoidance,
dysfunction, arousal, disorganized personality,
repetition, somatization, problematic behavior,
maladaptive cognition, awareness, and positive and
negative emotionality, among which somatization had
the highest frequency (13). There is strong evidence that
individuals from non-Western cultures significantly
report more somatic rather than psychological symptoms
(14, 15).
In this study, we used the term culture and ethnicity
interchangeably to refer to common heritage, shared
beliefs, and norms of a unit or a group of people. Iran is

a country with different cultural and ethnical
background, and this may be responsible for various
psychological manifestations. Moreover, there is no
adequate information about cultural aspects of anxiety in
Iranian population and because of the prominence of
cultural effects on anxiety symptoms (8, 9 and 12) and
culture-gene interactions (16, 17), studying the cultural
nature of anxiety disorders in Iranian population is of
utmost importance. Furthermore, the anxiety
phenomenon is extremely complex and passing of time
makes it even more complex in some ways, so the best
way to clarify a content-based phenomenon is to conduct
a qualitative research.
The qualitative method can illuminate some phenomena
which could not be reached out through qualitative
methods. Moreover, it can also help understand different
perspectives and contribute to mental health policy (18) .
The main objective of this research was to study the

cultural aspects of anxiety, mainly social anxiety, in four
ethnic groups (LOR, FARS, TURK, and KURD) in Iran,
who were diagnosed with social anxiety disorder. Thus,
generalization is possible. Specific aims in this research
were as follow: describing anxiety experience among
people suffering from anxiety disorders; evaluating
awareness and experience of anxiety among general
people; determining the causes of perceived anxiety
among participants in the study; describing the
participants’ opinions towards prognoses and
consequences of anxiety, describing the participants’
opinions towards prevention and treatment of anxiety
disorders.
Materials and Methods
The study design is a qualitative content analysis
research. Study conducted in the cities of Tehran, Urmia,
and Sanandaj- Iran. A total of 16 individuals with social
anxiety disorders (six men and 10 women) were selected

via purposeful sampling method (M = 24.43, SD = 4.56).
With respect to education level, nine participants had
high school diploma, one had a bachelor’s degree, and
six had a master’s degree. With respect to ethnicity, one
participant was identified as Lor, two as Fars, six as
Turk, and seven as Kurd. Patients were selected
according to some inclusion and exclusion criteria and
were recruited from counseling centers in
aforementioned cities. Main inclusion criteria were
age>18 and primary diagnosis of social anxiety disorder.
Main exclusion criteria were as follow: comorbid with
any debilitating mental illness like schizophrenia,
bipolar disorder, substance abuse, and mental
retardation; comorbid with debilitating physical illness.
The study was done during 2016-2017. All individuals
were interviewed by a psychiatrist and were diagnosed
as social anxiety disorder. Then, they were informed
about the purpose of study, and informed consent was

obtained from all of them. All voluntary participants
were asked open ended questions by a clinical
psychologist (MS.c.) through an in-depth and semi-
structured interview. Answers were audio recorded and
lasted 30 to 60 minutes. Questions were categorized into
three main groups: (1) personal experiences and
perception about anxiety; (2) factors causing anxiety;
and (3) coping strategies when feeling anxious. Ethical
approval was obtained from the National Institute for
Medical Research Development. Informed consent was
obtained before interviewing. Participants were assured
about the confidentiality of their information and were
debriefed about the purpose of the study .
Analysis
Results of the interview with each participant were
recorded, coded, and categorized. Overall, the
interviewed data were processed through thematic
analysis. An inductive method was used for data analysis

(19).
Results
Participants’ description of their experiences and beliefs
about coping consequences of anxiety, SAD reasons,
and coping strategies when facing anxiety were
categorized in the following categories (Table 1).
1 .Symptoms of Anxiety
1.1 Emotional
Anxiety was experienced mainly in public (feeling
anxious when speaking, asking questions, and
commenting) and in classroom (anxiety when
presenting, providing training courses, asking questions,
speaking, and commenting).
Example
Participant 1: I am afraid of speaking in public because I
feel I am not good at it .
1.2 .Cognitive

Cognitive aspect of anxiety was categorized into two
main categories as pre event rumination (thinking of
making a mistake and thinking of being humiliated,
thinking of being mocked, and thinking of not being able
to handle the situation) and post event rumination
(thinking of making mistakes, thinking of being
humiliated, and thinking of being mocked).
Example
Cultural Aspects of Social Anxiety Disorder
Participant 2. I am afraid of making mistakes and
classmates laugh at me because of it.
1.3 Behavioral
Behavioral aspect was categorized into 3 main sections
as avoidance (avoiding stressful situations), surrender
(inability of movement and inability to speak), and
safety behaviors (talking fast).

Example
Participant 5: When I am in stressful situations I can’t
speak or move, it is like I am in a cage .
1.4 Physical
Physical aspect consisted of several symptoms including
increasing heartbeat, feeling cold, feeling pressure on the
head, sweating, hoarseness, inability to swallow saliva,
suffocation, body weakness, lowering the pressure of the
body, blushing, feeling hot in the body, difficulty
sleeping, feeling of losing balance, flushing, and
lowering the tone of voice .
Example
Participant 9: when I am anxious, I feel flushed, I feel I
am losing balance, and I feel hot in my body.
2 .Core Beliefs
Profound beliefs related to social anxiety experienced by
participants were categorized in following categories:

2.1 Fear of negative evaluation: Being neglected by
others, rejected, mocked by others, loss of pride, loss of
popularity, and feeling ashamed.
Example
Participant 10: When I want to give presentation in class,
I feel like everybody is looking at me, they are making
fun of me, and they think I am not good at it .
2.2 Unworthiness: Not being worthy, not being satisfied
with oneself .
Example
Participant 12: I think something makes me most
vulnerable in these situations and that is I don’t feel
worthy enough.
2.3 Incompetency: loss, failure.
Example
Participant 7: When I think of my SAD symptoms, I
think about my previous failures.
3 .Reasons of Being Anxious

3.1 Familial factors: Family tension, parental
punishment, parental harshness, incorrect parenting
systems, and emotional deprivation.
Example
Participant 13: I was raised in a family full of tension
and stress that were beyond my ability to manage .
3.2 Fear: Fear of negative evaluation, fear of being
rejected, and losing loved ones .
Example
Participant 13: I think fear of other`s views about us and
fear of being rejected by them can make us anxious.
3.3 Core beliefs: Unworthiness and incompetency.
Example
Participant 16: In an anxious situation, I really feel like I
can’t help myself and this may be the reason of my
anxiety.
3.3 Society: Poverty and school (poor education and
inappropriate laws).

Example
Participant 15: I have been faced with poverty and other
stresses several times and since then I have been so
tensed and anxious.
4 .Effects of SAD on Life Aspects
4.1 .Social dysfunction (inability to speak in front of
others, inability to connect with others, inability to make
friends, inability to go out alone, losing job
opportunities, avoiding social relationships, and failure
to establish a relationship with the opposite sex).
4.2 .Emotional dysfunction (worry, lowering fear
threshold, and feeling disappointed)
Example
Participant 14: Social anxiety has ruined my life. I am
always worried about social situations .
4.3 .Behavioral Dysfunction (poor quality of life,
avoiding stressful situations)

Example
Participant 11: I don’t take part in social situations
where I am not acquainted.
5 .Coping Mechanisms
Participant’s explanation about strategies for handling
their anxiety was categorized in following sections:
5.1 .Treatment (psychotherapy and pharmacotherapy)
Example
Participant 12: A psychologist or a psychiatrist may be
helpful .
5.2 .Emotion-based mechanisms (watching movies,
overeating, sleeping, avoiding stressful situations,
praying, talking to others, drinking, smoking, listening to
music, and relaxing)
Example
Participant 11: When I am worried or anxious, I eat and
sometimes I listen to music.
5.3 .Problem-based strategies (studying psychological

books, practicing for presentation or speaking, studying
more about the presentation subject).
Example
Participant 8: I analyze the situation and find some
logical solutions for it, but it doesn’t always work .
5.4 .Behavioral and Cognitive Strategies (positive self-
statements, distractions, and avoiding eye contact).
Example
Participant 5: In classroom, when I am talking about
something, I cannot look in the eyes of others .
Furthermore, when participants were asked about the
onset of their social anxiety symptoms, some of them
stated that they had these feelings since childhood and
most of them pointed to some events, such as a new
job/changing job, teachers, and inappropriate behavior.

Table 1. Participants’ Categories of Experienced Social Anxiety
Symptoms Presented as Main
Categories, Subcategories, and Meaningful Codes
Categories Subcategories Codes
Anxiety experiences Emotional (public and classroom)
Feeling anxious when speaking
Asking questions
Commenting
Providing training courses
Cognitive (pre event rumination, and post
event rumination)
Thinking of making mistakes
Thinking of being humiliated
Thinking of being mocked

Thinking of not being able to handle the situation
Behavioral (avoidance, surrender, and safety
behaviors)
Avoiding stressful situations
Inability to move and inability to speak
Talking fast
Physical
Increasing heartbeat
Feeling cold in the body
Feeling pressure on the head
Sweating
Hoarseness
Inability to swallow saliva
Suffocation
Body weakness
Lowering the pressure of the body
Blushing
Feeling hot in the body

Difficulty sleeping
Feeling losing balance
Flushing
Lowering the tone of voice
Core beliefs Fear of negative evaluation
Being neglected by others
Being rejected
Bg mocked by others
Loss of pride
Loss of popularity
Feeling ashamed in front of others
The negative thoughts of others about oneself
Unworthiness
Not being worthy
Not being satisfied with oneself
Incompetency Loss, failure
Reasons of being
anxious
Familial factors

Family tension
Parental punishment
Parental harshness
Incorrect parenting systems
Emotional deprivation
Fear
Fear of negative evaluation
Fear of being rejected
Fear of losing important others
Core Beliefs Unworthiness and incompetency
Society Poverty and school
Effects of SAD on
life aspects
Social dysfunction

Inability to speak in front of others, inability to
connect with others, inability to make friends,
inability to go out alone, losing job opportunities,
avoiding social relationships, little to say, and
failure to establish a relationship with the opposite
sex
Emotional dysfunction
Worry
Lowering fear threshold
Feeling disappointed
Behavioral dysfunction Poor quality of life, avoiding stressful
situations
Coping mechanisms Treatment
Psychotherapy
Pharmacotherapy
Emotion-based mechanisms
Watching movies
Overeating, sleeping

Avoiding stressful situations
Praying
Talking with others
Drinking
Smoking
Listening to music
Relaxation
Problem-based mechanisms
Studying psychological books to practice for
presentation or speaking
Studying more about the presentation subject
Behavioral and Cognitive strategies
Positive self-statements
Distractions
Avoiding eye contact
Discussion
The present research was a qualitative study on anxiety
experiences and responses to anxiety among individuals

suffering from social anxiety disorder. This was the first
study in Iran to investigate some questions surrounding
the underlying experiences of anxiety and coping
strategies toward anxiety. Analysis of participants’
records yielded five distinct themes: (1) anxiety
experiences; (2) core beliefs; (3) reasons of being
anxious; (4) effects of SAD on life aspects; and (5)
coping strategies .
Anxiety symptoms reported by participants in this study
are similar to the last DSM criteria on SAD symptoms
showing that these symptoms are being experienced
globally (20). Moreover, these findings are comparable
with previous studies showing that there are no
significant differences between Americans and Japanese
on SAD symptoms; however, Taijin Kyofusho, which is
a form of social anxiety in Japanese culture, was more
reported by Japanese individuals (21), indicating that
some form of SAD may be more culturally dependent

and treatment should be tailored for them.
Physical symptoms, not a main symptom of SAD, were
reported significantly and by most participants of the
present study. This finding is consistent with that of
previous studies demonstrating this notion that people in
non-Western or Eastern countries (9), including Iran
(22), tend to somatize their distress and anxiety because
of different ethnomedical beliefs about physical
symptoms (23) or because they have learned to somatize
their distress to get more attention .
Results of core beliefs showed 3 main subthemes as fear
of negative evaluation, unworthiness, and inadequacy.
Fear of negative evaluation is the defining feature and
core of social anxiety (20). Unworthiness and
inadequacy are two underlying cognitions in classical
cognitive theory that predispose individuals to interpret
stimuli in a distorted way and as a result experience

social anxiety symptoms (24).
In case of causes of SAD, participants attribute SAD to
psychological (fear and core beliefs) and non-
psychological (society and family) processes; and the
impact of non-psychological process was highlighted.
This is in line with a previous study (25) and indicate
that Iran as a developing country with a different culture
and various ethnicities is exposed to many social,
economic, and political deprivations, which affect
Iranians’ life in unpleasant ways .
Analysis of data revealed that social anxiety symptoms
affect individuals’ life in various ways (social,
emotional, and behavioral), and this supports previous
studies indicating low quality of life in the participants
(26).

With respect to coping strategies, four main themes
(treatment, emotion-based mechanisms, problem-based
mechanisms, and behavioral and cognitive strategies)
were reported. Among them, praying and a special bond
with God were significantly reported. This finding
showed that Iran is a religious country and spirituali ty
could make a bigger difference in people’s lives and it is
used willingly by individuals with SAD as one of main
coping strategies. Inconsistent with this result, previous
studies have indicated the contributory role of religion
and spirituality in SAD (27).
Limitation
This study was the first in its field of inquiry. However,
there were some limitations that should be considered
carefully. First, this was a qualitative study and thus
findings should be generalized to other SAD individuals
with caution. Second, although in the present study
participants were from different ethnicities, the

difference between ethnicities in experiencing anxiety
and its related factors was not investigated. Thus, future
studies should be conducted to take a deeper look into
this topic. Third, there are some transdiagnostic and
common factors between disorders, especially emotional
disorders, which play an important role in etiology and
treatment of emotional disorders. Finally, the present
study assessed only four ethnicities and did not include
others.
Conclusion
The present study highlighted the importance of
experiencing social anxiety, interpretation of causes of
social anxiety, underlying beliefs of SAD and its effects,
and coping strategies in the diverse ethnic population of
Iran. Moreover, this study was the first of its kind,
especially in Iran, as a Middle-Eastern country. Findings
of the present study indicated that SAD symptoms and
the related psychological processes are a global problem

and this could be due to social media and other mass
media making people around the world more and more
alike.
Acknowledgment
We thank all participants of the present study.
Conflict of Interest
The authors have confirmed that there are not any
conflicts of interest.
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ISSN: 1555–7855
16
INTERNATIONAL JOURNAL OF BEHAVIORAL
CONSULTATION AND THERAPY
2013, VOL. 7, NO. 4
Social Anxiety Disorder and Social Skills: A Critical Review of
the Literature
Antonio Paulo Angélico1, José Alexandre S. Crippa2 and Sonia
Regina Loureiro2
1São João del-Rei Federal University and 2São Paulo University
Abstract
The objective of this article is to present a critical analysis of
the research outlines used in empirical studies published
between the years 2000 and March of 2007 about social anxiety
disorder and its associations with social skills. Seventeen
papers were identified and grouped into two classes for
analysis, namely: Characterization of Social Skills Repertoire
(N
= 10) and Therapeutical Modalities – Application and
Comparison of Clinical Intervention (N = 7). The critical
analysis of
the research outlines pointed to the necessity of new studies
with clinical and non-clinical samples, with random allocation
of individuals, with the proposition of contextualized

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