Fsxetiologia

The etiology of social phobia:
Empirical evidence and an initial model

Ronald M. Rapee
a,
*
, Susan H. Spence
b
a
Department of Psychology, Macquarie University, Sydney, NSW, Australia 2109
b
University of Queensland, Australia
Received 4 September 2003; received in revised form 14 March 2004; accepted 3 June 2004
Abstract
Research into the etiology of social phobia has lagged far behind that of descriptive and maintaining
factors. The current paper reviews data from a variety of sources that have some bearing on questions of the
origins of social fears. Areas examined include genetic factors, temperament, childrearing, negative life events,
and adverse social experiences. Epidemiological data are examined in detail and factors associated with social
phobia such as cognitive distortions and social skills are also covered. The paper concludes with an initial
model that draws together some of the current findings and aims to provide a platform for future research
directions.
D 2004 Elsevier Ltd. All rights reserved.
Keywords: Social phobia; Empirical evidence; Social anxiety
1. Introduction
Social phobia is a debilitating disorder that affects a relatively large percentage of the population.
While tremendous strides have been made in our understanding of potential maintaining factors in this
disorder and consequently in its management, we are still a long way from knowing why one person
develops the disorder and another does not. In turn, this information can be used to develop prevention
efforts and ultimately reduce the incidence of the disorder (see Spence, 2001). Given that social phobia
0272-7358/$ - see front matter D 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2004.06.004
* Corresponding author. Tel.: +61 2 9850 8032; fax: +61 2 9850 8062.
E-mail address: Ron.Rapee@mq.edu.au (R.M. Rapee).
Clinical Psychology Review 24 (2004) 737767
also precedes several other debilitating disorders such as depression and substance abuse for many
individuals, understanding of the etiology of social phobia may help to improve understanding of these
other disorders as well.
To date, there have been no single, landmark studies that comprehensively pull together a large part
of the puzzle of the onset of social phobia. However, a wealth of empirical evidence provides insight
and hints to a myriad of separate aspects that may be influential in the onset of social fears. These
include epidemiological studies that point to unique features of social phobia that may be involved in
its onset, as well as more descriptive and experimental studies in clinical and high-risk populations
that focus on putative causal constructs. In this article, we attempt to draw together a wide variety of
information relevant to social phobia that we believe may have bearing on questions of etiology. In
some ways, these data raise more questions than they answer, but this is beneficial since it is
important to provide guidance and direction to future investigations of causal mechanisms in social
phobia. While it is impossible at this stage to provide a complete picture of the causes of social fears,
in the final section we attempt to draw together some of this information and provide an initial model
that will hopefully allow some concerted efforts for future research to better understand the onset of
social phobia and ultimately produce far more comprehensive models.
2. Descriptive features of social phobia relevant to issues of onset
2.1. Diagnostic threshold
An issue of major consideration for any theory of the etiology of social phobia is whether the disorder
should be considered a qualitatively distinct category, or as simply a relatively arbitrary cut along a
broader dimension or continuum. Evidence on this point can be examined from studies of the
distribution of social fears in various samples. Such data generally indicate that fear and avoidance of
social situations typically occur broadly and normally across the population (Essau, Conradt, &
Peterman, 1999; Mattick & Clarke, 1998; Stein, Torgrud, & Walker, 2000; Turner, Beidel, Dancu, &
Stanley, 1989).
A related direction of research involves examination of the effects of variations in diagnostic
threshold on the prevalence of social phobia in community samples. Several studies have identified one
or more bsubthresholdQ or bsymptom onlyQ groups of individuals with social fears (Merikangas,
Avenevoli, Acharyya, Zhang, & Angst, 2002; Pelissolo et al., 2000; Stein, Walker, & Forde, 1994). In
most cases, differences between these bgroupsQ can be best explained by simple quantitative
relationships.
Some research has also examined similarities and differences between the diagnostic category of
social phobia and the highly related personality construct of shyness. Some early research comparing
individuals who scored high on measures of shyness with those who met diagnostic criteria for social
phobia, failed to indicate significant differences on measures of thought content, physiological
responsiveness, or behavioral patterns (Turner, Beidel, & Larkin, 1986; Turner, Beidel, & Townsley,
1990). In contrast, a more recent study has indicated some minor differences (Heiser, Turner, & Beidel,
2003), but methodological problems (such as measurement error) might easily explain these data.
Based on the above considerations, we would argue that social phobia should most parsimoniously be
viewed as lying on a continuum of social anxiety (Rapee, 1995). This continuum would begin at the
R.M. Rapee, S.H. Spence / Clinical Psychology Review 24 (2004) 737767 738
lowest end with total lack of social anxiety and move through normal levels of social anxiety in which a
desire to be positively evaluated does not inhibit performance or lead to excessive anxiety. Higher along
the continuum lies social anxiety that is commonly described as low-level shyness and then milder social
fears and avoidance. Finally, at the upper end lies a broader and more intense degree of social fear
(commonly diagnosed as generalized social phobia) and ultimately extreme social withdrawal
(diagnosed most often as avoidant personality disorder). However, we would argue that a diagnosis
of social phobia will be associated with, but not synonymous with, high levels of social anxiety on this
continuum (e.g., Chavira, Stein, & Malcarne, 2002; Heiser et al., 2003). Meeting criteria for a diagnosis
requires an additional consideration of the extent to which these concerns interfere with and cause
distress in an individuals life (American Psychiatric Association, 1994). We believe that this
consideration will be related to the severity of social anxiety, but is ultimately a distinct factor. Thus,
one may have relatively high levels of fear and concern about social situations, but may live ones life
within normal limits of social functioning and may not view this as a major life restriction. In this
instance, such an individual would not report these fears as being distressing or interfering and may even
down play the extent of the fears, thereby not meeting criteria for a disorder. On the other hand, an
individual with a lower level and more circumscribed social fear who nonetheless views this fear as a
major impediment to their quality of life may meet criteria for a diagnosis of social phobia. Thus, there
are likely to be several risk factors for the bdiagnosisQ of social phobia that are independent of risk for
higher levels of social anxiety. In the remainder of this paper, we will use the term bsocial phobiaQ to
refer to the diagnostic category and the terms bsocial anxietyQ to refer to levels along a normally
distributed continuum. The majority of the discussion will focus on risk and protective factors for social
anxiety by which we mean factors that may determine an individuals position and movement along this
continuum. However, we will also briefly discuss some potential risk factors for perceptions of life
distress and interference and we would propose that it is the combination of these risks that ultimately
predicts whether an individual will meet criteria for a diagnosis of social phobia.
One additional issue of strong relevance to any question of etiology is whether social phobia is a
unitary construct or consists of two or more qualitatively distinct subtypes. Empirical evidence on the
issue has been mixed and fraught with methodological limitations and confounded definitions. As a
result, we do not believe that any clear evidence currently exists that strongly supports the existence of
qualitatively distinct subtypes of social phobia (e.g., Furmark, Tillfors, Stattin, Ekselius, & Fredrikson,
2000; Stein et al., 2000). However, this is not to say that later research may not provide some evidence
supporting qualitative differences. Space limitations preclude a more detailed discussion of this issue
here and the interested reader is referred to earlier reviews and a later paper in this issue (Heimberg.,
Holt, Schneier, Spitzer, & Leibowitz, 1993; Hook & Valentiner, 2002; Rapee, 1995).
2.2. Demographic features of social phobia
2.2.1. Prevalence
Social phobia is a relatively common disorder that affects between 7% and 13% of individuals in
Western societies across their lifetime (Furmark, 2002). Variations in prevalence across populations
would have important implications for etiology by pointing to possible socio-environmental variables of
importance. However, variations in prevalence estimates belie the fact that estimating the prevalence of
social phobia is a complex issue that is characterized by several complex methodological considerations.
Furmark (2002) has provided an excellent recent review of the main issues and has highlighted several of
these concerns. First, diagnostic criteria will obviously influence prevalence estimates dramatically.
Across a wide number of studies, estimates based on DSM-III criteria (which focused primarily on very
specific fears of performance situations) are considerably lower than more recent estimates based on
DSM-III-R and DSM-IV (which include more of a focus on general interaction concerns). Estimates
based on ICD-10 also vary to some extent, but the pattern here is not as clear. Similarly, a major issue in
estimates of prevalence is the threshold or definition of bdiagnosis.Q Research has indicated that even
relatively minor variations in impairment criteria can dramatically influence estimated prevalence
(Merikangas et al., 2002; Pelissolo, Andre, Moulard-Martin, Wittchen, & Lepine, 2000). These data
perhaps indicate the value of considering social anxiety along a continuum as argued earlier rather than
in categorical terms.
One especially intriguing issue is whether the diagnosis of social phobia is increasing. A recent
reanalysis of data from the USAs National Comorbidity Survey set out to examine cohort effects
(Heimberg, Stein, Hiripi, & Kessler, 2000). Retrospective recall of age of onset of the first episode of
social phobia was used to compare the cumulative lifetime prevalence across four age-based groups. The
data indicated a significantly greater cumulative risk for recalled social phobia in the youngest age group
(ages 1524) relative to the oldest group (4554), suggesting an increase in incidence across time.
Further, the cohort effect was especially pronounced among whites, married people, and those with
higher education suggesting factors with possible etiological significance. Naturally, this single study is
limited by the complete reliance on retrospective reports. Therefore replication, especially using
longitudinal designs, is essential.
2.2.2. Gender
Epidemiological studies have consistently shown a greater proportion of females meeting criteria for
social phobia (Furmark, 2002). Similar gender differences are apparent at the level of individual
symptoms (Essau et al., 1999; Wittchen, Stein, & Kessler, 1999) and on questionnaire measures of social
anxiety and shyness, even in younger age groups (Campbell & Rapee, 1994; Spence, 1998). These
figures are in marked contrast to estimates from clinical populations in which males are often reported
more frequently than females or at least in equal proportions (Rapee, 1995). This discrepancy between
populations has been interpreted to reflect the likely greater impact of social anxiety on the lives of males
in many societies (Rapee, 1995).
2.2.3. Age of onset
Data from clinical populations as to the onset of the first episode of social phobia have consistently
indicated that social phobia is a disorder with early onset, generally in the early to mid teens (Rapee,
1995). Several studies have shown that the majority of individuals with social phobia report onset before
18 years, with a mean age of onset of 10 to 13 years (Nelson et al., 2000; Otto et al., 2001). Onset
appears to be especially early for the more severe (generalized) subtype (Degonda & Angst, 1993;
Wittchen et al., 1999). Data have also shown that the incidence of social phobia (i.e., new cases)
beginning in adulthood is very low (45 per 1000 per year) and that these new cases are mostly
secondary to another disorder (especially panic disorder or major depression) (Neufeld, Swartz,
Bienvenu, Eaton, & Cai, 1999). Thus, onset of completely new cases of social phobia beyond late
adolescence is extremely rare.
Interestingly, high levels of social anxiety (shyness) can be apparent even in early childhood. In
his theories about the onset of social fears, Buss (1985) proposed the existence of two types of
shyness. Fearful shyness is said to reflect fears of unfamiliar people and social intrusiveness while
self-conscious shyness is said to reflect feelings of self-consciousness and social awkwardness.
Asendorpf (1989) proposed a similar distinction between fear precipitated by strangers and fear
precipitated by social evaluation. Stranger fear or fearful shyness appears in the first year of life
and may be heavily integrated with physical threat anxiety, whereas self-consciousness or social-
evaluative anxiety do not appear until around 46 years of age (Asendorpf, 1989; Buss, 1985).
Etiologically, we could suggest that transition from a high level of social anxiety to a formal
diagnosis of social phobia will depend on the age at which symptoms result in impairment in the
individuals life. Early to mid adolescence is likely to be a critical time for many individuals due
to the increasing importance of social interactions at this developmental stage. Contrary to folklore,
several studies have indicated little change or even slight decreases in social anxiety and self-
consciousness from late childhood to early adolescence (Bruch & Cheek, 1995; Campbell, Rapee,
& Spence, 2001; Rankin, Lane, Gibbons, & Gerard, 2004). Thus, the apparent onset of social
phobia in early adolescence may perhaps have more to do with the increases in life interference
caused by social anxiety at this developmental stage than with increases in actual levels of social
distress.
2.2.4. Comorbidity
Several studies utilizing clinical samples have indicated high levels of comorbidity between social
phobia and a number of other disorders including anxiety, mood, and substance use disorders (de
Ruiter, Rijken, Garssen, van Schaik, & Kraaimaat, 1989; Hunt & Andrews, 1995; Last, Strauss, &
Francis, 1987; Sanderson, Di Nardo, Rapee, & Barlow, 1990). Clearly, models of etiology need to
account for this overlap. Levels of comorbidity appear to be similar to that found with most other
neurotic disorders. Substantial comorbidity has also been shown in surveys of social phobia in the
general population (Essau, Conradt, & Petermann, 2000; Lewinsohn, Zinbarg, Seeley, Lewinsohn, &
Sack, 1997; Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996; Wittchen et al., 1999). For
example, in the National Comorbidity Survey, 81% of those with a diagnosis of social phobia also
met criteria for another disorder (Magee et al., 1996). There appears to be little evidence among the
data for specific patterns of comorbidity between social phobia and other anxiety or mood disorders.
Where social phobia coexists with another disorder, retrospective reports indicate that in most cases,
the social phobia is reported to have preceded the other disorder (Lewinsohn et al., 1997; Wittchen
et al., 1999). However, this may simply reflect the relatively early age of onset of social phobia and
may not indicate a causal developmental pattern.
Similar overlap is also seen at the level of the social anxiety continuum. Questionnaire measures of
shyness and social anxiety have been shown to correlate substantially with measures of other forms of
anxiety, depression, and general neuroticism (e.g., Jones, Briggs, & Smith, 1986).
2.3. Stability and specificity of social anxiety across the lifespan
Research into the stability and specificity of social anxiety across the lifespan is extremely hard to
do and, as a result, there is limited evidence available. In addition, these issues can be addressed from
several different perspectives and this is reflected in the wide variety of research methodologies used.
Most importantly, assessment of stability is limited by the reliability of the measures used and
developmental differences in the manifestation of the disorder. Given the relatively modest reliability
of measures reflecting shyness and social anxiety, especially in early childhood, these data must be
interpreted with caution.
Many studies have examined the stability of temperament across the early years of life including
measures of shyness (Prior, 1992). These data will be described in more detail in the section on
temperament, but in general they have shown moderate to strong stability of an individuals position on
the continuum of shyness, especially across the later childhood years.
A small number of prospective studies have examined the persistence of an established diagnosis
of social phobia later in life. At least two studies have shown that anxiety disorders in adolescence
predict a range of disorders in adulthood including anxiety disorders, mood disorders, and substance
abuse (Stein et al., 2001a,b; Woodward & Fergusson, 2001). Data with more direct relevance to
social phobia come from one carefully conducted study that followed more than 770 children and
adolescents (aged 918 years) over a period of 9 years (Pine, Cohen, Gurley, Brook, & Ma, 1998).
Social phobia in adulthood was preceded significantly more often by adolescent social phobia and
also overanxious disorder. In adulthood, data from the Harvard/Brown longitudinal study were used
to determine the remission rate over 8 years for 98 adults with an established diagnosis of social
phobia (Yonkers, Dyck, & Keller, 2001). Only 35% of the sample demonstrated full remission and
50% demonstrated partial remission of symptoms 8 years later, with the majority of remission
occurring in the first one to two years. Thus, there appears to be a group of individuals with social
phobia who remit relatively quickly and the remainder show minimal remission. In fact, social
phobia has been shown to have the lowest overall remission rate of the major anxiety disorders
(Massion et al., 2002). Remission is also likely to be lower in the presence of comorbid personality
disorders, especially avoidant personality disorder, and higher for those with nongeneralized social
phobia (Massion et al., 2002). One interpretation of these findings is that persistence is higher given
greater severity of the disorder. Finally, one interesting study examined stability of social anxiety
when viewed from more of a continuum perspective (Merikangas et al., 2002). Almost 600
individuals were assessed on five occasions from 20 to 35 years of age and were categorized into
one of four groups: social phobia, subthreshold social phobia, social anxiety symptoms, or minimal
symptoms. As in other studies, stability within categories was moderate to strong. However, the
authors also found considerable movement between symptomatic categories. For example,
approximately half the diagnostic and subthreshold groups moved to the symptom category while
approximately a quarter of the symptom category moved to the diagnostic and subthreshold
categories. There was also some evidence that greater stability was shown by more severe
expressions of social anxiety.
Overall, the data across the lifespan indicate what might be described as a bmoderateQ stability
and specificity. Individuals who are socially anxious are at clearly increased risk for the later
experience of social fearsdata consistent with some degree of specificity in risk for social anxiety.
However, it is also apparent that social anxiety is associated with increased risk for other emotional
difficulties, suggesting either that risk is shared with other disorders or that the experience of social
anxiety (and its consequences) represents a risk factor for the development of other disorders.
Individuals also appear to move up and down the continuum of social anxiety over time, such that
meeting criteria for a formal diagnosis of social phobia may come and go at different life stages.
However, there is also evidence that any movement tends to occur within limitsin other words,
small degrees of movement may be relatively common, but larger movements may be relatively
rare.
2.4. Cultural issues
Prevalence data have suggested that social phobia may occur at different rates across different ethnic
and cultural groups. In particular, the reported prevalence for social phobia is markedly lower in the few
studies that have been conducted in South-East Asian countries (Korea and Taiwan) than in the Western
world (see Furmark, 2002). As noted earlier, assessing prevalence is marked by several serious
methodological difficulties. However, assuming these data are correct, this difference may indicate the
existence of cultural/ethnic influences on the existence, expression, or reporting of social fears.
One possibility is that the expression of social anxiety differs according to culture. Several authors
have described a disorder labeled the boffensive typeQ of social anxiety (listed in the DSM-IV under its
Japanese name, taijin kyofusho), which is categorized in the DSM-IV as a culture-bound disorder. The
central feature is a fear that one will embarrass or cause offense to others through an unpleasant odor,
expression, or movement. There has been some research and considerable discussion as to whether this
disorder is distinct from or equivalent to social phobia, but there is little doubt that the two descriptions
are closely related (Kleinknecht, Dinnel, & Kleinknecht, 1997; Lee & Oh, 1999; Russell, 1989).
Consideration of taijin kyofusho has raised the possibility that the way in which basic social anxiety is
expressed may be related to fundamental features of the culture. Theoretically, it has been suggested that
the concerns of more collectivist societies may focus on distress to others while those of more
individualistic societies may focus on distress to the self. To date, there has been no clear empirical
examination of this suggestion. Empirical research has been restricted to examination of individuals
preferences for independence versus interdependence (Dinnel, Kleinknecht, & Tanaka-Matsumi, 2002;
Kleinknecht et al., 1997), which is not the same as collectivism/individualism at a societal level.
Comparisons between societies are difficult to conduct due to possible differences in interpretation of
questionnaire items, however, a few such studies have failed to show strong differences in endorsement
of symptoms of social anxiety and taijin kyofusho in Asian and Western samples (e.g., Kleinknecht et al.,
1997). Thus, it is not yet clear whether cultural factors may work to reshape the nature and levels of
fundamental social fears. Of some relevance, some longitudinal work has indicated that the effects of
social anxiety may be different and perhaps greater in males than in females in some countries (Caspi,
Elder, & Bem, 1988; Kerr, Lambert, & Bem, 1996). Further, some data have suggested that gender
differences in inhibited behavior that appear in late childhood may be caused by cultural pressures that
view inhibited behaviors in boys as less desirable than those in girls (Kerr, Lambert, Stattin, &
Klackenberg-Larsson, 1994).
An alternative suggestion is that social anxiety is in fact similar across cultures but that the threshold
at which it is defined as a disorder varies across cultures. Once again, this difference may have
something to do with the degree to which the culture values collectivism versus individualism. In a
highly individualistic society, where one gains social advantage by asserting ones rights and leading the
pack, even relatively low levels of social fear will be viewed as distressing and interfering. In a
collectivist society, where it is more socially advantageous to fit in with the community and express
modesty, some degree of social anxiety would be viewed as positive and disorder would only be defined
at relatively high levels of social fear. Consistent with this suggestion, some research has indicated that
parents in Thailand view externalizing behaviors in their children as more problematic than internalizing,
whereas parents in the United States do not show a strong differentiation (Weisz, Suwanlert, Chaiyasit,
& Walter, 1987; Weisz et al., 1988). Thus, internalizing symptoms such as social anxiety might be
viewed as more impairing in some societies than in others.
2.5. Evolutionary aspects
One final issue of relevance to the etiology of social phobia is the argument by several authors that
social anxiety needs to be viewed within an evolutionary framework. There is no space here to discuss
this issue in detail and the reader is referred to more extensive reviews (e.g., Gilbert & Trower, 2001;
Mineka & Zinbarg, 1995). Briefly, it has been suggested that the behaviors comprising social anxiety
reflect naturally occurring reactions that can be adaptive under certain circumstances (Gilbert & Trower,
2001). The value of these behaviors is that they can serve to deflect aggression and conflict. However,
this frequently comes at a cost of reduced status and decreased attractiveness.
Given the potential role of socially submissive behaviors in selection and adaptation, individual
variation would most likely be viewed as largely a result of natural variation in genotypic expression.
Hence, the etiology of social anxiety from an evolutionary perspective is likely to be primarily seen in
genetic variance. However, an evolutionary framework cam also allow for additional variance in the
expression of social submission via environmental factors. Indeed, given that socially submissive
behaviors can be adaptive under some circumstances, social cues have been viewed as evolutionarily
bpreparedQ to support associations with threat (O
hman, 1986).
3. Risk and protective factors for social phobia
3.1. Internal factors
3.1.1. Genetics
There is now a good deal of evidence to suggest that genetic factors play a modest but significant role
in the development of social phobia and social anxiety, in both children and adults. Early studies
identified elevated rates of social phobia among close family members of sufferers of social phobia
(Fyer, 1993; Fyer et al., 1995). Children with social phobia were more likely than their non-affected
peers to have parents with social phobia and similarly the children of parents with social phobia were at
elevated risk for the disorder (Lieb et al., 2000; Mancini et al., 1996). There are now several
methodologically sound twin studies with large sample sizes that suggest a significant but moderate
genetic influence in the development of social phobia and social anxiety (Kendler et al., 1992; Nelson et
al., 2000; Stein, Jang, & Livesley, 2002; Warren, Schmitz, & Emde, 1999). A recent meta-analysis of
twin studies concluded a heritability estimate of around 0.65 for social anxiety (Beatty, Heisel, Hall,
Levine, & La France, 2002), although many authors assume a somewhat more modest estimate of
around 0.40.5 (Albano & Detweiler, 2001; Ollendick & Hirshfeld Becker, 2002). For example, Kendler
et al. (1992) reported a significant genetic contribution to social phobia of 0.31 in 2163 female twin
pairs. This research group subsequently reexamined the genetic influence on social phobia, taking into
account the reliability of measurement across an 8-year interval. The heritability estimate increased to
around 0.50 (Kendler, Karkowski, & Prescott, 1999). These data support the substantial heritability
involved in social phobia and further indicate that the persistence of social phobia is strongly under
genetic influence.
Other studies have examined the genetic influence upon related constructs such as shyness, fear of
negative evaluation, and behavioral inhibition. In an adult sample, Stein et al. (2002) demonstrated a
heritability estimate of 0.48 and strong unique environment effects for fear of negative evaluation in
437 adult twin pairs. This study also noted a common genetic influence upon negative evaluation
fears and a cluster of personality traits relating to submissiveness, anxiousness, and social avoidance.
Warren et al. (1999) examined genetic influences upon childhood anxiety in 326, 7-year-old twin
pairs. They found significant heritability (0.34) and unique, nonshared environment influences for
social symptoms of anxiety, closely related to shyness. Similar findings have been reported for the
heritability of temperament traits involving behavioral inhibition (Robinson, Kagan, Reznick, &
Corley, 1992). In one of the few adoption studies, Daniels and Plomin (1985) also found evidence
for a link between infant shyness at 24 months and shyness and sociability in their biological
mothers.
It is important to consider the degree to which what is inherited is specific to social anxiety rather than
a general predisposition to develop any one of a range of emotional or behavioral problems. The
majority of twin studies have indicated that the greatest proportion of variance in the heritability
component is one that is common to anxiety disorders in general and to depression (Andrews, 1996;
Eley, 1999). Some studies have also suggested that this general heritability may extend to other disorders
such as substance abuse and bulimia nervosa (Kendler et al., 1995). For example, Nelson et al. (2000)
examined the interrelationship of genetic influences upon social phobia, depression, and alcohol abuse in
the cohort described above. A common additive genetic component was found to influence all three
disorders to varying degrees, with a disorder-specific contribution only being evident for alcohol abuse
and not social phobia or depression. The finding of common genetic influences in social phobia,
depression, and alcohol abuse may explain the high level of comorbidity between these disorders.
Furthermore, a common genetic influence may also account for findings showing that adolescents with
high social anxiety are at particular risk for future depression and those with comorbid social phobia and
depression tend to have worse prognosis in terms of a malignant course of depression (greater
persistence and recurrence) (Stein et al., 2001a,b).
In addition to the bulk of literature showing a genetic component to social phobia that is shared
across most emotional disorders, there have been some intriguing hints indicating some additional
genetic components that are unique to social anxiety. For example, Kendler, Myers, Prescott, and
Neale (2001) in a study of 1198 male twin pairs, found that the best-fitting model indicated that as
much as 13% of the variance in social fears was accounted for by genetic factors unique to this type
of fear. Genetic factors common across all fear types accounted for only 5% of the variance in social
fears. Sundet, Skre, Okkenhaug, and Tambs (2003) in a recent twin study also found that, in addition
to genetic and environmental influences common to four fear dimensions (situational fears, illness
injury fears, social fears, and fear of small animals), there were significant fear-specific genetic and
environmental factors.
It must be concluded that genetic factors general to a range of emotional disorders, together with
some small role from genes that are more specifically involved in social anxiety, play a moderate role
in the development of social phobia and social concerns. However, we do not yet understand how the
genotype operates to determine the behavioral phenotype. Researchers have recently started to
examine possible mechanisms of action, searching for candidate genes that regulate specific
neurochemical systems. To date, such studies have produced conflicting findings. For example,
Rowe et al. (1998) reported that a repeat polymorphism in the dopamine transporter gene was
associated with social anxiety in children, but this was also evident for generalized anxiety, OCD, and
Tourettes. Arbelle et al. (2003), in a study of second grade children, found a significant association
between the long form of the serotonin transporter promoter region polymorphism and shyness. In
contrast, Schmidt, Fox, Rubin, Hu, and Hamer (2002) did not find shyness in 4 year olds to be
associated with the dopamine D4 receptor gene, the serotonin transporter gene, or the serotonin
receptor gene. Negative findings were also noted by other researchers who reported no evidence of a
genetic link to serotonin transporter protein and serotonin 2A receptor genes in social phobia or failed
to find evidence of dopamine system genes link to social phobia (Kennedy et al., 2001; Stein,
Chartier, Kozak, King, & Kennedy, 1998). No doubt there will be a good deal more research of this
type over the next decade, with increasingly sophisticated methods of examining the molecular
genetics of social phobia. Researchers will also need to clarify the degree to which these molecular
genetic factors are specific to social phobia, rather than internalizing problems in general.
3.1.2. Temperament
There has been considerable interest in the possibility that certain early temperament styles
represent a precursor to the development of social phobia. This is not to suggest that early
temperament causes later psychopathology, but rather certain types of early temperament and later
social phobia may reflect common causal mechanisms that may be genetic and/or environmental in
origin. It is also possible that certain temperament styles represent early behavioral and emotional
manifestations of the same construct that, when present at a more severe level and associated with
impairment or disruption to daily living, are later labeled a disorder. Probably the most widely
researched construct of this type has been labeled behavioral inhibition (Kagan, Reznick, Clarke,
Snidman, & Garcia Coll, 1984). Kagan et al. (1984) coined the term behavioral inhibition (BI) to
describe a relatively consistent pattern of behavioral and emotional responses to unfamiliar or novel
people, places/situations, or objects. Inhibited children typically respond to novel situations with initial
restraint, caution, low rates of approach, and quiet withdrawal, and with unfamiliar people they are
usually shy, timid, and reticent (Belsky & Park, 2000). Neal, Edelmann, and Glachan (2002) noted
similarities in the behavioral manifestations of BI and social anxiety, including avoidant strategies,
passive withdrawal, reticence to approach strangers, and a slower latency to verbalize. Several other
labels have been used to describe what appears to be essentially the same temperamental construct
including shyness, approach, withdrawal, or inhibition.
The stability of this factor across the early years has generally been shown to be relatively weak
in the first year of life (correlations around 0.2 or less), and moderate or better over the following
few years (correlations around 0.40.5) (Pedlow, Sanson, Prior, & Oberklaid, 1993). In general, the
closer the time points to each other, the higher the correlations. Using a structural equation
approach, Pedlow et al. (1993) examined the stability of maternal reports of approach in over 2000
children across the first 8 years of life. Stability was modest from 6 to 20 months but improved to
show relatively strong stability (stability 0.710.82) between ages 20 months and 8 years. There was
a slight tendency for stability to improve with increasing age. Estimates were only calculated for
adjacent time points (approximately 14-month periods). In a later analysis by this research group,
correlations decreased as the interval between measurement points increased (Sanson, Pedlow, Cann,
Prior, & Oberklaid, 1996). From a different perspective, the researchers examined the movement of
children across quartiles on the measure of shyness. Just under half the children remained within the
same quartile for up to 4 years and a further 40% moved only one quartile. Thus, stability for
temperamental shyness has been shown to be moderate to strong between approximately 2 to 6
years of age with almost half of children remaining in the same quartile on shyness scores. One
important finding is that the variance in shyness that is common across situations and across time
points (i.e., stability) appears to be mediated largely genetically, whereas the extent to which the
expression of shyness differs across time and place is mostly mediated by environmental factors
(both shared and nonshared) (Cherny, Fulker, Corley, Plomin, & DeFries, 1994).
There is a good deal of evidence to suggest that children who manifest a behaviorally inhibited
temperament style are at increased risk for later development of social phobia (Kagan et al., 1984; Neal,
Edelmann, & Glachan, 2002). Children who are highly behaviorally inhibited are more likely than their
uninhibited peers to show a particular pattern of physiological features, including greater activation of
the hypothalamicpituitary axis, the reticular activating system, and the sympathetic arm of the
autonomic nervous system in response to novelty (Kagan, 1987). However, these physiological
parameters are only evident for around one-third of children identified as showing elevated behavioral
inhibition and the exact brain mechanisms are yet to be identified (Kagan, Snidman, & Arcus, 1998;
Kagan, Snidman, Arcus, & Reznick, 1994).
Several prospective studies have identified higher rates of social phobia or social anxiety among
children and adolescents who were identified as being highly behaviorally inhibited earlier in childhood
(Biederman et al., 2001; Biederman et al., 1993; Biederman et al., 1990; Hayward, Killen, Kraemer, &
Taylor, 1998; Mick & Telch, 1998; Neal et al., 2002). It is clear, however, that a significant proportion of
BI children do not develop social phobia and indeed BI itself is relatively unstable over time. Schwartz,
Snidman, and Kagan (1999) conducted a 12-year follow-up of 79 adolescents who had been categorized
as high or low BI at age 2 years. In adolescence, 61% of children who were categorized as high BI at 2
years showed adolescent social anxiety compared with 27% of the low BI group. Interestingly, the effect
was specific to social anxiety and there was no association between early childhood BI and specific
fears, separation or performance anxiety in adolescence. Biederman et al. (2001) examined
psychopathology at age 5 years or more in children of parents with panic disorder alone, major
depression alone, and comparison controls. Social anxiety disorder (social phobia or avoidant disorder)
was significantly more likely to be found in children who at 26 years were identified as behaviorally
inhibited (17%) than in those who were not (5%). In contrast to these indications of specificity, Caspi,
Moffitt, Newman, and Silva (1996) found that children categorized as inhibited at 3 years of age were at
increased risk for a wide range of problems in adulthood, including depression, violence, alcohol abuse,
and suicide. Prior et al. (2000) also showed that children scoring high on a maternal measure of shyness
on several previous occasions had a fourfold risk of reporting high levels of bgeneral anxiety problemsQ
in adolescence. These data are consistent with the genetic literature (reviewed above) showing a
common genetic component across several emotional disorders.
A recent study, using retrospective report, examined the relationship between BI and social phobia
in more detail in order to contribute to our understanding of why some high BI children do not
proceed to develop social phobia (Neal et al., 2002). The authors pointed out that BI as defined and
assessed by the Kagan paradigm may not be a unitary construct and includes both physical and social
threat situations. This suggestion may be similar to the distinction between fearful and self-conscious
shyness described earlier (Asendorpf, 1989; Buss, 1985). Indeed, there is evidence to suggest that the
mix of social and physical wariness comprising BI should be regarded as two separate dimensions
(Kochanska, 1991; Kochanska & Radke-Yarrow, 1992). This is an important point as there is also
evidence that the stability of BI is greater for the specific social wariness of BI (Asendorpf, 1991;
Gest, 1997). Neal et al. (2002) suggested that it may be continuity of the social, rather than physical,
dimension of BI that for some individuals evolves into an extreme fear of social interaction and
performance situations. There is evidence to support this proposition, in that social phobia in
adulthood appears to be associated with the social, and not physical, fear components of childhood BI
(Mick & Telch, 1998; Neal et al., 2002; Van Ameringen, Mancini, & Oakman, 1998). In contrast, the
physical fear component appears to be less specific, being associated with anxiety disorders in general,
including panic disorder and OCD (Van Ameringen et al., 1998), although Neal et al. did not find this
component of BI to predict social phobia, agoraphobia, anxiety/panic, or depression. Of particular
interest are the findings of both Neal et al. and Van Ameringen et al. (1998) of a link between
childhood social BI and depression. This effect would make sense in light of the genetic data
discussed above in which common genetic factors were identified for both social phobia and later
depression in adolescents. Further, these results are consistent with literature showing that whereas all
of the anxiety disorders and depression share negative affectivity (or neuroticism) in common, only
social phobia and depression share a further common factor involving low extraversion/sociability
(Brown, Chorpita, & Barlow, 1998; Watson, Clark, & Carey, 1988).
3.1.3. Cognitive factors
Social phobia is characterized by biases and distortions in social-information processing and thoughts,
attitudes and beliefs that are proposed to trigger and maintain social phobic affect and behaviors (Clark
& Wells, 1995; Fenigstein, Scheier, & Buss, 1975; Rapee & Heimberg, 1997; Schlenker & Leary, 1982;
Trower & Gilbert, 1989). Clark and McManus (2002) provided an excellent overview of the literature
relating to cognitive processes in social phobic adults (see also Hirsch & Clark, this issue). Many of
these phenomena are also evident among social phobic children. These authors outlined evidence to
suggest that social phobia is maintained through a vicious cycle in which such individuals engage in a
series of biased pre- and post-interaction cognitive processes that act to generate anxious emotion and
may impair social performance. Subsequent social avoidance and adverse social outcomes are then
proposed to reduce opportunity for further psychosocial development and perpetuate the assumption that
social events will lead to negative outcomes (Banerjee & Henderson, 2001).
Studies indicate that these cognitive phenomena are evident in social phobic and socially anxious
children as young as 8 years (Epkins, 1996; Muris, Merckelbach, & Damsma, 2000; Spence, Donovan,
& Brechman Toussaint, 1999; Turner, Beidel, Cooley, & Woody, 1994). Spence et al. (1999) examined
cognitive distortion and bias among a clinical sample of social phobic children who were required to
complete reading aloud and social role-play tasks. Children were asked to rate the quality of their
expected performance before each task, to evaluate their performance after task completion, and then to
recall their cognitions relating to task performance using a video-mediated procedure. The participants
also completed a scale assessing subjective probabilities of positive and negative consequences across
social and nonsocial domains. Social phobic children showed a similar pattern of cognitive negativity
regarding social evaluative situations to that shown by adults with social phobia. In comparison to a
matched sample of non-anxious peers, social phobic children tended to anticipate negative outcomes,
evaluated their own performance more negatively, and showed a higher level of negative cognitions on
social evaluative tasks. Furthermore, the effect was limited to social events. Although the social phobic
children were rated as performing less well on the social task, they did not differ from controls in
performance on the reading task. The social phobic children rated their performance poorly on both
reading and social tasks, suggesting that their negative evaluation of their own performance is not always
grounded in reality.
We can only speculate as to the causal mechanisms that might lead to the development of social
phobic cognitive processes and events. Theoretically, it is possible that genetic factors could influence
neurological structures and processes that could result in a tendency to perceive the social world in a
more threatening manner, with elevated attention to threat cues, and/or interpretation of social cues as
indicative of threat. To date, we know little about how very young infants perceive and interpret social
threat. Children do not suddenly start thinking, attending, interpreting, and evaluating their social worlds
in later childhood. They have been doing it since birth and we need to carefully examine developmental
progression of social cognition and its role in social anxiety. Also, young children are not simply
responsive to their social environments, but are active participants, both influencing and being
influenced by their social world. Very early social behavior, whether determined by inherited or
environmental influences, or both, will influence the subsequent responses of others. From birth, a child
who easily becomes distressed by social contacts, who fails to smile and respond positively to others, is
likely to generate more negative social responses. A persistent pattern of negative social outcomes, or
traumatic social experiences, could contribute some variance to the development of anticipatory anxiety
to social situations.
Retrospective studies with social phobic adults provide some evidence to suggest that adverse social
experiences during childhood may play a role in the development of their social phobia (see below).
Adult social phobics frequently recall memories of criticism, humiliation, bullying, and other adverse
social consequences (Hackmann, Clark, & McManus, 2000; Hackmann, Surawy, & Clark, 1998; Hope,
Heimberg, & Klein, 1990). Social phobic adults also attach fundamental importance to being positively
appraised by others and tend to assume that other people are inherently critical and prone to evaluate
others negatively (Rapee & Heimberg, 1997). Again, we really do not know where such entrenched
beliefs come from. Parents have been suggested as one possible source of influence, but as yet we do not
have sufficient evidence to justify this conclusion. We know that, as part of normal development,
children gradually form a mental representation of themselves as seen by others (the baudienceQ). Why
children vary in the importance of positive appraisal or extent of threat attributed to this audience
remains to be determined.
3.1.4. Social skills deficits
Some early theories of social phobia stressed the role of a lack of social skills. However, not all
theorists have accepted the proposition that social phobic individuals tend to have poor social skills.
Some authors have pointed out that failure to use effective social skills does not necessarily mean that
a person has a fundamental inability to perform the behavior in question. Rather, the lack of
performance may reflect an inhibition of appropriate responding as a consequence of excessive anxiety
(Kashdan & Herbert, 2001; Rapee & Heimberg, 1997). It is also possible that deficits in social skills
play a more significant role in the development and maintenance of social phobia for children than
they do for adults. By adulthood, individuals may have learned a range of compensating social skills
and coping strategies, such as repeated rehearsal of social tasks that enable them to survive
challenging social situations from which they cannot escape. In support of this possibility are
empirical findings showing that adult social phobics are not always assessed as less socially skilled
than nonclinical controls (Rapee & Lim, 1992), although data on this issue are mixed (e.g., Stopa &
Clark, 1993). Some evidence has also shown that socially anxious adults can perform significantly
better when demand to do so is placed upon them, suggesting that social skills may be inhibited rather
than lacking (Thompson & Rapee, 2002).
In contrast to the adult literature, there is convincing evidence that socially phobic children do tend to
perform less well on socially challenging tasks. There is good evidence to suggest that socially anxious
children are less popular among their peers and are more likely to be ignored, neglected, rejected, and
excluded by the peer group (Gazelle & Ladd, 2003; Inderbitzen, Walters, & Bukowski, 1997; La Greca
& Silverman, 1993; La Greca, Silverman, & Wasserstein, 1998; Walters & Inderbitzen, 1998). Peer
responses of this type are likely to reflect a long-term history of social interaction patterns. We need to
determine what behaviors or features of children influence status among peers and other social
outcomes. Spence et al. (1999) found that socially phobic children were rated by themselves and others
as less socially competent with peers, less socially skilled, and less assertive compared to matched non-
anxious controls. Socially phobic children also showed significantly poorer social skills on a behavioral
assessment task, a finding also reported by Beidel, Turner, and Morris (1999). During behavioral
observation at school, Spence et al. showed that the socially phobic children initiated fewer interactions
with other children, spoke less and interacted for shorter duration compared to non-anxious peers.
There is also some evidence that socially anxious children have deficits in nonverbal communication
and social perception skills. For example, Melfsen, Osterlow, and Florin (2000) reported that socially
anxious children showed reduced general facial activity and less accurate facial expression in
communication of emotions compared to non-anxious controls. Of particular interest is a recent study by
Banerjee and Henderson (2001) showing that teachers rated socially anxious children as poorer in
comparison to non-anxious peers only on social skills that required insight into others mental states.
This finding fits with the proposition that socially anxious children, particularly those with high levels of
relevant negative emotion, have difficulty in understanding other peoples mental states during social
interactions and poorer appreciation of self-presentation strategies, partly as a consequence of excessive
self-focus which hampers attention to external social cues and acquisition of social knowledge. In
support of this proposition, Banerjee and Henderson found that socially anxious children who manifest
high levels of shy negative affect experienced socialcognitive difficulties but not a basic deficit in
understanding recursive mental states relating to the physical world.
In relation to social perception skills, some investigators have found socially phobic children to be
less competent in identifying emotions through facial expressions (Melfsen & Florin, 2002; Simonian,
Beidel, Turner, Berkes, & Long, 2001). It appears that socially phobic children have either been less
successful in learning to discriminate and label emotional expressions of others or this ability is impaired
as a consequence of high levels of anxiety. It is possible that high levels of self-focused attention
associated with social anxiety serve to divert attentional resources away from external social cues. Some
theorists have suggested that social anxiety may also be associated with a bias towards interpretation of
threatening social information. The evidence to date with socially phobic children, however, is
inconclusive. Simonian et al. (2001) noted that socially phobic children made more errors than non-
anxious peers in identifying happiness, sadness, and disgust, but not for anger, surprise, or fear. Melfsen
and Florin found no indication of an enhanced ability to decode negative facial expressions in socially
anxious children, nor was there a specific tendency to interpret neutral or positive faces as negative.
One possibility is that socially phobic children are actually less socially skilled at performing the
kinds of behaviors that increase the probability of achieving successful social outcomes and being
judged in a positive way by others. Impairment in the performance of social tasks is proposed to play a
key role in a vicious cycle involving negative social outcomes, anxiety, maladaptive cognitions,
avoidance behaviors, leading to further social skills deficits (Spence et al., 1999; Turner et al., 1994).
Such models suggest that a vicious cycle becomes established in which deficits in social skills lead to a
repeated pattern of unsuccessful outcomes from interactions with others, which in turn influence global
judgments about social competence and social status with peers. The negative interpersonal experiences
are also proposed to generate a range of maladaptive cognitive processes and outcomes, such as
anticipation of failure, low self-efficacy, excessive self-focus, and hypersensitivity to negative feedback
from others. These social failure experiences (through associative learning), in combination with
maladaptive cognitive processes, are suggested to engender a sense of anxiety in similar social contexts
in the future. The resulting consequences of social withdrawal, avoidance behavior, and exclusion by
others are then proposed to limit opportunities for further social skill development and social learning.
Lack of attempt at social interactions may mean not only that a child fails to learn important behavioral
and cognitive social skills, but also that he or she does not experience success and develop a sense of
mastery over key social tasks, thereby maintaining maladaptive and biased cognitive processing. Thus,
we suggest that social skills deficits could be both a cause and a consequence of social phobia. For some
individuals, such deficits could be a primary causal factor; for others they may play a maintaining role.
3.2. Environmental factors
Genetic, biological, and early temperament factors provide only a partial explanation of the
development of social phobia. We need to understand the processes that determine which individuals
who possess some genetic, biological, or temperament predisposition proceed to develop social phobia
while others do not. Evidence clearly shows that many individuals with such predispositions do not
develop social phobia. Twin studies, which have traditionally been used to estimate the genetic
contribution to disorders, also allow us to examine the variance in a behavior contributed by
environmental factors. These studies have generally indicated that a major proportion of the variance in
social anxiety (and indeed in all anxiety disorders) is accounted for by nonshared environmental factors
(that is, environmental factors that make individuals different to one another such as separate peer groups
or individual life events) (Kendler et al., 1999; Nelson et al., 2000; Warren et al., 1999). Unfortunately,
the modeling methods currently used combine variance from nonshared environment and measurement
error, so it is not possible to completely determine the amount of variance accounted for by nonshared
environment and is it likely that the current estimates dramatically overestimate this effect. In contrast,
estimates of the contribution of shared environmental factors (factors that make members of a family
similar to one another, such as family SES, certain family-wide stressors, and parenting styles) have been
more variable. In general, studies of anxiety in adult twins have tended to indicate little or no
contribution from the shared environment while studies of anxiety in child twins have shown some or
even substantial shared environmental contributions (Eley, 1999). Interestingly, social phobia is one of
the few disorders where shared environmental effects have been demonstrated, even in adult twins
(Kendler et al., 2001), although this appears to be a general shared environment effect across all anxiety
disorders. These results are consistent with the findings in the parenting literature (reviewed below) that
parental overprotection may be involved generally with all anxiety disorders (and even other disorders)
but may be somewhat more strongly associated with social anxiety.
While twin studies have indicated a relatively general genetic influence common to several emotional
disorders, family studies have tended to demonstrate a greater degree of diagnostic specificity. For
example, a large study of familial transmission of phobic disorders indicated that first degree relatives of
individuals with social phobia were at specifically increased risk for social phobia only (Fyer et al.,
1995). Combining these effects would appear to suggest that the emergence of specific symptom patterns
(as opposed to broad, general emotional difficulties) may be more an effect of factors shared across a
family (Hudson & Rapee, 2000).
Given that the majority of adults report the development of social phobia during late childhood and
early adolescence, we need to look closely at environmental factors during childhood. Children spend
most of their lives in two situations, the home and school, being strongly influenced by interactions with
parents, family members, teachers, and peers. Social learning theories of social anxiety suggest that a
history of aversive outcomes from social interactions and lack of modeling or instruction regarding
adaptive cognitive and behavioral coping strategies for managing challenging social situations (or
modeling/instruction in inappropriate strategies), may contribute to the development of social anxiety.
Parents represent the primary source of education regarding these latter factors, and parenting style has
received a good deal of investigation in relation to the development of child psychopathology generally.
Another less specific form of environmental influence includes a range of adverse life events that is
suggested to increase stress, and psychopathology in general. Such factors include death or illness of a
close family member or friend, parental conflict, separation, divorce, poverty, housing difficulties, and
living with a parent with a mental illness. These factors tend to be interrelated and their mechanism of
action is likely to reflect a combination of direct stressor effects and indirect effects through the impact
upon parents and their ability to parent effectively. We will try to examine the evidence of environmental
influence upon the development of social phobia in terms of (a) parenting behavior, (b) aversive social
outcomes, and (c) adverse life events.
3.2.1. Parent/child interaction
Understanding the role of parental influence on the development of anxiety is an extremely
complicated issue that is likely to involve complex interactions between many factors. Empirical
research into this issue has so far been relatively basic and has involved many limitations (Rapee, 1997;
Wood, McLeod, Sigman, Hwang, & Chu, 2003). However, as pointed out by Rapee (1997), despite the
extensive limitations of the research, a moderately consistent picture has emerged in which there is a
small, but significant, association between child anxiety and greater parental control and protection and
to a lesser extent less warmth. Whether these features play a causal role in the development of anxiety, or
whether they are more peripheral (e.g., reflecting shared genetics or a consequence of child anxiety) has
yet to be determined, although some evidence has shown that genetic factors play a relatively small role
in individuals reports of parental overprotection (Kendler, 1996; Rowe, 1981).
More specific examination of parent/child interactions in social phobia has been less extensive, but
some indications have emerged from the literature. Retrospective reports from adults with social phobia
have generally supported a picture of greater control and less warmth, much as it is for anxiety disorders
more broadly. Interestingly, some research has indicated that, if anything, these effects are even stronger
for adults with social phobia than for those with panic disorder (Arrindell, Emmelkamp, Monsma, &
Brilman, 1983; Arrindell et al., 1989; Parker, 1979; Rapee & Melville, 1997).
Several observational studies of parent/child interaction have included children with social phobia in
their sample and have supported the findings of greater parental control (Dadds, Barrett, Rapee, & Ryan,
1996; Hudson & Rapee, 2001; Hudson & Rapee, 2002; Moore, Whaley, & Sigman, 2003; Siqueland,
Kendall, & Steinberg, 1996). Only one study has examined the effect of diagnosis using these
paradigms. Parent/child interactions were shown to be similar across all the anxiety disorders and for
each child disorder (including social phobia) there was greater maternal involvement relative to
nonclinical controls (Hudson & Rapee, 2003). From the perspective of the parent, some research has
indicated that mothers of withdrawn preschoolers tend to report stronger beliefs that their children should
be handled in a high-powered and coercive manner (Rubin & Mills, 1990).
Examination of more detailed and specific parental influence has indicated that adults with social
phobia recall their parents as less sociable, stressing the importance of other peoples opinions, trying to
isolate them from interpersonal interactions, and also using shame as a method of discipline (Bruch &
Heimberg, 1994; Bruch, Heimberg, Berger, & Collins, 1989; Stravynski, Elie, & Franche, 1989). One
small study has also found corroboration for some of these findings from the mothers of socially phobic
adults (Rapee & Melville, 1997). While it is certainly possible that these data reflect the effects of shared
genes, one important study has indicated that this may not be the case. Using an adoption design, Daniels
and Plomin (1985) found that the degree of shyness in infants was significantly related to the sociability
of their adoptive mothers.
Determination of causal direction from these data is not possible at this stage. Theoretically, however,
several authors have argued for a reciprocal influence model of parent/child interaction (Hudson &
Rapee, 2004; Rubin & Mills, 1991). In other words, it is proposed that withdrawn features in a child will
elicit protective behaviors from the parent (especially if the parent himherself is anxious) and in turn,
these protective behaviors will maintain or even increase child withdrawal (Hudson & Rapee, 2004). In
one of the few longitudinal studies of shyness and parenting to date, shyness at age 2 was shown to
predict parental protection at age 4, but parental protection at age 2 failed to predict shyness at age 4
(Rubin, Nelson, Hastings, & Asendorpf, 1999). Thus, the data from this single study at this early age
were consistent with only a single direction of influence from child to parent. However, an observational
study of clinically anxious children and their nonclinical siblings showed similar greater levels of
maternal overprotection for both these groups relative to controls, although no differences were found
for fathers (Hudson & Rapee, 2002). Thus, these data suggest that there is a somewhat unique parental
style characteristic of mothers of anxious children. On the other hand, two studies have failed to show
that clinically anxious mothers are more protective of their child than are nonclinical mothers when their
child is not anxious (Moore et al., 2003; Whaley, Pinto, & Sigman, 1999).
3.2.2. Aversive social experiences
The arguably bpreparedQ nature of social threat cues combined with conditioning theory provides
one logical explanation for the onset of social fears as originating in aversive learning episodes (e.g.,
Mineka & Zinbarg, 1995). Surprisingly, there has been very little research into this issue and what
has been conducted suffers major methodological limitations. In one of the earliest studies, Hst and
Hugdahl (1981) asked 34 individuals with social phobia to report on the origins of their fears using
a retrospective questionnaire. Direct, traumatic social experiences were reported by 58% of the
sample. Given that this study was conducted at a time when the DSM-III definition of social phobia
was used, it is possible that a large proportion of the sample had more circumscribed social fears.
Indeed, a later study showed that social phobics with the specific subtype reported more traumatic
conditioning experiences than did generalized social phobics, who did not differ significantly from
controls (Townsley Stemberger, Turner, Beidel, & Calhoun, 1995). Naturally, it is far easier to report
specific events in relation to a highly focused issue than to a broader and more vague one,
suggesting that these results may be partly a methodological artifact. Further insight can be gained
from a replication by Mulkens and Bogels (1999), who examined traumatic conditioning events in
individuals with high or low blushing fears. As expected, more of the high fear individuals reported
onset of their fear following an aversive event. However, given that blushing is frequently seen as
an outcome of social fear, these data suggest that the high fear individuals may have already been
fearful before the so-called initiating event. In addition, Mulkens and Bo gels found that up to 66%
of their low fear individuals also reported a conditioning event, but did not develop later fear.
Finally, an examination of conditioning experiences in people with public-speaking fears
demonstrated the usual higher levels of reported events (Hofmann, Ehlers, & Roth, 1995). However,
more detailed examination indicated that almost all events reported as conditioning actually involved
the experience of a panic attack, once again begging the question of which comes first.
Given the early onset of social phobia, it may be more informative to examine aversive social
experiences that occur during the early years. The main negative social outcomes that have been
implicated in the development of social anxiety and social phobia include excessive teasing, criticism,
bullying, rejection, ridicule, humiliation, or exclusion by significant others (Asher & Coie, 1990;
Hackmann et al., 2000; La Greca & Lopez, 1998; Slee, 1994). However, most of the literature to date has
involved retrospective adult report of childhood experiences (Ishiyama, 1984), or cross-sectional data,
which of course are open to a good deal of bias in recall or reporting of events. Ishiyama (1984) reported
that histories of being teased, bullied, or ridiculed were seen by shy adults as critical childhood incidents
in the development of social fear and avoidance. Hackmann et al. (2000) found that adult social phobics
reported recurrent negative spontaneous images in which the content was relatively stable over time,
linked to memories of adverse social events that clustered in time around the onset of the disorder.
Hackmann et al. proposed that, in social phobia, early unpleasant experiences may lead to the
development of excessively negative images of the social self that are repeatedly activated in subsequent
social situations and fail to update in the light of subsequent, more favorable experiences.
The findings from adult retrospective reports are consistent with studies of socially anxious children.
For example, Spence et al. (1999), in an observational study, found that children with social phobia
received fewer positive outcomes from their interactions with peers at school, in comparison to non-
anxious matched controls. Similarly, Beidel et al. (1999) showed that social phobic children reported a
high occurrence of aversive social events. These findings suggest a significant relationship between
social phobia and adverse social outcomes, but the direction of causality is unclear. A recent longitudinal
study attempted to separate out these interrelationships (Gazelle & Ladd, 2003). These authors examined
the temporal relationships of interpersonal adversity in early childhood (peer exclusion, characterized by
indirect peer actions, such as being ignored or being unchosen or direct peer response such as deliberate
refusals to include in an activity) and anxious solitude (defined as an internal state of social anxiety and
behavioral manifestations of social anxiety, including shyness, verbal inhibition, and playing alone or
solitary onlooker behavior). Children were assessed over 5 years from kindergarten to fourth grade. The
results indicated bidirectional relationships. Anxious solitude not only predicted concurrent peer
exclusion but also an increasing exclusion trajectory over time. Similarly, high early exclusion predicted
elevated anxious solitude cross-sectionally and over time. Children who manifest anxious solitude and
also experienced high levels of early exclusion tended to show more stable patterns of anxious solitude
over time. The authors suggest peers tend to interpret anxious solitude behaviors as deviant, and come to
dislike and subsequently exclude anxious solitary children. In turn, peer rejection serves to confirm the
anxious solitude childs worst fears regarding peer social interaction, further enhancing avoidance
behaviors. It appears that this vicious cycle may commence with either the experience of peer rejection
or anxious solitude.
3.2.3. Negative life events
The factors outlined in the previous section relate to interpersonal adversity. However, many other,
more general forms of negative life events have been proposed to increase the risk of social phobia.
Childhood life events such as divorce, parental psychopathology, parental marital break-up, family
conflict, and sexual abuse have been shown to increase the risk of social phobia (Chartier, Walker, &
Stein, 2001; Kessler, Davis, & Kendler, 1997; Magee, 1999; Stein et al., 1996; Stemberger, Turner,
Beidel, & Calhoun, 1995). However, these events have typically been shown to increase the risk of many
forms of psychopathology and are not unique to social phobia. Also, in some instances, the research has
been cross-sectional or retrospective, making it difficult to determine direction of causality. For example,
Chartier et al. (2001) in a community study reported that having a history of no close personal
relationship with an adult, dropping out of school or requiring remedial education were significantly
associated with a diagnosis of social phobia in young adulthood. It is possible that adult social phobics
were also socially anxious youngsters, whose early relationships with adults and school performance
were impaired as a result of inability to respond appropriately to social demands. Clearly, more
longitudinal research is required to tease out these interrelationships. We are still a long way from
knowing exactly how negative life events influence the development of social phobia. It is not clear why,
in the face of adverse life situations, some young people progress to develop emotional and behavioral
problems while others do not. It is even less clear why some individuals develop a specific disorder such
as social phobia, rather than some other form of psychopathology, such as depression, panic disorder, or
conduct disorder. It is likely that the nature of the outcome reflects a complex interplay between
biological processes, psychological strengths or vulnerabilities, and environmental general (e.g., family
conflict) and specific influences (e.g., traumatic outcome from social interaction). A major task for
researchers is to tease apart these interrelationships and to determine the specific mechanisms of action.
4. A model of the etiology of social phobia
It is clear that the principles of equifinality and multifinality are both relevant to the development of
social phobia (Ollendick & Hirshfeld Becker, 2002). There are many possible pathways and risk factors
that may eventuate in higher levels of social fears and none of these is likely to be necessary for social
phobia to develop. In addition, few risk factors are likely to be specific to social anxiety and it is more
likely to be the particular combination of risks or the combination of one specific risk with several
nonspecific risks that ultimately leads to social phobia.
As argued earlier, we view social anxiety as lying on a continuum of social/evaluative concern and see
the principles and factors discussed here as influencing movement up or down that continuum. An actual
diagnosis of social phobia is associated with falling toward the upper end of the continuum. But it also
involves an additional factora concept or perception that these behaviors are impairing ones life. This
separate factor is likely to be mediated by distinct risks.
A diagrammatic model of the etiology of social phobia is shown in Fig. 1. There is little doubt that
genetic factors are involved in the etiology of social phobia. The vast majority of genetic variance is
likely to provide a broad risk for emotional disorders in general. However, it is possible that a smaller
proportion of the variance is also accounted for by genetically mediated factors that are more specific
to social concerns. The direct expression of these genetic factors is widely open for debate. Several
researchers have identified highly emotional and active infants who in turn are at greater risk of
developing higher levels of withdrawn and inhibited behaviors (Engfer, 1993; Kagan & Snidman,
1991). Hence, we would speculate that the combination of shared or common genetic factors might be
expressed as general emotionality (negative affectivity, neuroticism). Based on evidence that low
F
i
g
.
1
.
A
m
o
d
e
l
o
f
t
h
e
d
e
v
e
l
o
p
m
e
n
t
o
f
s
o
c
i
a
l
p
h
o
b
i
a
.
positive affectivity (low extraversion, low sociability) is also characteristic of social phobia and
distinguishes it from the other anxiety disorders, we might also speculate that the more specific
genetic components are expressed in this way. Hence, social anxiety might be comprised of a set of
genes that are common across a number of later disorders and express themselves collectively in
higher levels of general emotionality and arousal combined with genes that are more specific to a
smaller number of disorders and express themselves collectively in the form of avoidance of
interpersonal interactions. Of course, we are still talking here of relatively broad constructs and future
research should aim to break down these constructs to more specific components that might more
closely map onto individual gene expressions.
In summary, we suggest that, for many individuals, social phobia has its origins in two (or more)
broad genetic factors that, in combination, direct an individual toward a given level of social anxiety. We
further speculate that this genetically mediated level acts like an individuals bset point.Q By set point, we
are referring to an individuals degree of social anxiety that is moderately stable and consistent. Various
factors, mostly environmental in nature, could act to move the individual (up or down) from this level of
social anxiety, but movement (i.e. expression of a different level of social anxiety) will be increasingly
difficult the further the individual shifts from the set point.
Importantly, the set point is not permanent and can be altered. Thus, the ultimate level of the set point
is likely to reflect both genetic and environmental influence. This would occur when environmental
influences are powerful enough to produce fundamental changes in the architecture of social anxiety
expression (beliefs, biases, behavioral styles or even neurobiology). The power of an environmental
influence may be due to its timing (occurrence at certain critical stages of vulnerability), impact (the
intensity of the factor or its meaning for the individual), or chronicity (length of an individuals life over
which the factor is influential). For example, an individual may begin with a relatively low genetic
loading for social anxiety but due to a particularly traumatic or chronic set of environmental events (e.g.,
severe and chronic bullying over many school years) could move markedly up the continuum
(eventually developing social phobia). Alternately, an individual may be born with a high genetic
loading for social anxiety, but due to a strongly supportive family environment that simultaneously
encourages social interaction and risk taking over several influential years, may move to a consistently
low level of social anxiety.
More commonly however, any changes in the expression of social anxiety due to environmental
factors will be relatively minor and temporary. In other words, once a given environmental influence
stops, the individual will show a tendency to return toward their set point barring the influence of another
environmental factor. This explanation would be consistent with the data showing a greater genetic
influence on stability in shyness across time than on variance within a given situation (Cherny et al.,
1994). In addition, it may also help to explain why shared environmental influence appears to be
stronger in studies of children than of adults. Twins are far more likely to share environments during
childhood than in later life (Eley, 1999). If influences from these shared environments are temporary,
they will account for variance in studies of child twins, but their influence will no longer be apparent in
samples of adults.
Environmentally, a large number of possible influences have been identified and it is likely that many
more will emerge. Parent/child interactions appear to be important for the childs expression of social
concern, but it is likely that most interactional patterns will be general ones that influence a range of
psychopathology. Anxiety broadly and social anxiety more specifically have been shown to be influenced
to a small, but significant extent, by parental overprotection and by modeling of sociability and
interactional concerns. Given the importance of the early years for cognitive and attitudinal development, it
is likely that parenting style would produce more lasting influence in these years by moving the child
toward beliefs such as bothers are critical,Q bI am incompetent,Q etc. Thus, it may be that parental influence
will be more long lasting (more of a direct impact on the set point) when it occurs earlier in the childs
development. However, the degree of influence of parenting on a childs current levels of social concern is
likely to be relatively consistent as long as the child is under the parents influence (e.g., living at home). Of
course, it needs to be remembered that parent/child interaction may be a circular process whereby the
childs initial temperament will influence the parent who in turn influences the child.
As the child gets older, peers will start to have a greater influence on his/her behavior. The emotional
and withdrawn child is likely to elicit greater neglect and possibly even rejection and teasing from peers
and this, in turn, will move the child further up the social anxiety continuum. We might expect most of
these influences to have relatively little impact on the set point. Thus, they will account for a large
amount of variance in levels of social anxiety while they occur, but they may account for only a small
amount of variance in life-long levels of social anxiety (unless they are especially severe or chronic).
Throughout the individuals life, various negative life events and more specific learning experiences
will occur and will influence the individuals position on the social anxiety continuum. Particularly, severe
or perhaps highly meaningful experiences may have longer-terminfluences on the underlying architecture,
but we would predict that most life events would account for significant variance only while they and their
sequelae exist. Thus, chronic life events and their sequelae (such as loss of a loved one) should account for
greater variance across lengthy periods of the individuals life than shorter-termevents (such as job loss). It
is again important to remember that experience of life events will partly be influenced by the individuals
temperament, both in producing some events, and in terms of their interpretation. Therefore, an individual
who is already further up the continuum will be more likely to experience an environment that will
maintain or even increase this level of anxiety. For example, someone who is somewhat shy and gives a
presentation where s/he performs poorly may interpret this as a tragedy and subsequently increase their
social anxiety, whereas a more confident person would not have done so. Thus, this so-called specific
conditioning event is dependent on the individuals pre-existing level of social anxiety.
Additionally, the role of social behavior needs to be addressed. We would distinguish between two
conceptsinterrupted social performance and poor social skill. Interrupted social performance refers to
the interference of appropriate social behavior due to heightened anxiety. There is little doubt that high
levels of social anxiety produce deficits in appropriate behavior (either due to interruptions in ability or
more intentional efforts to avoid or protect oneself) and, in turn, these deficits can increase state distress
and ultimately maintain the individuals level of social anxiety. This construct is more relevant to models
of maintenance and has been addressed elsewhere (e.g., Clark & Wells, 1995; Rapee & Heimberg,
1997). However, when it is severe, it could in turn influence aspects of the environment such as forming
friendships and in this way have relevance to the etiology of social phobia. We predict that interrupted
social performance is considerably more overt and hence will have a significantly greater impact on
levels of social anxiety at earlier stages of development. This is both because individuals learn more
socially appropriate and subtle ways of coping with their anxiety and because adult members of society
typically do not laugh at or reject socially inappropriate behavior in a clearly overt fashion. On the other
hand, poor social skill refers to a fundamental lack of social ability (either due to actual lack of social
knowledge or more commonly lack of internalized ability to perform that knowledge) and as such could
be viewed as a factor that is independent of the effects of social anxiety. We do not believe that lack of
social skills on their own are a major cause of social anxiety, but it is very likely that when an individual
is low in social skill, the repeated experience of social failure will be a factor that does move the
individual further up the social anxiety continuum. Further, because low social skill is an internal factor,
it is likely to continue to influence the environment over a long period of the individuals life and hence
would account for variance in social anxiety over the longer-term. Of course, the source of social skill is
not the subject of this paper and may well involve both genetic and environmental inputs of its own.
The model also highlights the role of cultural influences on social anxiety and phobia. Cultural norms
and mores may influence the expression of social anxiety. That is, the underlying continuum of social
anxiety is likely to be relatively constant across cultures, but the way in which the features are expressed
as well as their consequences may differ depending on the specific issues of social concern for a given
culture. Thus, for example, in a collectivist culture where the greatest threat comes from disruptions to
the group, social anxiety will be manifested more strongly in fears of causing distress in others. Culture
may also be responsible for variations in levels of social anxiety. Most obviously, the differences in
social fears expressed by males and females from middle childhood are likely to be, at least partly, a
result of cultural pressure to reduce expression of social anxiety in males, while tolerating such features
in females. Similarly, cultures that accept the overt expression of social anxiety are likely to move
members toward higher levels of this continuum than cultures that pressure reduced expression. Finally,
culture is likely to influence the point at which social anxiety is seen as an impediment and bproblemQ in
ones life. In turn, this difference will influence the rates at which high levels of social anxiety are
diagnosed as a clinical condition in that cultural group. Given that most individuals spend all of their
lives in a given culture (or subculture), these cultural pressures are likely to be of relevance to the
expression of social anxiety across most of the lifespan.
Finally, as argued earlier, the model allows for a formal diagnosis of social phobia (or avoidant
personality disorder) to be a combined effect of the level the individual lies on the social anxiety
continuum and the extent to which s/he believes these concerns produce distress, interference and
impairment in his or her life. In turn, the extent of life interference is likely to be influenced by a
number of factors including the severity of social anxiety and the individuals age, gender, life goals,
and culture.
The preceding review highlights the highly complex nature of the social phobia and the strict limits to
our current knowledge and understanding of causal origins. The model we have provided will almost
certainly be proven wrong in parts and is most definitely incomplete. But it is an attempt to draw
together our current limited state of understanding and in this way should provide direction and a basis
for future research. Hopefully, the coming years will witness a marked increase in comprehensive
longitudinal studies that aim to test specific models such as the current one and in this way, gradually
increase our understanding of the etiology of social phobia.
References
Albano, A. M., & Detweiler, M. F. (2001). The development and clinical impact of social anxiety and social phobia in children
and adolescents. In Stefan G. Hofmann, & Patricia Marten Di Bartolo (Eds.), From social anxiety to social phobia: Multiple
perspectives (pp. 162178). Needham Heights, MA7 Allyn and Bacon.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC7
Author.
Andrews, G. (1996). Comorbidity in neurotic disorders: The similarities are more important than the differences. In R. M.
Rapee (Ed.), Current controversies in the anxiety disorders (pp. 320). New York7 Guilford Press.
Arbelle, S., Benjamin, J., Golin, M., Kremer, I., Belmaker, R. H., & Ebstein, R. P. (2003). Relation of shyness in grade school
children to the genotype for the long form of the serotonin transporter promoter region polymorphism. American Journal of
Psychiatry, 160(4), 671676.
Arrindell, W. A., Emmelkamp, P. M. G., Monsma, A., & Brilman, E. (1983). The role of perceived parental rearing practices in
the etiology of phobic disorders: A controlled study. British Journal of Psychiatry, 143, 183187.
Arrindell, W. A., Kwee, M. G. T., Methorst, G. J., van der Ende, J., Pol, E., & Moritz, B. J. M. (1989). Perceived parental
rearing styles of agoraphobic and socially phobic in-patients. British Journal of Psychiatry, 155, 526535.
Asendorpf, J. B. (1989). Shyness as a final common pathway for two different kinds of inhibition. Journal of Personality and
Social Psychology, 57, 481492.
Asendorpf, J. B. (1991). Development of inhibited childrens coping with unfamiliarity. Child Development, 62(6), 14601474.
Asher, S. R., & Coie, J. D. (Eds.). (1990). Peer rejection in childhood. New York, NY7 Cambridge University Press.
Banerjee, R., & Henderson, L. (2001). Socialcognitive factors in childhood social anxiety: A preliminary investigation. Social
Development, 10(4), 558572.
Beatty, M. J., Heisel, A. D., Hall, A. E., Levine, T. R., & La France, B. H. (2002). What can we learn from the study of twins
about genetic and environmental influences on interpersonal affiliation, aggressiveness, and social anxiety?: A meta-analytic
study. Communication Monographs, 69(1), 118.
Beidel, D. C., Turner, S. M., & Morris, T. L. (1999). Psychopathology of childhood social phobia. Journal of the American
Academy of Child and Adolescent Psychiatry, 38(6), 643650.
Belsky, J., & Park, S. Y. (2000). Exploring reciprocal parent and child effects in the case of child inhibition in US and Korean
samples. International Journal of Behavioural Development, 24(3), 338347.
Biederman, J., Hirshfeld Becker, D. R., Rosenbaum, J. F., Herot, C., Friedman, D., Snidman, N., et al. (2001). Further
evidence of association between behavioral inhibition and social anxiety in children. American Journal of Psychiatry,
158(10), 16731679.
Biederman, J., Rosenbaum, J., Bolduc-Murphy, E. A., Faraone, S. V., Chaloff, J., Hirshfeld Becker, D. R., et al. (1993). A three
year follow-up of children with and without behavioral inhibition. Journal of the American Academy of Child and
Adolescent Psychiatry, 32, 814821.
Biederman, J., Rosenbaum, J., Hirshfeld, D. R., et al. (1990). Psychiatric correlates of behavioral inhibition in young children of
parents with and without psychiatric disorders. Archives of General Psychiatry, 47, 2126.
Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relationships among dimensions of the DSM-IVanxiety and
mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology,
107(2), 179192.
Bruch, M. A., & Cheek, J. M. (1995). Developmental factors in childhood and adolescent shyness. In R. G. Heimberg, M. R.
Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 163182). New
York7 Guilford Press.
Bruch, M. A., Giordano, S., & Pearl, L. (1986). Differences between fearful and self-conscious shy subtypes in background and
current adjustment. Journal of Research in Personality, 20, 172186.
Bruch, M. A., & Heimberg, R. G. (1994). Differences in perceptions of parental and personal characteristics between
generalized and nongeneralized social phobics. Journal of Anxiety Disorders, 8, 155168.
Bruch, M. A., Heimberg, R. G., Berger, P., & Collins, T. M. (1989). Social phobia and perceptions of early parental and
personal characteristics. Anxiety Research, 2, 5765.
Buss, A. H. (1985). A theory of shyness. In W. H. Jones, J. M. Cheek, & S. R. Briggs (Eds.), Shyness: Perspectives on research
and treatment (pp. 3946). New York7 Plenum Press.
Campbell, M. A., & Rapee, R. M. (1994). The nature of feared outcome representations in children. Journal of Abnormal Child
Psychology, 22(1), 99111.
Campbell, M. A., Rapee, R. M., & Spence, S. H. (2001). The nature of feared outcome representations in anxious and
nonanxious children. Australian Journal of Guidance and Counselling, 11, 8599.
Caspi, A., Elder Jr., G. H., & Bem, D. J. (1988). Moving away from the world: Life-course patterns of shy children.
Developmental Psychology, 24, 824831.
Caspi, A., Moffitt, T. E., Newman, D. L., & Silva, P. A. (1996). Behavioral observations at age 3 years predict adult psychiatric
disorders: Longitudinal evidence from a birth cohort. Archives of General Psychiatry, 53, 10331039.
Chartier, M. J., Walker, J. R., & Stein, M. B. (2001). Social phobia and potential childhood risk factors in a community sample.
Psychological Medicine, 31(2), 307315.
Chavira, D. A., Stein, M. B., & Malcarne, V. L. (2002). Scrutinizing the relationship between shyness and social phobia.
Journal of Anxiety Disorders, 16, 585598.
Cherny, S. S., Fulker, D. W., Corley, R. P., Plomin, R., & DeFries, J. C. (1994). Continuity and change in infant shyness from 14
to 20 months. Behavior Genetics, 24(4), 365379.
Clark, D. M., & McManus, F. (2002). Information processing in social phobia. Biological Psychiatry, 51(1), 92100.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In M. R. Liebowitz (Ed.), Social phobia: Diagnosis,
assessment, and treatment (pp. 6993). New York, NY7 Guilford Press.
Dadds, M. R., Barrett, P. M., Rapee, R. M., & Ryan, S. M. (1996). Family process and child anxiety and aggression: An
observational analysis. Journal of Abnormal Child Psychology, 24, 715734.
Daniels, D., & Plomin, R. (1985). Origins of individual differences in infant shyness. Developmental Psychology, 21(1),
118121.
Degonda, M., & Angst, J. (1993). The Zurich study. European Archives of Psychiatry and Clinical Neuroscience, 243,
95102.
de Ruiter, C., Rijken, H., Garssen, B., van Schaik, A., & Kraaimaat, F. (1989). Comorbidity among the anxiety disorders.
Journal of Anxiety Disorders, 3, 5768.
Dinnel, D. L., Kleinknecht, R. A., & Tanaka-Matsumi, J. (2002). A cross-cultural comparison of social phobia symptoms.
Journal of Psychopathology and Behavioral Assessment, 24(2), 7584.
Edelmann, R. J., & Baker, S. R. (2002). Self-reported and actual physiological responses in social phobia. British Journal of
Clinical Psychology, 41(1), 114.
Eley, T. C. (1999). Behavioral genetics as a tool for developmental psychology: Anxiety and depression in children and
adolescents. Clinical Child and Family Psychology Review, 2(1), 2136.
Engfer, A. (1993). Antecedents and consequences of shyness in boys and girls: A 6-year longitudinal study. In K. H. Rubin,
& J. B. Asendorpf (Eds.), Social withdrawal, inhibition, and shyness in children (pp. 4979). Hillsdale, NJ7 Lawrence
Erlbaum.
Epkins, C. C. (1996). Cognitive specificity and affective confounding in social anxiety and dysphoria in children. Journal of
Psychopathology and Behavioral Assessment, 18(1), 83101.
Essau, C. A., Conradt, J., & Peterman, F. (1999). Frequency and comorbidity of social phobia and social fears in adolescents.
Behaviour Research and Therapy, 37, 831843.
Essau, C. A., Conradt, J., & Petermann, F. (2000). Frequency, comorbidity, and psychosocial impairment of anxiety disorders in
German adolescents. Journal of Anxiety Disorders, 14(3), 263279.
Fenigstein, A., Scheier, M. F., & Buss, A. H. (1975). Public and private self-consciousness: Assessment and theory. Journal of
Consulting and Clinical Psychology, 43(4), 522527.
Furmark, T. (2002). Social phobia: Overview of community surveys. Acta Psychiatrica Scandinavica, 105, 8493.
Furmark, T., Tillfors, M., Stattin, H., Ekselius, L., & Fredrikson, M. (2000). Social phobia subtypes in the general population
revealed by cluster analysis. Psychological Medicine, 30, 13351344.
Fyer, A. J. (1993). Heritability of social anxiety: A brief review. Journal of Clinical Psychiatry, 54(12, Suppl), 1012.
Fyer, A. J., Mannuzza, S., Chapman, T. F., Martin, L. Y., et al. (1995). Specificity in familial aggregation of phobic disorders.
Archives of General Psychiatry, 52(7), 564573.
Gazelle, H., & Ladd, G. W. (2003). Anxious solitude and peer exclusion: A diathesisstress model of internalizing trajectories
in childhood. Child Development, 74(1), 257278.
Gelernter, C. S., Stein, M. B., Tancer, M. E., & Uhde, T. W. (1992). An examination of syndromal validity and diagnostic
subtypes in social phobia amd panic disorder. Journal of Clinical Psychiatry, 53, 2327.
Gest, S. D. (1997). Behavioral inhibition: Stability and associations with adaptation from childhood to early adulthood. Journal
of Personality and Social Psychology, 72(2), 467475.
Gilbert, P., & Trower, P. (2001). Evolution and process in social anxiety. In W. R. Crozier, & L. E. Alden (Eds.), International
handbook of social anxiety: Concepts, research, and interventions relating to the self and shyness (pp. 259279). Brisbane,
Australia7 Wiley.
Hackmann, A., Clark, D. M., & McManus, F. (2000). Recurrent images and early memories in social phobia. Behaviour
Research and Therapy, 38(6), 601610.
Hackmann, A., Surawy, C., & Clark, D. M. (1998). Seeing yourself through others eyes: A study of spontaneously occurring
images in social phobia. Behavioural and Cognitive Psychotherapy, 26(1), 312.
Hayward, C., Killen, J. D., Kraemer, H. C., & Taylor, C. B. (1998). Linking self-reported childhood behavioral
inhibition to adolescent social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 37(12),
13081316.
Heimberg, R. G., Holt, C. S., Schneier, F. R., Spitzer, R. L., & Leibowitz, M. R. (1993). The issue of subtypes in the diagnosis
of social phobia. Journal of Anxiety Disorders, 7, 249269.
Heimberg, R. G., Stein, M. B., Hiripi, E., & Kessler, R. C. (2000). Trends in the prevalence of social phobia in the United
States: A synthetic cohort analysis of changes over four decades. European Psychiatry, 15, 2937.
Heiser, N. A., Turner, S. M., & Beidel, D. C. (2003). Shyness: Relationship to social phobia and psychiatric disorders.
Henderson, L., & Zimbardo, P. (2001). Shyness, social anxiety, and social phobia. In Stefan G. Hofmann, & Patricia Marten
DiBartolo (Eds.), From social anxiety to social phobia: Multiple perspectives (pp. 4685). Needham Heights, MA7 Allyn
and Bacon.
Hofmann, S. G., Ehlers, A., & Roth, W. T. (1995). Conditioning theory: A model for the etiology of public speaking anxiety.
Hook, J. N., & Valentiner, D. P. (2002). Are specific and generalized social phobias qualitatively distinct? American
Psychological Association, 9(4), 379395.
Hope, D. A., Heimberg, R. G., & Klein, J. F. (1990). Social anxiety and the recall of interpersonal information. Journal of
Cognitive Psychotherapy, 4(2), 185195.
Hudson, J. L., & Rapee, R. M. (2000). The origins of social phobia. Behavior Modification, 24(1), 102129.
Hudson, J. L., & Rapee, R. M. (2001). Parentchild interactions and anxiety disorders: An observational study. Behaviour
Research and Therapy, 39, 14111427.
Hudson, J. L., & Rapee, R. M. (2002). Parentchild interactions in clinically anxious children and their siblings. Journal of
Clinical Child and Adolescent Psychology, 31(4), 548555.
Hudson, J. L., & Rapee, R. M. (2003). Parent child interaction and childhood anxiety: Influence of age, gender, and diagnosis.
Unpublished manuscript.
Hudson, J. L., & Rapee, R. M. (2004). From anxious temperament to disorder: An etiological model of generalized anxiety
disorder. In R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and
practice (pp. 5176). New York7 Guilford Publications Inc.
Hunt, C., & Andrews, G. (1995). Comorbidity in the anxiety disorders: The use of a life-chart approach. Journal of Psychiatric
Research, 29(6), 467480.
Inderbitzen, H. M., Walters, K. S., & Bukowski, A. L. (1997). The role of social anxiety in adolescent peer relations: Differences
among sociometric status groups and rejected subgroups. Journal of Clinical Child Psychology, 26(4), 338348.
Ishiyama, F. I. (1984). Shyness: Anxious social sensitivity and self-isolating tendency. Adolescence, 19(76), 903911.
Jones, W. H., Briggs, S. R., & Smith, T. G. (1986). Shyness: Conceptualization and measurement. Journal of Personality and
Social Psychology, 51, 629639.
Kagan, J. (1987). Perspectives on infancy. In Joy Doniger Osofsky (Ed.), Handbook of infant development, (2nd ed.). Wiley
series on personality processes (pp. 11501198). New York, NY7 Wiley.
Kagan, J., Reznick, J. S., Clarke, C., Snidman, N., & Garcia Coll, C. (1984). Behavioral inhibition to the unfamilar. Child
Development, 55, 22122225.
Kagan, J., & Snidman, N. (1991). Infant predictors of inhibited and uninhibited profiles. Psychological Science, 2(1), 4044.
Kagan, J., Snidman, N., & Arcus, D. (1998). The value of extreme groups. In L. R. Bergman (Ed.), Methods and models for
studying the individual (pp. 6582). Thousand Oaks, CA7 Sage Publications Inc.
Kagan, J., Snidman, N., Arcus, D., & Reznick, J. S. (1994). Galens prophecy: Temperament in human nature. New York7 Basic
Books.
Kashdan, T. B., & Herbert, J. D. (2001). Social anxiety disorder in childhood and adolescence: Current status and future
directions. Clinical Child and Family Psychology Review, 4(1), 3761.
Kendler, K. S. (1996). Parenting: A geneticepidemiologic perspective. American Journal of Psychiatry, 153(1), 1120.
Kendler, K. S., Karkowski, L. M., & Prescott, C. A. (1999). Fears and phobias: Reliability and heritability. Psychological
Medicine, 29(3), 539553.
Kendler, K. S., Myers, J., Prescott, C. A., & Neale, M. C. (2001). The genetic epidemiology of irrational fears and phobias in
men. Archives of General Psychiatry, 58(3), 257265.
Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C., et al. (1992). The genetic epidemiology of phobias in women: The
interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia. Archives of General Psychiatry, 49(4),
273281.
Kendler, K. S., Walters, E. E., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1995). The structure of the genetic and
environmental risk factors for six major psychiatric disorders in women: Phobia, generalized anxiety disorder, panic
disorder, bulimia, major depression, and alcoholism. Archives of General Psychiatry, 52, 374383.
Kennedy, J. L., Neves Pereira, M., King, N., Lizak, M. V., Basile, V. S., Chartier, M. J., et al. (2001). Dopamine system genes
not linked to social phobia. Psychiatric Genetics, 11(4), 213217.
Kerr, M., Lambert, W. W., & Bem, D. J. (1996). Life course sequelae of childhood shyness in Sweden: Comparison with the
United States. Developmental Psychology, 32(6), 11001105.
Kerr, M., Lambert, W. W., Stattin, H., & Klackenberg-Larsson, I. (1994). Stability of inhibition in a Swedish longitudinal
sample. Child Development, 65, 138146.
Kessler, R. C., Davis, C. G., & Kendler, K. S. (1997). Childhood adversity and adult psychiatric disorder in the US National
Comorbidity Survey. Psychological Medicine, 27(5), 11011119.
Kessler, R. C., Stein, M. B., & Berglund, P. (1998). Social phobia subtypes in the national comorbidity survey. American
Journal of Psychiatry, 155(5), 613619.
Kleinknecht, R. A., Dinnel, D. L., & Kleinknecht, E. E. (1997). Cultural factors in social anxiety: A comparison of social
phobia symptoms and Taijin Kyofusho. Journal of Anxiety Disorders, 11(2), 157177.
Kochanska, G. (1991). Patterns of inhibition to the unfamiliar in children of normal and affectively ill mothers. Child
Development, 62, 250263.
Kochanska, G., & Radke-Yarrow, M. (1992). Inhibition in toddlerhood and the dynamics of the childs interaction with an
unfamiliar peer at age five. Child Development, 63, 325335.
La Greca, A. M., & Lopez, N. (1998). Social anxiety among adolescents: Linkages with peer relations and friendships. Journal
of Abnormal Child Psychology, 26(2), 8394.
La Greca, A. M., & Silverman, W. K. (1993). Parent reports of child behavior problems: Bias in participation. Journal of
Abnormal Child Psychology, 21(1), 89101.
La Greca, A. M., Silverman, W. K., & Wasserstein, S. B. (1998). Childrens predisaster functioning as a predictor of
posttraumatic stress following Hurricane Andrew. Journal of Consulting and Clinical Psychology, 66(6), 883892.
Last, C. G., Strauss, C. C., & Francis, G. (1987). Comorbidity among childhood anxiety disorders. Journal of Nervous and
Mental Disease, 175, 726730.
Lee, S., & Oh, K. S. (1999). Offensive type of social phobia: Cross-cultural perspectives. International Medical Journal, 6(4),
271279.
Levin, A. P., Saoud, J. B., Strauman, T., Gorman, J. M., Fyer, A. J., Crawford, R., et al. (1993). Responses of bgeneralizedQ and
bdiscreteQ social phobics during public speaking. Journal of Anxiety Disorders, 7, 207221.
Lewinsohn, P. M., Zinbarg, R., Seeley, J. R., Lewinsohn, M., &Sack, W. H. (1997). Lifetime comorbidity among anxiety disorders
and between anxiety disorders and other mental disorders in adolescents. Journal of Anxiety Disorders, 11(4), 377394.
Li, D., Chokka, P., & Tibbo, P. (2001). Toward an integrative understanding of social phobia. Journal of Psychiatry and
Neuroscience, 26(3), 190202.
Lieb, R., Wittchen, H. U., Hoefler, M., Fuetsch, M., Stein, M. B., & Merikangas, K. R. (2000). Parental psychopathology,
parenting styles, and the risk of social phobia in offspring: A prospective-longitudinal community study. Archives of General
Psychiatry, 57(9), 859866.
Magee, W. J. (1999). Effects of negative life experiences on phobia onset. Social Psychiatry and Psychiatric Epidemiology,
34(7), 343351.
Magee, W. J., Eaton, W. W., Wittchen, H., McGonagle, K. A., & Kessler, R. C. (1996). Agoraphobia, simple phobia, and social
phobia in the national comorbidity survey. Archives of General Psychiatry, 53, 159168.
Mancini, C., Van Ameringen, M., Szatmari, P., Fugere, C., et al. (1996). A high-risk pilot study of the children of adults with
social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 35(11), 15111517.
Massion, A. O., Dyck, I. R., Shea, M. T., Phillips, K. A., Warshaw, M. G., & Keller, M. B. (2002). Personality disorders and
time to remission in generalized anxiety disorder, social phobia, and panic disorder. Archives of General Psychiatry, 59(5),
434440.
Mattick, R. P., & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social
interaction anxiety. Behaviour Research and Therapy, 36, 455470.
Melfsen, S., & Florin, I. (2002). Do socially anxious children show deficits in classifying facial expressions of emotions?
Journal of Nonverbal Behavior, 26(2), 109126.
Melfsen, S., Osterlow, J., & Florin, I. (2000). Deliberate emotional expressions of socially anxious children and their mothers.
Journal of Anxiety Disorders, 14(3), 249261.
Merikangas, K. R., Avenevoli, S., Acharyya, S., Zhang, H., & Angst, J. (2002). The spectrum of social phobia in the Zurich
Cohort Study of young adults. Biological Psychiatry, 51, 8191.
Mick, M. A., & Telch, M. J. (1998). Social anxiety and history of behavioral inhibition in young adults. Journal of Anxiety
Disorders, 12(1), 120.
Mineka, S., & Zinbarg, R. (1995). Conditioning and ethological models of social phobia. In R. G. Heimberg, M. R. Liebowitz,
D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 134162). New York7
Guilford Press.
Moore, P. S., Whaley, S. E., & Sigman, M. Interactions between mothers and children: Impacts of maternal and child anxiety.
Unpublished manuscript.
Mulkens, S., & Bfgels, S. M. (1999). Learning history in fear of blushing. Behaviour Research and Therapy, 37, 11591167.
Muris, P., Merckelbach, H., & Damsma, E. (2000). Threat perception bias in nonreferred, socially anxious children. Journal of
Clinical Child Psychology, 29(3), 348359.
Neal, J. A., Edelmann, R. J., & Glachan, M. (2002). Behavioural inhibition and symptoms of anxiety and depression: Is there a
specific relationship with social phobia? British Journal of Clinical Psychology, 41(4), 361374.
Nelson, E. C., Grant, J. D., Bucholz, K. K., Glowinski, A., Madden, P. A. F., Reich, W., et al. (2000). Social phobia in a
population-based female adolescent twin sample: Co-morbidity and associated suicide-related symptoms. Psychological
Medicine, 30(4), 797804.
Neufeld, K. J., Swartz, K. L., Bienvenu, O. J., Eaton, W. W., & Cai, G. (1999). Incidence of DIS/DSM-IV social phobia in
adults. Acta Psychiatrica Scandinavica, 100, 186192.
O
hman, A. (1986). Face the beast and fear the face: Animal and social fears as prototypes for evolutionary analyses of emotion.
Psychophysiology, 23, 123145.
Ollendick, T. H., & Hirshfeld Becker, D. R. (2002). The developmental and psychopathology of social anxiety disorder.
Biological Psychiatry, 51(1), 4458.
Hst, L.-G., & Hugdahl, K. (1981). Acquisition of phobias and anxiety response patterns in clinical patients. Behaviour Research
and Therapy, 19, 439447.
Otto, M. W., Pollack, M. H., Maki, K. M., Gould, R. A., Worthington, J. J., Smoller, J. W., et al. (2001). Childhood history of
anxiety disorders among adults with social phobia: Rates, correlates, and comparisons with patients with panic disorder.
Depression and Anxiety, 14, 209213.
Parker, G. (1979). Reported parental characteristics of agoraphobics and social phobics. British Journal of Psychiatry, 135,
555560.
Pedlow, R., Sanson, A., Prior, M., & Oberklaid, F. (1993). Stability of maternally reported temperament from infancy to 8 years.
Developmental Psychology, 29(6), 9981007.
Pelissolo, A., Andre, C., Moulard-Martin, F., Wittchen, H. U., & Lepine, J. P. (2000). Social phobia in the community:
Relationship between diagnostic threshold and prevalence. European Psychiatry, 15, 2528.
Peters, L., Clark, D., & Cooper, L. (1998). Are computerised interviews equivalent to human interviwers? CIDI-Auto vs CIDI
in anxiety and depressive disorders. Psychological Medicine, 28, 201893.
Pine, D. S., Cohen, P., Gurley, D., Brook, J., & Ma, Y. (1998). The risk for early-adulthood anxiety and depressive disorders in
adolescents with anxiety and depressive disorders. Archives of General Psychiatry, 55, 5664.
Prior, M. (1992). Childhood temperament. Journal of Child Psychology and Psychiatry, 33, 249279.
Prior, M., Smart, D., Sanson, A., & Oberklaid, F. (2000). Does shy-inhibited temperament in childhood lead to anxiety
problems in adolescence?. Journal of the American Academy of Child and Adolescent Psychiatry, 39(4), 461468.
Rankin, J. L., Lane, D. J., Gibbons, F. X., & Gerrard, M. (2004). Adolescent self-consciousness: Longitudinal age changes and
gender differences in two cohorts. Journal of Research on Adolescence, 14, 121.
Rapee, R. M. (1995). Descriptive psychopathology of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, &
F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 4166). New York7 Guilford Press.
Rapee, R. M. (1997). Potential role of childrearing practices in the development of anxiety and depression. Clinical Psychology
Review, 17, 4767.
Rapee, R. M., & Heimberg, R. G. (1997). A cognitivebehavioral model of anxiety in social phobia. Behaviour Research and
Therapy, 35(8), 741756.
Rapee, R. M., & Lim, L. (1992). Discrepancy between self- and observer ratings of performance in social phobics. Journal of
Abnormal Psychology, 101(4), 728731.
Rapee, R. M., & Melville, L. F. (1997). Retrospective recall of family factors in social phobia and panic disorder. Depression
and Anxiety, 5, 711.
Robinson, J. L., Kagan, J., Reznick, J. S., & Corley, R. (1992). The heritability of inhibited and uninhibited behavior: A twin
study. Developmental Psychology, 28(6), 10301037.
Rowe, D. C. (1981). Environmental and genetic influences on dimensions of perceived parenting: A twin study. Developmental
Psychology, 17, 203208.
Rowe, D. C., Stever, C., Gard, J. M. C., Cleveland, H. H., Sander, M. L., Abramowitz, A., et al. (1998). The relation of
the dopamine transporter gene (DAT1) to symptoms of internalizing disorders in children. Behavior Genetics, 28(3),
215225.
Rubin, K. H., & Mills, R. S. L. (1990). Maternal beliefs about adaptive and maladaptive social behaviors in normal, aggressive,
and withdrawn preschoolers. Journal of Abnormal Child Psychology, 18, 419435.
Rubin, K. H., & Mills, R. S. L. (1991). Conceptualizing developmental pathways to internalizing disorders in childhood.
Canadian Journal of Behavioural Science, 23, 300317.
Rubin, K. H., Nelson, L. J., Hastings, P., & Asendorpf, J. (1999). The transaction between parents perceptions of their
childrens shyness and their parenting styles. International Journal of Behavioural Development, 23(4), 937957.
Russell, J. G. (1989). Anxiety disorders in Japan: A review of the Japanese literature on Shinkeishitsu and Taijinkyofusho.
Culture, Medicine and Psychiatry, 13, 391403.
Sanderson, W. C., Di Nardo, P. A., Rapee, R. M., & Barlow, D. H. (1990). Syndrome co-morbidity in patients diagnosed with a
DSM-III-Revised anxiety disorder. Journal of Abnormal Psychology, 99, 308312.
Sanson, A., Pedlow, R., Cann, W., Prior, M., & Oberklaid, F. (1996). Shyness ratings: Stability and correlates in early
childhood. International Journal of Behavioural Development, 19(4), 705724.
Schlenker, B. R., & Leary, M. R. (1982). Social anxiety and self-presentation: A conceptualization model. Psychological
Bulletin, 92(3), 641669.
Schmidt, L. A., Fox, N. A., Rubin, K. H., Hu, S., & Hamer, D. H. (2002). Molecular genetics of shyness and aggression in
preschoolers. Personality and Individual Differences, 33(2), 227238.
Schwartz, C. E., Snidman, N., & Kagan, J. (1999). Adolescent social anxiety as an outcome of inhibited temperament in
childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 38(8), 10081015.
Simonian, S. J., Beidel, D. C., Turner, S. M., Berkes, J. L., & Long, J. H. (2001). Recognition of facial affect by children and
adolescents diagnosed with social phobia. Child Psychiatry and Human Development, 32(2), 137145.
Siqueland, L., Kendall, P. C., & Steinberg, L. (1996). Anxiety in children: Perceived family environments and observed family
interaction. Journal of Clinical Child Psychology, 25, 225237.
Skre, I., Onstad, S., Torgersen, S., Lygren, S., et al. (1993). A twin study of DSM-III-R anxiety disorders. Acta Psychiatrica
Scandinavica, 88(2), 8592.
Slee, P. T. (1994). Situational and interpersonal correlates of anxiety associated with peer victimisation. Child Psychiatry and
Human Development, 25(2), 97107.
Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour Research and Therapy, 36(5), 545566.
Spence, S. H. (2001). Prevention strategies. In M. W. Vasey, & M. R. Dadds (Eds.), The developmental psychopathology of
anxiety (pp. 325354). New York7 Oxford University Press.
Spence, S. H., Donovan, C., & Brechman Toussaint, M. (1999). Social skills, social outcomes, and cognitive features of
childhood social phobia. Journal of Abnormal Psychology, 108(2), 211221.
Stein, M. B., Chartier, M. J., Kozak, M. V., King, N., & Kennedy, J. L. (1998). Genetic linkage to the serotonin transporter
protein and 5HT
2A
receptor genes excluded in generalized social phobia. Psychiatry Research, 81(3), 283291.
Stein, M. B., & Deutsch, R. (2003). In search of social phobia subtypes: Similarity of feared social situations. Depression and
Anxiety, 17, 9497.
Stein, M. B., Fuetsch, M., Muller, N., Hofler, M., Lieb, R., & Wittchen, H. (2001). Social anxiety disorder and the risk of
depression: A prospective community study of adolescents and young adults. Archives of General Psychiatry, 58(3),
251256.
Stein, M. B., Fuetsch, M., Mueller, N., Hoefler, M., Lieb, R., & Wittchen, H. U. (2001). Social anxiety disorder and the risk
of depression: A prospective community study of adolescents and young adults. Archives of General Psychiatry, 58(3),
251256.
Stein, M. B., Jang, K. L., & Livesley, W. J. (2002). Heritability of social anxiety-related concerns and personality
characteristics: A twin study. Journal of Nervous and Mental Disease, 190(4), 219224.
Stein, M. B., Torgrud, L. J., & Walker, J. R. (2000). Social phobia symptoms, subtypes, and severity. Archives of General
Psychiatry, 57, 10461052.
Stein, M. B., Walker, J. R., Anderson, G., Hazen, A. L., Ross, C. A., Eldridge, G., et al. (1996). Childhood physical and
sexual abuse in patients with anxiety disorders and in a community sample. American Journal of Psychiatry, 153(2),
275277.
Stein, M. B., Walker, J. R., & Forde, D. R. (1994). Setting diagnostic thresholds for social phobia: Considerations from a
community survey of social anxiety. American Journal of Psychiatry, 151, 408412.
Stemberger, R. T., Turner, S. M., Beidel, D. C., & Calhoun, K. S. (1995). Social phobia: An analysis of possible developmental
factors. Journal of Abnormal Psychology, 104(3), 526531.
Stopa, L., & Clark, D. M. (1993). Cognitive processes in social phobia. Behaviour Research and Therapy, 31(3),
255267.
Stravynski, A., Elie, R., & Franche, R. (1989). Perception of early parenting by patients diagnosed avoidant personality
disorder: A test of the overprotection hypothesis. Acta Psychiatrica Scandinavica, 80, 415420.
Sundet, J. M., Skre, I., Okkenhaug, J. J., & Tambs, K. (2003). Genetic and environmental causes of the interrelationships
between self-reported fears. A study of a non-clinical sample of Norwegian identical twins and their families. Scandinavian
Journal of Psychology, 44(2), 97106.
Thompson, S., & Rapee, R. M. (2002). The effect of situational structure on the social performance of socially anxious and non-
anxious participants. Journal of Behaviour Therapy and Experimental Psychiatry, 33, 91102.
Townsley Stemberger, R., Turner, S. M., Beidel, D. C., & Calhoun, K. S. (1995). Social phobia: An analysis of possible
developmental factors. Journal of Abnormal Psychology, 104(3), 526531.
Trower, P., & Gilbert, P. (1989). New theoretical conceptions of social anxiety and social phobia. Clinical Psychology Review,
9(1), 1935.
Turner, S. M., Beidel, D. C., Cooley, M. R., & Woody, S. R. (1994). A multicomponent behavioral treatment for social phobia:
Social effectiveness therapy. Behaviour Research and Therapy, 32(4), 381390.
Turner, S. M., Beidel, D. C., Dancu, C. V., & Stanley, M. A. (1989). An empirically derived inventory to measure social fears
and anxiety: The social phobia and anxiety inventory. Psychological Assessment: A Journal of Consulting and Clinical
Psychology, 1, 3540.
Turner, S. M., Beidel, D. C., & Larkin, K. T. (1986). Situational determinants of social anxiety in clinic and nonclinic samples:
Physiological and cognitive correlates. Journal of Consulting and Clinical Psychology, 54, 523527.
Turner, S. M., Beidel, D. C., & Townsley, R. M. (1990). Social phobia: Relationship to shyness. Behaviour Research and
Therapy, 28, 497505.
Van Ameringen, M., Mancini, C., & Oakman, J. M. (1998). The relationship of behavioral inhibition and shyness to anxiety
disorder. Journal of Nervous and Mental Disease, 186(7), 425431.
Veljaca, K. A., & Rapee, R. M. (1998). Detection of negative and positive audience behaviours by socially anxious subjects.
Behaviour Research and Therapy, 36(3), 311321.
Walters, K. S., & Inderbitzen, H. M. (1998). Social anxiety and peer relations among adolescents: Testing a psychobiological
model. Journal of Anxiety Disorders, 12(3), 183198.
Warren, S. L., Schmitz, S., & Emde, R. N. (1999). Behavioral genetic analyses of self-reported anxiety at 7 years of age.
Journal of the American Academy of Child and Adolescent Psychiatry, 38(11), 14031408.
Watson, D., Clark, L. A., & Carey, G. (1988). Positive and negative affectivity and their relation to anxiety and depressive
disorders. Journal of Abnormal Psychology, 97(3), 346353.
Weisz, J. R., Suwanlert, S., Chaiyasit, W., & Walter, B. R. (1987). Over- and undercontrolled referral problems among children
and adolescents from Thailand and the United States: The Wat and Wai of cultural differences. Journal of Consulting and
Clinical Psychology, 55(5), 719726.
Weisz, J. R., Suwanlert, S., Chaiyasit, W., Weiss, B., Walter, B. R., & Anderson, W. W. (1988). Thai and American perspectives
on over- and undercontrolled child behavior problems: Exploring the threshold model among parents, teachers, and
psychologists. Journal of Consulting and Clinical Psychology, 56(4), 601609.
Whaley, S. E., Pinto, A., & Sigman, M. (1999). Characterizing interactions between anxious mothers and their children. Journal
of Consulting and Clinical Psychology, 67, 826836.
Wittchen, H. U., Stein, M. B., & Kessler, R. C. (1999). Social fears and social phobia in a community sample of adolescents and
young adults: Prevalence, risk factors and co-morbidity. Psychological Medicine, 29, 309323.
Wood, J. J., McLeod, B. D., Sigman, M., Hwang, W., & Chu, B. C. (2003). Parenting and childhood anxiety: Theory, empirical
findings, and future directions. Journal of Child Psychology and Psychiatry, 44(1), 134151.
Woodward, L. J., & Fergusson, D. M. (2001). Life course outcomes of young people with anxiety disorders in adolescence.
Journal of the American Academy of Child and Adolescent Psychiatry, 40(9), 10861093.
Yonkers, K. A., Dyck, I. R., & Keller, M. B. (2001). An eight-year longitudinal comparison of clinical course and
characteristics of social phobia among men and women. Psychiatric Services, 52(5), 637643.

Fsxetiologia

Transféré par

Informations du document

Description originale:

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Fsxetiologia

Transféré par

Droits d'auteur :

Formats disponibles

The etiology of social phobia:

Empirical evidence and an initial model

Vous aimerez peut-être aussi