ABSTRACT Background: Individuals with social phobia (SP) show sensitivity and attentiveness to other people’s states of mind. Although cognitive processes in SP have been extensively studied, these individuals’ social cognition characteristics have never been examined before. We hypothesized that high socially anxious individuals (HSA) may exhibit elevated mentalizing and empathic abilities. Methods: Empathy was assessed using self-rating scales in HSA individuals (n=21) and low socially anxious (LSA) individuals (n=22), based on their score on the Liebowitz social anxiety scale. A computerized task was used to assess the ability to judge first and second order affective vs. cognitive mental state attributions. Results: HSA individuals exhibited elevated affective empathy tendencies. However, controlling for the general anxiety variable revealed that social anxiety was related to cognitive empathy measures, rather than affective empathy. In addition, compared with LSA participants, HSA participants exhibited higher accuracy levels on the affective mental state attribution conditions, but were less accurate than LSA individuals on the parallel cognitive mental state attribution conditions. Limitations: Additional research with larger samples and clinically diagnosed individuals is required. Conclusions: Results support the hypothesis that high socially anxious individuals may demonstrate a unique social-cognitive abilities profile with elevated cognitive empathy tendencies and high accuracy in affective mental state attributions. Introduction Attention processes such as hypervigilance to threatening social information and self-focused attention are assumed to play an important role in the maintenance of social phobia (SP) (1, 2). Although cognitive biases in SP have been extensively documented in the literature (3-6), these individuals’ social cognition capacities have never been examined before. Individuals with SP are preoccupied with the impression they make, and place fundamental importance to being positively appraised by others. As a result of their social concerns, they may ambivalently tune themselves to obtain insight into others’ state of mind, displaying heightened self-awareness and excessive alertness to social signals. These (internal and external) attentional biases which influence the perceptiveness of social stimuli in SP may overall be manifested in a unique social-cognitive abilities profile. One cardinal aspect of social cognition is the ability to empathize (7). Empathy, in its broadest sense, refers to the reactions of one individual to the observed experiences of another (8). While some investigators have emphasized empathy as the ability to engage in the cognitive process of adopting another’s psychological point of view (“cognitive empathy”), others stressed its emotional facets (“affective empathy”), referring to the capacity to experience a vicarious response to another person (9). In addition to the cognitive perspective taking component of empathy, another perspective taking type is referred to as visual perspective taking; the ability to take an others’ perspective visually (10). Interestingly, the state of visually taking an observer perspective is a common imagery phenomenon in SP (2, 11-13). The assumption that self-focused attention and social evaluative concerns increase the likelihood to adopt an observer perspective has gained support in non-anxious (14, 15) and socially anxious individuals as well (12, 13, 16). 99 Yasmin Tibi-Elhanany and Simone G. Shamay-Tsoory It had been suggested that the visual perspective ability may not be restricted to adopting an external viewpoint, but it may be related to the capacity to adopt mental perspectives in healthy subjects (17) and schizotypic individuals (18). Considering their vigilance with regard to social cues, increased other-awareness and self-monitoring in social situations, it was speculated that individuals with SP will show increased empathic tendencies. Empathy is thought to require not only adequate social perception (19), but also entails the capacity to comprehend complex mental states (20). Taking the others’ external vantage point in SP might also indicate increased mentalizing abilities. Theory of Mind (ToM), the ability to make inferences regarding the mental state, desires and intentions of other individuals, is another major component of social cognition (21). This ability to infer others’ mental states (mentalizing) is closely linked to the ability of empathizing, since failure to represent other persons’ beliefs and intentions may result in failure to see things from another person’s perspective and, thus, interfere with the empathic response (20, 22). Similarly to empathy, a dual feature of cognitive and affective ToM has been suggested. The first emphasizes the capacity to represent mental states of others that are manifested in their thoughts and beliefs (23), whereas the affective aspect of ToM includes the inferences one makes regarding others’ emotional states and feelings. Abu-Akel (24) has suggested that mentalizing deficits in developmental and psychiatric populations may be viewed as lying on a continuum, in which at one end ToM deficits stem from lack the awareness of others’ mental state (e.g., people with autistic spectrum disorders), whereas the other end of this range includes individuals whose abnormal ToM abilities are the consequence of a tendency to over attribute mental states to others (e.g., people with paranoid thinking). Although they were not placed on this ToM range, the basic ability of individuals with SP to represent others’ mental states is manifested in their concern about others’ attitudes towards them. However, their excessive alertness to the social world and the sense their worries are being “seen through” by others (11) might be associated with a tendency to over attribute mental states to others. Although empathic and ToM abilities have been extensively documented in several disorders such as antisocial personality disorders (25), autism (26), Asperger’s syndrome (27), and schizophrenia (28, 29), no reported study has explored these abilities in individuals with social anxiety disorder. Taken together, the purpose of the It had been suggested that the visual perspective ability may not be restricted to adopting an external viewpoint, but it may be related to the capacity to adopt mental perspectives in healthy subjects (17) and schizotypic individuals (18). Considering their vigilance with regard to social cues, increased other-awareness and self-monitoring in social situations, it was speculated that individuals with SP will show increased empathic tendencies. Empathy is thought to require not only adequate social perception (19), but also entails the capacity to comprehend complex mental states (20). Taking the others’ external vantage point in SP might also indicate increased mentalizing abilities. Theory of Mind (ToM), the ability to make inferences regarding the mental state, desires and intentions of other individuals, is another major component of social cognition (21). This ability to infer others’ mental states (mentalizing) is closely linked to the ability of empathizing, since failure to represent other persons’ beliefs and intentions may result in failure to see things from another person’s perspective and, thus, interfere with the empathic response (20, 22). Similarly to empathy, a dual feature of cognitive and affective ToM has been suggested. The first emphasizes the capacity to represent mental states of others that are manifested in their thoughts and beliefs (23), whereas the affective aspect of ToM includes the inferences one makes regarding others’ emotional states and feelings. Abu-Akel (24) has suggested that mentalizing deficits in developmental and psychiatric populations may be viewed as lying on a continuum, in which at one end ToM deficits stem from lack the awareness of others’ mental state (e.g., people with autistic spectrum disorders), whereas the other end of this range includes individuals whose abnormal ToM abilities are the consequence of a tendency to over attribute mental states to others (e.g., people with paranoid thinking). Although they were not placed on this ToM range, the basic ability of individuals with SP to represent others’ mental states is manifested in their concern about others’ attitudes towards them. However, their excessive alertness to the social world and the sense their worries are being “seen through” by others (11) might be associated with a tendency to over attribute mental states to others. Although empathic and ToM abilities have been extensively documented in several disorders such as antisocial personality disorders (25), autism (26), Asperger’s syndrome (27), and schizophrenia (28, 29), no reported study has explored these abilities in individuals with social anxiety disorder. Taken together, the purpose of the present study was to examine the hypothesis that socially anxious individuals may exhibit elevated empathic tendencies and emotional ToM abilities, based on their sensitivity and attentiveness to others’ state of mind. The first goal of the present study was to characterize the relationship between cognitive and affective empathy and social anxiety in sub-clinical socially anxious individuals. The second goal was to compare mentalizing abilities of individuals with low and high social anxiety. Finally, the relative contribution of trait/general anxiety on empathy was also examined to assess the specificity of the contribution of the social component in social anxiety as compared with the general tendency of participants to be anxious. Method Subjects Subjects were 87 volunteers (age ranged from 19 to 53) who responded to an advertisement. A trained clinical psychologist administered a demographic and clinical questionnaire which included questions regarding demographic details as well as physical and mental health questions. Individuals suffering from neurological problems or a major physical illness, alcohol or substance abuse were excluded from the study. All participants completed the self-report format of the Liebowitz Social Anxiety Scale (LSAS) (30). This version of the LSAS translated into Hebrew was reported to demonstrate high test-retest reliability in a sample of patients with SP (r=0.87 and r= 0.91 for the LSAS anxiety and avoidance scales respectively). In addition, the LSAS also demonstrated high internal consistency for both the anxiety and avoidance subscales, and good treatment sensitivity (31). In our sample, scores ranged from 0 to 84, Mean= 35.75, SD=18.19. All participants were fluent in Hebrew, and testing was conducted individually in two sessions. Clinical assessment Additionally to the LSAS, participants completed the Beck Anxiety Inventory (BAI) (32) and the Trait version (will be referred to as trait anxiety inventory; TAI) of the State-Trait Anxiety Inventory (33). Subjects were further assigned to either low or high social anxiety (LSA, HSA) groups according to their total LSAS scores. The LSA group consisted of subjects who scored lower than 25 (lower quartile) on the LSAS (n= 22; 12 males, 10 females), whereas the HSA group included subjects who scored higher than 45 (upper quartile) on the LSAS (n=21; 6 males, 15 females). Materials Assessment of empathic abilities Two self-report scales were used to assess empathic abilities. Affective empathy was evaluated by the Questionnaire Measure of Emotional Empathy (QMEE) (34) – a widely utilized instrument that evaluates the affective role taking ability, tapping the likelihood of the tendency to react emotionally to the observed experiences of other people in a variety of contexts. Both affective and cognitive empathy were further assessed using the Interpersonal Reactive Index (IRI) (35). This instrument consists of four seven-item subscales each tapping a separate component of empathy. The perspective taking scale (PT) measures the reported tendency to spontaneously adopt the psychological point of view of others in everyday life. The fantasy scale (FS) measures the tendency to imaginatively transpose oneself into fictional situations. Those two scales are considered to tap the cognitive facet of empathy. On the other hand the two other empathy scales measure an affective facet of empathy: the empathic concern (EC) scale assesses the tendency to experience feelings of sympathy and compassion for others and the personal distress scale (PD) taps the tendency to experience distress and discomfort in response of others’ observed distress. It has been suggested that while the PT and the FS subscales of the IRI assess cognitive empathy, the PD and EC subscales tap affective empathy. Therefore we used the sum of the PT and FS as a cognitive empathy index and the sum of the PD and EC as affective empathy indexes. The selection of the IRI scales was based on a pretest designed to evaluate the Hebrew version of these instruments, reliability analysis of the Hebrew versions of these empathy scales yielded high reliability coefficients for both the cognitive empathy scale (Alpha=0.79) and the affective empathy scale (Alpha = 0.82) (36). ToM Task: Cognitive and affective mental inference and a mentalistic significance of eye direction: This computerized task (programmed using E-prime) is based on a task described previously by Baron-Cohen (37) and involves the ability to judge mental states based on verbal and eye gaze cues. The task consists of 64 trials, each showing a cartoon outline of a face (named Yoni) and four colored pictures of either objects belonging to a single category (e.g., fruits, chairs) or faces, one in each corner of the computer screen. The subject’s task is to point to the correct answer (the image Yoni is referring to), based on a sentence that appears at the top of the screen and available cues such as Yoni’s eye gaze, Yoni’s facial expression or the face’s (the one Yoni is referring to) eye gaze and facial expression (Figure 1). There are three main conditions: “cognitive” (24 trials), “affective” (24 trials) and “physical” (16 trials), each requiring either a 1st (32 trials) or a 2nd (32 trials) order inference. The cognitive and the affective conditions involve mental inferences whereas the physical condition requires a choice based on a physical attribute of the character (thus serving as a control condition, to ensure that the subject understands the task). In the first order cognitive conditions (Figure 1a), both Yoni’s facial expression and the verbal cue are neutral, whereas in the affective conditions Figure 1a), both cues provide affective (For example: Yoni is thinking of ___ [Cog 1. condition] vs. Yoni loves___ [Aff 1. condition]). Each ToM condition had a control physical condition to control for errors made due to attention and working memory deficits. The control physical conditions also served as a test of the ability to understand the instructions and follow the task demands and assess basic visual scanning abilities. In the 2nd order condition (Cog2, Aff2, Phy2) the four stimuli consist of face images and the choice of the correct response requires understanding of the interaction between each of these figures and Yoni’s mental state Figure 1b). In 70% of the 2nd trials Yoni’s eye gaze is directed at one of the four faces stimuli (the correct answer) and in 30% trials Yoni’s gaze is directed straight ahead. (This was done after a pilot study that demonstrated that some subjects responded automatically to the stimuli to which the Yoni’s gaze was directed and avoided reading the sentences.) When Yoni’s gaze is directed straight ahead the decision must be based on the verbal cue and the face’s gaze. Subject’s performance was rated for accuracy and reaction time.... |