Anger experience and expression in social anxiety disorder: Pretreatment profile and predictors of...

BEHAVIOR THERAPY 34, 331--350, 2003

Anger Experience and Expression in Social Anxiety Disorder: Pretreatment Profile and Predictors of Attrition and Response

to Cognitive-Behavioral Treatment

BRIGETTE A . ERWIN

RICHARD G. HEIMBERG

Adult Anxiety Clinic, Temple University

FRANKLIN R . SCHNEIER

MICHAEL R . LIEBOWITZ

Anxiety Disorders Clinic, New York State Psychiatric Institute and Columbia University

The present study examined social anxiety, anger, and depression among 234 persons with social anxiety disorder and 36 nonanxious controls. In addition to greater social anxiety, persons with social anxiety disorder exhibited more severe depression, greater anger, and poorer anger expression skills than did nonanxious control participants. Analyses investigating attrition and response to cognitive-behavioral group treatment (CBGT) among a subset of 68 persons treated for social anxiety disorder indicated that patients who experienced anger frequently, perceived unfair treatment, and were quick-tempered were less likely to complete a 12-session course of CBGT. Among treatment completers, significant reductions in the frequent experience of anger to perceived negative evaluation and in anger suppression were noted. However, those who suppressed anger responded less favorably to CBGT. Future directions and clinical implications are discussed.

Social anxiety disorder is characterized by fear of embarrassment and humiliation in social and performance situations (American Psychiatric

Brigette A. Erwin is now at the Department of Psychiatry at the University of Pennsylvania School of Medicine, Philadelphia, PA.

This study was supported by grants from the National Institute of Mental Health to Richard G. Heimberg (MH44119), Michael R. Liebowitz (MH40121), and to the New York State Psychiat- ric Institute MHCRC (PO5 MH30906). Portions of this paper were presented at the annual meetings of the Anxiety Disorders Association of America, Boston, March 1998, and the Asso- ciation for Advancement of Behavior Therapy, New Orleans, November 2000, and Philadelphia, November 2001.

Address correspondence to Brigette A. Erwin, Department of Psychiatry, University of Penn- sylvania School of Medicine, 11 Gates, 3400 Spruce Street, Philadelphia, PA 19104; e-mall: berwin @ mail.med.upenn.edu.

331 005-7894/03/0331~)35051.00/0 Copyright 2003 by Association for Advancement of Behavior Therapy

All rights for reproduction in any form reserved.

332 ERWIN ET AL.

Association, 1994). It is a chronic condition (Reich, Goldenberg, Vasile, Gois- man, & Keller, 1994; Turner, Beidel, Dancu, & Keys, 1986) associated with significant social, educational, and vocational impairment (Liebowitz, Gor- man, Fyer, & Klein, 1985; Schneier et al., 1994; Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992; Turner et al., 1986). In one study, persons with social anxiety disorder reported that their academic functioning (84.6%), their occupational functioning (92.3%), and their general social relationships (69.2%) were significantly impaired. Fifty percent of single participants rated their heterosocial relationships as impaired (Turner et al.). Not surprisingly, persons with social anxiety disorder rate their quality of life very low (Safren, Heimberg, Brown, & Holle, 1997).

Empirical studies suggest that socially anxious persons expect others to view them critically, regardless of the nature of the social contact (Leafy, Kowalski, & Campbell, 1988), and believe that other people hold unexpressed expectations that they cannot meet (Alden & Wallace, 1991). Clinical observation also suggests that some persons with social anxiety disorder may experience intense anger at others upon perceived negative evaluation or when others expect them to engage in activities that are anxiety provoking. In preliminary studies, individuals with social anxiety disorder have been shown to exhibit a greater tendency to experience anger across a range of situations, an increased tendency to experience and express anger without provocation, and a greater propensity to express anger when criticized than nonanxious controls (Fitzgibbons, Franklin, Watlington, & Foa, 1997; Meier, Hope, Weilage, Elting, & Laguna, 1995). Furthermore, less belief in the trustworthiness and dependability of others has been associated with social anxiety (e.g., Collins & Read, 1990; Hazen & Shaver, 1987; Rapee & Heimberg, 1997; Trower & Gilbert, 1989; Walters & Hope, 1998). In a more recent investigation (Kachin, Newman, & Pincus, 2001), individuals with social anxiety disorder completed the Inventory of Interpersonal Problems (Horowitz, Rosenberg, Bear, Ureno, & Villansenor, 1988), and cluster analysis of their responses revealed two distinct groups. One evidenced problems with unassertiveness, exploit- ability, and overnurturance; however, the other was characterized by problems with anger, hostility, and mistrustfulness. Thus, it appears that at least a subset of persons with social anxiety disorder may experience difficulties with anger.

The experience and expression of anger may create a unique dilemma among persons with social anxiety disorder. Although anger may be provoked by perceived negative evaluation (Alden & Wallace, 1991; Leary et al., 1988), if expressed, it may increase the real or perceived threat of further negative evaluation. Anger may therefore elicit anxiety and be suppressed in the ser- vice of anxiety reduction. Indeed, discomfort with and suppression of anger, as indicated by feeling resentful and secretly critical of others, seem to be characteristic of the anger expression style of persons with social anxiety disorder. Trait anger in persons with social anxiety disorder has been associated with fear of negative evaluation (Meier et al., 1995), and individuals with

A N G E R A N D SOCIAL ANXIETY 333

social anxiety disorder have been shown to be more likely to suppress anger than nonanxious controls (Fitzgibbons et al., 1997). Anger suppression may have its own deleterious effects. Those who experience but suppress anger have higher rates of impairment and treatment noncompliance than those who do not (Begley, 1994; Clay, Anderson, & Dixon, 1993).

Cognitive-behavioral techniques are commonly used for the treatment of social anxiety disorder. Both qualitative (Juster & Heimberg, 1998) and meta-analytic reviews (e.g., Feske & Chambless, 1995; Gould, Buckminster, Pollack, Otto, & Yap, 1997; Taylor, 1996; see also Heimberg, 2002) suggest that these interventions are efficacious treatments for social anxiety disorder. One specific set of cognitive-behavioral techniques often employed in the treatment of social anxiety disorder is cognitive-behavioral group therapy (CBGT; Heimberg & Becker, 2002). CBGT has been shown to be superior to a credible placebo therapy (Heimberg et al., 1990) and similar in efficacy to the monoamine oxidase inhibitor phenelzine (Heimberg et al., 1998). Fur- ther, CBGT patients maintained gains at 4.5-6.25-year follow-up (Heimberg, Salzman, Holt, & Blendell, 1993) and were less likely than patients receiving phenelzine to relapse over the course of 6 months of maintenance treatment and 6 months of follow-up (Liebowitz et al., 1999). However, despite the demonstrated efficacy of CBGT and other cognitive-behavioral techniques for social anxiety disorder, some patients do not achieve clinically significant improvement by the end of treatment. There is a strong need to determine who will and will not complete or respond to cognitive-behavioral treatments for social anxiety disorder.

Few predictors of treatment outcome for social anxiety disorder have yet been identified. Pretreatment level of depression (e.g., Chambless, Tran, & Glass, 1997), subtype of social anxiety disorder (e.g., E. J. Brown, Heimberg, & Juster, 1995; Hope, Herbert, & White, 1995), compliance with homework assignments (Leung & Heimberg, 1996), and expectancy for treatment outcome (e.g., Chambless et al., 1997; Safren, Heimberg, & Juster, 1997) are among those variables that have been shown to predict treatment outcome. It is likely that factors related to anger also may interfere with treatment completion and response. For instance, in group therapy, patients who are high in anger may be less likely to affiliate with other patients, to be accepted by other patients, or both. In addition, patients high in anger may attend to thoughts and physi- ological reactions associated with their emotional experience of anger, thereby interfering with cognitive and emotional processing of anxiety-related informa- tion presented in treatment.

Despite preliminary findings of both elevated anger and anger suppression among persons with social anxiety disorder, anger in this population has received strikingly little attention. The present study examined relationships among social anxiety, anger, interpersonal trust, and depression. In addition, persons with social anxiety disorder and nonanxious controls were compared on measures of social anxiety, anger experience, anger expression, interpersonal trust, and depression. We expected that patients would exhibit greater

334 E R W I N ET AL.

social anxiety, greater anger, poorer anger expression skills, less interpersonal trust, and greater depression than control participants. We also explored whether anger and anger expression styles predicted attrition and response to CBGT and whether anger decreases and anger expression styles become more adaptive as a result of CBGT among persons with social anxiety disorder. We hypothesized that greater difficulties in anger experience and expression would be associated with greater attrition and poorer response to treatment and that anger experience and expression styles would improve as a result of CBGT.

Method Participants

Participants were 135 men and 99 women who sought treatment for interpersonal and performance anxiety at the Adult Anxiety Clinic of Temple University (AACT; n = 151), the Center for Stress and Anxiety Disorders of the University at Albany, State University of New York (CSAD; n = 25), or the Anxiety Disor- ders Clinic of the New York State Psychiatric Institute (NYSPI; n = 58); or who were recruited by the AACT to participate in a study of persons without significant psychological distress (nonanxious control participants; n = 36).

Before patients with social anxiety disorder were accepted into the current study, they underwent a semi-structured diagnostic interview. The Anxiety Disorders Interview Schedule for DSM-IV-Lifetime Version (ADIS-IV-L; DiNardo, Brown, & Barlow, 1994) was administered to patients at AACT and CSAD. The Structured Clinical Interview for DSM-IV-Patient Version (SCID-I/P; First, Spitzer, Gibbon, & Williams, 1996) was administered to patients at NYSPI. Patients received a principal diagnosis of DSM-IV social anxiety disorder and may also have met criteria for additional psychiatric diagnoses. Patients with principal diagnoses other than social anxiety disorder, or comorbid diagnoses of schizophrenia, clinically significant depression that was associated with prominent risk of self-harm, or an organic mental disorder were excluded from the study. Nonanxious controls were recruited from the greater Philadelphia community and paid to participate in a study of persons without significant psychological distress. Controls were recruited in such a way that they would closely reflect the AACT patient sample on the demographic characteristics of age, race, and sex. Control participants were interviewed with the ADIS-IV-L and did not meet criteria for any current Axis I diagnosis other than, in one case, specific phobia. Subsequent to completion of the diagnostic interview and prior to the commencement of treatment for patients, participants completed a battery of questionnaires that assessed demographic characteristics, social anxiety, anger, trust, quality of life, and depression.

Materials and Procedures

Semistructured diagnostic interview. Administered by a Ph.D. psycholo- gist or an advanced doctoral student in clinical psychology at AACT and

ANGER AND SOCIAL ANXIETY 335

CSAD, the ADIS-IV-L provides DSM-IV diagnoses for a subset of psychiatric disorders, including anxiety disorders, depressive disorders, and substance use disorders. Interviewers were trained in accordance with the criteria speci- fied by T. A. Brown, DiNardo, Lehman, and Campbell (2001). Specifically, trainees first studied the user's guide and observed at least three live interviews, which were conducted by a senior interviewer. While observing live interviews, the trainee made ratings and assigned diagnoses, which were later discussed with the senior interviewer. Thereafter the trainee conducted a min- imum of three interviews with the senior interviewer in the room. The trainee conducted the interview, but the senior clinician observed and interjected questions as needed. The trainee and senior interviewer derived diagnoses independently. Before the trainee could act as a diagnostic interviewer, the trainee must have agreed with the senior interviewer on three consecutive interviews on the principal diagnosis and on the presence of all additional current and lifetime diagnoses. Brown and colleagues reported a K of .77 for a principal diagnosis of social anxiety disorder in a sample of 362 anxiety disorder patients who received two independent ADIS-IV-L interviews. In a sample of 87 patients from the current study who were also interviewed by a second assessor who administered the social anxiety disorder module of the ADIS-IV-L, there was 100% agreement with the original principal diagnosis of social anxiety disorder (K = 1.0).

Administered at NYSPI by psychiatric and nursing staff, the SCID-I/P is widely used to determine DSM-IV diagnoses. Training in the administration of the SCID-I/P was conducted in a manner similar to that of the ADIS-IV-L. Evaluations of the reliability of diagnosis with the DSM-IV version of the SCID-I/P have been quite favorable (Ventura, Liberman, Green, Shaner, & Mintz, 1998). However, interrater agreement of SCID diagnoses was not assessed in this study.

Assessment of Clinical and Impairment Variables

All patients completed questionnaires that assess social anxiety disorder, interpersonal trust, quality of life, and depression. The Social Interaction Anxiety Scale (SIAS) and the Social Phobia Scale (SPS) measure anxiety in social interaction situations and in situations in which the person may be observed by others, respectively (Mattick & Clarke, 1998). Both the SIAS and SPS consist of 20 items] which are rated on a 5-point Likert-type scale from 0 (not at all characteristic) to 4 (extremely characteristic). Sample SIAS items include, "I feel I will say something embarrassing when talking" and "I have difficulty making eye contact with others" Sample SPS items include, "I get nervous that people are staring at me as I walk down the street" and "I worry I might do something to attract the attention of other people" Both the

1 Two versions of the SIAS are currently available, one with 19 items, the other with 20 items. We used the 20-item version, which has been much more commonly used in published research.

336 ERWIN ET AL.

SIAS and the SPS have been shown to be reliable instruments for the assessment of social anxiety disorder and to possess a high degree of convergent validity with other indices of social anxiety and avoidance (E. J. Brown et al., 1997; Heimberg, Mueller, Holt, Hope, & Liebowitz, 1992; Mattick & Clarke).

Based upon the original 30-item Fear of Negative Evaluation Scale (Wat- son & Friend, 1969), the 12-item Brief Fear of Negative Evaluation Scale (BFNE; Leary, 1983) assesses the degree to which people are fearful of the prospect of negative evaluation by others and perceive themselves to exhibit overt behavioral manifestations of that fear. Items are rated on a 5-point Likert- type scale, from 1 (not at all characteristic) to 5 (extremely characteristic). Sample items include, "When I am talking to someone, I worry about what they're thinking about me" and "Sometimes I think I 'm too concerned with what others think of me?' Leary reported that the internal consistency (e~ = .90) and test-retest reliability (r = .75) are strong. Scores on the BFNE were highly correlated (r = .96) with scores on the original measure. Participants' BFNE scores correlated with their verbal reports of how well they come across to others and how much they are bothered by negative evaluation by others. The BFNE is also related, in the expected direction, with other measures of social avoidance and anxiety.

The Revised Adult Attachment Scale-DEPEND subscale (RAAS- DEPEND; Collins, 1996) is one of three subscales of the RAAS, an updated version of the Adult Attachment Scale originally developed by Collins and Read (1990). RAAS-DEPEND is a 6-item measure of the degree to which one believes others can be trusted and depended upon when needed. Items are rated on a scale from 1 (not at all characteristic of me) to 5 (very characteristic of me). Sample items include, "I find it difficult to trust others com- pletely" and "I am not sure that I can always depend on others to be there when I need them?' The RAAS-DEPEND subscale has demonstrated adequate internal consistency and test-retest reliability over a 2-month time period (Collins & Read). Validity of the RAAS and its subscales has been demonstrated through association with earlier measures of attachment (Hazen & Shaver, 1987).

The Quality of Life Inventory (QOLI; Frisch, Cornell, Villanueva, & Retz- laff, 1992) is a measure of life satisfaction designed to complement symptom- oriented measures of psychological functioning. Ratings are obtained on a 3-point (0 to 2) scale of importance and a 6-point ( - 3 to +3) scale of satisfaction for 16 areas of life. Items probe the importance of and satisfaction with life domains such as friendships, romantic relationships, career, and self-esteem. Total scores are based upon the average of one's satisfaction with all 16 areas of life, weighted for the individual importance of those areas of life. Retest reliability (r = .80 to .91) and internal consistency of the QOLI (~ = .98) are high (Frisch et al., 1992). The QOLI is positively correlated with seven widely used measures of subjective well-being and life satisfaction and negatively related to measures of depression, anxiety, and general psychopathology. In the current investigation, control participants did not


complete this measure. Previous studies suggest that QOLI scores of patients with social anxiety disorder are substantially lower than those of comparison samples and improve as a function of cognitive-behavioral therapy (Eng, Coles, Heimberg, & Safren, 2001; Safren, Heimberg, Brown, et al., 1997).

Finally, the Beck Depression Inventory (BDI; Beck, Rush, Shaw, & Emery, 1979) is a 21-item paper-and-pencil measure of depressive symptoms and attitudes. Items are rated on a scale from 0 to 3, from neutral to maximal severity. Beck, Steer, and Garbin (1988) reported excellent reliability and validity for the BDI. With regard to internal consistency, coeffi- cient alpha values range from .76 to .95 with a mean of .86 in clinical samples. Stability coefficients range from .48 to .86 in clinical samples. The psychometric characteristics of the BDI in a sample of persons with social anxiety disorder were recently reported by Coles, Gibb, and Heimberg (2001).

Assessment of Anger Variables The State-Trait Anger Expression Inventory (STAXI; Spielberger, 1988) is

a 44-item measure designed to measure the experience and expression of anger. Anger experience scales include (1) State Anger, a 10-item scale (range = 10 to 40) that measures the intensity of anger as an emotional state at a particular time (e.g., "I feel like yelling at somebody"); and (2) Trait Anger, a 10-item scale (range = 10 to 40) that measures the disposition to experience anger in a wide range of situations (e.g., "It makes me furious when I am criticized in front of others"). Trait anger is further composed of two subscales: (3) Angry Temperament, a 4-item scale (range = 4 to 16) that measures the tendency to experience and express anger without provocation (e.g., "I am quick-tempered"); and (4) Angry Reaction, a 4-item scale (range = 4 to 16) that measures the inclination to express anger when criticized, evaluated negatively, or treated unfairly by others (e.g., "I get angry when I'm slowed down by others' mistakes"). Finally, three subscales measure the manner in which anger is managed and expressed: (5) Anger-In, an 8-item scale (range = 8 to 32) that measures the tendency to suppress anger or direct it inward (e.g., "I tend to harbor grudges that I don't tell anyone about"); (6) Anger-Out, an 8-item scale (range = 8 to 32) that measures the tendency to aggressively direct anger toward other people or objects (e.g., "I slam doors"); and (7) Anger Control, an 8-item scale (range = 8 to 32) that measures the tendency to monitor and control the expression of anger (e.g., "I control my angry feelings"). The STAXI is a widely used measure of anger experience and anger expression. The state and trait anger subscales and the anger expression subscales demonstrate adequate convergent and discrimi- nant validity as well as test-retest reliability (Jacobs, Latham, & Brown, 1988; Spielberger, 1988). For instance, among college students, trait anger evidenced moderate to strong associations with other measures of hostility (range: r = .27 to .71) and weak associations with measures of extraversion (range: r = -.03 to -.08) and curiosity (range: r = -.07 to -.08). Similarly,

338 ERWIN ET AL.

anger-in and anger-out evidenced moderate associations with anger in response to anger-provoking vignettes (anger-in range: r = - .26 to -.42; anger-out range: r = .24 to .36), low to moderate associations with measures of blood pressure (anger-in range: r = .16 to .47; anger-out range: r = - .13 to .05), and weak associations with measures of curiosity (anger-in range: r = -.01 to .06; anger-out range: r = .00 to .02).

Treatment

Of the 234 patients who were assessed at baseline, 68 patients participated in CBGT for social anxiety disorder (Heimberg & Becker, 2002), all of whom were recruited by the AACT. The remaining patients were either recruited by the CSAD or the NYSPI; or were recruited by the AACT but received non-cognitive- behavioral treatment in the study of Heimberg and colleagues (1998) or a study currently underway examining the efficacy of combined pharmacotherapy and CBGT for social anxiety disorder (Heimberg & Liebowitz, 2001); or did not ini- tiate treatment at the AACT. Because the current investigation sought to under- stand the relationships among social anxiety disorder, cognitive-behavioral treatment, and anger, analyses related to attrition and treatment response were limited to this sample of patients who received CBGT for social anxiety disorder.

Groups of five or six patients and two therapists met for twelve 2.5-hour weekly sessions. Patients were presented with a cognitive-behavioral model of social anxiety disorder, trained in cognitive restructuring skills (identifying maladaptive automatic thoughts, disputing cognitive errors in these automatic thoughts, and developing rational responses), and asked to complete in- session exposures to simulated feared situations. Patients also completed homework assignments for in vivo exposure to feared situations and employed cognitive restructuring skills before, during, and after these exposures. For a more detailed description of CBGT for social anxiety disorder, see Heimberg and Becker (2002) and Turk, Heimberg, and Hope (2001).

Assessment of treatment outcome. All measures described above were re- administered at the conclusion of the 12-week treatment.

Results Demographic Characteristics of the Study Sample

The three patient groups (AACT, CSAD, and NYSPI) were compared on categorical and continuous demographic variables using chi-square analyses and one-way analyses of variance (ANOVAs), respectively. The groups differed only with regard to race such that a smaller proportion of Caucasians and a greater proportion of Hispanics participated at NYSPI than at the other sites. However, one-way ANOVAs indicated that race was unrelated to all anger variables employed in the current investigation; 2 therefore, for subsequent

z Contact Brigette A. Erwin to obtain the results of the one-way ANOVAs that indicate that race is unrelated to all anger variables employed in the current investigation.


TABLE 1 COMPARISON OF PATIENTS AND NONANXIOUS CONTROLS ON DEMOGRAPHIC VARIABLES

Patients Controls n = 234 n = 36

/,/ O~ /,/ % }{2

Sex 0.31 Female 99 42.31 17 47.22 Male 135 57.69 19 52.78

Marital Status 4.28* Unmarried 187 79.91 34 94.44 Married 46 19.66 2 5.56

Education 2.20 Completed college 109 46.58 22 61.11 Did not complete college 119 50.85 14 38.89

Race 4.75 Caucasian 150 64.10 22 61.11 African American 42 17.95 10 27.78 Hispanic 20 8.55 1 2.78 Asian 11 4.70 3 8.33 Other 7 2.99 0 0.00

M SD M SD t Age (years) 33.71 10.02 33.03 10.68 -0.38

*p < .05.

ana lyses , the three pat ient groups were combined . Table 1 presents compar i - sons be tween the 234 pat ients and 36 nonanxious controls on ca tegor ica l and cont inuous demograph ic var iables . The compar i sons were made us ing chi- square analyses and t tests o f independent means , respect ively. The groups differed only with regard to mar i ta l status (more controls than pat ients were single) . Because data were miss ing for some measures , sample sizes vary s l ight ly in these and the fo l lowing analyses .

Pretreatment Clinical and Impairment Characteristics of the Study Sample

Patients and nonanxious controls differed on near ly all c l in ical and impair - ment measures (see Table 2). Af te r Bonfer roni correct ion, persons wi th social anxie ty d i sorder ev idenced more severe symptoms o f social anxie ty and more ext reme symptoms o f depress ion than the nonanxious controls , and the effect sizes for these compar i sons were large. 3 Patients and controls did not differ on the measure of in terpersonal trust after Bonfer roni correct ion. Because the

3 Cohen's d effect size interpretations for t tests (.20 = small, .50 = moderate, .80 = large) were used throughout this study (Cohen, 1990).

340 ERWIN ET AL.

T A B L E 2 COMPARISON OF PATIENTS AND NONANXIOUS CONTROLS ON CLINICAL

AND IMPAIRMENT VARIABLES

Patients Controls

n = 234 n = 36 Effect

M SD M SD t Size

Brief Fear of Negative Evaluation Scale 40.31 8.11 21.94 5.78 - 1 3 . 0 1 " * * 2.33 Social Interaction Anxiety Scale 48.95 15.37 11.67 9.32 - 19.76"** 2.53

Social Phobia Scale 31.08 15.75 4.61 5.94 - 1 7 . 9 3 " * * 1.78 Revised Adult Attachment Scale-DEPEND 15.91 5.23 18.03 4.53 2.29 0.41 Beck Depression Inventory 12.92 8.66 1.53 1.90 - 1 6 . 5 4 " * * 1.40 Quality of Life Inventory 0.04 1.85 . . . .

Note. A Bonferroni-corrected family-wise p-value of .01 (.05/5) was employed in these analyses. Cohen 's d effect size interpretations for t tests (.20 = small, .50 = moderate, .80 = large) were used. ***p < .001.

QOLI was not administered to the nonanxious controls, comparisons between the patients and controls on this measure were not possible; however, the mean score of the patient sample (M -- 0.04; SD = 1.85) was quite low in comparison to normative samples (Frisch, 1994; M = 2.6; SD = 1.3) and similar to previously studied samples of persons with social anxiety disorder (M = 0.79; SD = 1.62; Safren, Heimberg, Brown, et al., 1997).

Correlation of Anger Experience and Anger Expression With Measures of Social Anxiety, Depression, Quality of Life, and Interpersonal Trust

Table 3 presents Pearson correlation coefficients for the patient sample of the STAXI subscales with measures of social anxiety, depression, quality of life, and interpersonal trust. After Bonferroni correction, state anger, trait anger, angry reaction, and anger-in evidenced significant associations with several of these measures. Angry temperament, anger-out, and anger control were unrelated to the clinical/impairment measures. The strongest relationships (r > 1.451) were between state anger and increased depression and reduced quality of life, and between anger-in and increased social interaction anxiety, reduced interpersonal trust, and lower quality of life.

Pretreatment Anger in the Study Sample

The patients and nonanxious controls were compared on measures of anger experience and anger expression using t tests (see Table 4). After Bonferroni correction, patients endorsed greater anger and poorer anger expression skills than nonanxious controls. With regard to the experience of anger, persons with social anxiety disorder evidenced greater intensity of situationally experienced anger (state anger), disposition to experience anger in a wide range of


TABLE 3 CORRELATION OF MEASURES OF SOCIAL ANXIETY, DEPRESSION, QUALITY OF LIFE, AND

TRUST WITH ANGER EXPERIENCE AND ANGER EXPRESSION

STAXI

Brief Fear Social Revised Adult of Negative Interaction Socia Attachment Beck Quality Evaluation Anxiety Phobia Scale- Depression of Life

Scale Scale Scale DEPEND Inventory Inventory

State anger 0.03 0.17 0.20 t -0.26*** 0.46*** -0.45*** Trait anger 0.26*** 0.18 0.23*** -0.24*** 0.23*** -0.19 Angry reaction 0.23*** 0.26*** 0.2T -0.29*** 0.24*** -0.20 t Angry

temperament 0.18 0.03 0.14 -0.09 0.14 -0.11 Anger-in 0.26*** 0.49*** 0.35*** -0.48*** 0.36*** -0.46*** Anger-out 0.02 -0.13 0.06 -0.03 0.01 0.11 Anger control -0 .04 0.03 0.03 0.02 0.01 0.07

Note. Correlational analyses are computed only for the patient sample, n = 234. A Bonferroni- corrected family-wise (within anger subscale) p-value of .008 (.05/6) was employed in these analyses. STAXI = State-Trait Anger Expression Inventory. *p < .008. ***p < .001.

situations (trait anger), inclination to express anger when criticized, evaluated negatively, or treated unfairly by others (angry reaction), and tendency to experience and express anger without provocation (angry temperament). The effect sizes for these analyses were in the moderate range. With regard to anger expression, persons with social anxiety disorder were more likely than

TABLE 4 COMPARISON OF PATIENTS AND NONANXIOUS CONTROLS ON THE ANGER EXPERIENCE

AND ANGER EXPRESSION SUBSCALES OF THE STAXI

Patients Controls n = 234 n = 36 Effect

M SD M SD t Size

STAXI state anger 13.61 4.70 10.28 0.91 -9.22*** 0.76 STAXI trait anger 18.70 5.13 15.50 4.36 -3.53*** 0.63 STAXI angry reaction 9.22 2.72 7.83 2.58 -2.85 t 0.51 STAXI angry temperament 6.31 2.47 5.08 1 . 7 5 -3.63*** 0.51 STAXI anger-in 20.55 5.21 13.61 3.52 - 10.01"** 1.38 STAXI anger-out 14.20 3.42 14.17 3.13 -0.05 0.01 STAXI anger control 23.13 4.61 25.22 4.11 2.55 0.46

Note. A Bonferroni-corrected family-wise p-value of .007 (.05/7) was employed in these analyses. Cohen's d effect size interpretations for t tests (.20 = small, .50 = moderate, .80 = large) were used. STAXI = State-Trait Anger Expression Inventory. tp < .007. ***p < .001.

342 ERWIN ET AL.

controls to suppress anger or direct it inward (anger-in), and a large effect size was noted for this comparison. Persons with social anxiety disorder were no less likely than nonanxious controls to aggressively direct anger toward other people or objects (anger-out) or to monitor and control the expression of anger (anger control).

Relationship of Pretreatment Anger to Attrition From CBGT

In preliminary analyses, patients who discontinued treatment before the posttreatment assessment (n = 19; 27.9%) were compared to treatment completers (n -- 49; 72.1%) on pretreatment demographic, clinical, and impairment measures. Completers and noncompleters did not differ on sex, x2(df = 1, n = 68) = 1.08, ns, ES = 0.13, marital status, x2(df = 1, n = 68) = 2.04, ns, ES = 0.17, education, x2(df = 1, n = 66) = 3.04, ns, ES = 0.21, race, x2(df = 1, n = 65) = 6.97, ns, ES = 0.33, or age, t(64) = -0 . 05 , ns; ES = -0 . 01 , or on measures of social anxiety, trust, quality of life, or depression: BFNE t(63) = -0 .4 5 , ns; ES = -0 .13 ; SIAS t(63) = 1.05, ns; ES = 0.29; SPS t(63) = 1.68, ns; ES = 0.47; RAAS-DEPEND t(63) = -0 .24 , ns; ES = -0 .08; QOLI t(61) = -0 .64 , ns; ES = -0 .18; BDI t(62) = -0 .16 , ns; ES = -0 .04 .

Completers and noncompleters were then compared on pretreatment measures of anger experience and anger expression (see Table 5). Patients who did not complete treatment endorsed a greater disposition to experience anger in a wide range of situations (trait anger), a greater tendency to experience and express anger without provocation (angry temperament), and a greater inclination to express anger when criticized, evaluated negatively, or treated unfairly by others (angry reaction). The magnitude of these effects was in the moderate range. Because of sample size limitations, Bonferroni correction

T A B L E 5 COMPARISON OF CBGT COMPLETERS AND NONCOMPLETERS ON THE ANGER

EXPERIENCE AND ANGER EXPRESSION NUBSCALES OF THE STAXI

Completers Noncompleters n = 4 9 n = 19

Effect M SD M SD t Size

STAXI state anger 13.55 4.74 13.65 4.70 0.07 0.02

STAXI trait anger 17.66 4.33 21.25 5.42 2.69** 0.76 STAXI angry reaction 9.09 2.47 10.63 2.25 2.20* 0.63 STAXI angry temperament 5.57 1.90 7.29 2.73 2.83** 0.78 STAXI anger-in 21.19 5.57 21.69 5.12 0.31 0.09 STAXI anger-out 13.57 2.86 15.24 4.09 1.54 0.51 STAXI anger control 23.83 4.21 22.06 5.15 - 1.40 0.39

Note. Cohen 's d effect size interpretations for t tests (.20 = small, .50 = moderate, .80 = large) were used. STAXI = State-Trait Anger Expression Inventory. *p < . 05 .**p < .01.


TABLE 6 CHANGE FROM PRETREATMENT TO POSTrREATMENT ON THE ANGER EXPERIENCE AND ANGER

EXPRESSION SUBSCALES OF THE S T A X I

Pretreatment Posttreatment Effect

M SD M SD t Size

STAXI state anger 13.43 4.86 13.14 5.08 0.41 0.06 STAXI trait anger 17.62 4.29 16.67 4.27 2.13* 0.22 STAXI angry reaction 9.05 2.48 8.34 2.71 2.43* 0.27 STAXI angry temperament 5.59 1.90 5.39 1.69 0.75 0.11 STAXI anger-in 21.02 5.67 19.14 5.22 2.71"* 0.34 STAXI anger-out 13.44 2.91 13.88 3.30 - 1.20 0.14 STAXI anger control 24.00 4.31 23.19 4.50 1.18 0.18

Note. n = 49. Cohen 's d effect size interpretations for t tests (.20 = small, .50 = moderate, .80 = large) were use& STAXI = State-Trait Anger Expression Inventory. *p < .05. * * p < .01.

was not employed in these analyses, and these findings should be interpreted with caution.

Change in Anger Experience and Expression in CBGT

The pre- and posttreatment anger experience and anger expression scores of patients who completed treatment were compared using paired sample t tests (see Table 6). Patients evidenced reductions in the disposition to experience anger in a wide range of situations (trait anger), the inclination to express anger when criticized, evaluated negatively, or treated unfairly by others (angry reaction), and the propensity to suppress anger or direct it inward (anger-in). The effects for these comparisons were small. Because of sample size limitations, Bonferroni correction was not employed in these analyses, and these findings should be interpreted with caution.

Relationship of Pretreatment Anger to Treatment Response

The ability of pretreatment anger experience and anger expression scores to predict posttreatment social anxiety and depression was examined. Four regression equations were calculated for each of the seven anger experience and anger expression subscales. Pretreatment anger scores served as predic- tor variables and posttreatment scores on the BFNE, SIAS, SPS, and BDI as criterion variables in separate regression equations. Each regression equation was calculated with the relevant pretreatment social anxiety or depression score entered in step one, followed by the relevant pretreatment anger score entered in step two. Table 7 presents results of the regression equations for anger-in, state anger, and angry reaction. Higher pretreatment scores on anger-in and state anger significantly predicted higher posttreatment scores on the BFNE, SIAS, and BDI. Higher pretreatment scores on angry reaction

344 ERWIN ET AL.

T A B L E 7 RELATIONSHIP BETWEEN PRETREATMENT SCORES ON THE ANGER-IN, STATE ANGER,

AND ANGRY REACTION SUBSCALES OF THE STAXI AND POSTI'REATMENT SOCIAL ANXIETY AND DEPRESSION SCORES

Posttreatrnent Criterion Measures R 2 A F A B SE B [3

STAXI Anger-in Brief Fear of Negative Evaluation Scale 0.09 4.91 0.51 0.23 0.31" Social Interaction Anxiety Scale 0.08 7.41 0.86 0.32 0.33** Social Phobia Scale 0.02 2.06 0.34 0.24 0.16 Beck Depression Inventory 0.08 4.11 0.33 0.16 0.29*

STAXI State Anger Brief Fear of Negative Evaluation Scale 0.10 5.55 0.62 0.26 0.32* Social Interaction Anxiety Scale 0.09 8.56 0.97 0.33 0.32**

Social Phobia Scale 0.02 1.44 0.33 0.28 0.13 Beck Depression Inventory 0.15 9.29 0.60 0.20 0.45**

STAXI Angry Reaction Brief Fear of Negative Evaluation Scale 0.09 4.59 1.13 0.53 0.30* Social Interaction Anxiety Scale 0.03 2.17 1.02 0.70 0.17 Social Phobia Scale 0.05 4.25 1.14 0.56 0.24* Beck Depression Inventory 0.10 5.20 0.85 0.37 0.33**

Note. n = 49. Each regression analysis was calculated with the respective posttreatment criterion measure's pretreatment total score entered in step one, followed by the pretreatment STAXI total score entered in step two. STAXI = State-Trait Anger Expression Inventory. *p < .05. **p < .01.

significantly predicted higher posttreatment scores on the BFNE, SPS, and BDI. In addition, higher pretreatment scores on trait anger significantly predicted higher posttreatment scores on the BDI (R 2 A = 0.08, F A = 4.24, B = 0.45, SE B = 0.22, [3 = 0.30, p < .05). However, angry temperament, anger- out, and anger control were not significant predictors of any posttreatment measure of social anxiety or depression. 4 Because of sample size limitations, Bonferroni correction was not employed in these analyses, and these findings should be interpreted with caution.

Discussion This study examined anger experience and anger expression styles among

persons with social anxiety disorder and nonanxious controls. Persons with social anxiety disorder experienced elevated levels of anger and expressed that anger in more problematic ways than controls. Among patients, higher levels of state anger, trait anger, anger in response to perceived negative evaluation, and anger suppression were significantly associated with greater

4 A fuller report of these nonsignificant results is available from Brigette A. Erwin on request.


social anxiety and depression, less trust of other people, and lower perceived quality of life. In addition, indices of trait anger were associated with greater attrition from CBGT. Among patients who completed 12 sessions of CBGT, more intense episodes of anger, more chronic frustration and feelings of being treated unfairly by others, and greater anger suppression before treatment predicted greater posttreatment social anxiety and depressive symptom severity. For patients who remained in treatment, CBGT was associated with improvement in both trait anger and anger suppression.

Compared with nonanxious control subjects, patients with social anxiety disorder endorsed more extreme dysphoria. Similarly, persons with social anxiety disorder reported greater overall anger and poorer overall anger expression skills than nonanxious controls. Specifically, relative to controls, persons with social anxiety disorder reported more intense episodes of anger and more chronic frustration and feelings of being treated unfairly by others (Spielberger, 1988). With regard to the expression of anger, persons with social anxiety disorder indicated that they were more likely to suppress their anger (i.e., they endorsed items pertaining to harboring grudges, sulking, and being secretly critical of others) so that it may not be evident to others. Patients' mean score on the Anger-In subscale of the STAXI was greater by more than one standard deviation than that reported by control participants or by the normative sample (Spielberger, 1988). Thus, persons with social anxiety disorder may be more demanding and critical of others but hypersensitive to criticism themselves.

These findings substantiate clinical observation and the findings of preliminary investigations (Fitzgibbons et al., 1997; Meier et al., 1995). They suggest that a subset of persons with social anxiety disorder may experience both elevated levels of anger and maladaptive anger expression. Anger suppression in particular may be of substantial clinical importance, influencing both the pretreatment profile and response to treatment of persons with social anxiety disorder.

Due to sample size limitations, the analyses investigating attrition and response to CBGT did not control for experiment-wise error. Thus, these findings should be interpreted with caution and are in need of replication. The analyses of attrition indicated that persons with social anxiety disorder who frequently experienced anger, perceived unfair treatment, and were quick- tempered were less likely to complete CBGT. Demographic characteristics and measures of social anxiety, trust, quality of life, and depression were all unrelated to attrition. Although alternative hypotheses are plausible and the current investigation was not designed to investigate causal relationships, it is interesting to speculate whether such patients terminate treatment partially because they experience anger at the therapist or other group members, per- haps at having their vulnerabilities exposed or because they perceive the therapist as controlling and critical. This is an important area of investigation for future research.

Among CBGT completers, significant reductions in the frequent experience

346 ERWIN ET AL.

of anger in response to perceived negative evaluation and in anger suppression were noted. That anger in response to perceived negative evaluation and anger suppression evidenced improvement after 12 weeks of CBGT is intriguing. In CBGT, patients learn how to identify and modify maladaptive beliefs such as those that may also be associated with anger and other negative affects. Thus, do improvements in social anxiety generalize to anger? Alternatively, having the effect of distancing others, anger may serve as an avoidance mechanism that is less necessary after successful treatment for social anxiety. Reductions in anger suppression suggest that persons with social anxiety disorder are able to utilize more effective ways of asserting themselves so that they may have less need to suppress angry feelings. Reduc- tion in anger in response to perceived negative evaluation suggests that persons with social anxiety disorder no longer perceive negative evaluation as readily, that they have developed more adaptive ways of managing their response to perceived negative evaluation, or both. Nonetheless, it is ironic that one factor that may prevent someone with social anxiety disorder from completing treatment may improve if the patient perseveres.

Higher pretreatment levels of anger suppression and more intense episodes of anger predicted greater posttreatment fear of negative evaluation, social interaction anxiety, and depressive symptom severity. Greater pretreatment feelings of being treated unfairly by others predicted greater posttreatment fear of negative evaluation and of scrutiny by others and depressive symptom severity. More chronic pretreatment anger also predicted greater posttreatment depressive symptom severity. These pretreatment anger experience and expression variables accounted for significant additional variance in social anxiety and depressive symptom severity measures beyond that contributed by pretreatment scores. To the extent that anger suppression, intense episodes of anger, and chronic frustration and feelings of being treated unfairly predict poor treatment response and greater social anxiety and depressive symptom severity, it may be because they interfere with trust, rapport, and expectancy for treatment outcome.

This study supports clinical experience suggesting that persons with social anxiety disorder may have difficulty trusting others and expressing feelings of anger. If unidentified, these issues could lead to resentment of the therapist and interfere with the therapeutic alliance, expectations for outcome, and compliance with assignments to complete in vivo exposures. In fact, noncompliance with homework assignments (Leung & Heimberg, 1996) and poor expectancy for treatment outcome (e.g., Chambless et al., 1997; Safren, Heimberg, & Juster, 1997) are associated with poor treatment outcome among persons with social anxiety disorder. It may be that the disposition to experience anger across a range of situations mediates the relationship between these variables and treatment response. Thus, treatment for social anxiety disorder that includes assessment of and attention to anger may improve treatment compliance and completion. Carefully directing the patient toward his or her experience of anger and encouraging the patient to use the treatment


setting to test out assumptions and beliefs that are associated with the experience of anger may be particularly important since successful treatment of social anxiety disorder may also lead to reductions in anger and anger suppression.

This was the first study that explored relationships among anger and anger expression styles and attrition and response to CBGT among persons with social anxiety disorder. Comparisons of anger experience and anger expression styles of persons with social anxiety disorder to those of other clinical populations are necessary to determine the specificity of difficulties in anger experience and anger expression to social anxiety disorder. Nonetheless, the current investigation suggests the importance of anger and anger expression styles among individuals with social anxiety disorder with respect to distress, impairment, treatment completion, and treatment response. Also limiting the current investigation was that all assessments of anger were based on self- report. Self-report measures may not be the most appropriate indices of less socially acceptable constructs such as anger, particularly among patients with social anxiety disorder who, by definition, are concerned with evaluation. Future studies might include independent assessment and behavioral measures of anger experience and expression. Further, analyses exploring associations among anger, attrition, and treatment response were limited to the sample of patients who received CBGT. Although not the focus of the current investigation, the importance of investigating anger as it relates to pharmacological treatment and other psychosocial interventions is acknowledged and future studies might explore these associations. Also, the current investigation was not designed to explore ethnic differences in anger experience and expression. Such differences may be of substantial clinical importance both with respect to assessment and treatment and should be illuminated in future studies. Finally, follow-up assessments were not included in the current investigation; therefore it is not yet possible to determine whether improvements in anger or in social anxiety symptoms in the presence of anger are maintained over time.

References Alden, L. E., & Wallace, S. T. (1991). Social standards and social withdrawal. Cognitive Ther-

apy and Research, 15, 85-100. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disor-

ders (4th ed.). Washington, DC: Author. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New

York: The Guilford Press. Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the Beck

Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8, 77-100.

Begley, T. M. (1994). Expressed and suppressed anger as predictors of health complaints. Jour- nal of Organizational Behavior, 15,503-516.

Brown, E. J., Heimberg, R. G., & Juster, H. R. (1995). Social phobia subtype and avoidant personality disorder: Effect on severity of social phobia, impairment, and outcome of cognitive behavioral treatment. Behavior Therapy, 26, 467-486.

348 ERWIN ET AL.

Brown, E. J., Turovsky, J., Heimberg, R. G., Juster, H. R., Brown, T. A., & Barlow, D. H. (1997). Validation of the Social Interaction Anxiety Scale and the Social Phobia Scale across the anxiety disorders. Psychological Assessment, 9, 21-27.

Brown, T. A., DiNardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-IV anxiety and mood disorders: Implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110, 49-58.

Chambless, D. L., Tran, G. Q., & Glass, C. R. (1997). Predictors of response to cognitive- behavioral group therapy for social phobia. Journal of Anxiety Disorders, 11,221- 240.

Clay, D. L., Anderson, W. P., & Dixon, W. A. (1993). Relationship between anger expression and stress in predicting depression. Journal of Counseling and Development, 72, 91-94.

Cohen, J. (1990). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum.

Coles, M. E., Gibb, B. E., & Heimberg, R. G. (2001). A psychometric evaluation of the Beck Depression Inventory in adults with social anxiety disorder. Depression and Anxiety, 14, 145-148.

Collins, N. L. (1996). Working models of attachment: Implications for explanation, emotion, and behavior. Journal of Personality and Social Psychology, 71, 810-832.

Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship quality in dating couples. Journal of Personality and Social Psychology, 58,644-663.

DiNardo, R A., Brown, T. A., & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule for DSM-1V: Lifetime Version ( ADIS-IV-L ). Albany, NY: Graywind Publications.

Eng, W., Coles, M. C., Heimberg, R. G., & Safren, S. A. (2001). Quality of life following cognitive behavioral treatment for social anxiety disorder: Preliminary findings. Depression and Anxiety, 13,192-193.

Feske, U., & Chambless, D. L. (1995). Cognitive behavioral versus exposure only treatment for social phobia: A meta-analysis. Behavior Therapy, 26, 695-720.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. (1996). Structured Clinical Interview for DSM-IV Axis 1 Disorders-Patient Edition (SCID-I/P, Version 2.0). New York: Biometrics Research Department, New York State Psychiatric Institute.

Fitzgibbons, L., Franklin, M. E., Watlington, C., & Foa, E. B. (1997, November). Assessment of anger in generalized social phobia. Poster presented at the 31 st annual convention of the Association for Advancement of Behavior Therapy, Miami, FL.

Frisch, M. B. (1994). Quality of Life Inventory: Manual and treatment guide. Minneapolis, MN: National Computer Systems.

Frisch, M. B., Cornell, J., Villanueva, M., & Retzlaff, R J. (1992). Clinical validation of the Quality of Life Inventory: A measure of life satisfaction for use in treatment planning and outcome assessment. Psychological Assessment, 4, 92-101.

Gould, R. A., Buckminster, S., Pollack, M. H., Otto, M. W., & Yap, L. (1997). Cognitive-behavioral and pharmacological treatment for social phobia: A recta-analysis. Clinical Psychology: Science and Practice, 4, 291-306.

Hazen, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Jour- nal of Personality and Social Psychology, 52, 511-524.

Heimberg, R. G. (2002). Cognitive-behavioral therapy for social anxiety disorder: Current status and future directions. Biological Psychiatry, 51,101-108.

Heimberg, R. G., &Becker, R. E. (2002). Cognitive-behavioral treatment for social phobia: Basic mechanisms and clinical strategies. New York: The Guilford Press.

Heimberg, R. G., Dodge, C. S., Hope, D. A., Kennedy, C. R., Zollo, L. J., & Becker, R. E. (1990). Cognitive behavioral group treatment for social phobia: Comparison with a credible placebo control. Cognitive Therapy and Research, 14, 1-23.


Heimberg, R. G., & Liebowitz, M. R. (2001, July). Cognitive-behavioral group treatment and phenelzine for social anxiety disorder: Comparison of single-modality and combined treatments. Paper presented at the tri-annual meeting of the World Congress of Behavioral and Cognitive Therapies, Vancouver, British Columbia, Canada.

Heimberg, R. G., Liebowitz, M. R., Hope, D. A., Schneier, F. R., Holt, C. S., Welkowitz, L. A., Juster, H. R., Campeas, R., Bruch, M. A., Cloitre, M., Fallon, B., & Klein, D. F. (1998). Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome. Archives of General Psychiatry, 55, 1133-1141.

Heimberg, R. G., Mueller, G. E, Holt, C. S., Hope, D. A., & Liebowitz, M. R. (1992). Assess- ment of anxiety in social interaction and being observed by others: The Social Interaction Anxiety Scale and the Social Phobia Scale. Behavior Therapy, 23, 53-73.

Heimberg, R. G., Salzman, D. G., Holt, C. S., & Blendell, K. A. (1993). Cognitive behavioral group treatment for social phobia: Effectiveness at five-year follow-up. Cognitive Therapy and Research, 17, 325-339.

Hope, D. A., Herbert, J. D., & White, C. (1995). Diagnostic subtype, avoidant personality disorder, and efficacy of cognitive-behavioral group therapy for social phobia. Cognitive Ther- apy and Research, 19, 285-303.

Horowitz, L. M., Rosenberg, S. E., Bear, B. A., Ureno, G., & Villansenor, V. S. (1988). haven- tory of Interpersonal Problems: Psychometric properties and clinical applications. Journal of Consulting and Clinical Psychology, 56, 885-892.

Jacobs, G. A., Latham, L. E., & Brown, M. S. (1988). Test-retest reliability of the State- Trait Personality Inventory and the Anger Expression Scale. Anxiety Research, 1,263- 265.

Juster, H. R., & Heimberg, R. G. (1998). Social phobia. In A. S. Betlack & M. Hersen (Eds.), Comprehensive clinical psychology (Vol. 6, pp. 475-498). Oxford: Pergamon Press.

Kachin, K. E., Newman, M. G., & Pincus, A. L. (2001). An interpersonal problem approach to the division of social phobia subtypes. Behavior Therapy, 32,479-501.

Leary, M. R. (1983). A brief version of the Fear of Negative Evaluation Scale. Personality and Social Psychology Bulletin, 9, 371-375.

Leary, M. R., Kowalski, R. M., & Campbell, C. D. (1988). Self-presentational concerns and social anxiety: The role of generalized impression expectancies. Journal of Research in Personality, 22,308-321.

Leung, A. W., & Heimberg, R. G. (1996). Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia. Behaviour Research and Ther- apy, 34,423-432.

Liebowitz, M. R., Gorman, J. M., Fyer, A. J., & Klein, D. F. (1985). Social phobia: Review of a neglected anxiety disorder. Archives of General Psychiatry, 42,729-736.

Liebowitz, M. R., Heimberg, R. G., Schneier, F. R., Hope, D. A., Davies, S., Holt, C. S., Goetz, D., Juster, H. R., Lin, S. L., Bruch, M. A., Marshall, R., & Klein, D. K (1999). Cognitive- behavioral group therapy versus phenelzine in social phobia: Long-term outcome. Depres- sion and Anxiety, 10, 89-98.

Mattick, R. R, & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455- 470.

Meier, V. J., Hope, D. A., Weilage, M., Elting, D., & Laguna, L. (1995, November). Anger and social phobia: Its expression and relation to treatment outcome. Paper presented at the 29th annual convention of the Association for Advancement of Behavior Therapy, Wash- ington, DC.

Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research & Therapy, 35,741-756.

350 ERWIN ET AL.

Reich, J., Goldenberg, I., Vasile, R., Goisman, R., & Keller, M. (1994). A prospective follow- along study of the course of social phobia. Psychiatry Research, 54,249-258.

Safren, S. A., Heimberg, R. G., Brown, E. J., & Holle, C. (1997). Quality of life in social phobia. Depression and Anxiety, 4, 126-133.

Safren, S. A., Heimberg, R. G., & Juster, H. R. (1997). Client expectancies and their relationship to pretreatment symptomatology and outcome of cognitive-behavioral group treatment for social phobia. Journal of Consulting and Clinical Psychology, 65, 694- 698.

Schneier, F. R., Heckelman, L. R., Garfinkel, R., Campeas, R., Fallon, B. A., GRow, A., Street, L., Del Bene, D., & Liebowitz, M. R. (1994). Functional impairment in social phobia. Journal of Clinical Psychiatry, 55,322-331.

Schneier, F. R., Johnson, J., Hornig, C. D., Liebowitz, M. R., & Weissman, M. M. (1992). Social phobia: Comorbidity and morbidity in an epidemiological sample. Archives of Gen- eral Psychiatry, 49,282-288.

Spielberger, C. D. (1988). Manual for the State-Trait Anger Expression Inventory. Odessa, FL: Psychological Assessment Resources.

Taylor, S. (1996). Meta-analysis of cognitive-behavioral treatment for social phobia. Journal of Behavior Therapy and Experimental Psychiatry, 27, 1-9.

Trower, P., & Gilbert, R (1989). New theoretical conceptions of social anxiety and social phobia. Clinical Psychology Review, 9, 19-35.

Turk, C. L., Heimberg, R. G., & Hope, D. A. (2001). Social anxiety disorder. In D. H. Barlow (Ed.), Clinical handbook of psychoIogical disorders: A step-by-step treatment manual (3rd ed., pp. 114-153). New York: The Guilford Press.

Turner, S. M., Beidel, D. C., Dancu, C. V., & Keys, D. J. (1986). Psychopathology of social phobia and comparison to avoidant personality disorder. Journal of Abnormal Psychology, 95, 389-394.

Ventura, J., Liberman, R. R, Green, M. F., Shaner, A., & Mintz, J. (1998). Training and quality assurance with the Structured Clinical Interview for DSM-IV (SCID-I/P). Psychiatry Research, 79, 163-173.

Walters, K. S., & Hope, D. A. (1998). Analysis of social behavior in individuals with social phobia and nonanxious participants using a psychobiological model. Behavior Therapy, 29, 387-407.

Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consult- ing and Clinical Psychology, 33,448-457.

RECEIVED: May 10, 2002 ACCEPTED: March 21,2003

Anger experience and expression in social anxiety disorder: Pretreatment profile and predictors of...

Documents

Transcript of Anger experience and expression in social anxiety disorder: Pretreatment profile and predictors of...