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People who suffer Social Anxiety Disorder (SAD) are under substantial personal distress and endure impaired normal functioning in at least some parts of everyday life. Next, to the personal suffering, there are also the immense public health costs to consider, as SAD is the most common anxiety disorder and thereby one of the major psychiatric disorders in general. Over the last years, fundamental research found cognitive factors as essential components in the development and maintenance of social fears. Following leading cognitive models, avoidance behaviors are thought to be an important factor in maintaining the developed social anxieties. Therefore, this thesis aims to deepen the knowledge of avoidance behaviors exhibited in social anxiety, which allows to get a better understanding of how SAD is maintained.
To reach this goal three studies were conducted, each using a different research approach. In the first study cutting-edge Virtual Reality (VR) equipment was used to immerse participants in a virtual environment. In this virtual setting, High Socially Anxious (HSA) individuals and matched controls had to execute a social Approach-Avoidance Task (AAT). In the task, participants had to pass a virtual person displaying neutral or angry facial expressions. By using a highly immersive VR apparatus, the first described study took the initial step in establishing a new VR task for the implicit research on social approach-avoidance behaviors. By moving freely through a VR environment, participants experienced near real-life social situations. By tracking body and head movements, physical and attentional approach-avoidance processes were studied.
The second study looked at differences in attention shifts initiated by gaze-cues of neutral or emotional faces. Comparing HSA and controls, enabled a closer look at attention re-allocation with special focus on social stimuli. Further, context conditioning was used to compare task performance in a safe and in a threatening environment. Next to behavioral performance, the study also investigated neural activity using Electroencephalography (EEG) primarily looking at the N2pc component.
In the third study, eye movements of HSA and Low Socially Anxious (LSA) were analyzed using an eye-tracking apparatus while participants executed a computer task. The participants’ tasks consisted of the detection of either social or non-social stimuli in complex visual settings. The study intended to compare attention shifts towards social components between these two tasks and how high levels of social anxiety influence them. In other words, the measurements of eye movements enabled the investigation to what extent social attention is task-dependent and how it is influenced by social anxiety.
With the three described studies, three different approaches were used to get an in-depth understanding of what avoidance behaviors in SAD are and to which extent they are exhibited. Overall, the results showed that HSA individuals exhibited exaggerated physical and attentional avoidance behavior. Furthermore, the results highlighted that the task profoundly influences attention allocation. Finally, all evidence indicates that avoidance behaviors in SAD are exceedingly complex. They are not merely based on the fear of a particular stimulus, but rather involve highly compound cognitive processes, which surpass the simple avoidance of threatening stimuli. To conclude, it is essential that further research is conducted with special focus on SAD, its maintaining factors, and the influence of the chosen research task and method.
The Role of Attentional Control and Fear Acquisition and Generalization in Social Anxiety Disorder
(2020)
Although Social Anxiety Disorder (SAD) is one of the most prevalent mental disorders, still little is known about its development and maintenance. Cognitive models assume that deviations in attentional as well as associative learning processes play a role in the etiology of SAD. Amongst others, deficits in inhibitory attentional control as well as aberrations during fear generalization, which have already been observed in other anxiety disorders, are two candidate mechanisms that might contribute to the onset and retention of SAD. However, a review of the literature shows that there is a lack of research relating to these topics. Thus, the aim of the present thesis was to examine in which way individuals with SAD differ from healthy controls regarding attentional control and generalization of acquired fear during the processing of social stimuli.
Study 1 tested whether impairment in the inhibitory control of attention is a feature of SAD, and how it might be influenced by emotional expression and gaze direction of an interactional partner. For this purpose, individuals with SAD and healthy controls (HC) participated in an antisaccade task with faces displaying different emotional expressions (angry, neutral and happy) and gaze directions (direct and averted) serving as target stimuli. While the participants performed either pro- or antisaccades in response to the peripherally presented faces, their gaze behavior was recorded via eye-tracking, and ratings of valence and arousal were obtained. Results revealed that both groups showed prolonged latencies and increased error rates in trials with correct anti- compared to prosaccades. However, there were no differences between groups with regard to response latency or error rates, indicating that SAD patients did not exhibit impairment on inhibitory attentional control in comparison to HC during eye-tracking. Possible explanations for this finding could be that reduced inhibitory attentional control in SAD only occurs under certain circumstances, for example, when these individuals currently run the risk of being negatively evaluated by others and not in the mere presence of phobic stimuli, or when the cognitive load of a task is so high that it cannot be unwound by compensatory strategies, such as putting more effort into a task.
As not only deviations in attentional, but also associative learning processes might be pathogenic markers of SAD, these mechanisms were further addressed in the following experiments. Study 2 is the first that attempted to investigate the generalization of conditioned fear in patients with SAD. To this end, patients with SAD and HC were conditioned to two neutral female faces serving as conditioned stimuli (CS+: reinforced; CS-: non-reinforced) and a fearful face paired with a loud scream serving as unconditioned stimulus (US). Fear generalization was tested by presenting morphs of the two faces (GS: generalization stimuli), which varied in their similarity to the original faces. During the whole experiment, self-report ratings, heart rate (HR) and skin conductance responses (SCR) were recorded. Results demonstrated that SAD patients rated all stimuli as less pleasant and more arousing, and overestimated the occurrence of the US compared to HC, indicating a general hyperarousal in individuals with SAD. In addition, ratings and SCR indicated that both groups generalized their acquired fear from the CS+ to intermediate GSs as a function of their similarity to the CS+. However, except for the HR data, which indicated that only SAD patients but not HC displayed a generalization response in this measure, most of the results did not support the hypothesis that SAD is characterized by overgeneralization. A plausible reason for this finding could be that overgeneralization is just a key characteristic of some anxiety disorders and SAD is not one of them. Still, other factors, such as comorbidities in the individuals with SAD, could also have had an influence on the results, which is why overgeneralization was further examined in study 3.
The aim of study 3 was to investigate fear generalization on a neuronal level. Hence, high (HSA) and low socially anxious participants (LSA) underwent a conditioning paradigm, which was an adaption of the experimental design used study 2 for EEG. During the experiment, steady-state visually evoked potentials (ssVEPs) and ratings of valence and arousal were recorded. Analyses revealed significant generalization gradients in all ratings with highest fear responses to the CS+ and a progressive decline of these reactions with increasing similarity to the CS-. In contrast, the generalization gradient on a neuronal level showed highest amplitudes for the CS+ and a reduction in amplitude to the most proximal, but not distal GSs in the ssVEP signal, which might be interpreted as lateral inhibition in the visual cortex. The observed dissociation among explicit and implicit measures points to different functions of behavioral and sensory cortical processes during fear generalization: While the ratings might reflect an individual’s consciously increased readiness to react to threat, the lateral inhibition pattern in the occipital cortex might serve to maximize the contrast among stimuli with and without affective value and thereby improve adaptive behavior. As no group differences could be observed, the finding of study 2 that overgeneralization does not seem to be a marker of SAD is further consolidated.
In sum, the conducted experiments suggest that individuals with SAD are characterized by a general hyperarousal during the exposition to disorder-relevant stimuli as indicated by enhanced arousal and reduced valence ratings of the stimuli compared to HC. However, the hypotheses that reduced inhibitory attentional control and overgeneralization of conditioned fear are markers of SAD were mostly not confirmed. Further research is required to elucidate whether they only occur under certain circumstances, such as high cognitive load (e.g. handling two tasks simultaneously) or social stress (e.g. before giving a speech), or whether they are not characteristics of SAD at all. With the help of these findings, new interventions for the treatment of SAD can be developed, such as attentional bias modification or discrimination learning.
The present dissertation aims to shed light on different mechanisms of socio-emotional feedback in social decision-making situations. The objective is to evaluate emotional facial expressions as feedback stimuli, i.e., responses of interaction partners to certain social decisions. In addition to human faces, artificial emojis are also examined due to their relevance for modern digital communication. Previous research on the influence of emotional feedback suggests that a person's behavior can be effectively reinforced by rewarding stimuli. In the context of this dissertation, the differences in the feedback processing of human photographs and emojis, but also the evaluation of socially expected versus socially unexpected feedback were examined in detail in four studies. In addition to behavioral data, we used the electroencephalogram (EEG) in all studies to investigate neural correlates of social decision-making and emotional feedback.
As the central paradigm, all studies were based on a modified ultimatum game. The game is structured as follows: there is a so-called proposer who holds a specific amount of money (e.g., 10 cents) and offers the responder a certain amount (e.g., 3 cents). The responder then decides whether to accept or reject the offer. In the version of the ultimatum game presented here, different types of proposers are introduced. After the participants have accepted or rejected in the role of the responder, the different proposers react to the participant’s decision with specific emotional facial expressions. Different feedback patterns are used for the individual experiments conducted in the course of this dissertation.
In the first study, we investigated the influence of emotional feedback on decision-making in the modified version of the ultimatum game. We were able to show that a proposer who responds to the acceptance of an offer with a smiling face achieves more accepted offers overall than a control proposer who responds to both accepted and rejected offers with a neutral facial expression. Consequently, the smile served as a positive reinforcement. Similarly, a sad expression in response to a rejected offer also resulted in higher acceptance rates as compared to the control identity, which could be considered an expression of compassion for that proposer. On a neuronal level, we could show that there are differences between simply looking at negative emotional stimuli (i.e., sad and angry faces) and their appearance as feedback stimuli after rejected offers in the modified ultimatum game. The so-called feedback-related negativity was reduced (i.e., more positive) when negative emotions appeared as feedback from the proposers. We argued that these findings might show that the participants wanted to punish the proposers by rejecting an offer for its unfairness and therefore the negative feedback met their expectations. The altered processing of negative emotional facial expressions in the ultimatum game could therefore indicate that the punishment is interpreted as successful. This includes the expectation that the interaction partner will change his behavior in the future and eventually make fairer offers.
In the second study we wanted to show that smiling and sad emojis as feedback stimuli in the modified ultimatum game can also lead to increased acceptance rates. Contrary to our assumptions, this effect could not be observed. At the neural level as well, the findings did not correspond to our assumptions and differed strongly from those of the first study. One finding, however, was that the neural P3 component showed how the use of emojis as feedback stimuli particularly characterizes certain types of proposers. This is supported by the fact that the P3 is increased for the proposer who rewards an acceptance with a smile as well as for the proposer who reacts to rejection with a sad emoji compared to the neutral control proposer.
The third study examined the discrepancy between the findings of the first and second study. Accordingly, both humans and emojis representing the different proposers were presented in the ultimatum game. In addition, emojis were selected that showed a higher similarity to known emojis from common messenger services compared to the second study. We were able to replicate that the proposers in the ultimatum game, who reward an acceptance of the offer with a smile, led to an increased acceptance rate compared to the neutral control proposers. This difference is independent of whether the proposers are represented by emojis or human faces. With regard to the neural correlates, we were able to demonstrate that emojis and human faces differ strongly in their neural processing. Emojis showed stronger activation than human faces in the face-processing N170 component, the feedback-related negativity and the P3 component. We concluded that the results of the N170 and feedback-related negativity could indicate a signal for missing social information of emojis compared to faces. The increased P3 amplitude for emojis might imply that emojis appear unexpectedly as reward stimuli in a social decision task compared to human faces.
The last study of this project dealt with socially unexpected feedback. In comparison to the first three studies, new proposer identities were implemented. In particular, the focus was on a proposer who reacted to the rejection of an offer unexpectedly with a smile and to the acceptance with a neutral facial expression. According to the results, participants approach this unexpected smile through increased rejection, although it is accompanied by financial loss. In addition, as reported in studies one and three, we were able to show that proposers who respond to the acceptance of an offer with a smiling face and thus meet the expectations of the participants have higher offer acceptance rates than the control proposer. At the neuronal level, especially the feedback from the socially unexpected proposer led to an increased P3 amplitude, which indicates that smiling after rejection is attributed a special subjective importance.
The experiments provide new insights into the social influence through emotional feedback and the processing of relevant social cues. Due to the conceptual similarity of the studies, it was possible to differentiate between stable findings and potentially stimulus-dependent deviations, thus creating a well-founded contribution to the current research. Therefore, the novel paradigm presented here, and the knowledge gained from it could also play an important role in the future for clinical questions dealing with limited social competencies.
This thesis aims for a better understanding of the mechanisms underlying anxiety as well as trauma- and stressor-related disorders and the development of new therapeutic approaches. I was first interested in the associative learning mechanisms involved in the etiology of anxiety disorders. Second, I explored the therapeutic effects of transcutaneous vagus nerve stimulation (tVNS) as a promising new method to accelerate and stabilize extinction learning in humans.
For these purposes, I applied differential anxiety conditioning protocols realized by the implementation of virtual reality (VR). Here, a formerly neutral virtual context (anxiety context, CTX+) is presented whereby the participants unpredictably receive mildly aversive electric stimuli (unconditioned stimulus, US). Another virtual context (safety context, CTX-) is never associated with the US. Moreover, extinction of conditioned anxiety can be modeled by presenting the same contexts without US delivery. When unannounced USs were administered after extinction, i.e. reinstatement, the strength of the “returned” conditioned anxiety can provide information on the stability of the extinction memory.
In Study 1, I disentangled the role of elemental and conjunctive context representations in the acquisition of conditioned anxiety. Sequential screenshots of two virtual offices were presented like a flip-book so that I elicited the impression of walking through the contexts. Some pictures of CTX+ were paired with an US (threat elements), but not some other screenshots of the same context (non-threat elements), nor the screenshots depicting CTX- (safety elements). Higher contingency ratings for threat compared to non-threat elements revealed elemental representation. Electro-cortical responses showed larger P100 and early posterior negativity amplitudes elicited by screenshots depicting CTX+ compared to CTX- and suggested conjunctive representation. These results support the dual context representation in anxiety acquisition in healthy individuals.
Study 2 addressed the effects of tVNS on the stabilization of extinction learning by using a context conditioning paradigm. Potentiated startle responses as well as higher aversive ratings in CTX+ compared to CTX- indicate successful anxiety conditioning. Complete extinction was found in startle responses and valence ratings as no differentiation between CTX+ and CTX- suggested. TVNS did not affect extinction or reinstatement of anxiety which may be related to the inappropriate transferability of successful stimulation parameters from epilepsy patients to healthy participants during anxiety extinction.
Therefore, in Study 3 I wanted to replicate the modulatory effects of tVNS on heart rate and pain perception by the previously used parameters. However, no effects of tVNS were observed on subjective pain ratings, on pain tolerance, or on heart rate. This led to the conclusion that the modification of stimulation parameters is necessary for a successful acceleration of anxiety extinction in humans.
In Study 4, I prolonged the tVNS and, considering previous tVNS studies, I applied a cue conditioning paradigm in VR. Therefore, during acquisition a cue (CS+) presented in CTX+ predicted the US, but not another cue (CS-). Both cues were presented in a second context (CTX-) and never paired with the US. Afterward, participants received either tVNS or sham stimulation and underwent extinction learning. I found context-dependent cue conditioning only in valence ratings, which was indicated by lower valence for CS+ compared to CS- in CTX+, but no differential ratings in CTX-. Successful extinction was indicated by equal responses to CS+ and CS-. Interestingly, I found reinstatement of conditioned fear in a context-dependent manner, meaning startle response was potentiated for CS+ compared to CS- only in the anxiety context. Importantly, even the prolonged tVNS had no effect, neither on extinction nor on reinstatement of context-dependent cue conditioning. However, I found first evidence for accelerated physiological contextual extinction due to less differentiation between startles in CTX+ compared to CTX- in the tVNS than in the sham stimulated group.
In sum, this thesis first confirms the dual representation of a context in an elemental and a conjunctive manner. Second, though anxiety conditioning and context-dependent cue conditioning paradigms worked well, the translation of tVNS accelerated extinction from rats to humans needs to be further developed, especially the stimulation parameters. Nevertheless, tVNS remains a very promising approach of memory enhancement, which can be particularly auspicious in clinical settings.