Cognitive Behaviour Therapy, 2015 Vol. 44, No. 1, 63–73, http://dx.doi.org/10.1080/16506073.2014.961539

Cognitive Constructs and Social Anxiety Disorder: Beyond Fearing Negative Evaluation Michelle J. N. Teale Sapach1, R. Nicholas Carleton1, Myriah K. Mulvogue1, Justin W. Weeks2 and Richard G. Heimberg3 1

Department of Psychology, University of Regina, Regina, SK, Canada; 2 Department of Psychology, Ohio University, Athens, OH, USA; 3 Department of Psychology, Temple University, Philadelphia, PA, USA

Abstract. Pioneering models of social anxiety disorder (SAD) underscored fear of negative evaluation (FNE) as central in the disorder’s development. Additional cognitive predictors have since been identified, including fear of positive evaluation (FPE), anxiety sensitivity, and intolerance of uncertainty (IU), but rarely have these constructs been examined together. The present study concurrently examined the variance accounted for in SAD symptoms by these constructs. Participants meeting criteria for SAD (n ¼ 197; 65% women) completed self-report measures online. FNE, FPE, anxiety sensitivity, and IU all accounted for unique variance in SAD symptoms. FPE accounted for variance comparable to FNE, and the cognitive dimension of anxiety sensitivity and the prospective dimension of IU accounted for comparable variance, though slightly less than that accounted for by FNE and FPE. The results support the theorized roles that these constructs play in the etiology of SAD and highlight both FNE and FPE as central foci in SAD treatment. Key words: anxiety sensitivity; cognitive behavior therapy; fear of negative evaluation; fear of positive evaluation; intolerance of uncertainty; social anxiety disorder. Received 25 April 2014; Accepted 27 August 2014 Correspondence address: Michelle J. N. Teale Sapach, Department of Psychology, University of Regina, Regina, Saskatchewan S4S 0A2. Tel: (306) 337-2473. Fax: (306) 337-3275. Email: [email protected]

Introduction Several models of the development and maintenance of social anxiety disorder (SAD) have garnered empirical support. Models put forth by Heimberg and colleagues (Heimberg, Brozovich, & Rapee, 2010; Rapee & Heimberg, 1997), Clark and Wells (1995), Hofmann (2007), and Moscovitch (2009) focus on cognitive aspects of social anxiety— including the perception of an audience, negatively skewed view of the self, fear of negative evaluation (FNE), and self-perceived deficits—as well as behavioral aspects of social anxiety, such as safety behaviors. These models postulate that individuals with SAD attend more to negative stimuli during ambiguous events, overestimate the negativity of others’ appraisals of their performance, overestimate the probability of negative q 2014 Swedish Association for Behaviour Therapy

evaluations, and catastrophize the consequences of negative evaluations (for comparison of these and other models, see Wong, Gordon, & Heimberg, 2014). Researchers have identified several cognitive constructs as potential risk factors for social anxiety. FNE is considered central in SAD (e.g., Clark & Wells, 1995), and can be measured by assessing worry about others’ evaluations, expectations of negative evaluation, distress caused by negative evaluations, and avoidance of situations that could result in negative evaluation (Watson & Friend, 1969). Substantial empirical evidence supports FNE as a fundamental component of SAD (e.g., Weeks et al., 2005). Complementing the work on FNE, fear of positive evaluation (FPE; Weeks, Jakatdar, & Heimberg, 2010) has more recently been shown to contribute to social anxiety. FPE

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refers to apprehension and distress associated with favorable and public evaluations, which may result in direct social comparisons of the self to others and cause a person to feel conspicuous (Weeks, Heimberg, & Rodebaugh, 2008). FPE offers an explanation for the tendency of people with SAD to disqualify positive social experiences or outcomes by attributing them to factors other than their own abilities or efforts (Weeks, 2010). FPE accounts for unique variance in social anxiety symptoms, beyond the variance accounted for by FNE (Weeks, 2010; Weeks, Heimberg, & Rodebaugh, 2008), and uniquely predicts submissive behaviors and social comparison tendencies related to social anxiety (Weeks et al., 2010). After statistically controlling for FNE, FPE has been positively related to the high trait negative affect and low trait positive affect characteristic of socially anxious individuals (Weeks et al., 2010). Although FNE and FPE are highly correlated, evidence to date suggests that they are distinct constructs (Weeks et al., 2010). Indeed, recent work suggests that FNE may be a specific factor that contributes to several forms of psychopathology (e.g., SAD, depression, generalized anxiety disorder; Kotov, Watson, Robles, & Schmidt, 2007), whereas FPE may be a unique factor that contributes only to social anxiety (Wang, Hsu, Chiu, & Liang, 2012). Anxiety sensitivity describes a fear that anxiety symptoms (e.g., heart palpitations) will have harmful consequences (Taylor, 1999) and has demonstrated a relationship with SAD symptoms (e.g., Rodriguez, Bruce, Pagano, Spencer, & Keller, 2004). Anxiety sensitivity is typically described in terms of three factors—fear of physical sensations, fear of cognitive dyscontrol, and fear of public observation of anxiety symptoms (Taylor et al., 2007). For people with SAD, harm is expected to result when observable symptoms of anxiety telegraph an anxious state to others (Clark & Wells, 1995). Consequently, fear of public observation of anxiety symptoms has been most strongly related to SAD of all three latent factors (e.g., Olatunji & WolitzkyTaylor, 2009) and has been shown to account for unique variance in social anxiety symptoms (Carleton, Collimore, & Asmundson, 2010). A relatively recent construct that has also been related to social anxiety is intolerance of uncertainty (IU; Boelen & Reijntjes, 2009),

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which involves negative beliefs about uncertainty and the potential for and consequences of negative outcomes, regardless of the true probability of their occurrence (Carleton, 2012). IU encompasses inhibitory (i.e., behavioral) and prospective (i.e., cognitive) dimensions (McEvoy & Mahoney, 2011) that may be particularly relevant to social anxiety given the inherently uncertain nature of social situations (Carleton et al., 2010). IU contributes variance beyond neuroticism and anxiety sensitivity (Boelen & Reijntjes, 2009) to the prediction of social anxiety. Research using a community sample indicated that inhibitory IU may account for unique variance in social anxiety, beyond the variance accounted for by FNE (Carleton et al., 2010). IU may contribute to a range of anxiety and depressive disorders (e.g., panic disorder, generalized anxiety disorder, depression; Carleton et al., 2012; McEvoy & Mahoney, 2012), suggesting that it may exacerbate tendencies that maintain psychopathology. For example, IU may help to explain the tendency of those with SAD to overestimate the probability negative social evaluations (e.g., Heimberg et al., 2010). Indeed, people with SAD rated their performance more negatively than controls only when social performance expectations were ambiguous (Moscovitch & Hofmann, 2007). Furthermore, reductions in IU after cognitive behavioral group therapy predicted reductions in SAD symptoms (Mahoney & McEvoy, 2012). FNE, FPE, anxiety sensitivity, and IU have each demonstrated independent relationships with social anxiety symptoms; however, no study has examined all of these constructs together using data from a clinical sample. The present study was designed to concurrently examine responses to measures of FNE, FPE, anxiety sensitivity, and IU in a sample of individuals meeting diagnostic criteria for SAD. Concurrent examination of these cognitive constructs is necessary to provide a more comprehensive estimate of the proportion of variance accounted for by each construct in SAD symptoms, and ultimately inform treatment focus and improve treatment efficacy. Consistent with previous findings (Carleton et al., 2010; Weeks, Heimberg, & Rodebaugh, 2008), FNE, FPE, anxiety sensitivity, and IU were all expected to correlate positively with, and account for

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unique variance in, SAD symptoms. More specifically, FPE, the inhibitory dimension of IU, and the social dimension of anxiety sensitivity were expected to account for unique variance in severity of social anxiety, even after accounting for the contributions of FNE.

Method Participants

As part of a larger study approved by the local research ethics board, 197 Canadian participants (69 men aged 18– 64 years, [M ¼ 36.99; SD ¼ 12.67] and 128 women aged 18– 65 years [M ¼ 37.85; SD ¼ 12.89]) were recruited through flyer, web-based, and other media advertisements soliciting participants for a treatment study for social anxiety at the University of Regina. Most participants identified their ethnicity as Caucasian (89%) or First Nations (3%) and reported being married or cohabiting (50%). Participants were mostly employed full-time (45%), employed part-time (21%), or attending school (18%). The majority of the sample indicated that they had completed at least some university or college education (75%). Eligibility for participation was determined over the telephone by supervised master’s and doctoral-level clinical psychology students who administered the Structured Clinical Interview for DSM-IV-Axis I Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 2002) SAD module, a modified version of the SCID-I screener, and the Social Interaction Phobia Scale (SIPS; Carleton et al., 2009). A registered doctoral psychologist trained in SCID-I administration provided training to the assessors, which included demonstrating several interviews and then observing assessors conducting the interviews. No data on the inter-rater reliability of the SCID-I SAD module diagnoses are available for the current sample; however, the registered psychologist was available on a case-by-case basis if uncertainty regarding a participant’s eligibility arose. Participants had to be 18– 65 years of age, meet DSM-IV diagnostic criteria for generalized SAD, identify SAD as a primary psychological concern, self-report clinically significant symptom levels as measured by the SIPS (total score $ 21; Carleton et al., 2009; see below), not be actively engaged in psychotherapy for SAD, and, if taking

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prescription psychotropic medication, be on a stable dosage for at least the past month. Participation consisted of completing a battery of online questionnaires before commencing a six-week computer-based treatment protocol for SAD. Data reported here were drawn from participants’ pretreatment assessments.

Measures

Anxiety Sensitivity Index-3. The Anxiety Sensitivity Index-3 (ASI-3; Taylor et al., 2007) is an 18-item self-report measure designed to assess the tendency to fear anxiety symptoms, based on the belief that they may have harmful consequences (e.g., “It scares me when my heart beats rapidly”). Items are rated on a five-point Likert-type scale ranging from 0 (agree very little) to 4 (agree very much). Factor analyses support a three-factor structure (i.e., somatic, cognitive, and social fears; Taylor et al., 2007), which corresponds to the three theorized dimensions of anxiety sensitivity (i.e., fear of somatic sensations, fear of cognitive dyscontrol, and fear of socially observable signs of anxiety, respectively). The ASI-3 has displayed strong convergent, discriminant, and criterion validity. In the current sample, internal consistency was good for the total score (a ¼ .89), somatic subscale score (a ¼ .85), cognitive subscale score (a ¼ .88), and social subscale score (a ¼ .83). The average inter-item correlation was 0.31. Brief Fear of Negative Evaluation Scale, Straightforward Items. The Brief Fear of Negative Evaluation Scale, Straightforward Items (BFNE-S; Rodebaugh et al., 2004; Weeks et al., 2005) comprises eight items from the original Brief Fear of Negative Evaluation scale (BFNE; Leary, 1983) designed to measure FNE (e.g., “I am afraid that others will not approve of me”). Each item is rated on a five-point Likert-type scale, ranging from 0 (not at all characteristic of me) to 4 (extremely characteristic of me). Research suggests that the eight straightforwardly worded items are more reliable and valid indicators of FNE than the reverse-scored items from the BFNE, and therefore should only be used to calculate the total score (Carleton, Collimore, McCabe, & Antony, 2011; Rodebaugh et al., 2004; Weeks et al., 2005). The BFNE-S has demonstrated excellent internal consistency (a . .92), factorial

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validity, and construct validity in undergraduate (Rodebaugh et al., 2004) and clinical (Weeks et al., 2005) samples. In the current sample, internal consistency for the total score was excellent (a ¼ .95), and the average interitem correlation was 0.60. Fear of Positive Evaluation Scale. The Fear of Positive Evaluation Scale (FPES; Weeks, Heimberg, & Rodebaugh, 2008) is a 10-item measure designed to assess FPE (e.g., “I feel uneasy when I receive praise from authority figures”). Items are rated on a 10-point Likerttype scale ranging from 0 (not at all true) to 9 (very true). Two reversed-scored questions are included to reduce acquiescence, but are not included in the total score. The FPES has demonstrated good internal consistency and test– retest reliability, and strong factorial, discriminant, convergent, and criterionrelated validity in predicting social anxiety in both undergraduate and clinical samples (Weeks, Heimberg, Rodebaugh, Goldin, & Gross, 2012; Weeks, Heimberg, Rodebaugh, & Norton, 2008). In the current sample, internal consistency for the total score was good (a ¼ .86), and the average inter-item correlation was 0.36. Intolerance of Uncertainty Scale, Short Form. The Intolerance of Uncertainty Scale, Short Form (IUS-12; Carleton, Norton, & Asmundson, 2007) measures responses to uncertainty, ambiguous situations, and the future. The 12 items are rated on a five-point Likert-type scale ranging from 1 (not at all characteristic of me) to 5 (entirely characteristic of me). Research suggests that the IUS-12 has two factors that are consistent across anxiety and depressive disorders (Carleton et al., 2012; McEvoy & Mahoney, 2011): prospective IU (e.g., “I can’t stand being taken by surprise”) and inhibitory IU (e.g., “When it’s time to act, uncertainty paralyses me”). Good convergent and discriminant validity, as well as internal consistency, have been demonstrated for the IUS-12 total and subscale scores (Carleton et al, 2007; McEvoy & Mahoney, 2011). For the current sample, internal consistency was good to excellent for the total score (a ¼ .91), prospective subscale score (a ¼ .87), and inhibitory subscale score ( a ¼ .85). The average inter-item correlation for the current sample was 0.45. Social Interaction Phobia Scale. The SIPS (Carleton et al., 2009) is a 14-item self-report

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measure that assesses affective and behavioral symptoms particular to SAD (e.g., “When mixing socially I am uncomfortable”), rather than the cognitions underlying such anxiety (Reilly, Carleton, & Weeks, 2012). Items are rated on a five-point Likert-type scale, ranging from 0 (not at all characteristic of me) to 4 (entirely characteristic of me). A SIPS total score greater than 21 has been shown to discern clinically significant anxiety symptoms consistent with a diagnosis of SAD (Carleton et al., 2009). The SIPS has demonstrated good factorial validity, internal consistency, and strong convergent and discriminant validity (Carleton et al., 2009; Reilly et al., 2012). In the current sample, internal consistency was good for the total score (a ¼ .86). The average inter-item correlation was 0.31. The Structured Clinical Interview for DSM-IV-Axis I Disorders, screener and Social Anxiety Disorder Module. The SCID-I (First et al., 2002) is a semistructured clinical interview used to aid in the diagnoses of Axis I disorders based on DSM-IV criteria. The SCID-I has demonstrated acceptable test– retest reliability and inter-rater reliability for all disorders (k range from 0.69 to 1.0; baseline k for SAD ¼ 0.86; Zanarini & Frankenburg, 2001). Only the SCID-I screener and SAD module were used in this study to determine eligibility.

Analyses Descriptive statistics were calculated for the sample and, as per previous research (Carleton et al., 2010), independent-sample t-tests were conducted to assess gender differences in responding. Pearson correlations were used to test theorized relationships between all measured variables. The proportion of variance in SAD symptoms accounted for by each cognitive construct was tested with hierarchical regression using the SIPS total score as the dependent variable. Based on best practice for regressions (e.g., Tabachnick & Fidell, 2013) and extensive research highlighting the robust relationship between FNE and social anxiety, FNE was entered in Step 1. To determine the variance accounted for in social anxiety symptoms beyond the variance accounted for by FNE, the remaining constructs—FPE, anxiety sensitivity, and IU—were all entered in Step 2. More specifically, the FPES total;

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the ASI-3 somatic, cognitive, and social subscales; and the IUS-12 prospective and inhibitory subscales were all entered in the second step to further delineate the variance accounted for by each construct dimension. All analyses were performed using SPSS Statistics 20.0.

Results There were no missing data in the sample collected. Frequency statistics from responses to the SCID-I screener questions suggested that the sample may have had a fairly high rate of comorbidity, which is common for clinical samples with SAD (e.g., Brown, Campbell, Lehman, Grisham, & Mancill, 2001). Specifically, screener responses suggested that 36.0% of participants may have experienced comorbid major depression, 36.0% of participants may have experienced comorbid panic disorder, and 37.6% of individuals may have experienced comorbid generalized anxiety disorder. More in-depth assessment may have revealed slightly lower rates of comorbidity, but these estimates suggest that the sample is representative of clinical populations and that the results should be generalizable to other clinical populations. Although generalized anxiety (i.e., worry) and depression have shown independent relationships with IU and anxiety sensitivity, the influence of these symptoms was not controlled for in the current analyses for several reasons. The primary purpose of the data collection was for a larger project, for which comprehensive assessment of comorbid disorders was not necessary nor was assessment of worry symptoms. Therefore, between-

group comparisons were not possible and measures of worry were not available to be controlled for. Controlling for symptoms of depression would have run counter to the theoretical model being tested in the current manuscript, in that doing so would have violated the causal priority principle of hierarchical regression (Petrocelli, 2003) by suggesting that depression causes social anxiety. Research to date supports the opposite relationship—that SAD may be a risk factor for depression (e.g., Beesdo et al., 2007; Stein et al., 2001)—and does not justify controlling for depression in this analysis. Slight negative skew was evident (i.e., skewness statistic divided by standard error was . 2; Tabachnick & Fidell, 2013) for a few subscale and total scores (particularly, the BFNE-S total score), whereas slight positive skew was observed in the ASI-3 cognitive and somatic subscales; kurtosis values for all study measures were within the acceptable range (i.e., kurtosis statistic divided by standard error were all , 7; Tabachnick & Fidell, 2013). Given the slight skew in some of the measures, bootstrapping (i.e., 2000 samplings) was used on all variables to maximize adherence to normality requirements (Davison & Hinkley, 2006). Descriptive statistics for all dependent and independent variables are presented in Table 1. Responses from men and women were comparable (all p . .05) for most of the variables; however, women reported slightly higher scores than men on the prospective subscale of the IUS-12, t(195) ¼ 2.27, p ¼ .024, r 2 ¼ 0.03, 95% CI (2 3.72, 2 0.26); the BFNE-S, t(195) ¼ 2.73, p ¼ .007, r 2 ¼ 0.04, 95% CI (2 4.11, 2 0.66); and the

Table 1. Descriptive statistics and correlations M (SD)

1

1. IUS-12 prospective subscale 24.12 (5.95) 2. IUS-12 inhibitory subscale 16.93 (4.86) 0.65** 3. ASI-3 somatic subscale 9.05 (6.00) 0.32** 4. ASI-3 cognitive subscale 9.03 (6.13) 0.26** 5. ASI-3 social subscale 16.36 (5.03) 0.21** 6. BFNE-S 25.87 (5.94) 0.27** 7. FPES 52.17(16.78) 0.28** 8. SIPS total score 36.79 (8.95) 0.38**

2

3

0.20** 0.35** 0.23** 0.40** 0.31** 0.36**

0.52** 0.28** 0.01 0.12 0.20**

4

5

6

7

0.29** 0.25** 0.45** 0.27** 0.20** 0.33** 0.37** 0.32** 0.42** 0.43**

Note. Correlation results are based on bootstrapped data. All significance tests are two-tailed. *p , .05. **p , .01.

Note. All significance tests are two-tailed.

p DF

42.03 8.92 0.18 0.36 0.42 0.16 0.22 2 0.01 0.15 0.07 0.15 2 0.01 0.42 0.42 0.43 0.20 0.37 0.32 0.38 0.36 , .001 .006 , .001 .877 .013 .231 .011 .874 BFNE-S BFNE-S FPES ASI-3 somatic subscale ASI-3 cognitive subscale ASI-3 social subscale IUS-12 prospective subscale IUS-12 inhibitory subscale 1 2

0.42 0.21 0.25 2 0.01 0.19 0.08 0.21 2 0.01

6.48 2.80 3.84 2 0.16 2.51 1.20 2.57 2 0.16

r Predictor Model step

b

T

p

Part r

R2

Model step statistics Correlations Coefficient statistics

FPES, t(195) ¼ 2.26, p ¼ .025, r 2 ¼ 0.03, 95% CI (2 10.49, 2 0.71). Due to the slight sex differences in some of the responses, the regression analysis was first run while controlling for sex in the first step; however, sex was not a statistically significant predictor ( p . .05) and was therefore removed from the model. Correlational analyses produced statistically significant relationships between almost all criterion and predictor variables (Table 1). Results from the hierarchical regression using the SIPS total score as the dependent variable are presented in Table 2. There was no evidence of multicollinearity (all tolerances . 0.49; all variance inflation factors , 2.03), nor were there any problems with homoscedasticity, linearity, or normality (Tabachnick & Fidell, 2013). When entered in the first step, the BFNE-S accounted for a substantive proportion of variance in the SIPS total score, R 2 ¼ 0.18. Entering the FPES total score and all of the anxiety sensitivity and IU construct dimensions in Step 2 significantly improved the model, DF(6,189) ¼ 8.92, p , .001, DR 2 ¼ 0.18, accounting for an additional 18% of variance beyond that accounted for by the BFNE-S. Only the BFNE-S, the FPES, the cognitive subscale of the ASI-3, and the prospective subscale of the IUS-12 were statistically significant predictors in Step 2. The BFNE-S and the FPES accounted for similar proportions of variance (3% and 5%, respectively). The cognitive subscale of the ASI-3 and the prospective subscale of the IUS-12 also accounted for similar proportions of variance (2% each). Similar, though slightly larger, proportions of variance have been accounted for by FNE and FPE in undergraduate samples (e.g., Weeks, Heimberg, Rodebaugh, & Norton, 2008), which may reflect a range restriction in symptom variance for the current clinical sample. Dissimilar proportions of variance accounted for by the different subscales of the ASI-3 and the IUS-12 have been reported in community samples (e.g., Carleton et al., 2010), which may suggest that different relationships exist between these constructs at clinically significant levels of social anxiety. In particular, the social subscale of the ASI3 not accounting for statistically significant variance in the SIPS scores was contrary to the hypothesis and precedent research (e.g.,

, .001 , .001

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Teale Sapach, Carleton, Mulvogue, Weeks and Heimberg

Table 2. SIPS regression results

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Carleton et al., 2010; Rodriguez et al., 2004). To further explore this finding, a post hoc partial correlation between the ASI-3 social subscale and the SIPS was conducted controlling for BFNE-S scores. Indeed, the partial correlation was smaller (r ¼ 0.15, p ¼ .031) than the zero-order correlation (r ¼ 0.32, p , .001). Using Meng, Rosenthal, and Rubin’s (1992) test of dependent correlations, the relationship between the ASI-3 social subscale and the SIPS score did not differ significantly from the correlation between the BFNE-S and the SIPS ( p . .05).

Discussion The present study concurrently examined the variance accounted for in social anxiety symptoms by FNE, FPE, anxiety sensitivity, and IU using data from a clinical sample. Improved understanding of the proportion of variance accounted for by each construct can direct therapy focus in order to maximize treatment efficacy and efficiency. FNE, FPE, anxiety sensitivity, and IU were each expected to correlate positively with, and account for unique variance in, social anxiety symptoms. More specifically, FPE, the inhibitory dimension of IU, and the social dimension of anxiety sensitivity were expected to account for unique variance in social anxiety symptoms, beyond that accounted for by FNE (Carleton et al., 2010). Correlational analyses identified positive interrelationships between nearly all of the variables of interest. The correlations appeared in line with theory (e.g., Heimberg et al., 2010) and add to growing research indicating relationships between social anxiety, FNE, FPE, anxiety sensitivity, and IU. The exception was with the somatic dimension of anxiety sensitivity, for which the correlations with FNE and FPE were nonsignificant. Relatively smaller zero-order relationships between the somatic dimension of anxiety sensitivity and social anxiety are common among samples with SAD (i.e., mean r ¼ 0.25; Naragon-Gainey, 2010), possibly because such persons are more likely to focus on the social implications of somatic symptoms than the implications of the symptoms themselves. The nonsignificant relationships of the somatic dimension of anxiety sensitivity

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with FNE and FPE likely reflect extensions of this same pattern. As hypothesized, hierarchical regression indicated that FNE and FPE, as well as dimensions of anxiety sensitivity and IU, all accounted for unique variance in social anxiety symptoms. Congruent with previous findings (Carleton et al., 2010), FNE and FPE accounted for the greatest proportion of variance in social anxiety, adding to extensive evidence for the relationship between FNE and social anxiety, and to growing evidence for the relationship between FPE and social anxiety (Weeks et al., 2012). Indeed, FPE appeared to account for at least as much variance in social anxiety symptoms as FNE. Also in line with previous work (Carleton et al., 2010), anxiety sensitivity accounted for unique variance in social anxiety; however, the cognitive dimension was the only statistically significant predictor of the anxiety sensitivity factors when all constructs were entered together in the second step. Prior findings indicated a specific relationship between the social dimension of anxiety sensitivity and social anxiety (e.g., Olatunji & WolitzkyTaylor, 2009). Nonetheless, the present results are not unprecedented (Bailey, Morrison, Carleton, & Heimberg, 2012) and suggest that the relationship between the cognitive dimension of anxiety sensitivity and social anxiety warrants further attention. The relationship between anxiety sensitivity and social anxiety may change as a function of social anxiety intensity. The variance in social anxiety scores accounted for by the social dimension of anxiety sensitivity may have been largely accounted for in the regression equation by FNE scores. To test this explanation, a post hoc partial correlation was conducted and the results suggested that the relationship between the social dimension of anxiety sensitivity and the measure of social anxiety symptoms was much lower after statistically removing overlapping variance from the measure of FNE. This was further supported by Meng et al.’s (1992) test of dependent correlations, suggesting that social anxiety symptoms share a similar relationship with FNE and social anxiety sensitivity, which may help to explain the discrepancy between the current results and those of Carleton et al. (2010). In analog samples, measures of FNE and social anxiety

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sensitivity may discern unique contributions to social anxiety; however, in clinical samples, these measures may be analogous, in that the cause of the negative evaluation (i.e., whether due to observable anxiety or other factors) may not be as important as the actual fear. In short, subclinical symptoms of social anxiety may be more indicative of fear of appearing nervous—a largely ubiquitous phenomenon—whereas clinically significant symptoms of social anxiety may reflect a general fear of evaluation regardless of the cause. This position is also supported by the strong relationship between FPE and social anxiety in the present sample, which reinforces the idea that SAD stems from a fear of evaluation, regardless of its valence (Weeks et al., 2012). The current results also further support research and theory highlighting IU—the “newcomer” to social anxiety relative to the other constructs—as an underlying cognitive component of SAD (e.g., Carleton et al., 2012). Indeed, IU accounted for unique variance in social anxiety symptoms in the current sample; however, the pattern of relationships between the two IU dimensions and social anxiety symptoms contrasts previous work (e.g., McEvoy & Mahoney, 2011), which indicated that the inhibitory dimension better predicted social anxiety symptoms. In the current sample, the prospective dimension of IU was a statistically significant predictor of social anxiety, but the inhibitory dimension of IU was not. This discrepancy may illustrate the influence of comorbid disorders, which were not controlled for in the present sample or in the previous clinical samples that produced differing results (Carleton et al., 2012; McEvoy & Mahoney, 2011). Replication with a sample including a broader range of social anxiety symptoms (i.e., those with little social anxiety compared to those who seek treatment) and excluding or accounting for comorbid conditions may elucidate these discrepancies in the relationships between the dimensions of anxiety sensitivity and IU and social anxiety symptoms. There are several limitations in the current study that provide directions for future research. First, the sample included twice as many women as men, which—while not prohibitive for the current analyses—may

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indicate a sampling bias. Future studies using larger and more gender-balanced samples could explore whether men and women differentially report social anxiety and related symptoms, and whether differences contribute to the presentation of SAD. Second, the current participants were primarily Canadian Caucasians; as such, the results may not generalize to other ethnicities or cultures (Rapee & Spence, 2004). Third, only SAD was diagnostically assessed in this study and no inter-rater reliability information is available; formal assessment of all anxiety disorders with inter-rater reliability will be important in further assessing the relationships between these cognitive constructs and social anxiety in future studies controlling for comorbid disorders. Fourth, the current data are cross-sectional in nature, which precludes causal interpretation. Future research should include longitudinal designs if the variables hypothesized as vulnerability factors are to be empirically tested as causal factors. The current study examined the variance accounted for in social anxiety symptoms by FNE, FPE, dimensions of anxiety sensitivity, and dimensions of IU. The results suggest that FNE and FPE may account for comparable proportions of variance in social anxiety symptoms, each greater than the contributions of anxiety sensitivity and IU. The results also support SAD models that integrate FPE as an important maintenance factor (e.g., Heimberg et al., 2010). Understanding the contribution of FPE to SAD enhances our knowledge of the fundamental fear underlying SAD which, as these results and updates to existing models suggest, is a fear of evaluation in general, not just FNE as formerly posited. The similar proportions of variance accounted for by FNE and FPE highlight the contribution magnitude of FPE to SAD, which implies that it should be an important focus (in addition to FNE) in therapy. Thus, integrating cognitive restructuring and exposure to positive evaluation should improve SAD treatment outcomes (for a review, see Weeks & Howell, 2014). The current findings differed slightly from previous results with respect to the relationships between social anxiety and dimensions of anxiety sensitivity and IU, respectively, but still assert the importance of these constructs in SAD. Anxiety sensitivity and IU may underlie all anxiety pathology,

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which may exacerbate cognitive tendencies specific to pathology presentation (e.g., Carleton, 2012). For example, heightened IU may exacerbate judgments about the consequences of evaluation that are characteristic of SAD (Heimberg et al., 2010). Integrating elements of cognitive behavioral therapy designed to target anxiety sensitivity (e.g., Craske & Barlow, 2014) and IU (e.g., Dugas & Ladouceur, 2000) may provide additive symptom reductions in SAD symptomatology. Future replication and extension regarding the interrelationships of cognitive vulnerabilities will contribute to the refinement of SAD models and research addressing the efficacy of concurrently targeting anxiety sensitivity, IU and social anxiety symptoms may improve SAD treatment.

Acknowledgements This work was supported by the Saskatchewan Health Research Foundation, under the New Investigator Establishment Grant [Grant Number: 2456]. Disclosure statement: The authors have declared that no conflict of interest exists.

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