Emotion regulation in youth with social anxiety disorder: insights from ambulatory and laboratory assessments

With a typical onset in childhood and adolescence, social anxiety disorder (SAD) is a disorder affecting up to 12.4% of children and adolescents in high-income countries. The disorder is associated with severe impairment across multiple domains of life and with the occurrence of comorbid disorders. SAD often shows a chronic course, and treatments are not as effective as for other mental disorders. In contrast to maintenance models of adult SAD, which emphasize dysfunctional cognitive-behavioral processes, there are no empirically validated models for SAD in children and adolescents. There is preliminary evidence that similar processes could be implicated in the maintenance of SAD in children and adolescents. At the same time, emotion regulation (ER) may play an important role in dealing with the heightened emotional reactivity that affected children and adolescents typically experience in certain social situations. Using a theoretical framework combining the Process Model of ER (Gross, 1998, 2015) with maintenance models of adult SAD (Clark & Wells, 1995; Rapee & Heimberg, 1997), this dissertation aims to address the existing research gaps and examine emotional reactivity and ER in children and adolescents with SAD in a disorder-relevant setting. A multimethod approach using self-report, behavioral and psychophysiological data was chosen to capture both explicit and implicit processes of ER. To test for the specificity of ER processes for SAD, a clinical control group with other anxiety disorders was included in addition to a healthy control group. Children and adolescents with SAD were expected to engage in dysfunctional ER at both the explicit and implicit level, compared to both children with other anxiety disorders and healthy children. In addition, dysfunctional ER was expected to predict social anxiety 12 months later. In Study 1 (Chapter 3), explicit ER processes were repeatedly assessed in the daily lives of children and adolescents. Children and adolescents aged 10-13 years completed an Ecological Momentary Assessment (EMA) protocol in which they were interviewed by mobile phones twice daily for three consecutive school days. Children and adolescents with SAD (n = 29) were compared to both clinical controls with mixed anxiety disorders (n = 27) and healthy controls (n = 31) regarding emotional reactivity as well as use and effectiveness of the ER strategies reappraisal, suppression, avoidance and rumination in their daily lives. In Study 2 (Chapter 4), implicit ER processes were assessed in the controlled environment of the lab, using eye-tracking and pupillometry. Children and adolescents aged 10-15 years participated in a free-viewing paradigm using facial stimuli. Children and adolescents with SAD (n = 57) were compared to both a clinical group with specific phobia (n = 41) and a healthy control group (n = 65) regarding hypervigilant-avoidant attentional biases for faces. Results were only partly as hypothesized and differed depending on the level of ER. Results of Study 1 revealed more daily-life emotional reactivity as well as more use of suppression, avoidance and reappraisal in children and adolescents aged 10-13 years with SAD compared to healthy controls. In contrast, results of Study 2 revealed attentional biases in the form of hypervigilance and maintained attention only for older participants (13-15 years). In addition, only self-reported use of maladaptive ER strategies suppression, avoidance and rumination were able to predict social anxiety 12 months later in Study 1, whereas attentional bias measures had no predictive value for social anxiety 12 months later in Study 2. See Chapter 5 for a general discussion and integration of results with previous research, as well as a derivation of possible theoretical and practical implications.