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Intrusive re-experiencing in social anxiety disorder: Does context matter?

Subject Area Personality Psychology, Clinical and Medical Psychology, Methodology
General, Cognitive and Mathematical Psychology
Term from 2017 to 2022
Project identifier Deutsche Forschungsgemeinschaft (DFG) - Project number 391419683
 
Final Report Year 2023

Final Report Abstract

Classical conditioning processes within the context of negative social experiences (e.g., being embarrassed by a teacher) play a major role in the development of social anxiety disorder (SAD). However, even corrective positive experiences in 'safe' contexts do not seem to lead to the (longterm) extinction of fear. The return of fear might be related to a general deficit in discriminating contexts. Altered neural processes related to the recall of the fear or extinction memory trace might be associated with this deficit. Some patients with SAD moreover suffer from intrusive reexperiencing of the negative social experience, for example, in form of distorted negative images of themselves related to that experience. The occurrence of intrusive re-experiencing in later 'safe' situations might be associated with deficits in the extinction of fear. In order to investigate these questions, a study with 76 patients with SAD and 69 healthy control subjects (HC) was conducted. Besides clinical interviews on negative (social) experiences, a behavioral pattern separation task as an indicator for difficulties in basic contextual discrimination was used. A context-dependent fear conditioning paradigm was performed during functional magnetic resonance imaging (MRI) to investigate the acquisition and in particular the extinction of conditioned fear and its contextdependent retrieval 24 hrs later (N=54 patients with SAD, N=54 HC). The results show that subjects with SAD more frequently suffer from intrusive re-experiencing of negative social experiences, but also of traumatic and generally aversive experiences than HC. Unlike expected, there were no deficits in behavioral pattern separation. However, at the neural level, patients with SAD showed reduced amygdala activation during extinction recall in the safe context and during fear renewal in the acquisition context, which might be associated with stronger activation in response to the safety signal and probably reduced safety learning. Correspondingly, patients with SAD reported stronger fear in all three contexts compared with HC. An important finding of the present study is moreover that intrusive re-experiencing seems to be particularly relevant for a subgroup of patients with SAD. Thus, patients with intrusions in response to a negative social event (INT) differed from patients without intrusions (NO-INT) also with respect to activation of the amygdala and vmPFC during extinction training (stronger activation decrease in the amygdala in INT and stronger activation of the vmPFC in NO-INT at the end of extinction training), extinction recall (stronger activation of the vmPFC in NO-INT) and fear renewal in a novel context (stronger activation of the vmPFC in NO- INT) and the acquisition context (stronger activation of the amygdala in INT). Hypoactivation of the vmPFC could be indicative of dysfunctional inhibition of fear or its regulation in general. However, this interpretation cannot be supported by findings regarding skin conductance responses nor fear ratings. Moreover, there were no differences in behavioral pattern separation performance between these two groups. Intrusions in response to negative social experiences might therefore especially be related to an altered contextual modulation of extinction recall, which, however, might not be due to basic differences in pattern separation. Further analyses investigated if clinically relevant intrusion symptoms in response to any autobiographical event (not only negative social experiences) are associated with deficits in contextual processing. Indeed, these patients compared with patients without intrusions showed reduced pattern separation performance as well as altered contextdependent extinction processes, especially on the neural level. These results indicate the transdiagnostic relevance of deficits in contextual processing in association with the strongest intrusive re-experiencing symptoms independent of the specific situation. The results of this study may help to improve the treatment of social anxiety disorder by focusing attention to the relevance of posttraumatic stress symptoms for the respective patients, and, if appropriate, by using specific interventions targeting these symptoms. Moreover, interventions that facilitate extinction recall in novel, safe contexts should be developed and established for patients with SAD.

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