Abstract
Aim: This study aims to examine mechanisms that may account for the comorbidity between social anxiety and depression. We hypothesized that maladaptive metacognitions and anhedonia would serially mediate the link between social anxiety and depression.
Methods: We tested this notion by collecting data from 208 international, English-speaking participants ranging from the ages of 18 to 65 years old using the Social Interaction Anxiety Scale (SIAS), Self-Assessment Anhedonia Scale (SAAS), Patient’s Health Questionnaire-9 (PHQ-9), and Metacognition Questionnaire (MCQ-30).
Results: The results show a significant serial mediation effect from social anxiety via beliefs about uncontrollability and danger and anhedonia to depression, with the pathway from social anxiety via reduced beliefs in cognitive confidence and anhedonia to depression not being significant. Furthermore, a direct path from social anxiety to depression was also found to be significant.
Conclusion: Findings support both the tripartite model and the self-regulatory executive function model of anxiety and depression. While the findings imply the contributions of other mediating variables, they also indicate that metacognitive therapy with an additional focus on anhedonia could be effective in preventing the development of depression.
Graphical Abstract
[1]
Diagnostic and statistical manual of mental disorders.Arlington, VA: American Psychiatric Association. 2013. Available from: https://dsm.psychiatryonline.org/doi/epdf/10.1176/appi.books.9780890425596
[2]
Cohen JN, Taylor DM, Morrison AS, Gilbert KE, Heimberg RG, Gruber J. Positive and negative affect as links between social anxiety and depression: Predicting concurrent and prospective mood symptoms in unipolar and bipolar mood disorders. Behav Ther 2017; 48(6): 820-33.
[http://dx.doi.org/10.1016/j.beth.2017.07.003] [PMID: 29029678]
[http://dx.doi.org/10.1016/j.beth.2017.07.003] [PMID: 29029678]
[3]
Koyuncu A, İnce E, Ertekin E, Tükel R. Comorbidity in social anxiety disorder: Diagnostic and therapeutic challenges. Drugs Context 2019; 8: 212573.
[http://dx.doi.org/10.7573/dic.212573] [PMID: 30988687]
[http://dx.doi.org/10.7573/dic.212573] [PMID: 30988687]
[4]
Ratnani I, Vala A, Panchal B, et al. Association of social anxiety disorder with depression and quality of life among medical undergraduate students. J Family Med Prim Care 2017; 6(2): 243-8.
[http://dx.doi.org/10.4103/2249-4863.219992] [PMID: 29302525]
[http://dx.doi.org/10.4103/2249-4863.219992] [PMID: 29302525]
[5]
Anderson E, Hope D. A review of the tripartite model for understanding the link between anxiety and depression in youth. Clin Psychol Rev 2008; 28(2): 275-87.
[http://dx.doi.org/10.1016/j.cpr.2007.05.004] [PMID: 17582665]
[http://dx.doi.org/10.1016/j.cpr.2007.05.004] [PMID: 17582665]
[6]
Kessler RC, Stang P, Wittchen HU, Stein M, Walters EE. Lifetime co-morbidities between social phobia and mood disorders in the US National Comorbidity Survey. Psychol Med 1999; 29(3): 555-67.
[http://dx.doi.org/10.1017/S0033291799008375] [PMID: 10405077]
[http://dx.doi.org/10.1017/S0033291799008375] [PMID: 10405077]
[7]
Kobezak HM, Gibb BE. Prospective associations between social anxiety and depression in youth: The moderating role of maternal major depressive disorder. J Adolesc 2020; 82(1): 19-22.
[http://dx.doi.org/10.1016/j.adolescence.2020.05.003]
[http://dx.doi.org/10.1016/j.adolescence.2020.05.003]
[8]
Clark LA, Watson D. Tripartite model of anxiety and depression: Psychometric evidence and taxonomic implications. J Abnorm Psychol 1991; 100(3): 316-6.
[http://dx.doi.org/10.1037/0021-843X.100.3.316]
[http://dx.doi.org/10.1037/0021-843X.100.3.316]
[9]
Ho N, Sommers M. Anhedonia: A concept analysis. Arch Psychiatr Nurs 2013; 27(3): 121-9.
[http://dx.doi.org/10.1016/j.apnu.2013.02.001] [PMID: 23706888]
[http://dx.doi.org/10.1016/j.apnu.2013.02.001] [PMID: 23706888]
[10]
De Fruyt J, Sabbe B, Demyttenaere K. Anhedonia in depressive disorder: A narrative review. Psychopathology 2020; 53(5-6): 274-81.
[http://dx.doi.org/10.1159/000508773] [PMID: 32668436]
[http://dx.doi.org/10.1159/000508773] [PMID: 32668436]
[11]
Zielinski MJ, Veilleux JC, Winer ES, Nadorff MR. A short-term longitudinal examination of the relations between depression, anhedonia, and self-injurious thoughts and behaviors in adults with a history of self-injury. Compr Psychiatry 2017; 73: 187-95.
[http://dx.doi.org/10.1016/j.comppsych.2016.11.013] [PMID: 28040576]
[http://dx.doi.org/10.1016/j.comppsych.2016.11.013] [PMID: 28040576]
[12]
Sagud M, Tudor L, Šimunić L, et al. Physical and social anhedonia are associated with suicidality in major depression, but not in schizophrenia. Suicide Life Threat Behav 2021; 51(3): 446-54.
[http://dx.doi.org/10.1111/sltb.12724] [PMID: 33314250]
[http://dx.doi.org/10.1111/sltb.12724] [PMID: 33314250]
[13]
Jordan DG, Winer ES, Salem T, Kilgore J. Longitudinal evaluation of anhedonia as a mediator of fear of positive evaluation and other depressive symptoms. Cogn Emotion 2018; 32(7): 1437-47.
[http://dx.doi.org/10.1080/02699931.2017.1289895] [PMID: 28278732]
[http://dx.doi.org/10.1080/02699931.2017.1289895] [PMID: 28278732]
[14]
Clark DM, Wells A. A cognitive model of social phobia Social phobia: Diagnosis, assessment, and treatment. New York, NY, US: The Guilford Press 1995; pp. 69-93.
[15]
Wells A. A cognitive model of GAD: Metacognitions and pathological worry Generalized anxiety disorder: Advances in research and practice. New York, NY, US: The Guilford Press 2004; pp. 164-86.
[16]
Wells A, Cartwright HS. A short form of the metacognitions questionnaire: Properties of the MCQ-30. Behav Res Ther 2004; 42(4): 385-96.
[http://dx.doi.org/10.1016/S0005-7967(03)00147-5] [PMID: 14998733]
[http://dx.doi.org/10.1016/S0005-7967(03)00147-5] [PMID: 14998733]
[17]
Wells A, Matthews G. Modelling cognition in emotional disorder: The S-REF model. Behav Res Ther 1996; 34(11-12): 881-8.
[http://dx.doi.org/10.1016/S0005-7967(96)00050-2] [PMID: 8990539]
[http://dx.doi.org/10.1016/S0005-7967(96)00050-2] [PMID: 8990539]
[18]
Wells A. Meta-cognition and worry: A cognitive model of generalized anxiety disorder. Behav Cogn Psychother 1995; 23(3): 301-20.
[http://dx.doi.org/10.1017/S1352465800015897]
[http://dx.doi.org/10.1017/S1352465800015897]
[19]
Wells A. Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Hoboken, NJ, US: John Wiley & Sons Inc 1997.
[20]
Wong QJJ, Moulds ML. Do socially anxious individuals hold positive metacognitive beliefs about rumination? Behav Change 2010; 27(2): 69-83.
[http://dx.doi.org/10.1375/bech.27.2.69]
[http://dx.doi.org/10.1375/bech.27.2.69]
[21]
Fisak B Jr, Hammond AN. Are positive beliefs about post-event processing related to social anxiety? Behav Change 2013; 30(1): 36-47.
[http://dx.doi.org/10.1017/bec.2013.4]
[http://dx.doi.org/10.1017/bec.2013.4]
[22]
Vassilopoulos SP, Brouzos A, Moberly NJ. The relationships between metacognition, anticipatory processing, and social anxiety. Behav Change 2015; 32(2): 114-26.
[http://dx.doi.org/10.1017/bec.2015.4]
[http://dx.doi.org/10.1017/bec.2015.4]
[23]
Papageorgiou C, Wells A. Metacognitive beliefs about rumination in recurrent major depression. Cognit Behav Pract 2001; 8(2): 160-4.
[http://dx.doi.org/10.1016/S1077-7229(01)80021-3]
[http://dx.doi.org/10.1016/S1077-7229(01)80021-3]
[24]
Tabachnick BG, Fidell LS. Using Multivariate Statistics. Pearson. (7th ed..), 2019. Available from: http://www.ru.ac.bd/wp-content/uploads/sites/25/2019/
03/401_04_Fidell_Using-multivariate-statisticsFF.pdf
[25]
Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behav Res Methods 2009; 41(4): 1149-60.
[http://dx.doi.org/10.3758/BRM.41.4.1149] [PMID: 19897823]
[http://dx.doi.org/10.3758/BRM.41.4.1149] [PMID: 19897823]
[26]
Green S B. How many subjects does it take to do a
regression analysis. Multivariate Behav Res 1991; 26(3): 499-510.
[http://dx.doi.org/10.1207/s15327906mbr2603_7]
[http://dx.doi.org/10.1207/s15327906mbr2603_7]
[27]
Cohen J. Current directions in psychological science. J Am Psychol Soc 1992; 1(3): 98-101.
[http://dx.doi.org/10.1111/1467-8721.ep10768783]
[http://dx.doi.org/10.1111/1467-8721.ep10768783]
[28]
Hofmann SG, DiBartolo PM. Social anxiety: Clinical, developmental, and social perspectives. (Third ed.), London, England: Academic Press 2014.
[29]
Peters L. Discriminant validity of the Social Phobia and Anxiety Inventory (SPAI), the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale(SIAS). Behav Res Ther 2000; 38(9): 934-50.
[http://dx.doi.org/10.1016/s0005-7967(99)00131-x]
[http://dx.doi.org/10.1016/s0005-7967(99)00131-x]
[30]
Mattick RP, Clarke JC. Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. S.T. Behav Res Ther 1998; 36(4): 455-70.
[http://dx.doi.org/10.1016/S0005-7967(97)10031-6] [PMID: 9670605]
[http://dx.doi.org/10.1016/S0005-7967(97)10031-6] [PMID: 9670605]
[31]
Olivares JM, Berrios GE, Bousoño M. The Self-Assessment Anhedonia Scale (SAAS). Netherlands: Elsevier Science 2005; pp. 121-34.
[32]
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA 1999; 282(18): 1737-44.
[http://dx.doi.org/10.1001/jama.282.18.1737] [PMID: 10568646]
[http://dx.doi.org/10.1001/jama.282.18.1737] [PMID: 10568646]
[33]
Kroenke K, Spitzer RL, Williams JBW. The PHQ-9. J Gen Intern Med 2001; 16(9): 606-13.
[http://dx.doi.org/10.1046/j.1525-1497.2001.016009606.x] [PMID: 11556941]
[http://dx.doi.org/10.1046/j.1525-1497.2001.016009606.x] [PMID: 11556941]
[34]
Hayes AF. Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. (2nd ed.), New York, NY, US: Guilford Press 2018.
[35]
Brown EJ, Turovsky J, Heimberg RG, Juster HR, Brown TA, Barlow DH. Validation of the social interaction anxiety scale and the social phobia scale across the anxiety disorders. Psychol Assess 1997; 9(1): 21-7.
[http://dx.doi.org/10.1037/1040-3590.9.1.21]
[http://dx.doi.org/10.1037/1040-3590.9.1.21]
[36]
Gkika S, Wittkowski A, Wells A. Social cognition and metacognition in social anxiety: A systematic review. Clin Psychol Psychother 2018; 25(1): 10-30.
[http://dx.doi.org/10.1002/cpp.2127] [PMID: 28836318]
[http://dx.doi.org/10.1002/cpp.2127] [PMID: 28836318]
[37]
Kirk PA, Robinson OJ, Gilbert SJ. Trait anxiety does not correlate with metacognitive confidence or reminder usage in a delayed intentions task. Q J Exp Psychol 2021; 74(4): 634-44.
[http://dx.doi.org/10.1177/1747021820970156] [PMID: 33084484]
[http://dx.doi.org/10.1177/1747021820970156] [PMID: 33084484]
[38]
Germine LT, Garrido L, Bruce L, Hooker C. Social anhedonia is associated with neural abnormalities during face emotion processing. Neuroimage 2011; 58(3): 935-45.
[http://dx.doi.org/10.1016/j.neuroimage.2011.06.059] [PMID: 21763435]
[http://dx.doi.org/10.1016/j.neuroimage.2011.06.059] [PMID: 21763435]
[39]
Kwapil TR, Silvia PJ, Myin GI, Anderson AJ, Coates SA, Brown LH. The social world of the socially anhedonic: Exploring the daily ecology of asociality. J Res Pers 2009; 43(1): 103-6.
[http://dx.doi.org/10.1016/j.jrp.2008.10.008]
[http://dx.doi.org/10.1016/j.jrp.2008.10.008]
[40]
Silvia PJ, Kwapil TR. Aberrant asociality: How individual differences in social anhedonia illuminate the need to belong. J Pers 2011; 79(6): 1315-32.
[http://dx.doi.org/10.1111/j.1467-6494.2010.00702.x] [PMID: 21480908]
[http://dx.doi.org/10.1111/j.1467-6494.2010.00702.x] [PMID: 21480908]
[41]
Cicero DC, Krieg A, Becker TM, Kerns JG. Evidence for the discriminant validity of the revised social anhedonia scale from social anxiety. Assessment 2016; 23(5): 544-56.
[http://dx.doi.org/10.1177/1073191115590851] [PMID: 26092042]
[http://dx.doi.org/10.1177/1073191115590851] [PMID: 26092042]
[42]
Fredrick JW, Luebbe AM. Fear of positive evaluation and social anxiety: A systematic review of trait-based findings. J Affect Disord 2020; 265: 157-68.
[http://dx.doi.org/10.1016/j.jad.2020.01.042] [PMID: 32090737]
[http://dx.doi.org/10.1016/j.jad.2020.01.042] [PMID: 32090737]
[43]
Winer ES, Bryant J, Bartoszek G, Rojas E, Nadorff MR, Kilgore J. Mapping the relationship between anxiety, anhedonia, and depression. J Affect Disord 2017; 221: 289-96.
[http://dx.doi.org/10.1016/j.jad.2017.06.006] [PMID: 28668590]
[http://dx.doi.org/10.1016/j.jad.2017.06.006] [PMID: 28668590]
[44]
Capobianco L, Faija C, Husain Z, Wells A. Metacognitive beliefs and their relationship with anxiety and depression in physical illnesses: A systematic review. PLoS One 2020; 15(9): e0238457.
[http://dx.doi.org/10.1371/journal.pone.0238457] [PMID: 32911486]
[http://dx.doi.org/10.1371/journal.pone.0238457] [PMID: 32911486]
[45]
Lenzo V, Sardella A, Martino G, Quattropani MC. A systematic review of metacognitive beliefs in chronic medical conditions. Front Psychol 2020; 10: 2875-75.
[http://dx.doi.org/10.3389/fpsyg.2019.02875] [PMID: 31998178]
[http://dx.doi.org/10.3389/fpsyg.2019.02875] [PMID: 31998178]
[46]
Cartwright HS, Wells A. Beliefs about worry and intrusions: The meta-cognitions questionnaire and its correlates. J Anxiety Disord 1997; 11(3): 279-96.
[http://dx.doi.org/10.1016/S0887-6185(97)00011-X] [PMID: 9220301]
[http://dx.doi.org/10.1016/S0887-6185(97)00011-X] [PMID: 9220301]
[47]
Dannahy L, Stopa L. Post-event processing in social anxiety. Behav Res Ther 2007; 45(6): 1207-19.
[http://dx.doi.org/10.1016/j.brat.2006.08.017] [PMID: 17112463]
[http://dx.doi.org/10.1016/j.brat.2006.08.017] [PMID: 17112463]
[48]
Mills AC, Grant DM, Judah MR, White EJ. The influence of anticipatory processing on attentional biases in social anxiety. Behav Ther 2014; 45(5): 720-9.
[http://dx.doi.org/10.1016/j.beth.2014.04.004] [PMID: 25022782]
[http://dx.doi.org/10.1016/j.beth.2014.04.004] [PMID: 25022782]
[49]
Grant DM, Beck JG. What predicts the trajectory of rumination?: A prospective evaluation. J Anxiety Disord 2010; 24(5): 480-6.
[http://dx.doi.org/10.1016/j.janxdis.2010.03.004] [PMID: 20381304]
[http://dx.doi.org/10.1016/j.janxdis.2010.03.004] [PMID: 20381304]
[50]
Starr LR, Davila J. Responding to anxiety with rumination and hopelessness: Mechanism of anxiety-depression symptom co-occurrence? Cognit Ther Res 2012; 36(4): 321-37.
[http://dx.doi.org/10.1007/s10608-011-9363-1] [PMID: 22865943]
[http://dx.doi.org/10.1007/s10608-011-9363-1] [PMID: 22865943]
[51]
Bright M, Parker S, French P, Morrison AP, Tully S, Stewart SLK. Wells A Assessment of metacognitive beliefs in an at risk mental state for psychosis: A validation study of the metacognitions questionnaire-30. Clin Psychol Psychother 2018; 25(5): 710-20.
[http://dx.doi.org/10.1002/cpp.2301]
[http://dx.doi.org/10.1002/cpp.2301]
[52]
Huntley CD, Young B, Smith CT, Jha V, Fisher PL. Assessing metacognitive beliefs in test anxiety: Psychometric properties of the metacognitions questionnaire, 30 (mcq-30) among university students. Curr Psychol 2022; 41(3): 1425-33.
[http://dx.doi.org/10.1007/s12144-020-00662-y]
[http://dx.doi.org/10.1007/s12144-020-00662-y]
[53]
Marković V, Purić D, Vukosavljević-Gvozden T, Begović A. Validation of the serbian version of the metacognitions questionnaire-30 in nonclinical and clinical samples. Clin Psychol Psychother 2019; 26(4): 458-70.
[http://dx.doi.org/10.1002/cpp.2366]
[http://dx.doi.org/10.1002/cpp.2366]
