Abstract
The present study followed-up adolescents with social anxiety disorder (SAD) during the COVID-19 pandemic, approximately 5-years following their participation in an Attention Bias Modification Training (ABMT) program (Ollendick et al., 2019). The current study aimed to evaluate current functioning and quality of life (QoL) during the emerging adulthood period. Participants included 27 young adults who completed a randomized controlled trial of ABMT and were available for follow-up. Participants filled out self-report measures of QoL and functioning and underwent a clinical interview to assess current severity of social anxiety. Clinician-rated symptoms of SAD significantly decreased from post-treatment to 5-year follow-up. Additionally, results demonstrated that social anxiety severity was significantly related to poorer self-reported physical and psychological health as well as poorer functioning with regard to social distancing fears during COVID-19. Lastly, when evaluating change in symptoms over time, increases in social anxiety severity over a 5-year period significantly predicted worsened social distancing fears during COVID-19.
Keywords: Social anxiety disorder, COVID-19, Follow-up, Functioning, Quality of life
1. Introduction
Social anxiety disorder (SAD) is a chronic and functionally impairing psychological disorder characterized by recurring fears about one or more social or performance situations (American Psychiatric Association, 2013). SAD tends to develop during adolescence, at a median age of 13-14 years (Farrell et al., 2019). During adolescence, SAD has a prevalence rate of 10-15% and, if left untreated, tends to follow a chronic course into adulthood (Kessler et al., 2005; Merikangas et al., 2010). In addition to the pervasive nature of this disorder, SAD also carries a significant social burden, including self-reported deficits in friendships and romantic relationships (e.g., Rodebaugh 2009, Tonge et al. 2020). Further, in addition to persistent social difficulties, numerous studies have shown that SAD across the lifespan is associated with impairments in educational attainment, occupational functioning, and overall quality of life ([QoL]; e.g., Moitra et al. 2011, Vilaplana-Pérez et al. 2021).
Despite the long-term costs and consequences of SAD, remarkably few studies have provided long-term follow-up data beyond 18 months in adolescents and adults who have been treated for SAD (Steinert et al., 2013). The only exception was reported by García-López and Colleagues (2006), who were the first to report 1-year and 5-year follow-up findings from adolescents previously treated for SAD. Specifically, García-López and Colleagues (2006) report findings from a study of adolescents with SAD who underwent three different cognitive-behavioral treatments (García-López et al., 2002). Findings indicated that adolescents (n = 44) who received each of the treatments experienced reductions in SAD symptoms at 1-year follow-up and that the 23 of the 44 (52%) who were able to be contacted at 5-year follow-up maintained a reduction in these self-reported symptoms. It should be noted, however, that there were relatively few adolescents in each treatment group (approximately 8 in each) Yet, despite the small sample size, this study demonstrated that adolescents with SAD can maintain symptom improvement over time following intervention. While not evaluating follow-up of social anxiety treatment, an additional 4-year follow-up study on youth who underwent treatment for specific phobia also show significant loss of sample retention (Halldorsdottir and Ollendick, 2016). However, other relevant long-term outcomes, such as QoL were not evaluated in either study.
However, a couple of studies have attempted to target this gap in the literature. For example, in at least one study, improvements in QoL were noted following cognitive behavioral therapy (CBT) (Cottraux et al., 2000), at least in the short-term (i.e., immediately post-treatment). Long-term QoL outcomes were not explored in this study. An additional early study by Eng and Colleagues (2001) with adults with SAD did report negative associations between global QoL and social interaction anxiety 6 months following group CBT. These limited findings provide initial support regarding specific QoL changes for individuals with SAD. However, as mentioned above, no study to date has examined long-term influences on QoL in adolescents with SAD. Moreover, no studies have evaluated whether changes in social anxiety are associated with QoL over time.
In addition to sparse information regarding long-term outcomes for individuals who have undergone treatment for SAD, there is very little work to date examining the impact that SAD has had on functioning during the COVID-19 pandemic. Specifically, following the emergence of COVID-19, two studies have examined the perceived impact of COVID-19 on symptomatology, stress, behavior, and interpersonal outcomes in adults with SAD. Quittkat and Colleagues (2020) demonstrated that adults with SAD reported higher stress during the pandemic as compared to before; however, they did not find an increase in disorder-specific SAD symptom severity. In the second study, Ho and Moscovitch (2021) reported that pre-existing social anxiety symptoms predicted coronavirus-specific anxiety, loneliness, fears of negative evaluation, use of preventative approaches, and affiliative outcomes. In this investigation, it was further demonstrated that the presence of social anxiety symptomatology prior to the emergence of COVID-19 predicted poorer mental health functioning, higher levels of loneliness, and greater fear of negative evaluation during the pandemic. To our knowledge, these are the only two studies conducted with adults with SAD regarding COVID-19; moreover, no studies have been conducted with adolescents.
Accordingly, the overarching aim of the present study was to follow-up adolescents with SAD during the COVID-19 pandemic (approximately 5-years after participation in an Attention Bias Modification training study for SAD; Ollendick et al., 2019) to assess their current social anxiety severity during emerging adulthood. We predicted that social anxiety would remain relatively stable as compared to their post-treatment scores, as suggested by García-López and Colleagues (2006). Additionally, the current study evaluated current reports of functioning (e.g., severity of symptoms) and QoL during COVID-19 as they relate to social anxiety. We hypothesized that social anxiety would be related to self-reported functioning and QoL. Lastly, we aimed to assess whether changes in social anxiety over time were related to functioning and QoL during COVID-19. Based on prior work, we expected that improvements in social anxiety would be related to higher reports of functioning and QoL at this follow-up time.
2. Method
2.1. Participants
The present study was approved by the Virginia Tech Institutional Review Board (#13-180). All 58 participants who were included in the original RCT (Ollendick et al., 2019) were considered eligible for the present follow-up study and were re-contacted to assess current functioning 4 to 6 years later (M = 5.44, SD = 0.64). Recruitment occurred between August 2020 and March 2021 during the height of the COVID-19 global pandemic. All self-report measures and clinical interviews occurred online via the use of secure Qualtrics and HIPAA Compliant Zoom platforms, respectively. As participants were adolescents during the original RCT, parents of participants were contacted to relay the current study information to their child who was now 18 years of age or older. If their son or daughter was interested in taking part in the study, the parents were asked to contact the primary investigator and provide informed consent prior to inviting the now young adults to complete study measures and interviews. Of the 58 participants from the original study, 27 participated in the present 5-year follow-up study (46.6%). These 271 participants did not differ significantly from the other 31 participants with regard to post-treatment social anxiety scores (Mean clinician rating for social anxiety severity for the 31 participants from the original study at post-treatment was 4.83 on a 0-8 scale) nor by demographic breakdown. However, of the 27 participants in the present study, only 16 had completed post-treatment in the original study, therefore the sample size for subsequent analyses using change scores was limited to these 16 young adults. Chi-square analyses were carried out to assess if the subset of participants who had posttreatment data differed significantly from those who did not have posttreatment data. No significant differences emerged for age, gender, education, nor income. No participants were excluded from analyses as no outliers were identified. Demographic information is provided in Table 1 .
Table 1.
Demographics for all participants at 5-year follow-up.
| Age[Mean (SD)] | 19.41 (1.31) (N=27) |
|---|---|
| Gender(%) | |
| Male | 22.2 (N=6) |
| Female | 63.0 (N=17) |
| Transgender Male | 3.7 (N=1) |
| Genderqueer | 3.7 (N=1) |
| Gender Fluid | 7.4 (N=2) |
| Race(%) | |
| White | 85.2 (N=23) |
| Black | 7.4 (N=2) |
| Asian | 3.7 (N=1) |
| Other | 3.7 (N=1) |
| Income (%) | |
| $0-10,000 | 77.8 (N=21) |
| $10,001-20,000 | 11.1 (N=3) |
| $40,001-65,000 | 3.7 (N=1) |
| $65,001-100,000+ | 7.4 (N=2) |
| Education (%) | |
| Completed Grade School | 2.6 (N = 2) |
| High School Diploma/GED | 10.5 (N=8) |
| Some College | 19.7 (N = 15) |
| College Degree | 2.6 (N = 2) |
2.2. Measures
Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5; Brown and Barlow, 2014)
The ADIS-5 is a semi-structured interview designed to assess anxiety and related disorders. The SAD module of the ADIS-5 was used in the present study. As was done in the original RCT study (Ollendick et al., 2019), a trained and research-reliable clinician – who was supervised by a licensed clinical psychologist – assigned a clinical severity rating (CSR) on a 9-point scale (0–8, with any rating ≥ 4 indicating diagnostic presence) on the SAD module. The ADIS-5 administrations were videotaped and 44% (n = 12) of the diagnostic interviews were reviewed by a second clinician. Inter-rater agreement on the CSR score was high (i.e., CSR within one point of each other) such that agreement was 100% between independent coders.
World Health Organization Quality of Life (WHOQOL-BREF; WHOQOL Group, 1998)
The WHOQOL-BREF is a 26-item measure that assesses quality of life across the domains of physical health, psychological health, relationships, and environment. The WHOQOL-BREF was filled out by participants during the follow-up time point only. Participants were asked to respond to items (e.g., “Do you get the kind of support from others that you need”) on a 4-point scale, ranging from 1 “Not at all” to 4 “A great deal”. The WHOQOL-BREF has been shown to have generally good psychometric properties (αs = .66-.84 across domains; WHOQOL Group, 1998) and demonstrated good internal consistently across subscales (Physical Health, α = .75; Psychological Health, α = .87; Environment, α =.80), except for the Relationships subscale (α =.55) in the present study. Given the poor internal consistency of the Relationships subscale, this subscale was not included in subsequent analyses. Higher scores reflect better quality of life.
Fear of Illness and Virus Evaluation (FIVE; Ehrenreich-May, In preparation; Sáez-Clarke et al., 2022)
The FIVE is a 35-item measure that assesses fears regarding COVID-19 contamination and illness, fears about social distancing, behaviors related to illness and virus fears, and the impact of illness and virus fears as they specifically related to COVID-19. For questions assessing fears about contamination and illness as well as fears about social distancing, participants were asked to rate how often they felt afraid or worried about each item over the last week (e.g., “I am afraid I might die if I get a bad illness or virus”) on a scale ranging from 1 (“I am not afraid of this at all”) to 4 (“I am afraid of this all of the time”). For items regarding behaviors related to illness, participants were asked to rate how often they had engaged in certain behaviors over the last week (e.g., “I stay away from other people”) on a scale ranging from 1 (“I have not done this in the last week”) to 4 (“I did this all the time last week”). Lastly, for questions assessing the impact of illness or virus fears, participants were asked to indicate how true each statement was (e.g., “On average in the last week, being afraid of an illness or virus has caused me to experience strong emotions.”) on a 1 (“Not true of me at all”) to 4 (“Definitely true”) scale. Although not reported in previous studies, the FIVE showed acceptable to good internal consistency across subscales (αs = .70 - .93) in the present study. Greater scores on the FIVE indicate worse functioning.
2.3. Data analytic plan
To assess current functioning in the sample as compared to the post-treatment in the original study, descriptive statistics were run for all participants at post-treatment and at 5-year follow-up. Additionally, paired samples t-tests were run to examine if social anxiety symptomatology and severity were significantly different from post-treatment to the 5-year follow-up. Next, to evaluate the relation among social anxiety, current functioning, and QoL, correlation analyses were carried out. Lastly, to assess whether changes in social anxiety over time were associated with higher reports of functioning and QoL, linear regression analyses were run.
2.4. Transparency & openness
The present study was not preregistered. We report how our sample size was determined and recruited, the inclusion of all participants, as well as include a summary of all measures in the present study. Moreover, data and syntax for the current study are available upon request.
3. Results
3.1. Functioning during COVID-19 as Compared to posttreatment
Means and standard deviations for all measures are presented in Table 2 . At post-treatment, the mean clinician-reported SAD CSR was 4.79 (SD = 1.03); indicating that on average participants continued to meet a diagnosis for SAD. At 5-year follow-up, the mean SAD CSR was 3.46 (SD = 1.62), showing a decrease in social anxiety severity from post-treatment to follow-up and no longer meeting criteria for SAD as a group. To evaluate whether diagnostic social anxiety status significantly changed from post-treatment to follow-up, a paired samples t-test was performed with the SAD CSR. Results indicated that there was a significant average difference between post-treatment and follow-up for the SAD CSR (t = 3.616, p < .01).
Table 2.
Descriptive statistics for variables of interest.
| Mean | SD | |
|---|---|---|
| SAD CSR Posttreatment | 4.79 | 1.03 |
| SAD CSR 5-Year Follow-Up | 3.46 | 1.62 |
| Change in SAD CSR | 1.44 | 1.59 |
| WHOQOL-BREF | ||
| Physical | 15.00 | 2.44 |
| Psychological | 11.93 | 2.99 |
| Environment | 15.11 | 2.27 |
| FIVE | ||
| Contamination | 19.48 | 7.03 |
| Social Distancing | 19.56 | 6.73 |
| Behaviors Related to Illness | 33.52 | 7.05 |
| Impact of Illness | 4.15 | 1.75 |
Note: SAD = social anxiety disorder; CSR = clinician severity rating; WHOQOL-BREF = World Health Organization Quality of Life; FIVE = Fear of Illness and Virus Evaluation. All variables presented in this table refer to self-reported measures from participants, with the exception of the SAD CSR, which is a clinician rating based on the participants report of social anxiety impairment and interference.
3.2. Relations between social anxiety, functioning, and QoL during COVID-19
Results from correlational analyses are presented in Table 3 . As can be seen, social anxiety severity at 5-year follow-up (i.e., SAD CSR) was significantly and negatively related to both the Physical Health (r = -.67, p < .01) and Psychological Health (r = -.70, p < .01) domains of the WHOQOL-BREF, indicating that as social anxiety increased, reports of physical and psychological health decreased; however, the Environment domain was not significantly correlated with social anxiety (r = -.03, p > .05). Additionally, social anxiety severity at 5-year follow-up was significantly and positively related to the Contamination and Social Distancing domains of the FIVE, suggesting that as social anxiety severity increased, so too did fear of contamination and impact of social distancing. Yet the Behaviors Related to Illness and Impact of Illness domains of the FIVE were not significantly correlated with social anxiety (r = .17, p > .05 and r = .19, p > .05, respectively), suggesting no significant association between these variables.
Table 3.
Correlations among all variables of interest.
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | |
|---|---|---|---|---|---|---|---|---|
| 1. SAD CSR 5-Year Follow-Up | - | |||||||
| WHOQOL-BREF | ||||||||
| 2. Physical | -.67** | - | ||||||
| 3. Psychological | -.70** | .82** | - | |||||
| 4. Environment | -.03 | .37 | .43* | - | ||||
| FIVE | ||||||||
| 5. Contamination | .54** | -.16 | -.14 | -.11 | - | |||
| 6. Social Distancing | .69** | -.28 | -.36 | -.25 | .52** | - | ||
| 7. Behaviors Related to Illness | .17 | .02 | -.03 | .17 | .42* | .22 | - | |
| 8. Impact of Illness | .19 | .07 | .14 | .19 | .36 | .48* | .52** | - |
Note: SAD = social anxiety disorder; CSR = clinician severity rating; WHOQOL-BREF = World Health Organization Quality of Life; FIVE = Fear of Illness and Virus Evaluation. All variables presented in this table refer to self-reported measures from participants, with the exception of the SAD CSR, which is a clinician rating based on the participant's report of social anxiety impairment and interference.
3.3. Change in social anxiety as it predicts functioning and QoL during COVID-19
As shown in Table 4 , results from linear regression analyses demonstrated that changes in social anxiety severity (i.e., SAD CSR) did not have any significant associations with any QoL domain. However, changes in social anxiety severity did significantly predict FIVE Social Distancing (β = -2.03, p < .05).
Table 4.
Linear regression results for change in SAD CSR from posttreatment to follow-up as it predicts functioning and QoL.
| ΔSAD CSR | |||
|---|---|---|---|
| β | R2 | p | |
| WHOQOL-BREF | |||
| Physical | .393 | .096 | .242 |
| Psychological | .295 | .036 | .482 |
| Environment | .341 | .083 | .281 |
| FIVE | |||
| Contamination | -.926 | .051 | .402 |
| Social Distancing | -2.03 | .293 | .030* |
| Behaviors Related to Illness | -.354 | .009 | .723 |
| Impact of Illness | -.099 | .012 | .687 |
Note: SAD = social anxiety disorder; CSR = clinician severity rating; WHOQOL-BREF = World Health Organization Quality of Life; FIVE = Fear of Illness and Virus Evaluation. All variables presented in this table refer to self-reported measures from participants, with the exception of the SAD CSR, which is a clinician rating based on the participant's report of social anxiety impairment and interference
4. Discussion
The primary aim of the present study was to assess current functioning in socially anxious individuals during COVID-19 as compared to their post-treatment functioning approximately 5 years earlier. Based on existing work suggesting that treatment gains for social anxiety are stable over time (García-López et al., 2006), we predicted that social anxiety severity would remain relatively stable relative to post-treatment severity (5-years prior). However, this hypothesis was not supported; instead, our results demonstrated a divergence from previous although limited work on this topic. Specifically, results from the present study indicated that clinician-rated SAD CSRs decreased from post-treatment to follow-up, and that this decrease was statistically significant. This pattern may be due to recent social distancing restrictions imposed due to COVID-19, such that these individuals are less frequently interacting in-person with others; and perhaps facilitating avoidance of anxiety-provoking situations. Therefore, the short-term avoidance of social situations due to COVID-19 may be linked to lower functional impairment due to social anxiety.
The second aim of the present study was to evaluate functioning and QoL during COVID-19 as they relate to social anxiety. We hypothesized that social anxiety would be correlated with self-reported functioning and QoL. Results supported this hypothesis, such that social anxiety severity was associated with lower reports of QoL in the domains of physical and psychological health; however, social anxiety severity did not significantly relate to the Environment domain. Additionally, social anxiety severity was indeed associated with poorer functioning per reports on the Social Distancing and Contamination domains of the FIVE. Findings from this study align with previous reports of lower QoL ratings in individuals with higher social anxiety (Eng et al., 2001), as well as work suggesting that social anxiety is related to worse functioning during COVID-19 (e.g., Ho and Moscovitch 2021, Quittkat et al. 2020); however, it should be noted that the Behaviors Related to Illness and Impact of Illness domains of the FIVE were not significantly correlated with social anxiety. These results suggest that targeting social anxiety may help improve specific facets of QoL and functioning during COVID-19.
The final aim of the current study was to determine if changes in social anxiety severity were predictive of current functioning and QoL during COVID-19. Given extant work suggesting that decreased social anxiety is linked to improvements in psychological domains of QoL in the short-term (i.e., Eng et al. 2001), we expected that improvements in social anxiety and severity over time would be related to improvements in QoL. Moreover, given prior work regarding the association among social anxiety and functioning, we hypothesized that change in social anxiety severity would also predict functioning outcomes during COVID-19. Findings indicated that this hypothesis was only partially supported. Regarding QoL, change in social anxiety severity did not significantly predict any domain of the WHOQOL-BREF. These results are inconsistent with previous work (e.g., Eng et al. 2001) showing the linkage between improvements following treatment for social anxiety and psychological domains of QoL, perhaps in part due to the small sample size included in the study. However, change in social anxiety severity was significantly predictive of functioning within the FIVE Social Distancing domain, suggesting that if social anxiety severity increased over time, fears of the impact of social distancing increased as well.
As with any study, findings presented here should be evaluated considering study limitations. For example, as was the case in García-López and Colleagues (2006), our sample size was relatively small. We were limited in the present study to recruitment of participants who had previously participated in the original RCT when they were adolescents. An additional factor pertaining to recruitment was that we were unable to contact the participants directly. However, despite this small sample size, we have a comparable number of participants as was re-recruited by García-López and Colleagues (2006) – the only other investigation of a long-term follow-up of adolescents with SAD. An additional limitation due to this small sample size is that we were not powered to evaluate potential mediators or moderators of treatment outcomes. Future work should examine these to determine mechanisms of change for this population. As noted, data were collected between August 2020 and March 2021, during which time the region of recruitment was on lock down orders which shifted to social distancing orders with mask mandates due to the onset and continuance of COVID-19. However, a limitation of our study is that we did not collect information regarding the daily lives of our participants to get more fine-grained detail on how COVID-19 impacted our participants. Lastly, the present sample largely identified as female college students residing in a rural Appalachian community thus limiting the generalizability of these results without further investigation. Therefore, future research should evaluate this pattern of results in more equal proportions of other genders as well as non-college student populations.
5. Conclusion
The present study followed-up a sample of adolescents who were previously treated for SAD (Ollendick et al., 2019) approximately 5-years later during COVID-19. Overall, findings indicated that functional impairments in SAD as measured by CSRs decreased over time. Additionally, results demonstrate a linkage among social anxiety severity, QoL, and functioning during COVID-19. Lastly, findings presented here suggest that improvements in social anxiety are related to better functioning during COVID-19, thus identifying a potential treatment target.
Funding
This work was supported by the National Institute of Mental Health [R34 MH096915].
Statement of human rights
This study received approval from the Virginia Tech's Institutional Review Board, and all participants provided informed consent to participant in the study.
CRediT authorship contribution statement
Corinne N. Carlton: Data curation, Formal analysis, Writing – review & editing. Katelyn M. Garcia: Data curation, Writing – review & editing. Makayla Honaker: Data curation, Writing – review & editing. John A. Richey: Supervision, Writing – review & editing. Thomas H. Ollendick: Conceptualization, Supervision, Writing – review & editing.
Declaration of Competing Interest
The authors report that there are no competing interests to declare.
Acknowledgements
We would like to acknowledge the graduate students, research assistants, and undergraduate students who assisted us with various aspects of this project. We also wish to express appreciation to the adolescents and families who participated in this clinical research.
Footnotes
Of these 27 participants included in the 5-year follow-up 16 were in the Attention Bias Modification condition and 11 were in the Attention Control condition. As seen in the original study (Ollendick et al., 2019), length of the treatment was twice a week for 5-weeks long, assessment clinicians were aware of study aims but were blind to participant's treatment condition, and outcomes per condition were not significantly different. Additionally, these 27 participants did not significantly differ in their outcomes by condition.
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