14 Chapter 1 feared outcomes (e.g., people may actually reject her because she avoids looking at them; Cuming et al., 2009; Piccirillo, Taylor Dryman, & Heimberg, 2016). A number of studies indeed showed that the use of safety behaviors impedes exposure efficacy in SAD (McManus et al., 2009; Morgan & Raffle, 1999; Piccirillo et al., 2016). However, studies in other anxiety disorders show that the controlled use of safety behaviors may be beneficial in the context of exposure treatment (Milosevic & Radomsky, 2008), as it might help individuals in taking the first steps in exposure and it promotes acceptability. Avoidance tendencies Individuals with SAD do not only show overt social avoidance such as avoiding a social event, they also show more automatic and implicit avoidance tendencies that can be picked up in speeded experimental tasks. An example is the biased information processing toward threatening stimuli. This is usually characterized by initial increased attention to negative emotional information, such as angry faces followed by attentional avoidance of these stimuli, specifically avoidance of the eyes, in order to regulate anxiety provoked by the initial registration of threat (the CS), (Chen & Clarke, 2017). In addition, biased action tendencies seem to play a particular role in individuals with SAD. These action tendencies can for instance be assessed by means of social Approach Avoidance Tasks (AAT: Rinck & Becker, 2007), in which participants respond to social stimuli (for example faces) by pushing (avoidance) or pulling (approach) a joystick. Socially anxious individuals typically show avoidance of social stimuli; i.e. stronger avoidance tendencies compared to approach tendencies toward angry, but also happy faces (Heuer, Rinck, & Becker, 2007; Loijen, Vrijsen, Egger, Becker, & Rinck, 2020; Roelofs, Putman, et al., 2010; Roelofs, van Peer, et al., 2009a) and even neutral faces, compared to non-social stimuli and healthy controls (Kuckertz, Strege, & Amir, 2017). Angry faces communicate potential threat and neutral and happy faces are ambiguous to individuals with SAD and therefore labeled as threatening, and thereby activating avoidance mechanisms (Heuer et al., 2007; Roelofs et al., 2010). Previous work showed that automatic avoidance tendencies assessed by an AAT could predict real life avoidance in specific phobia (Rinck & Becker, 2007). These findings indicate that automatic avoidance tendencies may underly overt avoidance behavior, an important maintaining factor in SAD. Moreover, it could be hypothesized that these avoidance tendencies hinder successful exposure, presumably since they prevent individuals with SAD to really engage in the exposure.
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