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Brief Report: Social Anxiety in Autism Spectrum Disorder Is Based on Deficits in Social Competence

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Title: Brief Report: Social Anxiety in Autism Spectrum Disorder Is Based on Deficits in Social Competence
Language: English
Authors: Espelöer, J. (ORCID 0000-0003-2847-0648), Hellmich, M., Vogeley, K., Falter-Wagner, C. M.
Source: Journal of Autism and Developmental Disorders. Jan 2021 51(1):315-322.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 8
Publication Date: 2021
Document Type: Journal Articles
Reports - Research
Descriptors: Autism, Pervasive Developmental Disorders, Anxiety Disorders, Interpersonal Competence, Symptoms (Individual Disorders), Scores
DOI: 10.1007/s10803-020-04529-w
ISSN: 0162-3257
Abstract: This study differentially examined the relation between two clinical constructs: "social anxiety" and "social competence" in autism spectrum disorder (ASD). Employing two questionnaires (SASKO; IU), individuals with ASD (n = 23) showed increased scores of SOCIAL ANXIETY (SASKO) and of INTOLERANCE OF UNCERTAINTY (IU), compared to a non-clinical comparison group (NC; n = 25). SOCIAL ANXIETY scores were equally increased for ASD and a reference population of individuals with social anxiety disorder (SAD; n = 68). However, results showed increased SOCIAL COMPETENCE DEFICITS in ASD compared to SAD and NC groups. This study allows drawing the conclusion that social anxiety symptoms in ASD can be traced back to autism-specific deficits in social skills and are therefore putatively based on different, substantially "deeper" implemented cognitive mechanisms.
Abstractor: As Provided
Entry Date: 2021
Accession Number: EJ1281122
Database: ERIC
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  Value: <anid>AN0148114435;aut01jan.21;2021Jan18.05:59;v2.2.500</anid> <title id="AN0148114435-1">Brief Report: Social Anxiety in Autism Spectrum Disorder is Based on Deficits in Social Competence </title> <p>This study differentially examined the relation between two clinical constructs: "social anxiety" and "social competence" in autism spectrum disorder (ASD). Employing two questionnaires (SASKO; IU), individuals with ASD (n = 23) showed increased scores of SOCIAL ANXIETY (SASKO) and of INTOLERANCE OF UNCERTAINTY (IU), compared to a non-clinical comparison group (NC; n = 25). SOCIAL ANXIETY scores were equally increased for ASD and a reference population of individuals with social anxiety disorder (SAD; n = 68). However, results showed increased SOCIAL COMPETENCE DEFICITS in ASD compared to SAD and NC groups. This study allows drawing the conclusion that social anxiety symptoms in ASD can be traced back to autism-specific deficits in social skills and are therefore putatively based on different, substantially "deeper" implemented cognitive mechanisms.</p> <p>Keywords: Autism spectrum disorder (ASD); Social competence deficit; Social anxiety; Information processing deficits; Adulthood</p> <hd id="AN0148114435-2">Introduction</hd> <p>Deficits in social interactional skills represent core diagnostic impairments of autism spectrum disorder (ASD). UK charity "Autistica" recently identified anxiety as one of the top ten targets for autism research (Autistica [<reflink idref="bib2" id="ref1">2</reflink>]). Comorbidity rates of social anxiety disorder (SAD) encompassing the fear of scrutiny by other people and the fear of showing embarrassing behavior or expectation to be negatively evaluated (APA [<reflink idref="bib1" id="ref2">1</reflink>]) and ASD ranges across studies from 6 to 38% (Kerns et al. [<reflink idref="bib20" id="ref3">20</reflink>]).</p> <p>Although a bi-directional relationship between ASD-related social impairments and social anxiety symptoms in ASD has been proposed (White et al. [<reflink idref="bib42" id="ref4">42</reflink>], [<reflink idref="bib44" id="ref5">44</reflink>]; White and Roberson-Nay [<reflink idref="bib41" id="ref6">41</reflink>]), only very few studies have investigated social anxiety symptoms in adults with ASD (Bejerot et al. [<reflink idref="bib6" id="ref7">6</reflink>]; Cath et al. [<reflink idref="bib11" id="ref8">11</reflink>]; Kanai et al. [<reflink idref="bib18" id="ref9">18</reflink>]; Spain et al. [<reflink idref="bib35" id="ref10">35</reflink>]). Most of these show a positive relationship between autistic and social anxiety symptoms (Bejerot et al. [<reflink idref="bib6" id="ref11">6</reflink>]; Cath et al. [<reflink idref="bib11" id="ref12">11</reflink>]; Kanai et al. [<reflink idref="bib18" id="ref13">18</reflink>]; Spain et al. [<reflink idref="bib35" id="ref14">35</reflink>]). In individuals with ASD, symptoms of social anxiety might occur due to difficulties in understanding social communication and resulting social retreat. However, some symptoms of ASD might be misinterpreted as social anxiety symptoms, which represents a challenge for differential diagnostics so that particularly individuals with ASD diagnosed late in life might be prone to a misdiagnosis of SAD (Tebartz van Elst et al. [<reflink idref="bib36" id="ref15">36</reflink>]). The reason for this misinterpretation might be that individuals with ASD diagnosed late in life often possess high cognitive skills and have had years of developing and refining cognitive learning processes to compensate for their fundamental deficits in social communication and interaction (Lehnhardt et al. [<reflink idref="bib25" id="ref16">25</reflink>], [<reflink idref="bib26" id="ref17">26</reflink>]). The high effort though that has to be invested for the compensation strategies can result in exhaustion, depression and social retreat, which in turn could resemble SAD (Cath et al. [<reflink idref="bib11" id="ref18">11</reflink>]; Davis et al. [<reflink idref="bib12" id="ref19">12</reflink>]). Social retreat may even be aggravated by greater self-reflecting abilities due to the awareness of personal impairments in social interactions (Bellini [<reflink idref="bib7" id="ref20">7</reflink>]; Kuusikko et al. [<reflink idref="bib24" id="ref21">24</reflink>]; Maddox and White [<reflink idref="bib27" id="ref22">27</reflink>]; Tyson and Cruess [<reflink idref="bib37" id="ref23">37</reflink>]; White et al. [<reflink idref="bib40" id="ref24">40</reflink>], [<reflink idref="bib42" id="ref25">42</reflink>]). Finally, ASD-related core deficits in mentalizing, i.e. difficulties in inferring other's thoughts, feelings, and intentions, may result in social distress (White et al. [<reflink idref="bib42" id="ref26">42</reflink>]), perceived uncertainty in social situations (White et al. [<reflink idref="bib44" id="ref27">44</reflink>]), and subsequently in social avoidance (Kerns and Kendall [<reflink idref="bib19" id="ref28">19</reflink>]; White et al. [<reflink idref="bib44" id="ref29">44</reflink>]) which again might be misinterpreted as SAD instead of ASD (Beidel et al. [<reflink idref="bib5" id="ref30">5</reflink>]; Kerns and Kendall [<reflink idref="bib19" id="ref31">19</reflink>]).</p> <p>Notably, avoidance behaviour or social retreat and social competence deficits may be mutually dependent (Kleinhans et al. [<reflink idref="bib21" id="ref32">21</reflink>]; White et al. [<reflink idref="bib44" id="ref33">44</reflink>]) in that avoidance leads to a lack of experience and practice with social interactions and a lack of opportunities to improve social competence. In the current study, we applied the measure Social Anxiety—Social Competence Deficit Scale (SASKO; Kolbeck [<reflink idref="bib22" id="ref34">22</reflink>]; Kolbeck and Maß [<reflink idref="bib23" id="ref35">23</reflink>]). The aim of the current study was to examine the characterization of social anxiety symptoms in ASD, that can be addressed by the appropriate subscales of SASKO <emph>anxiety of speaking and being in focus of attention</emph> (SPEAKING) and <emph>anxiety of being rejected by others</emph> (REJECTION)<emph>,</emph> under special consideration of social competence deficits, including the SASKO subscales <emph>interaction deficits</emph> (INTERACTION) and <emph>deficits in processing social information</emph> (INFORMATION), in a group of high-functioning adults with ASD, adults with SAD, and a non-clinical (NC) comparison group.</p> <p>Previous research assumed that social unpredictability and the inability to accurately interpret and grasp intentions of others in rapidly changing social interactions might overwhelm individuals with ASD (Mazefsky and Herrington [<reflink idref="bib29" id="ref36">29</reflink>]; Wood and Gadow [<reflink idref="bib47" id="ref37">47</reflink>]) and potentially relate to social anxiety as manifested in ASD. Additionally, the concept of intolerance of uncertainty (IU) has been included because it has been shown that IU represents an essential mechanism underlying the development and maintenance of anxiety in adults with ASD (Boulter et al. [<reflink idref="bib8" id="ref38">8</reflink>]).</p> <p>Investigating this relationship is important in order to better understand social retreat in ASD and to provide guidelines for appropriate differential diagnostics and treatment in ASD.</p> <hd id="AN0148114435-3">Method</hd> <p></p> <hd id="AN0148114435-4">Participants</hd> <p>24 individuals with ASD and 25 NC individuals were included in the study. Additional, a reference group with social anxiety disorder (SAD; n = 68) published with the SASKO manual (Kolbeck [<reflink idref="bib22" id="ref39">22</reflink>]; Kolbeck and Maß [<reflink idref="bib23" id="ref40">23</reflink>]) was included. ASD was diagnosed according to ICD-10 (WHO [<reflink idref="bib48" id="ref41">48</reflink>]) criteria in the Autism Outpatient Clinic, Department of Psychiatry. The NC group was recruited from a participant database (demographic data in Table 1). Inclusion criteria were IQ ≥ 80 (WAIS-III; Wechsler [<reflink idref="bib39" id="ref42">39</reflink>]; WIE; Jacobs and Petermann [<reflink idref="bib16" id="ref43">16</reflink>]) and age 18–65 years. One participant with ASD was excluded due to incomplete filling of the questionnaires. In the final sample, the ASD group (n = 23) and the NC group (n = 25) were matched with respect to IQ and age. The SAD group showed no significant difference in age. The three groups were not matched on gender, [χ<sups>2</sups>(<reflink idref="bib2" id="ref44">2</reflink>) = 8.09, <emph>p</emph> = 0.018], accordingly, gender was included as a covariate in all analyses. Ethics approval was granted by the Ethics Committee of the Medical Faculty. Written informed consent was obtained before testing.</p> <p>Table 1 Demographic information for groups</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left" colspan="2"><p>NC</p><p>(<italic>n</italic> = 25)</p></th><th align="left" colspan="2"><p>ASD</p><p>(<italic>n</italic> = 23)</p></th><th align="left" colspan="2"><p>SAD</p><p>(<italic>n</italic> = 68)</p></th></tr><tr><th align="left"><p>Variables</p></th><th align="left"><p>M</p></th><th align="left"><p>SD</p><p>(Range)</p></th><th align="left"><p>M</p></th><th align="left"><p>SD</p><p>(Range)</p></th><th align="left"><p>M</p></th><th align="left"><p>SD</p><p>(Range)</p></th></tr></thead><tbody><tr><td align="left"><p>Full IQ</p></td><td align="left"><p>110.28</p></td><td align="left"><p>14.11</p></td><td align="left"><p>118.65</p></td><td char="." align="char"><p>15.58</p></td><td char="." align="char" /><td align="left" /></tr><tr><td align="left"><p>Age</p></td><td align="left"><p>38.80</p></td><td align="left"><p>10.41</p><p>(23–57)</p></td><td align="left"><p>44.00</p></td><td char="." align="char"><p>10.55</p><p>(23–58)</p></td><td char="." align="char"><p>37.00</p></td><td align="left"><p>10.00</p><p>(22–62)</p></td></tr></tbody></table> </ephtml> </p> <p>Table 1 Demographic information for groups</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Gender</p></th><th align="left" colspan="2"><p><italic>n</italic></p></th><th align="left" colspan="2"><p><italic>n</italic></p></th><th align="left" colspan="2"><p><italic>n</italic></p></th></tr></thead><tbody><tr><td align="left"><p>Male</p></td><td char="." align="char" colspan="2"><p>10</p></td><td char="." align="char" colspan="2"><p>17</p></td><td char="." align="char" colspan="2"><p>28</p></td></tr><tr><td align="left"><p>Female</p></td><td char="." align="char" colspan="2"><p>15</p></td><td char="." align="char" colspan="2"><p>6</p></td><td char="." align="char" colspan="2"><p>40</p></td></tr></tbody></table> </ephtml> </p> <p>Groups: <emph>NC</emph> non-clinical control, <emph>ASD</emph> autism spectrum disorder, <emph>SAD</emph> social anxiety disorder</p> <hd id="AN0148114435-5">Instruments</hd> <p>The Social Anxiety—Social Competence Deficit Scale <emph>(</emph>SASKO) (Kolbeck [<reflink idref="bib22" id="ref45">22</reflink>]; Kolbeck and Maß [<reflink idref="bib23" id="ref46">23</reflink>]) is a German 40-item self-report measure. The total SASKO score consists of the two main scales SOCIAL ANXIETY and SOCIAL COMPETENCE DEFICITS including two subscales, respectively. The main scale SOCIAL ANXIETY is composed of the two subscales <emph>anxiety of speaking and being in focus of attention</emph> (SPEAKING) and <emph>anxiety of being rejected by others</emph> (REJECTION). The main scale SOCIAL COMPETENCE DEFICITS includes the two subscales <emph>interaction deficits</emph> (INTERACTION) and <emph>deficits in processing of social information</emph> (INFORMATION). Respondents indicated how strong each statement applies to them on a unipolar 4-point scale ("always/mostly", "often", "sometimes", and "never"). The Intolerance of Uncertainty Scale (IU) (Gerlach et al. [<reflink idref="bib14" id="ref47">14</reflink>]) is an abbreviated 18-item German version of the original English version (Buhr and Dugas [<reflink idref="bib9" id="ref48">9</reflink>]; Carleton et al. [<reflink idref="bib10" id="ref49">10</reflink>]; Freeston et al. [<reflink idref="bib13" id="ref50">13</reflink>]). Ratings are made on 5-point Likert scales ("not characteristic of me at all", "something characteristic of me", and "very characteristic of me").</p> <hd id="AN0148114435-6">Results</hd> <p>Raw scores of the SASKO and the IU were analysed (descriptive data in Table 2; raw values in Figs. 1 and 2). The IU was only completed in the ASD group and the NC group. Two missing data in the SASKO were handled in accordance with the manual (Kolbeck and Maß [<reflink idref="bib23" id="ref51">23</reflink>]). One missing value was replaced with the mean of the scale (Maisel et al. [<reflink idref="bib28" id="ref52">28</reflink>]; Wigham et al. [<reflink idref="bib45" id="ref53">45</reflink>]). Skewness and kurtosis were within acceptable range of the absolute value of two (Gravetter [<reflink idref="bib15" id="ref54">15</reflink>]).</p> <p>Table 2 Means and SDs for self-report measures by groups</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left" colspan="2"><p>NC</p><p>(<italic>n</italic> = 25)</p></th><th align="left" colspan="2"><p>ASD</p><p>(<italic>n</italic> = 23)</p></th><th align="left" colspan="2"><p>SAD</p><p>(<italic>n</italic> = 68)</p></th></tr><tr><th align="left"><p>Measures</p></th><th align="left"><p>M</p></th><th align="left"><p>SD</p></th><th align="left"><p>M</p></th><th align="left"><p>SD</p></th><th align="left"><p>M</p></th><th align="left"><p>SD</p></th></tr></thead><tbody><tr><td align="left"><p>SASKO total</p></td><td char="." align="char"><p>28.52</p></td><td char="." align="char"><p>13.35</p></td><td char="." align="char"><p>76.57</p></td><td char="." align="char"><p>16.93</p></td><td char="." align="char"><p>72.18</p></td><td char="." align="char"><p>18.33</p></td></tr><tr><td align="left"><p>SASKO deficit</p></td><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /></tr><tr><td align="left"><p>Subscale interaction</p></td><td char="." align="char"><p>6.52</p></td><td char="." align="char"><p>4.40</p></td><td char="." align="char"><p>21.52</p></td><td char="." align="char"><p>4.11</p></td><td char="." align="char"><p>16.40</p></td><td char="." align="char"><p>5.62</p></td></tr><tr><td align="left"><p>Subscale information</p></td><td char="." align="char"><p>5.88</p></td><td char="." align="char"><p>2.55</p></td><td char="." align="char"><p>17.65</p></td><td char="." align="char"><p>3.42</p></td><td char="." align="char"><p>13.00</p></td><td char="." align="char"><p>3.94</p></td></tr><tr><td align="left"><p>SASKO anxiety</p></td><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /></tr><tr><td align="left"><p>Subscale speaking</p></td><td char="." align="char"><p>8.36</p></td><td char="." align="char"><p>5.60</p></td><td char="." align="char"><p>21.96</p></td><td char="." align="char"><p>7.33</p></td><td char="." align="char"><p>24.00</p></td><td char="." align="char"><p>6.87</p></td></tr><tr><td align="left"><p>Subscale rejection</p></td><td char="." align="char"><p>7.76</p></td><td char="." align="char"><p>4.75</p></td><td char="." align="char"><p>15.43</p></td><td char="." align="char"><p>7.06</p></td><td char="." align="char"><p>18.78</p></td><td char="." align="char"><p>5.14</p></td></tr><tr><td align="left"><p>IU</p></td><td char="." align="char"><p>41.56</p></td><td char="." align="char"><p>14.63</p></td><td char="." align="char"><p>67.09</p></td><td char="." align="char"><p>14.72</p></td><td char="." align="char" /><td char="." align="char" /></tr></tbody></table> </ephtml> </p> <p>Groups: <emph>NC</emph> non-clinical control, <emph>ASD</emph> autism spectrum disorder, <emph>SAD</emph> social anxiety disorder, <emph>SASKO</emph> Social Anxiety—Social Competence Deficit Scale, <emph>IU</emph> Intolerance of Uncertainty Scale</p> <p>Graph: Fig. 1 Boxplots of raw values for SASKO subscales. Groups: NC non-clinical control, ASD autism spectrum disorder, SAD social anxiety disorder, SASKO Social Anxiety—Social Competence Deficit Scale, SPEAKING SASKO subscale anxiety of speaking and being in focus of attention, REJECTION SASKO subscale anxiety of being rejected by others, INTERACTION SASKO subscale interaction deficits, INFORMATION SASKO subscale deficits in processing of social information. ns: p > 0.05. ***p ≤.001</p> <p>Graph: Fig. 2 Boxplots of raw values for IU scale. Groups: ASD autism spectrum disorder, NC non-clinical control, IU Intolerance of Uncertainty Scale. ***p ≤.001</p> <p>One-way MANCOVA with one between-participant factor of Group (ASD, NC, SAD), the dependent variable Scale (SASKO TOTAL, subscales SPEAKING, REJECTION, INTERACTION, and INFORMATION), and one covariate (gender, 0–1-valued) resulted in a significant difference between the three groups on the combined dependent variables [<emph>F</emph>(<reflink idref="bib10" id="ref55">10</reflink>, 216) = 48.62, <emph>p</emph> < 0.001; Wilks' Λ = 0.095, partial η<sups>2</sups> = 0.69]. Pairwise comparison of the ASD and the SAD group showed significantly increased scores of both subscales INTERACTION and INFORMATION in the ASD group. In both groups, values were above the clinical cut-off (cut-off raw values: INTERACTION = 10.0, INFORMATION = 9.0). No significant differences were found between the ASD and SAD group on the SASKO TOTAL scale, even though values were increased in the ASD group. In the SAD group, values of the subscales SPEAKING and REJECTION were pronounced compared to the ASD group, but no significant difference was found. However, values of both subscales were above the cut-off value (cut-off raw values: SPEAKING = 15.0, REJECTION = 13.0, SASKO TOTAL = 49.0). In the NC group, comparisons showed significantly decreased scores of all SASKO scales compared to the ASD and the SAD group (see Table 3). Results of Pearson correlations indicated that there were significant associations between all subscales, respectively, and the total score (<emph>p</emph> < 0.000 to <emph>p</emph> = 0.012). Thus, we have calculated one-way MANCOVA without SASKO TOTAL and results did not change significantly (F(<reflink idref="bib8" id="ref56">8</reflink>, 218) = 29.49, <emph>p</emph> < 0.001; Wilks' Λ = 0.231, partial η<sups>2</sups> = 0.52).</p> <p>Table 3 Pairwise comparisons for the SASKO Scales and the IU between groups</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left" /><th align="left" /><th align="left" /><th align="left" colspan="2"><p>95% CI</p></th></tr><tr><th align="left"><p>Measures</p></th><th align="left"><p>Groups</p></th><th align="left"><p><italic>SE</italic></p></th><th align="left"><p><italic>p</italic></p></th><th align="left"><p><italic>LL</italic></p></th><th align="left"><p><italic>UL</italic></p></th></tr></thead><tbody><tr><td align="left"><p>SASKO total<sup>a</sup></p></td><td align="left" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /></tr><tr><td align="left" /><td align="left"><p>NC: ASD</p></td><td char="." align="char"><p>4.91</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>− 63.15</p></td><td char="." align="char"><p>− 39.29</p></td></tr><tr><td align="left" /><td align="left"><p>NC: SAD</p></td><td char="." align="char"><p>3.88</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>− 53.19</p></td><td char="." align="char"><p>− 34.35</p></td></tr><tr><td align="left" /><td align="left"><p>ASD: SAD</p></td><td char="." align="char"><p>4.13</p></td><td char="." align="char"><p>.222</p></td><td char="." align="char"><p>− 2.59</p></td><td char="." align="char"><p>17.49</p></td></tr><tr><td align="left"><p>SASKO interaction<sup>a</sup></p></td><td align="left" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /></tr><tr><td align="left" /><td align="left"><p>NC: ASD</p></td><td char="." align="char"><p>1.51</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>− 19.13</p></td><td char="." align="char"><p>− 11.79</p></td></tr><tr><td align="left" /><td align="left"><p>NC: SAD</p></td><td char="." align="char"><p>1.19</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>− 12.79</p></td><td char="." align="char"><p>− 7.00</p></td></tr><tr><td align="left" /><td align="left"><p>ASD: SAD</p></td><td char="." align="char"><p>1.27</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>2.48</p></td><td char="." align="char"><p>8.65</p></td></tr><tr><td align="left"><p>SASKO information<sup>a</sup></p></td><td align="left" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /></tr><tr><td align="left" /><td align="left"><p>NC: ASD</p></td><td char="." align="char"><p>1.03</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>− 14.92</p></td><td char="." align="char"><p>− 9.91</p></td></tr><tr><td align="left" /><td align="left"><p>NC: SAD</p></td><td char="." align="char"><p>.82</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>− 9.12</p></td><td char="." align="char"><p>− 5.16</p></td></tr><tr><td align="left" /><td align="left"><p>ASD: SAD</p></td><td char="." align="char"><p>.87</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>3.16</p></td><td char="." align="char"><p>7.38</p></td></tr><tr><td align="left"><p>SASKO speaking<sup>a</sup></p></td><td align="left" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /></tr><tr><td align="left" /><td align="left"><p>NC: ASD</p></td><td char="." align="char"><p>1.92</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>− 19.59</p></td><td char="." align="char"><p>− 10.28</p></td></tr><tr><td align="left" /><td align="left"><p>NC: SAD</p></td><td char="." align="char"><p>1.51</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>− 19.36</p></td><td char="." align="char"><p>− 12.01</p></td></tr><tr><td align="left" /><td align="left"><p>ASD: SAD</p></td><td char="." align="char"><p>1.61</p></td><td char="." align="char"><p>1.000</p></td><td char="." align="char"><p>− 4.67</p></td><td char="." align="char"><p>3.16</p></td></tr><tr><td align="left"><p>SASKO rejection<sup>a</sup></p></td><td align="left" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /></tr><tr><td align="left" /><td align="left"><p>NC: ASD</p></td><td char="." align="char"><p>1.60</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>− 12.31</p></td><td char="." align="char"><p>− 4.52</p></td></tr><tr><td align="left" /><td align="left"><p>NC: SAD</p></td><td char="." align="char"><p>1.27</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>− 14.13</p></td><td char="." align="char"><p>− 7.97</p></td></tr><tr><td align="left" /><td align="left"><p>ASD: SAD</p></td><td char="." align="char"><p>1.35</p></td><td char="." align="char"><p>.161</p></td><td char="." align="char"><p>− 5.91</p></td><td char="." align="char"><p>.65</p></td></tr><tr><td align="left"><p>IU<sup>a</sup></p></td><td align="left" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /><td char="." align="char" /></tr><tr><td align="left" /><td align="left"><p>NC: ASD</p></td><td char="." align="char"><p>4.48</p></td><td char="." align="char"><p>.000*</p></td><td char="." align="char"><p>− 40.69</p></td><td char="." align="char"><p>− 18.71</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>CI</emph> confidence interval, <emph>LL</emph> lower limit, <emph>UL</emph> upper limit Groups: <emph>NC</emph> non-clinical control, <emph>ASD</emph> autism spectrum disorder, <emph>SAD</emph> social anxiety disorder, <emph>SASKO</emph> Social Anxiety—Social Competence Deficit Scale, <emph>IU</emph> Intolerance of Uncertainty Scale <sups>a</sups>Adjustment for multiple comparisons: Bonferroni *<emph>p</emph> <.05</p> <p>A significant group effect between the ASD and the NC group was found for the total score of the IU scale, <emph>F</emph>(<reflink idref="bib1" id="ref57">1</reflink>, 45) = 38.46, <emph>p</emph> < 0.001, η<subs>p</subs><sups>2</sups> = 0.461. No significant Levene's test results were found for the total score of the IU scale, <emph>F</emph>(<reflink idref="bib1" id="ref58">1</reflink>, 64) = 0.05,<emph> p</emph> = 0.819. Pairwise comparisons indicated statistically significant differences between the ASD and the NC group (see Table 3). In the manual of the IU scale it is indicated that the scale was not standardized, but an interpretation of the individual measurements is possible by comparing them with data from the outpatient clinic (published control group: n = 651, M = 38.0, SD = 11.61; published generalized anxiety disorder group: n = 20, M = 56.7, SD = 12.49) (Gerlach et al. [<reflink idref="bib14" id="ref59">14</reflink>]).</p> <hd id="AN0148114435-7">Discussion</hd> <p>This study aimed to characterize social anxiety in ASD and compare it to SAD and NC controls with the purpose of allowing reliable differential diagnostics and possibly suggesting tailored interventions of specific aspects of social anxiety particularly relevant in ASD. To this end, we examined deficits in social competence, defined as deficits in processing social information and interaction deficits (INFORMATION, INTERACTION) and compared it to social anxiety as accessible by the subscales of SASKO (SPEAKING, REJECTION).</p> <p>SASKO TOTAL values did not differ between the ASD and the SAD group, but were clinically significant in both groups as compared to the NC group. We found SOCIAL ANXIETY values, with respect to the subscales SPEAKING and REJECTION, to be as high in the ASD group as in the SAD comparison group, confirming increased level of social anxiety in ASD (Bejerot et al. [<reflink idref="bib6" id="ref60">6</reflink>]; Cath et al. [<reflink idref="bib11" id="ref61">11</reflink>]; Kanai et al. [<reflink idref="bib18" id="ref62">18</reflink>]; Spain et al. [<reflink idref="bib35" id="ref63">35</reflink>]). Additionally, DEFICITS in SOCIAL COMPETENCE, encompassing deficits in INTERACTION and in processing social INFORMATION were significantly pronounced in the ASD group compared to individuals with SAD and the NC group.</p> <p>Results suggest that social anxiety symptoms, if they occur in individuals with ASD can be traced back to the more fundamental and "deeper" layer of social competence deficits based on the idea by Karl Jaspers of a "hierarchy in the diagnostic value of symptoms" (Jaspers [<reflink idref="bib17" id="ref64">17</reflink>], p. 612). According to this idea a disturbance on the "lowest plane reached by examination of the individual case decides the diagnosis." (Jaspers [<reflink idref="bib17" id="ref65">17</reflink>], p. 612). For instance, in the case of a patient with a brain injury and psychopathological symptoms resembling those of a personality disorder, the much more "fundamental" brain injury would be the dominating diagnosis but not the additional symptoms "on the surface". In the case of ASD, one could argue that social competence deficits are fundamental whereas social anxiety symptoms are a consequence of the more fundamental disturbance of social competence skills.</p> <p>Clinically, the inclusion of deficits in social skills are crucial in order to prevent misinterpretation of autistic symptoms as SAD. Social deficits in ASD might cause repeated social failure due to the perceived complexity of social interactions (Volkmar and Klin [<reflink idref="bib38" id="ref66">38</reflink>]), which in turn might cause supposed symptoms of social anxiety as well as social isolation (Kerns et al. [<reflink idref="bib20" id="ref67">20</reflink>]; Maddox and White [<reflink idref="bib27" id="ref68">27</reflink>]). In the case of ASD, we can make further plausible that it is the lack of social competence that leads to the avoidance of social situations rather than a disinterest in social contact (Maddox and White [<reflink idref="bib27" id="ref69">27</reflink>]). Indeed, many persons with ASD express a desire for social belonging to different communities (Bauminger and Kasari [<reflink idref="bib3" id="ref70">3</reflink>]; Bauminger et al. [<reflink idref="bib4" id="ref71">4</reflink>]; Maddox and White [<reflink idref="bib27" id="ref72">27</reflink>]; Muller et al. [<reflink idref="bib30" id="ref73">30</reflink>]; Tyson and Cruess [<reflink idref="bib37" id="ref74">37</reflink>]; White et al. [<reflink idref="bib44" id="ref75">44</reflink>]; Williamson et al. [<reflink idref="bib46" id="ref76">46</reflink>]).</p> <p>Clinically elevated SOCIAL ANXIETY in both groups point out on the one hand the occurrence of social anxiety symptoms in ASD and on the other hand the problem of precise delimitation. Avoidance behavior occurs in both, individuals with ASD and individuals with SAD, but in the latter, social anxiety visible on a superficial level may cover preserved social skills (Beidel et al. [<reflink idref="bib5" id="ref77">5</reflink>]), whereas ASD is characterized by mentalizing deficits on a fundamental level hampering social information processing (Maddox and White [<reflink idref="bib27" id="ref78">27</reflink>]; White and Schry [<reflink idref="bib43" id="ref79">43</reflink>]). This difference is shown by significantly increased deficits in processing social information (INFORMATION) in ASD in comparison to the SAD and the NC group in the current study. In SAD, mentalizing is generally preserved, but individuals with SAD do not fully succeed to adequately evaluate social situations, which may result in dysfunctional reactions. Impaired mentalizing in ASD calls for modified interpretations of the concept of social anxiety, possibly based on Jaspers´ idea on a "hierarchy in the diagnostic value of symptoms" (Jaspers [<reflink idref="bib17" id="ref80">17</reflink>], p. 612).</p> <p>The results of the current study support the assumption of either atypical manifestation of SAD or co-occurring anxiety symptoms in ASD (Kerns and Kendall [<reflink idref="bib19" id="ref81">19</reflink>]; Kerns et al. [<reflink idref="bib20" id="ref82">20</reflink>]; Tyson and Cruess [<reflink idref="bib37" id="ref83">37</reflink>]; Wood and Gadow [<reflink idref="bib47" id="ref84">47</reflink>]) whereby a monodimensional model is probably not sufficient to characterize the reciprocity of social anxiety symptoms and ASD. In this context, alternatively suggested to Jaspers ([<reflink idref="bib17" id="ref85">17</reflink>]), the psychopathological construct of so-called equifinality was proposed referring to the idea that a range of varying processes can result in the same outcome (Ollendick and Hirshfeld-Becker [<reflink idref="bib32" id="ref86">32</reflink>]; White et al. [<reflink idref="bib44" id="ref87">44</reflink>]) and thus, several anxiety symptoms appear similar, but differ in a subtle way (Kerns et al. [<reflink idref="bib20" id="ref88">20</reflink>]). SAD might arise from a multifaceted spectrum of etiological factors during development (Ollendick and Hirshfeld-Becker [<reflink idref="bib32" id="ref89">32</reflink>]; White et al. [<reflink idref="bib44" id="ref90">44</reflink>]) and has been linked rather to the cognitive capacity for social evaluative efforts and, moreover, to temperamental factors that represent a deeply entrenched personal characteristic (Neal and Edelmann [<reflink idref="bib31" id="ref91">31</reflink>]; Tyson and Cruess [<reflink idref="bib37" id="ref92">37</reflink>]). ASD as a pervasive developmental disorder might be better explained by a "deeper layer" of mentalizing disturbances occurring on a more profound level of social information processing. Particularly in adulthood, SAD as an acquired disorder, seems to be more likely to be described as a more superficial layer.</p> <p>Research suggests less pronounced cognitive components of anxiety in ASD than in individuals with SAD (Maddox and White [<reflink idref="bib27" id="ref93">27</reflink>]). By contrast, in SAD, fear of negative evaluation referred to one's own self and the cognitive component was highlighted, as well as temperamental factors (Maddox and White [<reflink idref="bib27" id="ref94">27</reflink>]; Neal and Edelmann [<reflink idref="bib31" id="ref95">31</reflink>]; Tyson and Cruess [<reflink idref="bib37" id="ref96">37</reflink>]; White and Schry [<reflink idref="bib43" id="ref97">43</reflink>]). Individuals with ASD may worry about how their own behavior affects others instead of expecting negative evaluations of their own self which again might describe the surface level. White et al. ([<reflink idref="bib44" id="ref98">44</reflink>]) assumed an association between perceived uncertainty in social situations and mentalizing deficits but without any concern of negative evaluations of one's own self. In ASD, fear of negative evaluation might rather affect the worry about uncertainty in social situations. Present results support this assumption by representing increased IU as well as pronounced social competence deficits in ASD. Likewise, the inability to endure uncertainty might cause social avoidance, which limits opportunities to acquire and practice social skills and to improve interpersonal communication abilities (Rubin and Burgess [<reflink idref="bib33" id="ref99">33</reflink>]).</p> <p>This assumption of a different manifestation of social anxiety in ASD based on a more fundamental deficit could support especially the process of differential diagnosis and may possibly also enrich the development of specific psychotherapeutic interventions. Spain et al. ([<reflink idref="bib34" id="ref100">34</reflink>]) suggest that cognitive and behavioral interventions have shown success in individuals with ASD and SAD. However, consistent with results of the current study, modified or combined interventions focusing on deficits in processing social information, emotional literacy, and impairments in social skills were recommended. Furthermore, individuals with ASD and social anxiety symptoms may benefit from continuous period of treatment as well as the opportunity to practice social skills in real-life situations (Spain et al. [<reflink idref="bib34" id="ref101">34</reflink>]). In addition, the SASKO instrument may serve as an important tool in the improvement of differential diagnostics.</p> <p>In conclusion, individuals with ASD show a level of SOCIAL ANXIETY comparable to individuals with SAD. Nevertheless, decreased SOCIAL COMPETENCE and pronounced deficits in processing social information (INFORMATION) represent specific factors associated with social anxiety in ASD and suggest a more fundamental disturbance compared to SAD as a possible indicator of differential values of symptoms for diagnostics (Jaspers [<reflink idref="bib17" id="ref102">17</reflink>]). Social retreat might additionally aggravate social competence deficits throughout development.</p> <hd id="AN0148114435-8">Supplementary Note</hd> <p>In addition, a further group of outpatients with ICD-10 axis-I diagnoses but without ASD was tested (n = 20). Due to the diagnostic heterogeneity of this group, statistical comparison is not readily generalizable.</p> <hd id="AN0148114435-9">Acknowledgments</hd> <p>Open Access funding provided by Projekt DEAL. We thank all the participants who took part in this study. We also thank Hannah Gsella who was involved in the data collection of the study.</p> <hd id="AN0148114435-10">Author Contributions</hd> <p>All authors contributed to the study conception and design. Material preparation and data collection were performed by JE and analysis were performed by JE and MH. The first draft of the manuscript was written by JE and all authors commented on previous versions of the manuscript. All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved the final manuscript for publication.</p> <hd id="AN0148114435-11">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0148114435-12"> <title> References </title> <blist> <bibl id="bib1" idref="ref2" type="bt">1</bibl> <bibtext> American Psychiatric Association. 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  Data: Brief Report: Social Anxiety in Autism Spectrum Disorder Is Based on Deficits in Social Competence
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  Data: English
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  Data: <searchLink fieldCode="AR" term="%22Espelöer%2C+J%2E%22">Espelöer, J.</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-2847-0648">0000-0003-2847-0648</externalLink>)<br /><searchLink fieldCode="AR" term="%22Hellmich%2C+M%2E%22">Hellmich, M.</searchLink><br /><searchLink fieldCode="AR" term="%22Vogeley%2C+K%2E%22">Vogeley, K.</searchLink><br /><searchLink fieldCode="AR" term="%22Falter-Wagner%2C+C%2E+M%2E%22">Falter-Wagner, C. M.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. Jan 2021 51(1):315-322.
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  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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  Data: Y
– Name: Pages
  Label: Page Count
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  Data: 8
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  Label: Publication Date
  Group: Date
  Data: 2021
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  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Pervasive+Developmental+Disorders%22">Pervasive Developmental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Anxiety+Disorders%22">Anxiety Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Interpersonal+Competence%22">Interpersonal Competence</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Scores%22">Scores</searchLink>
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  Data: 10.1007/s10803-020-04529-w
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0162-3257
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: This study differentially examined the relation between two clinical constructs: "social anxiety" and "social competence" in autism spectrum disorder (ASD). Employing two questionnaires (SASKO; IU), individuals with ASD (n = 23) showed increased scores of SOCIAL ANXIETY (SASKO) and of INTOLERANCE OF UNCERTAINTY (IU), compared to a non-clinical comparison group (NC; n = 25). SOCIAL ANXIETY scores were equally increased for ASD and a reference population of individuals with social anxiety disorder (SAD; n = 68). However, results showed increased SOCIAL COMPETENCE DEFICITS in ASD compared to SAD and NC groups. This study allows drawing the conclusion that social anxiety symptoms in ASD can be traced back to autism-specific deficits in social skills and are therefore putatively based on different, substantially "deeper" implemented cognitive mechanisms.
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  Data: 2021
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  Data: EJ1281122
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        PageCount: 8
        StartPage: 315
    Subjects:
      – SubjectFull: Autism
        Type: general
      – SubjectFull: Pervasive Developmental Disorders
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      – SubjectFull: Anxiety Disorders
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      – TitleFull: Brief Report: Social Anxiety in Autism Spectrum Disorder Is Based on Deficits in Social Competence
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