Cogn Ther Res (2013) 37:1101–1109
DOI 10.1007/s10608-013-9553-0
ORIGINAL ARTICLE
In the Presence of Social Threat: Implicit and Explicit Self-Esteem
in Social Anxiety Disorder
Viktoria Ritter • Christine Ertel • Katja Beil •
Melanie C. Steffens • Ulrich Stangier
Published online: 7 June 2013
Ó Springer Science+Business Media New York 2013
Abstract The present study investigated implicit and
explicit self-esteem and the effects of co-morbid depressive
disorders on both in a clinical sample of patients with
Social Anxiety Disorder (SAD) (n = 40), and in healthy
controls (n = 35) following social-threat induction (giving
an impromptu speech). Implicit self-esteem was assessed
using an implicit association test. Explicit self-esteem was
measured with the Rosenberg Self-Esteem Scale. Results
indicated that SAD patients had significantly lower implicit
self-esteem, relative to healthy controls, and were also
characterized by lower explicit self-esteem. Depressed
SAD patients revealed more negative explicit self-esteem
than non-depressed SAD patients, but no such group dif-
ferences were found in implicit self-esteem. There were
also strong relationships between patients’ explicit self-
esteem and symptoms of social anxiety and depression.
The findings support cognitive models of SAD and suggest
that biased self-processing works on both implicit and
explicit levels. Further, it seems that social anxiety and
depression are characterized by differential implicit self-
evaluative processes.
V. Ritter (&)
U. Stangier
Department of Psychology, J.W. Goethe University,
Varrentrappstr. 40-42, 60486 Frankfurt, Germany
e-mail: Ritter@psych.uni-frankfurt.de
C. Ertel
K. Beil
Department of Psychology, F. Schiller University, Am Steiger 3,
07743 Jena, Germany
M. C. Steffens
Department of Psychology, University of Koblenz-Landau,
Fortstr. 7, 76829 Landau/Pfalz, Germany
Keywords Implicit self-esteem
Social Anxiety Disorder

Implicit association test
Explicit self-esteem
Depression
Introduction
Cognitive models emphasize the key role of dysfunctional
beliefs about the self in the development and maintenance
of Social Anxiety Disorder (SAD) (Clark and Wells 1995;
Rapee and Heimberg 1997). According to Clark and Wells
(1995), conditional beliefs (e.g., ‘‘If I make mistakes others
will reject me.’’) and unconditional beliefs (e.g., ‘‘I am
inferior.’’) are activated by anticipating or participating in
social situations. Misinterpretation of these situations as
threatening and avoidance behaviors contribute to a failure
to achieve important personal goals and to low self-esteem.
Consistent with cognitive models, research has demon-
strated that individuals with SAD endorse maladaptive
self-beliefs (e.g., Wong and Moulds 2011) and report low
self-esteem (e.g., de Jong 2002). Other studies have further
shown that low self-esteem is a risk factor for the devel-
opment of social anxiety (Acarturk et al. 2009), and is
associated with negative autobiographical experiences,
such as childhood emotional abuse and neglect (Kuo et al.
2011). Thus, if low self-esteem is linked with early nega-
tive experiences (Rudman et al. 2007b), it may also be
represented in ways that are not easily verbalizable or
accessible to conscious awareness and control (Greenwald
and Banaji 1995). To help address these automatic, affec-
tive concerns, implicit self-esteem can be examined.
Implicit self-esteem results from automatic, associative
self-evaluative processes, whereas explicit self-esteem is
generated on the basis of controlled, deliberate self-
evaluative processes (Gawronski and Bodenhausen 2006).
Both implicit and explicit self-esteem can be activated by an
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anxiety-provoking event in SAD that provides access to an
associative network of self-evaluations (Tanner et al. 2006).
To date, only a few studies investigated implicit and explicit
self-esteem in social anxiety. Two analogue studies exam-
ined implicit and explicit self-esteem in high and low
socially anxious adults using the implicit association test
(IAT; Greenwald et al. 1998) and explicit measures of self-
esteem. De Jong (2002) observed relatively lower (i.e., less
positive) implicit self-esteem in high socially anxious
female students, as compared to low socially anxious female
students. Again, Tanner et al. (2006) demonstrated that high
socially anxious individuals were characterized by relatively
lower implicit self-esteem, as compared to low socially
anxious participants. Furthermore, in both studies, individ-
uals in the high-anxiety groups reported low explicit self-
esteem. Recently, Glashouwer et al. (2013) provided also
evidence for relatively low implicit self-esteem in a clinical
sample of adults with SAD, as compared to non-clinical
controls, and showed that low implicit self-esteem was
related to high SAD symptom severity in men. Finally, in an
analogue sample of adolescents, de Jong et al. (2012) found
an association between low implicit self-esteem and SAD
symptoms in high socially anxious girls with low explicit
self-esteem. In contrast to these studies, Schreiber et al.
(2012) observed high implicit and low explicit self-esteem
in a clinical sample of adolescents with SAD, whereas
healthy adolescents were characterized by concurrently high
implicit and explicit self-esteem. These results suggest a
pattern of discrepant self-esteem (‘damaged self-esteem’:
Schröder-Abé et al. 2007) in adolescents with SAD that
could be explained by an implicit self-defensive mechanism
in response to threat (Rudman et al. 2007a).
In conclusion, studies on implicit and explicit self-
esteem in social anxiety provide inconsistent results. While
concurrent low implicit (i.e., less positive) and low explicit
self-esteem seems to be involved in adult SAD (Glashou-
wer et al. 2013; Tanner et al. 2006; de Jong 2002), dis-
crepant self-esteem seems to be associated with adolescent
SAD (Schreiber et al. 2012). Thus, it remains unclear to
what extent implicit biases play a role in social anxiety. So
far, research on implicit self-esteem in socially anxious
adults has been primarily conducted on analogue samples
(but see Glashouwer et al. 2013), and it seems plausible
that clinical groups exhibit lower implicit self-esteem.
Furthermore, given that social anxiety and depression fre-
quently co-occur (Ohayon and Schatzberg 2010), and both
disorders share common clinical features (e.g., negative
self-schematic processing, cognitive distortions: Clark
et al. 1999; Dozois and Frewen 2006), it seems important
to incorporate co-morbid depression when examining
implicit and explicit self-esteem in SAD.
Previous research has provided evidence of high implicit
and low explicit self-esteem in currently and formerly
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Cogn Ther Res (2013) 37:1101–1109
depressed patients (e.g., Franck et al. 2008; Franck et al.
2007; De Raedt et al. 2006; Gemar et al. 2001), suggesting
discrepant self-esteem that might be explained by a dis-
crepancy between desired implicit needs (e.g., appreciation)
and perceived explicit reality (e.g., failure) (Franck et al.
2007). However, there is also empirical support of low
implicit and low explicit self-esteem in currently and
recurrently depressed patients (Risch et al. 2010) which is in
line with cognitive models of depression (Clark et al. 1999),
and seems to indicate that at least the repeated activation of
negative self-evaluations in recurrent depression may
impair implicit self-esteem (Risch et al. 2010). Thus,
although most of the IAT studies in depression did not
demonstrate low implicit self-esteem, it could be that the
co-existence of impaired implicit self-evaluations in social
anxiety (cf. Glashouwer et al. 2013; Tanner et al. 2006; de
Jong 2002) and depression (cf. Risch et al. 2010) leads to a
stronger impairment of implicit self-esteem.
In the present study, we therefore compared SAD patients
with and without co-morbid depressive disorders, and
healthy controls. Assuming that implicit and explicit self-
esteem would be decreased in clinical SAD samples, we
hypothesized that SAD patients would be characterized by
lower implicit and explicit self-esteem, relative to healthy
controls. Further, in line with Risch et al. (2010), we
expected that depressed SAD patients would exhibit lower
implicit and explicit self-esteem, relative to non-depressed
SAD patients and healthy controls. Finally, we examined
inter-relationships between implicit and explicit measures.
Methods
Participants
The clinical group consisted of 40 patients with a primary
diagnosis of SAD (22 females, mean age = 34.55,
SD = 12.49) who participated in a multicenter randomized
controlled trial (Leichsenring et al. 2013) after conducting
the present IAT study. Diagnoses were confirmed by trained
and qualified clinical psychologists administering the Ger-
man version of the Structured Clinical Interview for DSM-
IV Axis I and II disorders (SCID I, SCID II; Wittchen et al.
1997) and the German version of the Liebowitz Social
Anxiety Scale (LSAS; Stangier and Heidenreich 2005; Li-
ebowitz 1987). To examine the reliability for the LSAS, 17
videotaped interviews were re-rated by an independent
doctoral-level clinician. Inter-rater reliability for the LSAS-
total score was high (r = 0.98). SCID interviews revealed
the following current co-morbid Axis I and II diagnoses:
first-onset Major Depressive Disorder (n = 7), Recurrent
Major Depressive Disorder (n = 6), Dysthymia (n = 3),
Agoraphobia (n = 2), Panic Disorder (n = 4), Specific
Cogn Ther Res (2013) 37:1101–1109
Phobia (n = 2), Generalized Anxiety Disorder (n = 1),
Avoidant-Personality Disorder (n = 16), Obsessive-Com-
pulsive Personality Disorder (n = 3), Dependent-Personal-
ity Disorder (n = 1). Sixteen SAD patients fulfilled the
criteria for a current co-morbid depressive disorder (diag-
noses see above) and scored higher than or equal to 18 on the
BDI. Seventy-five percent of the SAD sample met criteria
for the generalized subtype of social phobia. Patients with a
history of psychotic or bipolar disorders, current alcohol
abuse or other substance-related disorders, personality dis-
orders of cluster A and B and concurrent psychopharma-
cological and/or psychotherapeutic treatment were
excluded.
The control group (HC) consisted of 35 healthy controls
(23 females, mean age = 38.57, SD = 11.60), with no
current Axis I and II psychiatric history, as determined by
the SCID. The groups did not significantly differ with
respect to age, F(1, 73) = 2.07, p = .16, g2P = 0.03, gender,
v2[1] = 0.89, p = .35, or educational level, v2[8] = 9.52,
p = .30. All participants were recruited through advertise-
ments in newspapers and flyers. Specifically, SAD patients
were also recruited through self-help groups and outpatient
units at university.
Materials
Explicit Measures
The German version of the Liebowitz Social Anxiety Scale
(LSAS; Stangier and Heidenreich 2005; Liebowitz 1987) is
a 24-item, clinician-rated scale that assesses SAD symptom
severity. Total scores range from 0 to 144, with scores
higher than or equal to 30 indicating specific Social Anx-
iety Disorder; scores higher than or equal to 60 indicating a
generalized Social Anxiety Disorder. The German version
of the Social Phobia and Anxiety Inventory (SPAI; Fydrich
2002; Turner et al. 1989) is a 22-item self-report instru-
ment that assesses cognitive, somatic and behavioral
dimensions of social anxiety. Scores higher than or equal to
60 indicate higher functional impairment. Cronbach’s
alpha in the current sample was 0.98. The German version
of the Beck Depression Inventory (BDI; Hautzinger et al.
2000; Beck and Steer 1987) is a 21-item self-report
instrument that assesses depressive symptoms. Cronbach’s
alpha in the current sample was 0.91. The German version
of the Rosenberg Self-Esteem Scale (RSES; Collani and
Herzberg 2003; Rosenberg 1965) is a 10-item self-report
measure of explicit self-esteem. Total scores of 0–15 rep-
resent low self-esteem, scores of 15–25 indicate normal
self-esteem, and scores higher than 25 represent high self-
esteem. Cronbach’s alpha in the current sample was 0.93.
Visual Analogue Scales (VAS; Cella and Perry 1986) were
1103
used to rate anxiety level and to control the effectiveness of
social-threat induction (ranging from 0 = ’’I do not feel
anxious at all’’ to 10 = ’’I feel extremely anxious’’).
Implicit Measure
The self-esteem implicit association test (IAT; Greenwald
and Farnham 2000) is a computerized reaction-time task to
measure the relative strength of automatic positive and
negative associations towards the self and others. The
rationale behind the IAT is that participants classify words
into superordinate categories, and are able to categorize
quickly when the pair of categories is closely associated in
the memory. A generic self-esteem IAT (Bluemke and
Friese 2012) was programmed with the software E-prime
1.1. We used pronouns as stimuli for the categories ‘self’
and ‘other’ (Hofmann et al. 2005), and a set of adjectives
for the categories ‘positive’ and ‘negative’ which were
taken from the item pool used by Tanner et al. (2006) (see
Appendix for all IAT stimuli).
The IAT comprised five blocks: three practice blocks
(block 1, 2, and 4, each 10 trials) and two combined-task
blocks (block 3 and 5, each 52 trials). In block 3, the cat-
egories self ? positive shared the same response key and
the categories other ? negative, the other response key
(compatible task). In block 5, the categories self ? negative
shared the same response key and the categories other ?
positive, the other response key (incompatible task). The
presentation order of the compatible and incompatible tasks
was counterbalanced across participants (Greenwald et al.
2003). Each of the five blocks started with instructions that
described the categories for the block and the assignments
of response keys (‘a’ or ‘l’) to the categories. Participants
were instructed to decide rapidly and accurately, what key
should be pressed after the presentation of a word. Stimuli
were presented in the centre of the computer screen in black
letters against a white background. The inter-trial interval
was 200 ms. In the case of an incorrect response, visual
feedback in the form of a red x appeared immediately and
replaced the word stimulus for 500 ms. A correction of the
decision on an error trial was not required and participants
continued to the next judgement. The split-half reliability of
the present IAT was good; with Spearman-Brown corrected
correlation of 0.70 for SAD patients, and 0.85 for controls.
Procedure
Written consent was obtained by all participants, as
approved by the ethics committee of the university. During
the first visit, participants underwent the SCID to determine
diagnostic eligibility, and then completed LSAS, SPAI, and
BDI. During the second visit (24 h later), they completed
the IAT after social-threat induction. The RSES was
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assessed after conducting the IAT. Participants were tested
individually, and the procedure took approximately 30 min.
During a brief anticipation period, participants were
given the following instruction: ‘‘In a few minutes, you will
be asked to give an impromptu 5-min speech, in front of a
camera, on a controversial topic. I will hand you a list of
three topics and leave the choice to you. You have about
5 min to prepare the speech. Afterwards, I will ask two
colleagues to enter the room to observe you and to rate the
quality of your presentation. Please note that you may not
read the speech.’’ Following instruction, the camera was
turned on and participants left alone in the room. After
3 min, the examiner returned and participants were told: ‘‘I
am sorry, but we have to place the speech on hold, as one
of my colleagues is still in a therapy session. She will be
ready in a few minutes. I suggest you continue with a
computer test which was planned for the end of the
experiment.’’ The examiner started the IAT, and partici-
pants were left alone. They then were instructed on the
computer screen, and another on-screen note informed
participants when all blocks had been completed. After-
wards, participants completed RSES, were debriefed, and
received compensation for their participation. VAS ratings
followed each stage of the IAT study (before social-threat
induction, after social-threat induction, before IAT, after
IAT, after RSES, and after debriefing).
Data Reduction
IAT data were analysed using the improved scoring algo-
rithm (D measure) proposed by Greenwald et al. (2003). The
procedure required the following steps: (a) trials with
reaction times greater than 10,000 ms were eliminated;
(b) latencies of error trials were included but, in order to
avoid explicit contamination of implicit data, no error pe-
nalities were used (Steffens et al. 2008); (c) the IAT effect
was calculated by computing the difference between the
mean latencies of block 5 (incompatible task) and block 3
(compatible task). These differences were divided by the
individual standard deviation of all latencies of the combined
tasks. Higher IAT effects indicate more positive implicit
self-esteem (i.e., stronger associations between self ?
positive and other ? negative). No IAT data needed to be
excluded because of unusually fast response times ([10 %
trials below 300 ms) or high error rates ([20 %). The overall
average error rate was 3.9 % and the error rates did not differ
across groups, F(1, 73) = 1.14, p = .29, g2P = 0.01.
Statistical Analyses
Data were analyzed with the SPSS statistical software
package (SPSS Inc, Chicago, III). Prior to conducting
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Cogn Ther Res (2013) 37:1101–1109
analyses, data were examined for outliers. No data had to
be omitted as a result of these checks. The main analyses
were performed using one-way ANOVAs as well as
ANCOVAs with BDI as the covariate, and Bonferroni-
corrected post hoc t tests for simple comparisons between
the groups. To examine the relationship between the
implicit measure (IAT) and the explicit measures (RSES,
LSAS, SPAI, BDI), bivariate Pearson correlation coeffi-
cients were computed. Significance levels were set at
p \ .05, two-tailed.
Results
Explicit Measures and Effects of Social-Threat
Induction
The means and standard deviations of the explicit measures
are presented in Table 1. As expected, SAD patients dis-
played significantly higher SAD symptom severity, as
measured with the LSAS, F(1, 73) = 230.03, p \ .001,
g2P = 0.76, and the SPAI, F(1, 73) = 342.02, p \ .001,
g2P = 0.82, and reported significantly more depressive
symptoms, as measured with the BDI, F(1, 73) = 48.48,
p \ .001, g2P = 0.40, relative to healthy controls. Depressed
SAD patients, non-depressed SAD patients and healthy
controls differed significantly on the LSAS, F(2,
72) = 125.89, p \ .001, g2P = 0.78, the SPAI, F(2,
72) = 203.27, p \ .001, g2P = 0.85, and the BDI, F(2,
72) = 116.99, p \ .001, g2P = 0.77. Bonferroni-corrected
post hoc t tests indicated that depressed SAD patients had
higher LSAS scores, relative to both non-depressed SAD
patients, p \ .05, Cohen’s d = 0.64, and healthy controls,
p \ .001, d = 5.13, and non-depressed SAD patients had
higher LSAS scores than healthy controls, p \ .001,
d = 3.58. On the SPAI, depressed SAD patients had higher
SAD symptom scores, relative to non-depressed SAD
patients, p \ .01, d = 1.13, and healthy controls, p \ .001,
d = 5.47, and non-depressed SAD patients had higher SAD
symptom scores than healthy controls, p \ .001, d = 4.23.
On the BDI, depressed SAD patients reported more
depressive symptoms, relative to both non-depressed SAD
patients, p \ .001, d = 3.03, and healthy controls,
p \ .001, d = 5.64, who also differed from one another,
p \ .01, d = 1.17.
To check the effectiveness of social-threat induction, we
conducted a group (SAD vs. HC) x time (before vs. after
social-threat induction) repeated-measures ANOVA with
VAS scores as the dependent variable. The analysis
revealed a significant time effect, F(1, 73) = 115.74,
p \ .001, g2P = 0.61, a significant time x group interaction,
F(1, 73) = 27.34, p \ .001, g2P = 0.27, and a significant
Cogn Ther Res (2013) 37:1101–1109 1105

Table 1 Descriptive statistics

Measure Full SAD sample Depressed SAD Non-depressed SAD Healthy controls
(means and SDs) for the implicit
(n = 40) patients (n = 16) patients (n = 24) (n = 35)
and explicit measures
M SD M SD M SD M SD

LSAS Liebowitz Social Anxiety LSAS 75.22 22.13 83.25 20.19 69.88 22.14 13.83 9.74
Scale, SPAI Social Phobia and
SPAI 90.81 16.40 100.38 14.32 84.43 14.69 25.68 13.74
Anxiety Inventory, BDI Beck
Depression Inventory, RSES BDI 14.92 9.15 24.06 3.86 8.83 5.96 3.51 3.40
Rosenberg Self-Esteem Scale, RSES 15.35 5.60 12.38 3.61 18.17 5.53 25.97 2.73
IAT Implicit Association Test, IAT 0.51 0.46 0.51 0.45 0.52 0.47 0.78 0.29
SAD Social Anxiety Disorder

group effect, F(1, 73) = 31.57, p \ .001, g2P = 0.30.
Paired t tests showed an increase in anxiety after the threat
manipulation for both SAD patients and controls
(ps \ 0.001), indicating successful social-threat induction.
Simple comparisons between groups indicated that SAD
patients had significantly higher anxiety than controls on
both VAS ratings (first rating: p \ .05, second rating:
p \ .001).
Implicit Self-esteem
The means and standard deviations of the IAT D scores are
presented in Table 1. As expected, an ANOVA with
implicit self-esteem (IAT D score) as the dependent vari-
able, and group (SAD vs. HC) as the independent variable
yielded a significantly lower implicit self-esteem in SAD
patients, relative to healthy controls, F(1, 73) = 8.75,
p \ .01, g2P = 0.11. In addition, since the groups differed
with respect to depressive symptoms, the IAT was analysed
using an ANCOVA with the BDI as the covariate.
Depressive symptoms did not co-vary with the IAT scores,
F(1, 72) = 0.32, p = .57, indicating that depression did
not influence the results of the IAT, but the main effect of
group diminished to a non-significant, although strong
trend for lower implicit self-esteem in SAD, F(1, 72) =
3.70, p = .058, g2P = 0.05.
Depressed SAD patients, non-depressed SAD patients
and healthy controls differed significantly with respect to
implicit self-esteem, F(2, 72) = 4.32, p \ .05, g2P = 0.11.
Bonferroni-corrected post hoc tests indicated that depres-
sed SAD patients had lower IAT scores, relative to healthy
controls, p \ .05, Cohen’s d = 0.79, but not relative to
non-depressed SAD patients, p = 1, d = 0.02, and non-
depressed SAD patients revealed lower scores than healthy
controls, p \ .05, d = 0.71. Note in Table 1 that the IAT
effect is positive for all groups, indicating relatively more
positive self-associations (relative to others-associations).
Therefore, the group differences should be interpreted as
evidence of less positive implicit self-esteem among the
SAD groups.
Explicit Self-esteem
The means and standard deviations of the RSES scores are
presented in Table 1. An ANOVA with explicit self-esteem
(RSES score) as the dependent variable and group (SAD
vs. HC) as the independent variable yielded significantly
lower explicit self-esteem in SAD patients, relative to
healthy controls, F(1, 73) = 94.70, p \ .001, g2P = 0.57.
When including the BDI as the covariate in an additional
ANCOVA, depressive symptoms co-varied significantly
with the RSES, F(1, 72) = 30.09, p \ .001, g2P = 0.30.
Nonetheless, the main effect of group remained stable, F(1,
72) = 29.76, p \ .001, g2P = 0.29.
Depressed SAD patients, non-depressed SAD patients
and healthy controls differed significantly with respect to
explicit self-esteem, F(2, 72) = 69.82, p \ .001, g2P =
0.66. Follow-up Bonferroni tests indicated that depressed
SAD patients had lower RSES scores, relative to both non-
depressed SAD patients, p \ .001, Cohen’s d = 1.22, and
healthy controls, p \ .001, d = 4.58, and non-depressed
SAD patients had lower scores than controls, p \ .001,
d = 1.94.
Relationships Between Implicit and Explicit Self-esteem,
Social Anxiety and Depression
The correlations among the implicit and explicit measures
are shown in Table 2. In general, results indicated the
weak relationships between implicit and explicit measures
that one would expect (e.g., Hofmann et al. 2005). In
SAD patients, there was only a trend for a significant
correlation between implicit self-esteem and SAD symp-
tom severity, as assessed by the SPAI) (p = .09). Strong
inter-relationships were evident among the explicit mea-
sures. There was a strong correlation between explicit
self-esteem (RSES) and SAD symptom severity (LSAS,
SPAI) as well as depressive symptoms (BDI). Finally, a
strong correlation was evident between SAD symptom
severity (LSAS, SPAI) and severity of depressive symp-
toms (BDI).

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Table 2 Correlations among the implicit and explicit measures in
SAD patients
Measures IAT RSES LSAS SPAI BDI
IAT .11 -.18 -.27? -.08
RSES .11 -.65*** -.60*** -.61***
LSAS -.18 -.65*** .78*** .39**
SPAI -.27? -.60*** .78*** .56***
BDI -.08 -.61*** .39** .56***
IAT Implicit association test; RSES Rosenberg Self-Esteem Scale,
LSAS Liebowitz Social Anxiety Scale, SPAI Social Phobia and
Anxiety Inventory, BDI Beck Depression Inventory, SAD Social
Anxiety Disorder
*** p \ .001, ** p \ .01, * p \ .05, ? p \ .10
Discussion
The present study was designed to investigate implicit and
explicit self-esteem in a clinical sample of adults with
SAD, and to determine whether the co-occurrence of social
anxiety and depression leads to further impairments in
implicit and explicit self-esteem. In line with hypotheses,
individuals with SAD showed significantly lower (i.e., less
positive) implicit self-esteem than healthy controls. This
finding is consistent with previous studies in analogue and
clinical samples of high socially anxious individuals
(Glashouwer et al. 2013; Tanner et al. 2006; de Jong 2002),
and provides some of the first evidence of less positive
implicit self-esteem in a diagnosed sample of SAD (see
also Glashouwer et al. 2013). Importantly, this result con-
firms cognitive models of SAD (Hofmann 2007; Clark and
Wells 1995; Rapee and Heimberg 1997) and suggests that
not only explicit but also implicit self-evaluative biases
seem to be involved in the maintenance of social anxiety.
The less positive implicit self-esteem may result from
impairments in implicit defensive mechanisms which are
assumed to regulate negative emotions caused by self-
threat (Rudman et al. 2007b). Accordingly, SAD patients
may have experienced poorer self-worth in the presence of
self-threat, and may have automatically processed self-
relevant information in a less self-serving manner. This is
also consistent with a recent finding showing that auto-
matic threat-related associations are involved in social
anxiety (de Hullu et al. 2011). In contrast, Schreiber et al.
(2012) found high implicit self-esteem (in combination
with low explicit self-esteem) before and after social threat
induction in adolescent SAD, suggesting a pattern of dis-
crepant (‘damaged’) self-esteem (Schröder-Abé et al.
2007) that may be maintained by an increase in implicit
self-esteem to defend unbearable feelings of inferiority.
However, on the basis of the present and past IAT findings
in social anxiety it seems premature to conclude that high
implicit self-esteem is indicative for SAD (Schreiber et al.
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Cogn Ther Res (2013) 37:1101–1109
2012). Due to the small sample size of the Schreiber et al.
study, the lacking convergent validity of the applied
implicit measures and the possible impact of practice
effects (Ebert et al. 2009; Nosek et al. 2006; Greenwald
et al. 2003) further studies are needed to clarify whether
discrepant self-esteem plays a plausible role in social
anxiety.
Depressed and non-depressed SAD patients had signif-
icantly lower implicit self-esteem than healthy controls.
However, contrary to hypotheses, no group difference was
observed between depressed and non-depressed SAD
patient. Several explanations may account for these find-
ings. First, it seems that the significant group difference
between depressed SAD patients and healthy controls can
be primarily attributed to implicit biases related to social
anxiety suggesting differential automatic self-evaluative
processes in social anxiety and depression (cf. de Jong
et al. 2012). Given that, the preponderance of a rapid
biased processing of self-threatening information might
have led to lower implicit self-esteem in depressed SAD
patients. By contrast, the null finding between depressed
and non-depressed SAD patients could be primarily
explained by methodological limitations of the present
study. Due to the relatively small sample size of the SAD
sample (n = 40), and the relatively small sample size of
the group of depressed SAD patients (n = 16) and non-
depressed SAD patients (n = 24), statistical power was
low. Further, depressed SAD patients represented different
subgroups of depressive disorders (major depressive dis-
order (MDD), recurrent MDD, and dysthymia), which
might be characterized by different self-evaluative pro-
cessing styles. For instance, it has been shown that cur-
rently and formerly depressed patients have high (or even
average) implicit self-esteem (e.g., Franck et al. 2007,
2008; De Raedt et al. 2006; Gemar et al. 2001). By con-
trast, Risch et al. (2010) demonstrated that impaired
implicit self-esteem primarily occurs after the repeated
activation of negative self-related concerns in the course of
recurrent depression, and it might be that similar self-
evaluative processes occur in the course of chronic
depression. However, in the present study, patients with a
history of recurrent depressive episodes or chronic forms of
depression, such as dysthymia, were underrepresented.
Therefore, studies with larger sample sizes and more varied
co-morbid depressive disorders are necessary before more
definitive conclusions can be drawn.
In addition, our results revealed that implicit self-esteem
was not significantly correlated with SAD symptom
severity and depressive symptoms. However, there was a
trend for a significant correlation between implicit self-
esteem and SAD symptom severity (as assessed by the
SPAI) (p = .09), suggesting that automatic self-evalua-
tions could be central to emotional dysregulation in social
Cogn Ther Res (2013) 37:1101–1109
anxiety. In line with this, an association between low
implicit self-esteem and SAD symptom severity has been
proved to date in female adolescents with low explicit self-
esteem (de Jong et al. 2012) and in male SAD patients
(Glashouwer et al. 2013). However, in the present study,
the weak correlation should be interpreted with caution
because of the small sample size, limiting power to observe
statistically significant correlations.
As expected, SAD patients endorsed significantly lower
explicit self-esteem than healthy controls, and depressed
SAD patients reported significantly lower explicit self-
esteem than non-depressed SAD patients and healthy
controls. Importantly, these results suggest that the
co-occurence of depression and social anxiety may lead to
a more negative explicit self-view. There were strong
relationships between explicit self-esteem and symptom
severity of SAD and depression, indicating that SAD
patients with lower explicit self-esteem are characterized
by stronger explicit symptoms of social anxiety and
depression. These findings are in line with recent research
(de Jong et al. 2012) showing that the co-occurrence of
depressive and SAD symptoms could be largely explained
by low explicit self-esteem. These correlations also support
cognitive models of SAD (Hofmann 2007; Clark and Wells
1995; Rapee and Heimberg 1997) suggesting that negative
self-evaluations play an important role in SAD psychopa-
thology. Finally, SAD symptom severity was highly asso-
ciated with symptom severity of depression, indicating that
social anxiety is frequently accompanied by depressive
symptoms (de Jong et al. 2012; Ohayon and Schatzberg
2010).
The current study has several limitations. First, because
of the IAT’s bipolar nature, the self is evaluated in
comparison to others (Pinter and Greenwald 2005).
Unfortunately, we did not use an implicit alternative
measure to determine the valence of others (e.g., GNAT:
Nosek and Banaji 2001), independent of the self-evalua-
tion. Second, we used a generic self-esteem IAT and
presented pronouns as target stimuli, in order to avoid
idiosyncratic confounds due to semantic associations
(Steffens et al. 2008). However, idiographic stimuli (e.g.,
first name) are, in contrast to generic stimuli (e.g., me),
more specific and assess self-esteem in IATs more validly
(Bluemke and Friese 2012). Third, the small sample size
of the depressed and non-depressed SAD groups limits the
interpretation of null findings (i.e., no significant group
differences on the IAT) within these groups. Fourth, due
to the exclusion of patients with more severe co-morbid
disorders, our results are not generalizable to individuals
with stronger impairments from co-morbid disorders such
as depression. Fifth, unfortunately, we did not include a
baseline assessment of self-esteem, specifically with
respect to implicit self-esteem, in order to avoid practice
1107
effects which can be problematic when the IAT is
administered close in time (Ebert et al. 2009; Nosek et al.
2006, Greenwald et al. 2003). Thus, it remains unclear
whether implicit self-esteem decreases due to the social
threat induction (i.e., state self-esteem) or whether implicit
self-esteem is generally impaired in patients with SAD
(i.e., trait self-esteem). However, given that the IAT has
been shown to measure not only variable, state-like but at
the same time also stable trait-like components of self-
attitudes (e.g., Schmukle and Egloff 2004; Steffens and
Buchner 2003), and previous studies with and without
threat induction (Glashouwer et al. 2013; Tanner et al.
2006; de Jong 2002) concordantly demonstrated low
implicit self-esteem in social anxiety, our results might be
also partially attributed to generally impaired implicit self-
evaluative processes.
Notwithstanding the above limitations, the present study
provides further evidence for concurrent low implicit and
low explicit self-esteem in a diagnosed sample of adults
with SAD. These findings are consistent with cognitive
models (e.g., Hofmann 2007; Clark and Wells 1995) and
suggest that biased self-processing works on both implicit
and explicit levels. Further, our results suggest that the
co-occurence of social anxiety and depression leads to a
stronger impairment in explicit self-esteem. No such dif-
ferences were found in implicit self-esteem. In future
research it will be interesting to examine whether low
implicit and explicit self-esteem plays a potential moder-
ating role in the formation of social anxiety. The impor-
tance of addressing this is strengthened by first findings
showing that low self-esteem is a risk factor in the devel-
opment of SAD (Acarturk et al. 2009). If so, these findings
offer support for cognitive models of SAD (e.g., Hofmann
2007; Clark and Wells 1995) that suggest that dysfunc-
tional beliefs about the self play a key role in the devel-
opment and maintenance of SAD. In addition, it will
interesting to investigate whether implicit and explicit self-
associations change over the course of treatment. Recently,
Clerkin and Teachman (2010) provided the first evidence
that implicit self-rejection associations in high socially
anxious individuals can be modified by using a computer-
based conditioning paradigm. Further, there is initial evi-
dence for higher (i.e., more positive) implicit and explicit
self-esteem following cognitive and psychodynamic ther-
apy in SAD (Ritter et al. 2013). These promising findings
offer support for interventions that make it possible to
modify self-evaluations in social anxiety, even at an
implicit level.
Appendix
See Table 3.
123
1108 Cogn Ther Res (2013) 37:1101–1109

Table 3 IAT categories and associated stimuli

Category Stimuli

Positive (Positiv) Intelligent (Klug), Interesting (Interessant), Likeable (Sympathisch),

Charismatic (Charismatisch), Worthy (Wertvoll), Lovable (Liebenswert)
Negative (Negativ) Stupid (Dumm), Boring (Langweilig), Disliked (Unbeliebt), Incompetent
(Unfähig), Inferior (Minderwertig), Worthless (Wertlos)
Self (Selbst) I (Ich), Me (Mir), Myself (Mich), My (Mein), Self (Selbst), Own (Eigenes)
Others (Andere) You (Ihr), Yours (Eure), Yourselves (Euch), Yours (Euer), Others (Andere),
Theirs (Ihres)
Stimuli (in German) used in the study in parentheses

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