Academic literature on the topic 'Fear of blushing'

The diagnosis of social anxiety disorder (SAD) has seen substantial changes in the last 35 years from its first appearance in the DSM-III in 1980 up to the most recent ones in the DSM-5. Throughout all these changes, this disorder, previously called social phobia, is still considered one homogenous entity with only one specifier (“performance only”) introduced in the DSM-5 revision with specific fears or associated personality profiles not being considered relevant clinical markers to define SAD subtypes. However, our therapeutic experience suggested substantial particularities associated with the fear of blushing in patients with SAD. Some patients presenting this profile, historically called “erythrophobia”, seem to have a very specific type of social anxiety that does not include shyness and other characteristics of classical SAD. In a study conducted in a sample of 450 new consecutive outpatients seeking treatment for SAD, we compared 142 subjects with fear of blushing without other social fears, 97 subjects with fear of blushing with other associated social fears and 190 SAD subjects without fear of blushing. The group with pure fear of blushing presented a different profile when compared with the two other groups: later age of onset, less comorbidity, lower behavioral and temperamental inhibition, i.e. less shyness, and higher self-esteem. Furthermore, from a therapeutic point of view, some specific strategies such as the Task Concentration Training have shown to be particularly effective in fear of blushing. We will further argue the validity of a possible “fear of blushing” subtype of SAD.Disclosure of interestThe authors have not supplied their declaration of competing interest.

By means of a single case study, the effects of redirecting attention above exposure only on fear of blushing, avoidance, and idiosyncratic dysfunctional beliefs were tested. A social phobic patient with fear of blushing as the predominant complaint received sessions of Task Concentration Training (TCT) and Exposure in Vivo (EXP) alternately, after a steady baseline had been established. The treatment consisted of 14 individual sessions. Assessments were held before and after baseline, after treatment, after 4 weeks follow-up, and after 1-year follow-up. Continuous measurements were held throughout the treatment in order to measure the differential effects of TCT and EXP on fear, avoidance and beliefs. TCT and EXP together, turned out to be an effective treatment for fear of blushing: large effects were observed on all three outcome measurements. When differential effects are closely looked at, EXP seemed more effective in decreasing fear of blushing. However, the patient appeared to have used TCT strategies as well during the EXP weeks, which may have contributed to the favourable effects of EXP.

Although it has been suggested that attentional processes play a crucial role in blushing, to date research on the relationship between blushing and self-focused attention (SFA) has yielded conflicting results. In order to examine this relationship further, we conducted an empirical study in which we induced blushing and, using infrared thermography, measured changes in the facial temperature of 29 people with a high trait of SFA and 27 people with a low trait of SFA. The results suggest that high SFA not only increased actual physiological arousal levels (facial skin temperature) during blushing, but also delayed recovery from blushing episodes. These findings may provide valuable information for individuals with a high level of fear of blushing, including possible treatments such as an attentional distraction program.

Rosacea is a chronic skin disorder, characterized by redness and flushing of the cheeks, nose, chin or forehead. It has been proposed that rosacea is a result of frequent blushing (Miller, 1921; Klaber & Whittkower, 1939). However, the relationship between rosacea and blushing is uncertain. The aim of the present research was to investigate the relationship between psychological stress and vascular disturbances in rosacea. Five studies were conducted. The first study explored the relationship between rosacea and mental health while the next two investigated vascular responses in rosacea sufferers and controls to acetylcholine (which induces endothelial vasodilatation and axon reflexes) and psychological stress (embarrassment). The fourth study aimed to examine the relationship between psychological indicators and rosacea symptoms on a daily basis. The fifth study consisted of three case studies looking at the use of Cognitive Behavioural Therapy (CBT) and Task Concentration Training (TCT) with rosacea sufferers presenting with social anxiety and fear of blushing symptoms. In study 1, sixty-two participants were asked to complete the Blushing Propensity Scale (BPS), Fear of Negative Evaluation (FNE), Depression, Anxiety and Stress Scale (DASS), Social Interaction Anxiety Scale (SIAS) and Social Phobia Scale (SPS). Outcomes from the first study indicated that Type 2 rosacea sufferers (n= 12) perceived themselves as blushing more frequently and intensely than Type 1 rosacea sufferers (n=19) or controls (n=31). This suggested that Type 2 rosacea sufferers experiencing frequent blushing may have a lower sensitivity threshold to blushing episodes. In addition, Type 2 rosacea sufferers perceived themselves as more stressed than Type 1 rosacea sufferers or controls, possibly indicating that managing the condition can be stressful. Contrary to previous reports (Gupta et al., 2006; National Rosacea Society, 2005) severity of rosacea was not associated with depression, social anxiety or fear of negative evaluation. However, a few participants who reported high social anxiety and stress scores were offered psychological intervention (Study 5). The aim of the second study was to investigate vascular responses in rosacea sufferers. Cutaneous endothelial and axon reflex function was assessed using an acetylcholine dose response curve. The axon reflex was assessed by inducing a flare with ACh iontophoresis. Outcomes from this study indicated that Type 2 rosacea sufferers had a greater axon reflex response than Type 1 rosacea sufferers. Thus over-reactivity of the axon reflex in Type 2 rosacea sufferers might contribute to prolonged vasodilatation. However, cutaneous endothelial responses to ACh were similar in rosacea and control groups. The results suggested that neural pathways mediated the flushing response rather than cutaneous endothelial function. The third study investigated facial blood flow while participants attempted laboratory induced embarrassment tasks. Type 2 rosacea sufferers were found to have a greater blood flow in the facial region than Type 1 rosacea sufferers during singing and speech tasks, suggesting that Type 2 rosacea sufferers blushed more than type 1 rosacea sufferers or controls. Furthermore, Type 2 rosacea sufferers reported higher embarrassment and blushing ratings than Type 1 rosacea sufferers. This indicated that Type 2 rosacea sufferers perceived themselves as emotionally more aroused than other participants. Taken together, it would appear that a combination of physiological and cognitive factors increased facial blood flow in Type 2 rosacea sufferers in laboratory induced embarrassment tasks. The fourth study explored the relationship between stress and symptoms of rosacea. Using a diary, 15 rosacea sufferers recorded their stress, anxiety and mood and their intensity of rosacea symptoms daily. Stress was associated with increased stinging/facial redness on the same day for 1 to 2 months. Furthermore, it was associated with increased stinging ratings the next day. However, feeling anxious or having low mood was not related to increase stinging the next day. The presence of increased stress found in rosacea participants on the day where stinging and redness occurred should be taken into consideration when formulating psychological interventions for rosacea sufferers. In study 5, individual psychological intervention was provided to three participants experiencing stress, fear of blushing and social anxiety symptoms. Cognitive Behavioural Therapy (CBT) and Task Concentration Training (TCT) were helpful in managing stress, anxiety and fear of blushing symptoms in individual rosacea sufferers. Encouragingly, all participants reported a gain in their repertoire of strategies and showed a decrease in anxiety symptoms on assessment questionnaires following their intervention. Replication of the intervention protocol and investigation of other psychological approaches are required to establish best practise outcome for rosacea sufferers who require psychological interventions. The present findings suggest that over-reactivity of axon reflexes contributes to facial flushing. In addition, emotional flushing in rosacea sufferers appears to be maintained by a combination of cognitive and physiological factors. On a clinical level, the study recommends that emotional stress associated with facial flushing in rosacea sufferers to be targeted for psychological intervention.

Erythrophobie wird als klinische Bezeichnung für die Angst zu erröten verwendet, wenn das Einzelsymptom Erröten im Vordergrund einer Angstproblematik steht. Die vorliegende Übersicht beruht auf einer umfangreichen Literaturrecherche und wird ergänzt durch eigene klinische Beobachtungen aus einer Pilotstudie zur kognitiv-behavioralen Gruppentherapie der Errötungsangst. Wir referieren den aktuellen Kenntnisstand zu Erythrophobie in Bezug auf die differentialdiagnostische Einordnung, auf ätiologische und pathogenetische Konzepte sowie auf die Verhaltenstherapie der Störung. Insgesamt zeigt die Übersicht, dass Erythrophobie am sinnvollsten als Subsyndrom der Sozialen Phobie beschrieben werden kann. Patienten mit Errötungsangst als Hauptbeschwerde unterscheiden sich jedoch von anderen Patienten mit Sozialer Phobie im Hinblick auf Behandlungsanliegen, Inanspruchnahmeverhalten, Behandlungserwartung und Therapieziele sowie durch spezifische aufrechterhaltende Mechanismen der Störung, insbesondere durch eine übertriebene und inflexible Aufmerksamkeitsfokussierung auf körperliche Symptome. Der Einsatz eines Aufmerksamkeitstrainings als spezifisches Behandlungsmodul bei Errötungsangst ist vielversprechend und sollte in bekannte Ansätze zur Therapie der Sozialen Phobie integriert werden. Abschließend werden Impulse für weiterführende Forschungsaktivitäten skizziert
Erythrophobia is the pathological form of fear of blushing. This review is based upon an extensive literature research and supplemented by clinical observations from a pilot study of a cognitive-behavioural group therapy for fear of blushing. Current knowledge about fear of blushing is reported regarding diagnostic considerations, aetiologic and pathogenetic mechanisms, and cognitive-behavioural therapy. In conclusion, this review indicates that fear of blushing should be classified as a sub-syndrome of social phobia. Patients suffering from fear of blushing as predominant complaint differ from other patients with social phobia in health-care utilisation, treatment expectation and treatment goals. However, the most prominent difference lies in the exaggerated and inflexible self-focused attention these patients direct to their arousal and bodily symptoms. Therefore, attention training as a specific treatment unit is promising and should be integrated in standard treatment approaches for social phobia. Finally, options for further research are outlined
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich

Erythrophobie wird als klinische Bezeichnung für die Angst zu erröten verwendet, wenn das Einzelsymptom Erröten im Vordergrund einer Angstproblematik steht. Die vorliegende Übersicht beruht auf einer umfangreichen Literaturrecherche und wird ergänzt durch eigene klinische Beobachtungen aus einer Pilotstudie zur kognitiv-behavioralen Gruppentherapie der Errötungsangst. Wir referieren den aktuellen Kenntnisstand zu Erythrophobie in Bezug auf die differentialdiagnostische Einordnung, auf ätiologische und pathogenetische Konzepte sowie auf die Verhaltenstherapie der Störung. Insgesamt zeigt die Übersicht, dass Erythrophobie am sinnvollsten als Subsyndrom der Sozialen Phobie beschrieben werden kann. Patienten mit Errötungsangst als Hauptbeschwerde unterscheiden sich jedoch von anderen Patienten mit Sozialer Phobie im Hinblick auf Behandlungsanliegen, Inanspruchnahmeverhalten, Behandlungserwartung und Therapieziele sowie durch spezifische aufrechterhaltende Mechanismen der Störung, insbesondere durch eine übertriebene und inflexible Aufmerksamkeitsfokussierung auf körperliche Symptome. Der Einsatz eines Aufmerksamkeitstrainings als spezifisches Behandlungsmodul bei Errötungsangst ist vielversprechend und sollte in bekannte Ansätze zur Therapie der Sozialen Phobie integriert werden. Abschließend werden Impulse für weiterführende Forschungsaktivitäten skizziert.
Erythrophobia is the pathological form of fear of blushing. This review is based upon an extensive literature research and supplemented by clinical observations from a pilot study of a cognitive-behavioural group therapy for fear of blushing. Current knowledge about fear of blushing is reported regarding diagnostic considerations, aetiologic and pathogenetic mechanisms, and cognitive-behavioural therapy. In conclusion, this review indicates that fear of blushing should be classified as a sub-syndrome of social phobia. Patients suffering from fear of blushing as predominant complaint differ from other patients with social phobia in health-care utilisation, treatment expectation and treatment goals. However, the most prominent difference lies in the exaggerated and inflexible self-focused attention these patients direct to their arousal and bodily symptoms. Therefore, attention training as a specific treatment unit is promising and should be integrated in standard treatment approaches for social phobia. Finally, options for further research are outlined.
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Cognitive behaviour therapy for anxiety disorders is a brief psychological treatment (1 to 16 sessions), based on the cognitive model of emotional disorders. Within this model, it is assumed that it is not events per se, but rather people's expectations and interpretations of events, which are responsible for the production of negative emotions such as anxiety, anger, guilt, or sadness. In anxiety, the important interpretations, or cognitions, concern perceived physical or psychosocial danger. In everyday life, many situations are objectively dangerous. In such situations, individuals’ perceptions are often realistic appraisals of the inherent danger. However, Beck argues that in anxiety disorders, patients systematically overestimate the danger inherent in certain situations, bodily sensations, or mental processes. Overestimates of danger can arise from distorted estimates of the likelihood of a feared event, distorted estimates of the severity of the event, and/or distorted estimates of one's coping resources and the availability of rescue factors. Once a stimulus is interpreted as a source of danger, an ‘anxiety programme’ is activated. This is a pattern of responses that is probably inherited from our evolutionary past and originally served to protect us from harm in objectively dangerous primitive environments (such as attack from a predator). The programme includes changes in autonomic arousal as preparation for flight/fight/fainting and increased scanning of the environment for possible sources of danger. In modern life, there are also situations in which these responses are adaptive (such as getting out of the path of a speeding car). However, when, as in anxiety disorders, the danger is more imagined than real, these anxiety responses are largely inappropriate. Instead of serving a useful function, they contribute to a series of vicious circles that tend to maintain or exacerbate the anxiety disorder. Two types of vicious circle are common in anxiety disorders. First, the reflexively elicited somatic and cognitive symptoms of anxiety become further sources of perceived danger. For example, blushing can be taken as an indication that one has made a fool of oneself, and this may lead to further embarrassment and blushing; or a racing heart may be taken as evidence of an impending heart attack and this may produce further anxiety and cardiac symptoms. Second, patients often engage in behavioural and cognitive strategies that are intended to prevent the feared events from occurring. However, because the fears are unrealistic, the main effect of these strategies is to prevent patients from disconfirming their negative beliefs. For example, patients who fear that the unusual and racing thoughts experienced during panic attacks indicate that they are in danger of going mad and often try to control their thoughts and (erroneously) believe that if they had not done so, they would have gone mad. Within cognitive models of anxiety disorders, at least two different levels of disturbed thinking are distinguished. First, negative automatic thoughts are those thoughts or images that are present in specific situations when an individual is anxious. For example, someone concerned about social evaluation might have the negative thought, ‘They think I'm boring’, while talking to a group of acquaintances. Second, dysfunctional assumptions are general beliefs, which individuals hold about the world and themselves which are said to make them prone to interpret specific situations in an excessively negative and dysfunctional fashion. For example, a rule involving an extreme equation of self-worth with social approval (‘Unless I am liked by everyone, I am worthless’) might make an individual particularly likely to interpret silent spells in conversation as an indication that others think one is boring. Cognitive behaviour therapy attempts to treat anxiety disorders by (a) helping patients identify their negative danger-related thoughts and beliefs, and (b) modifying these cognitions and the behavioural and cognitive processes that normally maintain them. A wide range of procedures are used to achieve these aims, including education, discussion of evidence for and against the beliefs, imagery modification, attentional manipulations, exposure to feared stimuli, and numerous other behavioural assignments. Within sessions there is a strong emphasis on experiential work and on working with high affect. Between sessions, patients follow extensive homework assignments. As in cognitive behaviour therapy for other disorders, the general approach is one of collaborative empiricism in which patient and therapist view the patient's fearful thoughts as hypotheses to be critically examined and tested.