Relationship between Internalized Shame, Safety Behaviors and Cognitive Avoidance Strategies with Multidimensional Social Anxiety in Students of Medical Science

Document Type : Original Article


1 abadan university of medical science

2 Faculty member in clinical psychology/shahid chamran univesity of ahvaz

3 clinical psychology in Faculty member/shahid chamran university of ahvaz


Introduction: the purpose of this study was to investigate the relationship between Internalized Shame, Safety Behaviors and Cognitive Avoidance Strategies with Multidimensional Social Anxiety in students of medical science faculty.
Method: By a correlational design among statistical population including all students of Abadan medical science faculty, a total sample of 285 students (176 female and 109 male) were selected by available sampling method, and asked to complete 4 instruments of 1- Internalized Shame scale, 2- Subtle Avoidance and Safety Behaviors Inventory,3- Cognitive Avoidance Coping Style scale and 4- Multidimensional Assessment of Social Anxiety Inventory. Data was analyzed by a Canonical Correlation method.
Results: The final results showed significant  canonical correlation betweenshame, safety behaviors and cognitive avoidance strategies with social anxiety. About 84 percent of variance components of social anxiety dimensions was explained by predictor variables.
Conclusion: It was concluded that internalized shame, safety behaviors and cognitive avoidance strategies are associated to social anxiety dimensions. Relavant interventions on shame, safety behaviors and cognitive avoidance strategies in students of medical science is recommended.


1- American Psychiatric Association. Diagnostic and   Statistical Manual Of Mental Disorders, 5 th Ed (DSM-V). Author: American Psychiatric Association. 2013. [Available from]
2- Ghayour- Kazemi FMA, Sephri- Shamloo Z, Mashhadi A, Ghanaie – Chamanabad, A.A Comparative study effectiveness of metacognitive therapy with neurofeedback training on reducing anxiety symptoms in female students with social anxiety disorder. Journal of Clinical Psychology. 2015; 7(3): 21-35. [Persian]. 
3- Aderka IM, McLean CP, Huppert JD, Davidson JR, Foa EB. Fear, avoidance and physiological symptoms during cognitive-behavioral therapy for social anxiety disorder. Behavior research and therapy. 2013; 51(7): 352-8.
4- Norouzi M, Michaeli Manee F,Issazadegan A The prevalence of self-reported social anxiety disorder on Iranian students. The Journal of Urmia University of Medical Sciences. 2016; 27(2): 155-66. [Persian].
5- jenadeleh KH,Bassak Nejad S, Yunesi A,Sadatmand KH. The relationship between anxiety sensitivity and experimental avoidance and resiliency with test anxiety in male students. Journal of Clinical Psychology. 2018; 10(1): 71-7.[Persian].
6- Roushani KH, Bassak Nejad S,Arshadi N, Mehrabizadeh Honarmand M,Fakhri A. The Effects of Cognitive Behavioral Therapy Based on Hofmann’s Model on Anxiety Sensitivity and Positive and Negative Affects Among Undergraduate Female Students with Social Anxiety Symptoms in Ahvaz Jundishapur University of Medical Sciences. Jentashapir Journal of Health Research. 2017; 8(1): 1-7 .
7- Zargar Y, Besaknezhad S, Akhlaghi Jami L, Zemestani M. The Comparison of  The Effectiveness of Group Training of Social Skills and Group Cogntive-Behavior Therapy in Reducing Social Anxiety Among Students. The Journal of Urmia University of Medical Sciences. 15; 25(3): 172-81. [Persian].
8- Moitra E, Herbert JD, Forman EM. Behavioral avoidance mediates the relationship between anxiety and depressive symptoms among social anxiety disorder patients. Journal of Anxiety Disorders. 2008; 22(7): 1205-13.
9- Michail M, Birchwood M. Social anxiety disorder and shame cognitions in psychosis. Psychological Medicine. 2013; 43: 133-42.
10- Gilbert P, Miles JN. Sensitivity to Social Put-Down: it's relationship to perceptions of social rank, shame, social anxiety, depression, anger and self-other blame. Personality and Individual Differences. 2000; 29(4): 757-74.
11- Gilbert P, McEwan K, Irons C, Bhundia R, Christie R, Broomhead C, Rockliff H. Self‐harm in a mixed clinical population: The roles of self‐criticism, shame, and social rank. British Journal of Clinical Psychology. 2010; 49(4): 563-76.
12- Matos M, Pinto‐Gouveia J, Gilbert P. The effect of shame and shame memories on paranoid ideation and social anxiety. Clinical psychology & psychotherapy. 2013; 20(4): 334-49.
13- Stangier U, Heidenreich T,Schermelleh –engel K. Safety Behaviors and Social Performance in Patients With Generalized Social Phobia. Journal of Cognitive Therapy. 2006; 20(1): 17-31.
14- Cuming S, Rapee RM, Kemp N, Abbott MJ, Peters L, Gaston JE. A self-report measure of subtle avoidance and safety behaviors relevant to social anxiety: Development and psychometric properties. Journal of Anxiety Disorders. 2009; 23(7): 879-83.
15- Lee J, Kim M, Park M. The impact of internalized shame on social anxiety in adolescence: The mediating role of experiential avoidance. Journal of Asian Pacific Counselling. 2014; 4(1): 65-81.
16- Ottenbreit ND, Dobson KS. Avoidance and depression: the construction of the Cognitive–Behavioral Avoidance Scale. Behavior research and therapy. 2004; 42 (3): 293-313.
17- Rudaz M, Lederman T, Margraf J, Becke ES, Craske MG. The moderating role of avoidance behavior on anxiety over time : Is there a difference between social anxiety disorder and specific phobia/ PLoS ONE. 12(7): e0180298.
18- Thwaites R, Freeston M. Safety- seeking behaviors: Fact or fiction? How can we clinically differentiate between safety behaviors and adaptive coping strategies across anxiety disorders? Behavioral and Cognitive Psychotherapy. 2005; 33(2): 177-88.
19- Hassanvand Amouzadeh M, Shairi MR, Moghadam A, Ali M. Social anxiety prediction pattern with regard to cognitive behavioral factors. Journal of Research and Health. 2013; 3(2): 379-87. [Persian].
20- Basak Nejad S, Moini N, Mehrabizade-Honarmand M. The Relationship between Post event processing and cognitive avoidance with social anxiety among students. J Behav Sci. 2010; 4(14): 335-40.[ Persian]
21- Moscovitch DA, Rowa K, Paulitzki JR, Ierullo MD, Chiang B, Antony MM, McCabe RE. Self-portrayal concerns and their relation to safety behaviors and negative affect in social anxiety disorder. Behaviour research and therapy. 2013; 51(8): 476-86.
22- Kocovski NL, Endler NS, Rector NA, Flett GL. Ruminative coping and post-event processing in social anxiety. Behaviour Research and Therapy. 2005; 43(8): 971-84.
23- Rajabi gh, abbasi gh. An Investigation of Relationship between self-criticism, social interaction anxiety, and fear of failure with Internalized shame in students. Journal clinical psychology Research and Counseling. 2012; 2(1): 171-82. [Persian].
24- Del Rosairo PM, White RC. The internalized shame scale: Temporal stability, internal consistency and principal components analysis. Personality and Individual Differences.2006; 41(1): 95-103.
25- Bassak nejad S, Hooman F,Ghasemi nejad GH. The relationship between cognitive-behavioral avoidance coping styles with eating disorder among university students. Journal of Fundamentals of Mental Health. 2013; 4(56): 278-85. [Persian]
26- Gros DF, Simms LJ, Antony MM, McCabe RE. Development and psychometric evaluation of the Multidimensional Assessment of Social Anxiety (MASA). Journal of clinical psychology. 2012; 68(4): 432-47.
27- Okjima I, Kanai Y, Chen J, Sakano Y. Effect of safety behavior on the maintance of anxiety and negative belief social anxiety disorder. International Journal of Social Psychiatry. 2009; 55(1): 71-81.
28- Kashdan TB, Roberts J. Social anxiety, depressive symptoms, and post event rumination: Affective consequences and social contextual influences. Journal of Anxiety Disorder. 2007; 21: 284-301.
29- Jose PE, Wilkins H, Spendelow JS. Does social anxiety predict rumination and co-rumination among adolescents?. Journal of Clinical Child & Adolescent Psychology. 2012;
30- Hashemi- Nosratabad,T.,Mahmoud-Alilou, M.,Gholozadeh, A. The effectiveness of cognitive behavioral therapy based on Hofman, s model on fear of negative evaluation and self- focused attention in social anxiety disorder. Journal of Clinical Psychology. 2017; 33(1): 101-11.[Persian].