Vulnerability to Anxiety 115
be most important in social phobia. Wilson and Rapee (2006), for example, found that
it was certainty of self- concept that was reduced in social phobia, whereas Mansell and
Clark (1999) found that socially anxious individuals had reduced positivity recall for
public but not private self- referent trait adjectives. Finally, differences in self- esteem may
depend on whether automatic (i.e., implicit) or more effortful (i.e., explicit) processes are
assessed. Implicit Association Test (IAT) studies suggest that the problem of low self-
esteem in anxiety may be reflected in more controlled, effortful processes rather than an
underlying, automatic evaluative bias (see de Jong, 2002; Tanner et al., 2006).
Although considerably less is known about the role of low self- esteem in other anxi-
ety disorders, there is some preliminary research that is noteworthy. Ehntholt, Salkovs-
kis, and Rimes (1999) found that both OCD and non-OCD anxious groups had signifi-
cantly lower self-worth and generalized self- esteem than a nonclinical control group but
concluded that low generalized self- esteem may be a consequence of anxiety rather than
a predisposing factor. Wu, Clark, and Watson (2006) found that OCD patients were
distinguished by a very low self-image based on profile analysis of the SNAP-2 and low
self- esteem has been implicated in the development of PTSD symptoms (Piotrkowski &
Brannen, 2002). Doron and Kyrios (2005) proposed that a restricted self- concept may
constitute an underlying vulnerability for OCD. Thus there is increasing interest among
researchers on the role that low self- esteem and other selfhood concepts might play in
the pathogenesis of the anxiety disorders.
Summary
Although there is empirical evidence that low self- esteem characterizes the anxiety dis-
orders, it is not clear whether this is a cause or a consequence of the disorder. Research
on self- esteem vulnerability in anxiety has lagged far behind the empirical literature
on low self- esteem in depression. Two types of studies are critical to progress beyond
mere speculation. First, longitudinal studies are needed to determine if low self-worth
is indeed a predisposing contributor to an anxiety disorder. These types of studies are
practically nonexistent in the anxiety literature. And second, experimental research is
needed to determine if variations in self- esteem have a corresponding causal effect on
anxious symptoms. Causal effects must be demonstrated if low self- confidence in deal-
ing with threat is a true cognitive vulnerability for anxiety.
If low self-worth is a cognitive vulnerability for anxiety, the preliminary findings
suggest it is highly specific to threatening content perceived relevant to an individual’s
primary anxious concerns. In addition the lack of self- confidence is most likely evident
at the secondary phase of anxiety where effortful, controlled processes predominant
(see Figure 2.1). However, a conclusion on the empirical support for Hypothesis 11 must
wait until further research has been completed.
Clinician Guideline 4.4
When assessing self-worth issues in anxiety, the clinician should evaluate the client’s level of
self- confidence in dealing with situations that exemplify the individual’s primary anxious
concerns.