Depression from social anxiety

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  • SAMHSA’s National Helpline is a free, confidential, 24/7, 365-day-a-year treatment referral and information service (in English and Spanish) for individuals and families facing mental and/or substance use disorders.

    Also visit the online treatment locator.

SAMHSA’s National Helpline, 1-800-662-HELP (4357) (also known as the Treatment Referral Routing Service), or TTY: 1-800-487-4889 is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations.

Also visit the online treatment locator, or send your zip code via text message: 435748 (HELP4U) to find help near you. Read more about the HELP4U text messaging service.

The service is open 24/7, 365 days a year.

English and Spanish are available if you select the option to speak with a national representative. Currently, the 435748 (HELP4U) text messaging service is only available in English.

In 2020, the Helpline received 833,598 calls. This is a 27 percent increase from 2019, when the Helpline received a total of 656,953 calls for the year.

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depression and anxiety are unrelated

The vast majority of people with depression are diagnosed with an anxiety disorder. A group of researchers from Novosibirsk found out that the centers of brain activity that "supervise" depression and anxiety are opposite in their actions. The results of the work will help improve the methods of differential diagnosis and treatment, according to a press release from the Russian Science Foundation. The study was published in the August issue of the journal Brain Research.

“Anxiety and depression go hand in hand in the sense that anxiety often precedes depression, sometimes they alternate, but they are qualitatively different conditions, even if they are combined in one person. There is also a kind of depression that is not associated with anxiety, but arising from anhedonia, that is, the inability to experience positive emotions, ”explains Gennady Knyazev, head of the study, head of the laboratory of differential psychophysiology at the Research Institute of Physiology and Fundamental Medicine.

Tendencies to depression and anxiety were determined in healthy people who had not previously sought help from psychotherapists and psychiatrists. The severity of depressive symptoms in 44 participants in the experiment was determined using the Beck questionnaire, in which 21 questions on the main symptoms of depression, and respondents are asked to indicate how often they experienced the corresponding state over the past two weeks. To determine anxiety, the researchers used an appropriate personality questionnaire. After identifying symptoms, participants were shown pictures of people expressing emotions—negative, neutral, or positive. Respondents recorded the preferred way of interacting with a person in the photo (befriend, ignore, attack), at the same time they took an electroencephalogram of the brain.

Scientists have found that the mechanisms of brain activity associated with depression and anxiety are largely opposite. Anxiety is associated with increased reactivity of the attention system, and depression is associated with reduced cognitive reactivity.

In addition, in individuals predisposed to depression, unequal compensatory activation of emotion regulation centers was found, which is necessary to ensure the required level of social interactions. It is noted that some participants in the experiment tried to ignore other people's emotions, other participants with depressive symptoms showed a negative reaction even to neutral stimuli.

It is generally accepted that the pathologies of depression and anxiety are often combined with each other, genetic studies show that the same regions of the genome are responsible for both disorders. Both pathologies were even proposed to be combined in the classifier of diseases, with which Novosibirsk scientists do not agree. Genes determine only 50% of the predisposition, the rest depends on environmental influences, explains Gennady Knyazev.

“The emergence of psychopathology is always the interaction of genes and environment. The same stress in someone passes without a trace, and in someone it causes depression, or post-traumatic stress disorder. In the same way, the same degree of predisposition in some conditions will lead to illness, and in others to a completely happy life, ”Gennady Knyazev clarifies.

According to scientists, the data obtained may be of importance both for the development of methods for the differential diagnosis of mental pathologies, and, potentially, for the treatment of depression.


Media about the Foundation, Medicine, Special project

Temperament in early childhood and the development of anxiety and depression

Nathan A. Fox, PhD, Tahl I. Frenkel, MA
University of Maryland, USA
(English). Translation: June 2015

PDF Document


Anxiety disorders in general, and social anxiety disorder (social anxiety disorder, SAD) in particular, cause severe distress and increase the risk of long-term adverse effects. Most anxiety disorders in adults begin in childhood or adolescence at an extremely steady rate of 5 to 10 percent; and the level of social phobia varies from 1.6% to 8.5%. 2-4 Longitudinal studies show that the temperamental trait of behavioral inhibition appears to be the most likely predictor of the risk of developing anxiety later in life. 5-6

The purpose of this chapter is to explore in general terms the relationship between this temperament and the occurrence of anxiety disorders. We will review research on two cognitive processes, attention and executive processes, that contribute to anxiety disorders among children with behavioral inhibition. Finally, in line with recent evidence that behavioral inhibition may represent not only a specific temperamental predisposition to anxiety, but also a more general risk factor for internalizing disorders, 7 we will review the existing (still limited) literature linking early temperament with the subsequent development of depression.


Behavioral inhibition is a type of temperament that can be identified in infancy and early childhood. Infants with this temperament show increased irritability and motor reactivity to unusual stimuli. During their early preschool years, they avoid social contact and tend to withdraw in unfamiliar social situations, which makes them less self-confident5,6 and more susceptible to peer rejection, 8,9 what is the reason for negative self-perception. 10 In general, inhibited children have fewer friends, 11 they are more likely to show increased anxiety and feel lonely. 12

Anxiety risk studies focus on early temperamental traits, especially behavioral inhibition. 10,13,14 For example, Schwartz et al6 found that 61% of thirteen-year-olds who were noted to show signs of behavioral inhibition at age two showed clear signs of anxiety during social interactions, compared with only 27% of those who showed no inhibition. Similarly, Chronis-Tuscano et al. 15 found a fourfold increased likelihood of a lifetime diagnosis of social anxiety disorder among adolescents with persistently high levels of behavioral inhibition between the ages of 1 and 7 years. Data from both studies suggest that early temperament limits but does not predetermine outcomes. Only about half of inhibited children are at significant risk, and anxiety tends to wax and wane over time. 16

We argue that temperament in childhood shapes how a person perceives their environment, which reciprocally affects social interaction and possible social outcomes and mental health outcomes. 17 This dynamic is particularly evident in early adolescence, during which the emergence of a peer group with more significant developmental influence coincides with a dramatic increase in psychopathology,16 in particular social phobia. 6,15,18 Temperament also shapes vital cognitive processes such as attention and certain executive processes that underpin how children perceive and respond to social stimuli in the environment.


Questions concerning the functional and structural relationship between temperament and anxiety remain open. 19 Several reviews 10,17,20,21 noted a variety of behavioral and physiological similarities and differences between both temperamentally retarded and anxious individuals. If anxiety and inhibited temperament are seen as two distinct constructs, then temperament either exposes the child to the risk of developing anxiety or influences the persistence or severity of anxiety disorders once they occur. 10 On the other hand, these terms may simply refer to different aspects of the same construct, and the differences between them are then forced by opinions in the field. 21

Scientific context

It has been suggested in the scientific literature that deviations in both "upward" a attentional mechanisms and "downward" a executive control processes may play a key role in the etiology and maintenance of anxiety. 22 These disturbances extend to both emotionally charged and emotionally neutral stimuli, reflecting a prioritization of certain categories of stimuli (i.e. erroneous attitudes towards stimuli) along with increased alertness to one's own activity and behavior (i.e. cognitive monitoring) .

Anxious children 23-25 ​​ and adults 26-27 show attention bias towards threatening stimuli. Previous work has shown 28.29 that adolescents with clinically severe anxiety showed disturbances in the reaction of the amygdala b and ventrolateral prefrontal cortex c (vlPFC) to threat when performing tasks for attention distortions. Attention distortions, as such, are automatic "bottom-up" mechanisms that shape cognition and behavior. The study also implies a neural network in the prefrontal cortex that engages attention to closely follow the activity, taking into account the feedback as the person then applies more specialized executive control mechanisms to correct subsequent behavior. 30-32 Anxiety-related disorders of this pattern are evident in both children, 33 and adults. 34 Imaging studies have implicated the anterior cingulate cortex d (ACC) in this process, as it is hyperactive in anxious people during tasks that require cognitive control or "top-down" control. 35

Key Questions

Among typically developing children, approximately 15-20% of Caucasian children in the United States exhibit a behaviorally inhibited temperament in early childhood. Longitudinal studies have shown that about half of these behaviorally retarded children go on to develop anxiety disorders into adolescence and adulthood. A key research question in terms of early intervention is to identify the factors that lead to these different trajectories over time. That is, what factors (either in surrounding adults or in the child himself) protect against anxiety or increase the risk of developing it.

Recent research findings

Attention distortions in relation to threat

Recent research suggests that behavioral inhibition is characterized by impaired control of attention. 36.37 Two recent longitudinal studies 18.38 examined the relationship between behavioral inhibition in childhood, attentional distortions to threatening stimuli, and propensity to withdraw from social contact. Pérez-Edgar et al 18 found that adolescents who were behaviorally retarded as children exhibited a distortion of attention towards a potential threat. In addition, threat attention bias mediated a statistical association between behavioral inhibition in childhood and propensity to withdraw from social contact during adolescence. In a separate study, Pérez-Edgar et al. 38 found that behavioral inhibition at the age of walking was predictive of high social avoidance in early childhood. Again, this relationship was statistically mediated by threat attention bias such that the relationship between behavioral inhibition and social avoidance was only noticeable in children who showed threat attention bias. These data provide support for a view that threat attention distortions are an important mediator of behavioral inhibition and the subsequent occurrence of clinical anxiety.

Executive processes: inhibitory control and cognitive monitoring

Inhibitory control characterizes the ability to restrain and suppress dominant responses and behaviors in favor of more appropriate or subdominant responses and behaviors39. Cognitive monitoring represents the ability to pay attention to one's own activities, notice errors, and correct behavior based on feedback. It is believed that these control processes play a role in the regulation of negative emotions and in such a property of temperament as reactivity. 40-42

Several studies have shown that inhibitory control mediates the ability to predict the occurrence of anxiety behaviors based on measurements of temperamental manifestations of behavioral inhibition. Children with a high level of inhibitory control were found to be more socially anxious, 43 less socially competent and more socially withdrawn, 44 than behaviorally inhibited children with a low level of inhibitory control. Similarly, White et al. 45 found that a high level of inhibitory control increased the risk of anxiety disorders among highly behaviorally inhibited children.

In independent studies, increased cognitive monitoring has been found to be associated with increased anxiety in both adults and children. 48 McDermott et al49 found that the level of cognitive monitoring was higher in adolescents with severe childhood behavioral retardation compared with adolescents with low levels of behavioral retardation. Moreover, increased monitoring mediated early behavioral inhibition and later anxiety disorders. 49 Thus, like the distortions of attention to threatening stimuli, the executive processes of inhibitory control and cognitive monitoring act as a mediator for the child's temperament prone to an increased risk of anxiety.

Unexplored areas

Age changes result from the interaction between the child's innate characteristics and environmental context, making the child both creator and product of the environment. 50 Behavioral inhibition may prompt the child to go in one of a number of directions, and the expected outcome may be the result of multiple provocative paths. 10 Research thus needs to explain the operation of a number of mediating factors that may come into play at various points during development. So far, there are very few studies analyzing the discontinuous nature of behavioral retardation and possible confounding protective factors that may contribute to the discontinuity of the behavioral retardation trajectory and further prevention of psychopathology. The discontinuity of these behaviors provides a good opportunity to identify factors that could potentially be used in prevention efforts.

In addition, the relationship between behavioral retardation and depression is much less understood. Given the relationship between behavioral retardation and depression, it is important to note that people with anxiety disorders have an increased risk of developing depression compared to non-anxious people, 51 and data show that in many cases, the presence of one or another anxiety disorder precedes the development of depression. deep depression. 52 Given this temporal relationship between anxiety and depression, it is important to understand that the relationship between behavioral inhibition and depression can be highly dependent on the presence of anxiety. One study is known to have found that social anxiety was a necessary intermediate between behavioral retardation and depression. 53 Similarly, other studies 54 that have found relationships between behavioral retardation, anxiety, and depression have used structural equation modeling, which showed that the pathway by which behavioral retardation leads to anxiety, which in turn leads to depression, provided the most accurate match to the data.

The specificity of the social and non-social components of behavioral inhibition in childhood and their relationship to symptoms of anhedonic depression, social anxiety, and agitation in young adults have now been studied by self-reporting in additional studies. The results were compared with studies showing that non-social behavioral retardation (“fearfulness”), but not social behavioral retardation, increased the risk of future depression; 55 and with other studies showing that depressive symptoms were more strongly associated with social than with non-social behavioral disorder in childhood. 56

Interestingly, Sportel 57 et al. investigated the direct (additive) and indirect (interactive) effects of behavioral retardation and attention control on different dimensions of internalization in a sample of normal adolescents. The results showed a stronger association of behavioral retardation, compared with attention control, with symptoms of anxiety, and a stronger association of attention control, compared with behavioral retardation, with symptoms of depression. Moreover, while behavioral retardation was associated with both anxiety and depression, attentional control mediated this relationship, thus reducing the impact of severe behavioral retardation on both dimensions of internalization.

Finally, in considering temperament as a vulnerability factor for depression, it is important to note that, in addition to behavioral inhibition, some theorists have developed temperament models that associate additional temperament styles, namely Positive Emotion (PE) and Negative Emotion (NE), with depression. 58 Many cross-sectional studies have provided evidence that young people and adults diagnosed with depressive symptoms have reduced levels of PE and increased levels of NE, 59,60,61 and their combination was associated with coinciding depressive symptoms in samples of clinical groups 62,63 and groups of people examined en masse at the place of residence. 61,64,65 Moreover, longitudinal studies have shown that lower levels of PE 60,66,67 and higher levels of NE in childhood 68-70 predict the development of depressive symptoms and disorders. For example, low levels of PE in preschoolers predicted high levels of depressogenic-type cognitive style at age 7 and depressive symptoms at age 10. 71.72


Behavioral inhibition is a risk factor for the development of internalizing disorders, although research suggests that not all children with this temperament develop the disorder. Current research is focused on describing the complex interplay of temperament with potential mediating factors that can alter temperament trajectories. Studies focusing on endogenous factors suggest that both attention and executive processes are important regulators of the development of behavioral inhibition towards anxiety or psychological resistance to such disorders. Although it is not mentioned in this review, there is a large body of work on the role of exogenous factors in regulating the temperament of behavioral inhibition. 16.73

Recommendations for parents, services and policy

Identifying young children who are at risk of developing anxiety disorders and implementing preventive (prophylactic) interventions to reduce risk are important outcomes of behavioral inhibition research. Due to the obedient and "comfortable" nature of behaviorally retarded children, teachers and parents may not always recognize such children in early childhood and primary school. Since only a few children with inhibited behavior develop anxiety disorders later on, it is important to identify both endogenous and exogenous factors that mediate the relationship of temperament and psychopathology. Preliminary research contributes to an optimistic view of prevention strategies and easily accessible educational programs for parents and caregivers of adult behaviorally inhibited preschoolers. 74 These programs are aimed at teaching adults about the nature of temperament and withdrawal and how to apply techniques by which they can help behaviorally retarded children develop the ability to manage reactions to new situations, thus promoting the development of social skills and reducing inhibited and anxious behavior over time. Finally, innovative approaches that include training in attention and executive processes can significantly reduce anxiety-induced withdrawal in temperamentally at-risk individuals.


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  1. Upward and downward information processing strategies are two complementary cognitive processes. The "bottom-up" strategy refers to processes that involve sensory stimulation leading to perceptual processing and subsequent cortical interpretation. In general, the structures involved are, firstly, the subcortical, limbic, then the cortical areas of the brain. "Downstream" processing refers to the control or modulation of subcortical or limbic processing by cortical regions. – (approx. per.)
  2. A brain structure believed to be involved in the detection of a threat or novelty and the production of a conditioned response in connection with the experience of fear.
  3. The most initial part of the anterior cerebral cortex, located behind the frontal bone. This region of the brain is involved in higher-level executive functions such as attention control, emotion regulation, conflict resolution, complex goal-directed behavior planning, and decision-making processes.
  4. Subdivision of the anterior cingulate cortex responsible for error detection, response and conflict monitoring, anticipation, attention, motivation, and regulation/impairment of emotional response.

For citation:

Fox NA, Frenkel TI. Temperament in early childhood and the development of anxiety and depression.

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