Diagnostic Criteria For Social Phobia Research Articles

Social Phobia Among Depressed Individuals Entering Residential Rehabilitation Programmes: Prevalence and Correlates

Social phobia commonly co-occurs with substance use disorders and depression; however, the prevalence and correlates of social phobia among individuals with both of these disorders remain unknown. Interviews were conducted with 120 individuals entering residential rehabilitation for substance use treatment, who endorsed criteria for major depression and were recruited to a randomised controlled trial. Nearly three quarters (72.5%) of the sample met diagnostic criteria for social phobia. These individuals were more likely to report problematic drinking, more severe anxiety and depressive rumination, and lower distress tolerance, compared to individuals without social phobia. When examining the impact of applying diagnostic exclusion rules for social phobia among this cohort, results indicate that one third (32.2%) of those with social phobia specified their fear was related to a co-occurring mental health and/or substance use disorder. This group—who would not have met diagnostic criteria for social phobia if exclusion rules were strictly followed—experienced more severe depression, anxiety, depressive rumination, and repetitive negative thinking than those who did not make such attributions. The high prevalence and burden associated with social phobia among depressed substance users highlight the importance of screening for, assessing, and treating the disorder upon entry to treatment, irrespective of whether symptoms are related to other conditions.

Social Interpretation Bias in Children and Adolescents with Anxiety Disorders: Psychometric Examination of the Self-report of Ambiguous Social Situations for Youth (SASSY) Scale.

Anxiety disorders are among the most common mental health problems in youth, and faulty interpretation bias has been positively linked to anxiety severity, even within anxiety-disordered youth. Quick, reliable assessment of interpretation bias may be useful in identifying youth with certain types of anxiety or assessing changes on cognitive bias during intervention. This study examined the factor structure, reliability, and validity of the Self-report of Ambiguous Social Situations for Youth (SASSY) scale, a self-report measure developed to assess interpretation bias in youth. Participants (N=488, age 7 to 17) met diagnostic criteria for Social Phobia, Generalized Anxiety Disorder, and/or Separation Anxiety Disorder. An exploratory factor analysis was performed on baseline data from youth participating in a large randomized clinical trial. Exploratory factor analysis yielded two factors (Accusation/Blame, Social Rejection). The SASSY full scale and Social Rejection factor demonstrated adequate internal consistency, convergent validity with social anxiety, and discriminant validity as evidenced by non-significant correlations with measures of non-social anxiety. Further, the SASSY Social Rejection factor accurately distinguished children and adolescents with Social Phobia from those with other anxiety disorders, supporting its criterion validity, and revealed sensitivity to changes with treatment. Given the relevance to youth with social phobia, pre- and post-intervention data were examined for youth social phobia to test sensitivity to treatment effects; results suggested that SASSY scores reduced for treatment responders. Findings suggest the potential utility of the SASSY Social Rejection factor as a quick, reliable, and efficient way of assessing interpretation bias in anxious youth, particularly as related to social concerns, in research and clinical settings.

Predictors of response to individual and group cognitive behaviour therapy of social phobia

Increased knowledge of factors that predict treatment outcome is important for planning and individualizing of treatment. This study analysed predictors of response to individual cognitive therapy (ICT), and intensive (3-week) group cognitive treatment (IGCT) for social phobia. Participants (n = 54) met diagnostic criteria for social phobia within a randomized controlled trial. Predictors assessed were fear of negative evaluation, anticipatory worry, self-directedness (SD) and cluster C personality disorder. Results were analysed by means of multiple regression analyses with both groups combined, and for each of the treatment groups. Anticipatory worry, an aspect of a harm-avoidance personality trait, was the strongest negative predictor of outcome in ICT and IGCT both at post-treatment and 1-year follow-up. Whereas low SD, signs of cluster C personality disorder and fear of negative evaluation were negative predictors of post-treatment outcome in ICT, the corresponding pattern of results was not to be found in IGCT. Anticipatory worry appears to be a particularly important trait for explaining variance in the outcome of social phobia. The finding is consistent with the assumed stability of such personality traits over time. Further studies are warranted to replicate the finding.

Characteristics and anxiety symptom presentation associated with autism spectrum traits in youth with anxiety disorders

There is limited information about the nature of anxiety among youth with symptoms of autism spectrum disorder (ASD). The present study examined (a) differences in the clinical characteristics of anxious youth with and without symptoms of ASD and (b) the symptoms of anxiety that best distinguish between these groups. Results indicated that anxious youth with elevated ASD symptoms had significantly more diagnoses (e.g., specific phobias), and were more likely to meet diagnostic criteria for social phobia (and list social concerns among their top fears) than youth without elevated ASD symptoms. At the symptom level, severity of interpersonal worry based on parent report and severity of fear of medical (doctor/dentist) visits based on youth report best differentiated ASD status. The findings inform diagnostic evaluations, case conceptualization, and treatment planning for youth with anxiety disorders and ASD symptoms.

Interpretation of ambiguous social scenarios in social phobia and depression: Evidence from event-related brain potentials

In the current study, event-related potentials (ERPs) and behavioral responses were measured in individuals meeting diagnostic criteria for social phobia, depression, their combination, or neither in order to examine the unique and combined effects of social phobia and depression on the interpretation of ambiguous social scenarios. ERPs revealed a lack of positive interpretation bias and some suggestion of a negative bias in the semantic expectancy N4 component across all clinical groups. Furthermore, socially phobic and comorbid individuals showed reductions in baseline attention allocation to the task, as indexed by P6 amplitude. RT and accuracy likewise revealed a lack of positive interpretation bias across disordered groups. When considered on a continuum across all samples, social phobia and depression symptoms were related to the N4 interpretation bias effect whereas P6 amplitude reduction and RT interpretation bias appeared uniquely associated with social phobia.

W06-03 - Internet-based psychotherapeutic interventions for social phobia: How much and what kind of therapeutic contact is needed?

Internet-based self-help for social phobia with minimal therapist support via email have shown efficacy in several controlled trials by independent research teams. The role and necessity of therapist guidance is, however, still largely unclear. The present study compared the benefits of a 10-week web-based unguided self-help treatment for social phobia with the same intervention complemented with minimal, although weekly, therapist support via email. Further, a third treatment arm was included, in which the level of support was flexibly stepped up, from no support to email or telephone contact, on demand of the participants. Eighty-one individuals meeting diagnostic criteria for social phobia were randomly assigned to one of the three conditions. Results showed significant symptom reductions in all three treatment groups with large effect sizes for primary social phobia measures (Cohen's d = 1.47) and for secondary outcome measures (d = 1.16). No substantial and significant between-groups effects were found on any of the measures (Cohen's d = .00−.36). Moreover, no difference between the three conditions was found regarding diagnosis-free status, clinically significant change, dropout rates, or adherence measures such as sessions or exercises completed.

Internet-based treatment of social phobia: A randomized controlled trial comparing unguided with two types of guided self-help

Internet-based self-help for social phobia with minimal therapist support via email have shown efficacy in several controlled trials by independent research teams. The role and necessity of therapist guidance is, however, still largely unclear. The present study compared the benefits of a 10-week web-based unguided self-help treatment for social phobia with the same intervention complemented with minimal, although weekly, therapist support via email. Further, a third treatment arm was included, in which the level of support was flexibly stepped up, from no support to email or telephone contact, on demand of the participants. Eighty-one individuals meeting diagnostic criteria for social phobia were randomly assigned to one of the three conditions. Primary outcome measures were self-report measures of symptoms of social phobia. Secondary outcome measures included symptoms of depression, interpersonal problems, and general symptomatology. Measures were taken at baseline, post-treatment, and at 6-month follow-up. Data from a telephone-administered diagnostic interview conducted at post-treatment were also included. Results showed significant symptom reductions in all three treatment groups with large effect sizes for primary social phobia measures (Cohen’s d = 1.47) and for secondary outcome measures (d = 1.16). No substantial and significant between-groups effects were found on any of the measures (Cohen’s d = 00–.36). Moreover, no difference between the three conditions was found regarding diagnosis-free status, clinically significant change, dropout rates, or adherence measures such as lessons or exercises completed. These findings indicate that Internet-delivered treatment for social phobia is a promising treatment option, whether no support is provided or with two different types of therapist guidance.

The Efficacy of Bibliotherapy for Social Phobia

This study investigated the efficacy of bibliotherapy (BT) in the treatment of social phobia. Thirty-eight subjects who met the diagnostic criteria for social phobia were randomly assigned to one of three conditions: bibliotherapy with feedback (BT 1), bibliotherapy without feedback (BT 2), and a waiting-list (WL) control condition. Before and after treatment, the Social Phobia Scale (SPS) and Social Interaction Anxiety Scale (SIAS), two of the most widely and consistently used measures of social anxiety, were administered. Those individuals in the BT 1 and BT 2 groups exhibited significant reductions from preto posttreatment on the SPS relative to the WL group but not on the SIAS. In addition, there were more individuals who showed a clinically significant improvement (CSI) in the BT 1 and BT 2 groups than in the WL group. However, there were no significant differences between the BT 1 and BT 2 groups. After the BT, 16 of the 38 participants received cognitive–behavioral group treatment (CBGT). After CBGT, those participants who had received BT and shown a CSI exhibited a significantly higher reduction on the SPS than both those participants who had received BT but did not show a CSI and the WL group. The implications for future research are discussed. [Brief Treatment and Crisis Intervention 8:390–401 (2009)]

Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial.

A new cognitive therapy (CT) program was compared with an established behavioral treatment. Sixty-two patients meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria for social phobia were randomly assigned to CT, exposure plus applied relaxation (EXP = AR), or wait-list (WAIT). CT and EXP = AR were superior to WAIT on all measures. On measures of social phobia, CT led to greater improvement than did EXP = AR. Percentages of patients who no longer met diagnostic criteria for social phobia at posttreatment-wait were as follows: 84% in CT, 42% in EXP = AR, and 0% in WAIT. At the 1-year follow-up, differences in outcome persisted. In addition, patients in EXP = AR were more likely to have sought additional treatment. Therapist effects were small and nonsignificant. CT appears to be superior to EXP = AR in the treatment of social phobia.

Do empirically supported treatments generalize to private practice? A benchmark study of a cognitive‐behavioural group treatment programme for social phobia

There is much debate as to whether the treatment effects achieved in well-controlled studies such as randomized controlled trials (RCTs) are generalizable to more "naturalistic" clinical populations, such as that seen in private practice. The current study sought to examine this issue in relation to social phobia. A benchmarking strategy was used to compare the effectiveness of a cognitive-behaviour therapy group programme for social phobia that was developed and evaluated in a research unit, to that of a private practice population. Fifty-eight participants from a university research unit and 54 participants from an independent private practice who met the principal diagnostic criteria for social phobia completed the 10-session group programme. Symptom severity was measured at pre-treatment, post-treatment, and 3 months after treatment. No significant treatment differences were found between the research unit and private practice groups. Both groups showed significant treatment effects that were maintained at 3-month follow-up. These findings suggest that treatments developed for RCTs are potentially transportable to private practice settings.

Virtual reality exposure in the treatment of social anxiety

Virtual reality as a medium for exposure therapy in the treatment of social anxiety was utilized in a private-practice setting for two different courses of individual treatment: weekly psychotherapy and a 3-day intensive course of therapy. Participants met diagnostic criteria for social phobia with prominent public speaking fears, and completed self-report questionnaires at pretreatment and posttreatment. During exposure therapy, participants were presented with a virtual audience, consisting of video of actual people embedded within a virtual classroom environment. Results indicated that treatment was successful as measured by completion of a behavioral avoidance test at the end of treatment, decreases in self-reported measures of public speaking anxiety comparable to controlled clinical outcome trials for social phobia, and qualitative feedback. Follow-up data, obtained from 1 participant, showed continued improvement after therapy was completed. These preliminary findings suggest that virtual reality may be a useful tool for exposure therapy within a comprehensive treatment of social anxiety.

Alcohol abuse in social phobic patients: is there a bipolar connection?

Background: Epidemiological and clinical studies have reported the frequent co-occurrence of social phobia (SP) and alcohol use disorders. Patients with SP often use alcohol to cope with the social situations they fear, and to lessen anticipatory anxiety, behavioral inhibition, and phobic avoidance. We investigated whether the presence of lifetime comorbidity with alcohol abuse was associated with significant differences as regards demographic and clinical features, family history and pattern of comorbidity in a large clinical sample of SP outpatients. Method: The sample comprised 153 outpatients who met DSM-III-R diagnostic criteria for SP. Demographic, family history and course characteristics were investigated by a semi-structured interview. Social phobic symptoms and the severity of the illness have been assessed by the Liebowitz Social Anxiety Scale (LSAS) and the Liebowitz Social Phobic Disorders Rating Scale, Severity (LSPDRS). Patients completed the Hopkins Symptom Checklist (HSCL 90). Results: Thirty-four patients (22.2%) had a past or current history of alcohol abuse for at least 1 year. There were no significant differences between these patients and those without a history of alcohol abuse, as regards demographic features and lifetime comorbidity with major depression and other anxiety disorders. Bipolar disorder type II was found almost exclusively among patients with alcohol abuse, as well as family history for bipolar disorders. Limitations: Retrospective study. Conclusions: Our data indicate a strong relationship between bipolar II disorder and alcohol abuse comorbidity in patients with SP. The socializing and disinhibiting effect that many social phobics report might be mediated by mood elation induced by alcohol. The presence of bipolar diathesis in patients presenting with social anxiety might explain their increased susceptibility to alcohol, as they might undertake alcohol abuse as an attempt to overcome social difficulties.

School-Based Behavioral Treatment for Social Anxiety Disorder in Adolescents: Results of a Pilot Study

To provide preliminary estimates of feasibility and effectiveness for school-based behavioral treatment in adolescents with social anxiety disorder. Six adolescents with social anxiety disorder were treated in a 14-session group treatment program conducted at their school. Assessments were conducted at baseline and after treatment. All participants were classified as treatment responders (markedly or moderately improved). Half of the participants did not meet diagnostic criteria for social phobia after treatment. Clinician severity ratings, as measured by the Anxiety Disorders Interview Schedule for Children for DSM-IV: Child Version and the Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA), decreased significantly after intervention, with effect sizes of 2.5 and 1.8, respectively. All LSAS-CA scale scores decreased significantly after treatment. Self-reported social phobia symptoms on the Social Phobia and Anxiety Inventory for Children were not significantly reduced. Fear and avoidance ratings of the 10 most feared situations significantly decreased after treatment, with effect sizes of 1.5 for anxiety and 2.1 for avoidance. This study provides preliminary support for the promise of school-based behavioral intervention for treating social phobia in adolescents. The school environment may be a rich and innovative setting for implementation of behavioral treatment because this is the setting where adolescents with social phobia endure the most distress.

Clinical features and co-morbidity of social phobics in Turkey

The aim of this study is to investigate the clinical features and frequency and importance of related co-morbid disorders of social phobia in a clinical sample. Eighty-seven patients meeting DSM-III-R diagnostic criteria for social phobia were studied. All patients were assessed by using a semi-structured socio-demographic form, the Structured Clinical Interview for DSM-III-R, Manual for the Structured Clinical Interview for DSM-III-R Personality Disorders, Liebowitz Social Anxiety Scale, Hamilton Rating Scale for Depression and Hamilton Rating Scale for Anxiety. Sixty-eight (78.2%) of the group were male, 19 (21.8%) were female. The ages varied between 16–58 years, with a mean of 26.2 years (SD = 8.5). Fifty-one point seven percent of the subjects were assessed as having a co-morbid axis I disorder, of which 12.6% consisted of panic disorder and 10.3% agoraphobia. An additional axis II disorder had been found in 67.8% of the subjects, and 54.0% of them had been diagnosed as having avoidant personality disorder. The frequency of co-morbid disorders in our social phobic sample is lower than most of the studies in the literature. The interface between social phobia and avoidant personality disorder needs to be studied and discussed further.

Social phobia and avoidant personality disorder as related to parental history of social anxiety: a general population study

Using a validated and DSM-IV compatible questionnaire, the present study related family history of excessive social anxiety to social phobia and avoidant personality disorder (APD) in epidemiologically identified probands in the general population. Probands met diagnostic criteria for social phobia with or without APD and APD with or without social phobia. A two- to three-fold increased relative risk of social anxiety was observed for all diagnostic groups. Increasing severity in probands by varying diagnostic criteria did not affect the relative risk. Because familial aggregation of social anxiety was not modulated by Axis I or II diagnosis or diagnostic cut-off levels, data imply that social phobia and APD may represent a dimension of social anxiety rather than separate disorders. Thus, having an affected family member is associated with a two- to three-fold risk increase for both social phobia and APD.

Functional brain imaging and pharmacotherapy in social phobia: Single photon emission computed tomography before and after treatment with the selective serotonin reuptake inhibitor citalopram

1. 1. Despite increased understanding of the prevalence and pharmacotherapy of social phobia (or social anxiety disorder), the neurobiology of the disorder is little understood. 2. 2. Little data exists on the effect of pharmacotherapeutic intervention on regional cerebral blood flow (rCBF) in this disorder. Patients (n = 15) who met DSM-IV diagnostic criteria for social phobia were subjected to single photon emission computed tomography (SPECT) with technetium-99m hexamethylpropylene amine oxime (Tc-99m HMPAO) before and after an eight-week trial of pharmacotherapy with the selective serotonin reuptake inhibitor (SSRI) citalopram. 3. 3. Pharmacotherapy led to significantly reduced activity in the anterior and lateral part of the left temporal cortex; the anterior, lateral and posterior part of the left mid frontal cortex; and the left cingulum. 4. 4. Despite the small sample size, medication non-responders (n = 6) had higher activity at baseline in the anterior and lateral part of the left temporal cortex and the lateral part of the left mid frontal regions compared with responders (n = 9). These data from this exploratory study are consistent with work suggesting that the anxiety disorders share certain mediating neurocircuitry, although activity in other brain regions may differ. 5. 5. Further research is necessary to determine the neurobiological underpinnings of social phobia.

Behavioral treatment of childhood social phobia.

Sixty-seven children (ages 8 and 12) with social phobia were randomized to either a behavioral treatment program designed to enhance social skills and decrease social anxiety (Social Effectiveness Therapy for Children, SET-C) or an active, but nonspecific intervention (Testbusters). Children treated with SET-C were significantly more improved across multiple dimensions, including enhanced social skill, reduced social fear and anxiety, decreased associated psychopathology, and increased social interaction. Furthermore, 67% of the SET-C group participants did not meet diagnostic criteria for social phobia at posttreatment compared with 5% of those in the Testbusters group. Treatment gains were maintained at 6-month follow-up. The results are discussed in terms of treatment of preadolescent children with social phobia and the durability of treatment effects.

Social phobia in the community: relationship between diagnostic threshold and prevalence

This paper investigates the prevalence of symptoms and various diagnostic criteria of DSM-IV social phobia in a French national representative population of 12,873 subjects, aged 15 or more. Respondents filled out a mailed questionnaire based on the social phobia section of the Munich-Composite International Diagnostic Interview (M-CIDI) in the year 1996. Response rate was 80.5%. Sixty-seven point one percent of the sample acknowledge having at least once in their lifetime a strong fear of one or more of the six prototypical social fear situations that are used as the CIDI social phobia stem items. However, only a few fulfilled all DSM-IV diagnostic criteria for social phobia. Depending on the type of diagnostic algorithms used and the stringency in which these criteria are applied, the resulting prevalence varied between 1.9 and 7.3%. These findings provide some further evidence about the considerable effects of varying diagnostic criteria and thresholds on prevalence rates for social phobia, explaining why most recent surveys have reported considerably higher rates of social phobia than those in the early 1980s.

Social phobia in the general population: prevalence and sociodemographic profile.

The present study examined the prevalence of social phobia in the Swedish general population and demographic characteristics associated with this anxiety disorder. Data were obtained by means of a postal survey administrated to 2000 randomly selected adults. A questionnaire, validated against clinical interviews and established social phobia scales, was used to assess social distress in a broad range of phobic situations, as well as the diagnostic criteria for social phobia corresponding to DSM-IV. Interpretable questionnaires were obtained from 1202 respondents (60.1%). The point prevalence of social phobia was estimated at 15.6%, but prevalence rates varied between 1.9 and 20.4% across the different levels of distress and impairment used to define cases. Public speaking was the most common social fear. Social phobia was associated with female gender, low educational attainment, psychiatric medication use, and lack of social support. Although the exact diagnostic boundaries for social phobia are difficult to determine, it can be concluded that social anxiety is a distressing problem for a considerable proportion of the general population.

An empirically derived inventory to measure social fears and anxiety: The Social Phobia and Anxiety Inventory.

The development, reliability, and discriminative ability of a new instrument to assess social phobia are presented. The Social Phobia and Anxiety Inventory (SPAI) is an empirically derived instrument incorporating responses from the cognitive, somatic, and behavioral dimensions of social fear. The SPAI has high lest-retest reliability and good internal consistency. The instrument appears to be sensitive to the entire continuum of socially anxious concerns and is capable of differentiating social phobics from normal controls as well as from other anxiety patients. The utility of this instrument for improved assessment of social phobia and anxiety and its use as an aid for treatment planning are discussed. Social phobia is perhaps the least understood and the least researched of the anxiety disorders. Although there are several scales available to measure social anxiety, most were constructed prior to publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-lII; American Psychiatric Association, 1980), where the diagnostic criteria for social phobia were first introduced. Because social anxiety is experienced by individuals with many psychiatric disorders as well as by normals, these scales may not be specific to social phobia. Preparation of an instrument designed more specifically to assess social phobia requires consideration of several issues, including the critical features of the disorder, its cognitive, physiological, and behavioral dimensions (Lang, 1977), and the capability to sample behavior across a range of potentially distressful social situations. In addition, because social phobics differ in the degree of distress or functional impairment resulting from the disorder, the ability to assess level of severity would be a particularly positive feature of such an instrument. The Social Phobia and Anxiety Inventory (SPAI) is a new, empirically derived self-report inventory. Its construction was based on the behavioral-analytic model outlined by Goldfried and D'Zurilla (1969). It assesses specific somatic symptoms, cognitions, and behavior across a range of potentially fear-producing situations. In order to assess severity, a Likert-scale format is used. This article describes the development and initial psychometric characteristics of the SPAI.