An examination of syndromal validity and diagnostic subtypes in social phobia and panic disorder.

BACKGROUND: We investigated whether patients with DSM-III-R panic disorder and patients with social phobia could be distinguished on the basis of selected demographic variables and by several commonly used anxiety and phobia rating scales. METHOD: Sixty-six patients with social phobia and 60 patients with panic disorder (42 with and 18 without agoraphobia) were studied. Subjects completed a battery of self-report measures that assessed phobic fears, avoidance, and related problems. RESULTS: Social phobic patients showed an earlier age at onset than the panic disorder group, and there was a trend for more social phobics to have never married. Social phobics reported significantly greater levels of social phobic avoidance and distress, fear of negative evaluation, and avoidance of social situations than the panic disorder patients who reported more overall anxiety and rated themselves as significantly more avoidant of situations involving exposure to public places and to blood or injury. Discriminant function analyses showed that social phobic and panic disorder patients can be reliably discriminated on these scales. CONCLUSION: The results of this study lend further support for the validity of the DSM-III-R nosologic distinctions between social phobia and panic disorder. Furthermore, generalized social phobia appears to be remarkably different from discrete social phobia on these measures. This study provides less support for considering panic disorder with agoraphobia to be distinct from panic disorder without agoraphobia.     

Primary and secondary social phobia: psychopathologic and familial differentiations

We compared "primary" social phobic patients (n = 25) with patients whose social phobia developing in the setting of panic disorder ("secondary" social phobics, n = 26) and panic-agoraphobic patients (n = 82). Familial, demographic, and symptomatologic data suggest a categorical distinction between the two types of social phobia. Secondary social phobics were essentially similar in all parameters to panic disorder with agoraphobia. These data support DSM-III conventions.     

The relationship between agoraphobia, social phobia and blood-injury phobia in phobic and anxious-depressed patients

This paper reports the results of principal components and stepwise discriminant analyses of anxiety, depression and fear scores for 74 phobic and anxious-depressed psychiatric patients. Factor analysis indicated a coherent agoraphobia factor, with less coherent blood-injury and social phobia factors. Discriminant analysis showed a high degree of correct classification of diagnosed agoraphobic, blood-injury and social phobic patients particularly for agoraphobia. A frequency distribution of the phobia scores indicated an all or nothing quality to agoraphobic fears. The results indicate that agoraphobia is a fairly coherent syndrome, but that more work is needed on the concepts and measurement of blood-injury and social phobias.     

Familial transmission of simple phobias and fears. A preliminary report

Preliminary data from a blind direct interview family study indicate a significantly higher risk for simple phobia among first-degree relatives (n = 49) of simple phobic probands (who had no other anxiety disorder) as compared with first-degree relatives (n = 119) of never mentally ill controls (31% vs 11%, relative risk = 3.3). Female relatives were more likely to be affected than male relatives (48% vs 13%), though this difference did not reach conventional significance in an age-corrected analysis. Significant between-group differences were not found in risks for (1) other anxiety, affective, and substance abuse disorders, and (2) simple irrational fears that did not meet disorder criteria. The results suggest that simple phobia is a highly familial disorder that does not transmit increased risk for other phobic or anxiety disorders. The specificity of increased risk among the relatives of simple phobics is consistent with the distinction between simple phobia, social phobia, and agoraphobia. However, complete delineation of the transmissional relationship between these illnesses requires assessment of the extent to which risk for simple phobia can be transmitted by individuals with other phobic or anxiety disorders. Replication of these preliminary findings in larger clinically and epidemiologically selected samples is needed.     

Early separation anxiety and adult agoraphobia

The authors compared 137 adult patients who had agoraphobia with 81 patients who had either simple or social phobia for a history of childhood and adolescent separation anxiety. Female agoraphobics reported significantly more childhood separation anxiety than female combined simple and social phobics; males showed no significant difference between diagnostic groups. The reported prevalence of separation anxiety in adolescence was relatively low, but agoraphobics of both sexes reported significantly more separation anxiety than combined simple and social phobics. There were no significant differences between groups for parental losses or severe family disruption during childhood. The results suggest that childhood separation anxiety is a risk factor in females but not in males for the later development of agoraphobia.     

The Zurich study

Summary The problems in association with agoraphobia and social phobia were examined in an 11-year prospective longitudinal study of a Swiss cohort of young adults. The weighted prevalence rates according to DSM-III were 2.9% for agoraphobia and 3.8% for social phobia. Although the problem of agoraphobia was greater in females, an equal sex ratio was observed for social phobia. There was a significant degree of comorbility between the two subtypes of phobia, with females exhibiting a significantly greater frequency of co-occurrence of both disorders than males. The course of the two disorders was quite similar. In general, subjects with both disorders reported a more severe course. Assessment of comorbidity of phobias and other disorders revealed that agoraphobia was most significantly associated with extended neurasthenia, sexual problems, and the consumption of cannabis. On the other hand, social phobia was associated with other disorders than agoraphobia, with the strongest associations emerging for simple phobia, extended insomnia, and alcohol abuse. These findings support the validity of the distinction between different subtypes of phobia. The longitudinal analysis revealed that also phobia in general was not stable at the diagnostic level phobic symptoms were quite persistent across time.     

Age at onset, precipitating events, sex distribution, and co-occurrence of anxiety disorders.

178 outpatients were administered to a structured interview evaluating diagnostic, illness history, and sociodemographic data of DSM-III-R anxiety disorders. Patients with panic disorder with agoraphobia were a more severely ill subgroup than patients with panic disorder without agoraphobia. Simple and social phobia had the earliest age at onset, panic disorder the latest age at onset. Conjugal stress was the most frequent event preceding the onset of the anxiety disorders. Female patients showed more severe impairment suffering more frequently from concomitant phobic avoidance, generalized anxiety, and depression compared to male patients.     

Comorbidity and social phobia: evidence from clinical,epidemiologic, and genetic studies

This paper reviews evidence from clinical, epidemiologic, and family studies regarding the association between social phobia and other syndromes. Social phobia is strongly associated with other anxiety disorders, substance abuse, and affective disorders in both clinical and community samples. An average of 80% of social phobics identified in community samples meet diagnostic criteria for another lifetime condition. Social phobia is most strongly associated with other subtypes of anxiety disorders, with an average of 50% of social phobics in the community reporting a concomitant anxiety disorder including another phobic disorder, generalized anciety, or panic disorder. Approximately 20% of subjects in the community meet lifetime criteria for a major depressive disorder. The onset of social phobia generally precedes that of all other disorders, with the exception of simple phobia. Both clinical severity and treated prevalence are consistently greater among social phobics with comorbid disorders The results of family and twin studies reveal that shared etiologic factors explain a substantial proportion of the comorbidity between social phobia and depression, whereas the association between social phobia and alcoholism derives from a nonfamilial causal relationship between the two conditions. Clinical and phenomenologic implications of these findings are discussed.     

Panic and phobic anxiety: associations among neuroticism, physiological hyperarousal, anxiety sensitivity, and three phobias

A dimensional and psychometrically informed taxonomy of anxiety is emerging, but the specific and nonspecific dimensions of panic and phobic anxiety require greater clarification. In this study, confirmatory factor analyses of data from a sample of 438 college students were used to validate a model of panic and phobic anxiety with six content factors; multiple scales from self-report measures were indicators of each model component. The model included a nonspecific component of (1) neuroticism and two specific components of panic attack, (2) physiological hyperarousal, and (3) anxiety sensitivity. The model also included three phobia components of (4) classically defined agoraphobia, (5) social phobia, and (6) blood-injection phobia. In these data, agoraphobia correlated more strongly with both the social phobia and blood phobia components than with either the physiological hyperarousal or the anxiety sensitivity components. These findings suggest that the association between panic attacks and agoraphobia warrants greater attention.     

Validation of a scale for responsibility (Salkovskis Responsibility Scale)

Appraisal of inflated responsibility for harm is the cornerstone of Salkovskis's cognitive theory for obsessive compulsive disorder. The aim of our study is to present the validation study of the French translation of the R scale. The present study compared 50 subjects with obsessive compulsive disorder, 37 patients suffering from social phobia and 183 control subjects on a responsibility questionnaire (R scale). The cognitive hypothesis of Obsessive Compulsive Disorder (OCD) specifies two levels of responsibility-related cognitions: responsibility assumptions (attitudes) and responsibility appraisals (interpretations). The R scale evaluates the responsibility assumptions. Such attitudes should reflect the more generalized tendency to assume responsibility in a given situation, particularly situations involving intrusions and doubts. It is possible that such assumptions may be less specific to OCD. The inclusion of social phobia subjects in the present study allows evaluation of the specificity of any findings to OCD. Patients were diagnosed and classified according DSM IV criteria. The control subjects were taken in the general population. No formal interview was conducted. The three groups were compared for sex, age and educational level. Before treatment, all the participants filled in the Responsibility Scale of Salkovskis (27 items), the Beck Depression Inventory (21 items), the Beck Anxiety Inventory and the Bouvard's Obsessive Compulsive Thoughts Checklist. The results indicate that the two anxious groups scored significantly higher than the control group on Beck Depression and Anxiety Inventories but no significant difference was observed between the two anxious groups. OCD patients scored significantly higher than both social phobic patients and control subjects on the Obsessive Compulsive Thoughts Checklist (OCTC). The social phobic group scored this checklist significantly higher than the control group. In sum, the three groups were different on obsessive compulsive thoughts. On the washing subscale of the Obsessive Compulsive Thoughts Checklist, the OCD patients differed significantly from the control group and the social phobia patients. No difference was observed between the social phobia subjects and the control group. On the two other subscales of the OCTC, the checking and the responsibility scales, the three groups were different: OCD patients scored significantly higher than both social phobic patients and control subjects; the social phobic patients scored higher than the control group. Results support the reliability (test retest) and the internal consistency of the questionnaire. Patients with obsessive compulsive disorder (OCD) and social phobia subjects had significantly elevated score on the total scale compared to control subjects. However social phobia patients did not differ from patients with OCD. So, the responsibility for harm, evaluated by the R-scale seems not to be specific of OCD. This finding does not support the results of two studies (28, 30). But these two studies compared OCD patients with an anxious group including panic disorder with agoraphobia, generalized anxiety disorder and social phobia. The correlations with a measure of OCD symptoms were higher than the correlations with anxiety and depression. Finally, the factor structure was only studied on the control group. The exploratory factor analysis indicates that the R scale is a two-dimensional scale, reflecting a need to prevent risks and the belief that one has power to harm. The first dimension is less specific to the pathology than the second. Only patients with OCD had significantly elevated score on the "need to prevent risks" compared to the non-clinical group. The two anxious groups differed on "the belief that one has power to harm" from the non-clinical group but social phobia patients did not differ from patients with OCD. In sum, the two subscales of the R scale did not discriminate OCD patients and social phobic subjects. Further research is needed to replicate the present findings and to confirm the two dimensions of the R scale. Overall, the results are consistent with the hypothesis that responsibility beliefs are important in the experience of obsessional problems. However, responsibility assumptions such as the belief that one has the power to harm are shared with social phobia.     

Agoraphobics and social phobics: differences in background factors, syndrome profiles and therapeutic response

Seventy-three agoraphobic and 31 social phobic women, all rated unsuitable for insight-oriented psychotherapy, were compared regarding family and personal history, intelligence, personality and factors pertaining to the disorder. The same patients, with 11 men included in the social phobic group, were also compared regarding response to four randomly assigned types of treatment given over a 3 month period, with a 9 months' follow-up. The following differences were revealed: 1) Social phobias were associated with a higher social class of the parental home, higher education, higher scores on verbal intelligence, and a higher social class of the patient. 2) Social phobics scored higher on the personality factor, aggressive non-conformance, otherwise there were no differences in the personality factor. 3) Agoraphobias were associated with mother working outside home during the patient's childhood, neurotic symptoms in childhood, and current economic difficulties. Agoraphobics more often gave experience of death as a cause of the disorder. 4) Social phobias started at an earlier age. 5) Target phobia and the global rating were of equal severity in the two syndromes, but the agoraphobics had higher ratings on free anxiety and depersonalization. 6) Social phobics responded better to prolonged exposure in vivo, while agoraphobics responded better to supportive therapy of dynamic type, or to a simple basal therapy. Social phobics more often wanted the therapists to give advice and guidance.     

Personality and treatment response in agoraphobia with panic attacks.

The present study investigated the association of specific personality characteristics with agoraphobia, and whether they predicted long-term outcome following a group cognitive behavior therapy program. Thirty-three patients with agoraphobia with panic attacks, 18 with social phobia, and 26 "normals" were used in the study. Personality factors were measured with the Maudsley Personality Inventory (MPI), the Hostility and Direction of Hostility Questionnaire (HDHQ), and the Fundamental Interpersonal Relations Orientation-Behavior Scale (FIRO-B). The results showed that (1) agoraphobics are more extroverted and more likely to include others in their activities than are social phobics; however, they are less extroverted, more neurotic, more hostile and intropunitive, and less likely to include others in their activities than are normals; (2) social phobics are similarly less extroverted, more neurotic, and more hostile and intropunitive than normals, but, in addition, are less likely to exert control over others, more likely to want to be controlled, and less expressive of affection than normals; and (3) personality characteristics did not predict treatment outcome.     

The Persian Version of the COVID-19 Phobia Scale (Persian-C19P-S) and the Differences in COVID-19-Related Phobic Reactions in Patients with Anxiety Disorders

Coronavirus disease 2019 (COVID-19) is a pandemic outbreak increasing several psychological distress, such as anxiety and phobia, and may affect patients with anxiety disorders. A scale has been recently designed to assess COVID-19-related phobic reactions named the COVID-19 Phobia Scale (C19P-S). The present study aimed to evaluate factor structure, reliability, and validity of the Persian version of the C19P-S (Persian-C19P-S) in patients with anxiety disorders and to compare COVID-19-related phobia among these patients. Three hundred patients with anxiety disorders completed the Persian-C19P-S and other scales assessing anxiety traits (e.g., the Short Health Anxiety Inventory (SHAI), the Health Concerns Questionnaire-54 (HCQ-54), and the Patient Health Questionnaire-4 (PHQ-4)) and COVID-19-related distress (e.g., the COVID Stress Scales (CSS) and the Fear of COVID-19 Scale (FCV-19)). The results showed that the Persian-C19P-S replicated the four-factor structure of the original C19P-S. Internal consistency and test-retest reliability coefficients evidenced the reliability of the scale. The validity of the scale (convergent and discriminant validity) was confirmed. Patients who had generalized anxiety and panic disorders showed higher phobic reactions related to COVID-19 than those with social anxiety disorder and specific phobia. This study indicates that the Persian version of the C19P-S is a valid scale to be used in Iranian patients with anxiety disorders to evaluate COVID-19-related phobia. Moreover, COVID-19-related phobic reactions are higher in some specific types of anxiety disorders.

     

DSM-III-R subtypes of social phobia. Comparison of generalized social phobics and public speaking phobics

Social phobic patients who fear most or all social interaction situations are labeled generalized social phobics in DSM-III-R. Thirty-five patients who met this criterion were compared with 22 social phobic patients whose fears were restricted to public speaking situations. Generalized social phobics were younger, less educated, and less likely to be employed, and their phobias were rated by clinical interviewers as more severe than those of public speaking phobics. Generalized social phobics appeared more anxious and more depressed and expressed greater fears concerning negative social evaluation. They performed more poorly on individualized behavioral tests and differed from public speaking phobics in their responses to cognitive assessment tasks. The two groups showed marked differences in their patterns of heart rate acceleration during the behavioral test. The implications of these findings for the classification and treatment of social phobic individuals are discussed.     

Phobic disorders and anxiety states: how do they differ?

A review of the clinical literature to date has shown that the nature of the relationship between phobic disorders and anxiety states is still unclear. As a wide range of symptoms are shared by patients with all DSM-III anxiety disorder diagnoses, at this stage there is still a need to investigate the latent dimensions which distinguish the anxiety disorder subtypes. In the present study 176 patients with the DSM-III diagnoses of agoraphobia with panic attacks, social phobia, panic disorder and generalized anxiety disorder completed the Fear Survey Schedule, Fear Questionnaire, Hostility and Direction of Hostility Questionnaire, Maudsley Personality Inventory, and the Hamilton Anxiety and Depression Scales. Group membership was significantly predicted by a discriminant analysis which yielded a Fear Questionnaire agoraphobia function and a social phobia function. The results from discriminant analysis suggests that agoraphobia and anxiety states may be closely related. Classification errors were also determined, providing further evidence with which to refute the claim that agoraphobia has "all or none" characteristics.     

Situational panic attacks: impact on distress and impairment among patients with social phobia

To investigate the impact of situational panic attacks in social phobia, this study examined symptoms of social anxiety and avoidance, dysfunction, and associated psychopathology among individuals with social phobia who experience situational panic attacks, individuals meeting criteria for both social phobia and panic disorder, and individuals with social phobia but no report of panic attacks. One hundred thirty-three persons with a principal diagnosis of social phobia were evaluated. Fifty-seven individuals, who experienced panic attacks exclusively in the context of feared social situations, were compared to 15 individuals with social phobia who also experienced spontaneous panic attacks and met criteria for panic disorder and 61 social phobics who did not experience panic attacks. Compared to social phobics without panic, social phobics with situational panic attacks demonstrated greater fear and avoidance of social situations and higher ratings of somatic anxiety, were more distressed and impaired by their social phobias, and reported higher levels of anxiety sensitivity and hopelessness than social phobics without panic. Additionally, social phobia patients with situational panic but without panic disorder reported greater hopelessness than participants with comorbid panic disorder. In regression analyses, situational panic attacks accounted for significant unique variance beyond that contributed by the presence of comorbid panic disorder. Situational panic attacks are common in social phobia. They are associated with significant and unique disturbances compared either to the absence of panic attacks or to panic attacks in the context of comorbid panic disorder and deserve attention in both research and treatment of social phobia.     

Phobias in India and the United Kingdom. A trans-cultural study

Thirty-nine phobic patients from India were compared with 39 similarly diagnosed age and sex matched patients from the United Kingdom. The British sample contained significantly more patients with agoraphobia and social phobia compared to the Indian group. Sudden death and illness phobias were more frequent in the Indian group. The Indian phobic patients also had more somatic and depressive symptoms. The influence of culture on the presentation of different phobias is discussed.     

Anxiety sensitivity in social phobia: comparison between social phobics with and without panic attacks

The current study examines levels of anxiety sensitivity among social phobic patients with and without panic attacks. Two-hundred fourteen individuals with a primary diagnosis of social phobia completed the Anxiety Sensitivity Index (ASI) prior to treatment. Social phobics who experienced panic attacks reported higher levels of anxiety sensitivity than those without panic attacks. Patterning of response to ASI items differed between panicking and non-panicking patients, with the panicking patients reporting greater fear of catastrophic consequences of bodily sensations. Individuals with an additional diagnosis of panic disorder did not differ from those with exclusively situational panic attacks. The findings suggest the importance of examining differences between anxiety-disordered individuals who experience panic attacks and their non-panicking counterparts.     

Evaluative conditioning of fear and disgust in blood-injection-injury phobia: specificity and impact of individual differences in disgust sensitivity

The present study examines whether the repeated pairing of neutral facial expressions with phobic-relevant stimuli differentially influences evaluative ratings of fear and disgust between analogue blood-injection-injury (BII) phobic (n=40) and non-phobic (n=40) participants. Consistent with prior research, BII phobics reported greater disgust sensitivity than non-phobic participants even after controlling for between group differences in anxiety symptoms. Results from the evaluative conditioning experiment indicated that pre- to posttest increases in fear ratings were only marginally greater for phobic compared to non-phobic participants. However, increases in disgust from pre- to posttest were greater for phobic compared to non-phobic participants and greater for neutral expressions that were paired with threat-relevant stimuli compared to stimuli not paired with threat-relevant stimuli. Subsequent analysis also indicated that pre- to posttest increases in disgust ratings of neutral expressions that were paired with threat-relevant stimuli was moderated by disgust sensitivity levels among phobic and non-phobic participants. Heightened fear and disgust ratings were subsequently reduced by an extinction procedure. Implications of present findings in understanding the role of fear and disgust in BII phobia are discussed.     

Psychometric properties of the Social Phobia and Anxiety Inventory-Child version in a Swedish clinical sample

The Social Phobia and Anxiety Inventory for Children (SPAI-C) is a 26 item, empirically derived self-report instrument developed for assessing social phobic fears in children. Evidence for satisfactory psychometric properties of the SPAI-C has been found in multiple community studies. Since its development, however, no study has presented an extensive psychometric evaluation of SPAI-C in a sample of carefully diagnosed children with social phobia. The present study sought to replicate and expand previous studies by administrating the SPAI-C to a sample of 59 children that fulfilled DSM-IV criteria for social phobia, and 49 children with no social phobia diagnosis. An exploratory factor analysis resulted in a three factor solution reflecting: (1) fear of social interactions, (2) fear of public performance situations, and (3) physical and cognitive symptoms connected with social phobia. These factors appear to parallel domains of social phobia also evident in adults. The SPAI-C total scale and each factor was found to possess good internal consistency, good test–retest reliability and was generally strongly correlated with both self-report and clinician measures of anxiety and fears. The discriminative properties of the total scale were satisfactory.