Childhood history of anxiety disorders among adults with social phobia: rates, correlates, and comparisons with patients with panic disorder.

We examined the rates and correlates of a childhood history of anxiety disorders in 100 adults with a primary diagnosis of social phobia (social anxiety disorder). Adulthood and childhood disorders were assessed by experienced clinicians with structured clinical interviews. Rates of childhood anxiety disorders were evaluated to diagnostic comorbidity and a comparison group of patients with panic disorder. Onset of social phobia occurred before age 18 in 80% of the sample. Over half of the sample (54%) met criteria for one or more childhood anxiety disorders other than social phobia: 47% for overanxious disorder, 25% for avoidant disorder, 13% for separation anxiety disorder, and 1% for childhood agoraphobia. A history of childhood anxiety was associated with an early age of onset of social phobia, greater severity of fear and avoidance of social situations, greater fears of negative evaluation, and greater anxiety and depression morbidity. Rates of childhood social phobia, overanxious disorder, and avoidant disorder were significantly higher in patients with social phobia relative to our panic-disordered comparison group. We found approximately equal rates of a childhood history of separation anxiety disorder in patients with social phobia and panic disorder, providing further evidence against a unique relationship between separation anxiety disorder and panic disorder.     

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.     

Temperament and character dimensions in patients with social phobia: patterns of change following treatments?

The aim of this study was to examine Temperament and Character Inventory (TCI) profiles in patients with social phobia (DSM-IV) and to outline patterns of change following intensive group cognitive therapy (IGCT), individual cognitive therapy (ICT) and treatment as usual (TAU). One hundred patients recruited by advertisements in local papers were randomized to IGCT, ICT and TAU. Patients (n=59) who completed diagnostic evaluation and TCI assessments at baseline and 1-year follow-up were examined in this study. Patients differed from healthy controls in novelty seeking (NS), harm avoidance (HA), self-directedness (SD), cooperativeness (C), and self-transcendence (ST). Treatments overall were associated with decrease in HA, while increase in SD was observed after psychotherapy only. Reduced social anxiety was correlated with decrease in HA and increase in SD. High HA at baseline was related to poor treatment outcome in all treatments. To conclude, patients with social phobia show a temperamental vulnerability for developing anxiety and character traits associated with personality disorders. Successful treatment is related to decrease in HA and increase in SD. High HA at baseline may suggest a need for extensive treatment in order to achieve remission.     

Heritability of social anxiety-related concerns and personality characteristics: a twin study

Negative evaluation fears figure prominently in the cognitive psychology of patients with social phobia. In this study, we examine the heritability of negative evaluation fears by using a twin sample. The authors also examine the relationships between negative evaluation fears and personality dimensions relevant to social phobia. Scores on the brief version of the Fear of Negative Evaluation Scale (BFNE) were examined in a sample of 437 (245 monozygotic and 192 dizygotic) twin pairs. Biometrical model fitting was conducted by using standard statistical methods. Genetic and environmental correlations with personality dimensions (from the Dimensional Assessment of Personality Pathology-Basic Questionnaire) were also calculated. Broad heritability estimate of the BFNE was 48%. Additive genetic effects and unique environmental effects emerged as the primary influences on negative evaluation fears. Genetic correlations between BFNE scores and the submissiveness, anxiousness, and social avoidance facets of the Dimensional Assessment of Personality Pathology-Basic Questionnaire were high (r(g) =.78 to.80). A cognitive dimension central to the phenomenology (and, perhaps, cause) of social phobia, the fear of being negatively evaluated, is moderately heritable. Moreover, the same genes that influence negative evaluation fears appear to influence a cluster of anxiety-related personality characteristics. Implications and limitations of these findings are discussed.     

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.     

The relationship between the maladaptive self-beliefs characteristic of social anxiety and avoidance

The Clark and Wells (1995) model of social phobia proposes that there are three types of maladaptive self-beliefs responsible for persistent social anxiety (high standard, conditional, and unconditional beliefs). Another prominent feature of social phobia is the avoidance of social-evaluative situations. To our knowledge, there have been no studies that have examined the relationship between these specific maladaptive self-belief types and avoidance. We hypothesised that while accounting for potential confounding variables (i.e., fear of negative evaluation and general symptomology), each of the three maladaptive self-belief types would be significantly and positively associated with cognitive and behavioural avoidance in the social domain, but not these forms of avoidance in the non-social domain. In a sample of undergraduates (N = 361), we found only partial support for our hypotheses. In the social domain, stronger high standard beliefs predicted less behavioural avoidance, stronger unconditional beliefs predicted more behavioural avoidance, and stronger conditional beliefs predicted more cognitive avoidance. In the non-social domain, stronger unconditional beliefs predicted more cognitive avoidance. These relationships were obtained at all levels of social anxiety. Additionally, the unconditional beliefs partially mediated the relationship between social anxiety and behavioural avoidance in the social domain, and the conditional beliefs fully mediated the relationship between social anxiety and cognitive avoidance in the social domain. These results emphasise the distinct nature of each of the maladaptive self-belief types and the need to elucidate their relationship with other components in theoretical models of social phobia.     

Avoidant personality disorder, generalized social phobia, and shyness: putting the personality back into personality disorders

With increasing recognition of social phobia as a common and often debilitating disorder, interest is developing in its boundaries with other disorders such as avoidant personality disorder and temperamental constructs such as shyness. Such interest reflects the more general debate concerning Axis I disorders, personality disorders, and what is considered normal personality variance. This review summarizes the available literature comparing avoidant personality disorder (APD), generalized social phobia (GSP), and shyness. In studies comparing APD and GSP, comorbidity rates have varied from approximately 25% to numbers high enough that the ability to diagnose one disorder without the other was questioned. Comparisons of the characteristics of APD and GSP have yielded few qualitative differences, although some studies have shown evidence that APD may represent a more severe form of GSP with respect to levels of symptoms, fear of negative evaluation, anxiety, avoidance, and depression. Personality dimensions including, but not limited to, shyness have been found to be strongly associated with GSP and APD, and there is some evidence that persons who suffer from social anxiety also suffer from fears and avoidance across nonsocial domains. In conclusion, although there is evidence that shyness, GSP, and APD exist along a continuum, the factors that constitute this continuum may need to be revised.     

Multimodal comparisons of social phobia subtypes and avoidant personality disorder.

The purpose of the present study was to further clarify the behavioral, physiological, and verbal response of patients with circumscribed social (speech) phobia, generalized social phobia without avoidant personality disorder, and generalized social phobia with avoidant personality disorder. Patients completed a battery of verbal report instruments and participated in two behavioral assessment tests. Measures of avoidance/escape behavior, cardiac response, level of behavioral skill, state anxiety, and positive and negative self-statements during performance were collected. Significant differences across response domains were found between the circumscribed social phobia and the generalized groups. Most of the distinctions were between individuals with circumscribed social phobia and those with both generalized social phobia and avoidant personality disorder, with the former group having less overall psychopathology. In addition, there was substantial overlap of problems between generalized social phobia individuals with and without avoidant personality disorder. Implications for the conceptualization of social phobia are discussed in terms of the differences among social phobia subtypes.     

Social anxiety disorders

A main feature of social anxiety disorders is the fear or avoidance of social situations in which one is the center of attention and fears criticism or negative judgement. According to current diagnostic systems, three types of these disorders can be classified: specific social phobia, generalised social phobia, and avoidant personality disorder. Social anxiety disorders are prevalent mental disorders (lifetime prevalence up to 13%). Other mental disorders often appear together with them. Following the criteria for evidence-based medicine, psychotherapeutic and pharmacologic interventions are described. Regarding psychotherapeutic approaches, the best results have been seen with cognitive-behavioural methods. Among psychopharmacologic treatments, selective serotonin reuptake inhibitors and the selective noradrenalin reuptake inhibitor Venlafaxin are the first-choice treatments.     

Defense Styles and Personality Dimensions of Research Subjects with Anxiety and Depressive Disorders

We used the Bond Defense Style and Cloninger Tridimensional Personality questionnaires to assess defense styles and personality dimensions in subjects with anxiety and depressive disorders. When measured against a comparison group, maladaptive defense style scores were significantly higher in those with major depression, panic disorder, generalized anxiety disorder, and social phobia, and higher at a trend level in the subjects with obsessive-compulsive disorder and mixed anxiety and depression. However, there were no differences in adaptive defense style scores between the subjects and the comparison group. The harm avoidance personality dimension scores were significantly higher in subjects with both anxiety and depressive disorders than in the comparison group. The harm avoidance scores correlated positively with the maladaptive defense scores, but negatively with the adaptive defense scores. These findings are discussed in terms of severity of illness, level of functioning, and relationships between Axis I and II disorders.     

Social phobic symptoms in patients with panic disorder: practical and theoretical implications

Of 35 patients with DSM-III-R diagnoses of panic disorder, 16 also received diagnoses of social phobia, and 15 of these 16 reported past episodes of major depression. Only nine of the 19 panic patients without social phobia had histories of depression. The panic patients with histories of depression had significantly higher self-ratings of social anxiety and avoidance, but not agoraphobic fear and avoidance, than those without histories of depression. Panic disorder and social phobia may coexist in many cases, and the presence of social phobia may be associated with a higher morbid risk for major depression in this population.     

The association between bodily anxiety symptom dimensions and the scales of the Revised NEO Personality Inventory and the Temperament and Character Inventory

The association between anxiety disorders and different measures of personality has been extensively studied to further the understanding of etiology, course, and treatment, and to possibly prevent the development of anxiety disorders. We have proposed a hierarchical model of bodily anxiety symptoms with 1 second-order severity factor and 5 first-order factors: cardio-respiratory, gastro-intestinal, autonomic, vertigo, and tension. The aim of this study was to investigate whether personality traits were differentially related to distinct symptom subdimensions or exclusively related to the general severity factor. Structural equation modeling of data on 120 patients with a primary diagnosis of social phobia and 207 patients with a primary diagnosis of panic disorder was used to examine the association between anxiety symptom dimensions and the scales of the Temperament and Character Inventory and of the Revised NEO Personality Inventory. When both sets of personality measures were simultaneously modeled as predictors, the Revised NEO Personality Inventory scales, neuroticism and extraversion, remained significantly associated with the severity factor, whereas the association between the Temperament and Character Inventory dimensions, harm avoidance and novelty seeking, and the severity factor became nonsignificant. Harm avoidance was negatively associated with the vertigo first-order factor, whereas neuroticism was negatively associated with the cardio-respiratory first-order factor, indicating that personality factors may be differentially related to specific anxiety subdimensions.     

Generalization of social anxiety to sporting and athletic situations: gender, sports involvement, and parental pressure

Although researchers have documented that social anxiety may occur in a wide range of interpersonal and performance situations, little attention has been paid to the potential influence of social anxiety on participation in athletics or physical activity. The performance demands of sport and potential social evaluative nature of exercise make it likely that social anxiety would generalize to these situations. Given the physical and psychological benefits of engaging in regular physical activity, avoidance of such activities by socially anxious individuals may have profound health consequences. One-hundred and eighty undergraduate university students completed a battery of standardized social anxiety measures, and a series of 5-point Likert-type questions examining fear and avoidance of sporting and athletic situations. Results indicated that social anxiety and fear of negative evaluation were generally related to social-evaluative fears in sporting or athletic situations, particularly for women. Furthermore, social anxiety was positively correlated with avoidance of individual sporting activities, but not with avoidance of team activities. Further analyses revealed social anxiety did not differ by competition level. However, for men, familial pressure to play sports during high school was associated with higher fear of negative evaluation. Implications for the assessment and treatment of social anxiety disorder are discussed.     

Is post-event processing specific for social anxiety?

In their model of social phobia, Clark and Wells [1995. A cognitive model of social phobia. In R. G. Heimberg, M. Liebowitz, D. A. Hope & F. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69-93). New York, London: The Guilford Press] introduced a process called "post-event processing" (PEP), which is characterized by prolonged rumination about past social situations. The present study examined to what extent PEP is specific for (a) social anxiety or (b) social situations. In a cross-sectional study, 217 participants reported about a social and a phobic event followed by negative thinking. PEP as well as its potential predictors such as social anxiety, general anxiety, and depression were measured by questionnaires. Results showed that social events were followed more often and by more intense PEP. Further confirming specificity, the fear of negative evaluation as an aspect of social anxiety was significantly associated with PEP for social but not for phobic situations, and vice versa; general anxiety predicted PEP only after phobic but not after social situations. Furthermore, PEP was elevated particularly for interaction (as opposed to performance) situations, indicating that the ambiguity of the situation may be an important predictor for prolonged processing.     

A comparison of the efficacy of clonazepam and cognitive-behavioral group therapy for the treatment of social phobia

There is a growing body of evidence that social phobia may be treated effectively by either pharmacologic or cognitive-behavioral interventions. but few studies have examined the relative benefits of these treatments. In this study, we examined the relative efficacy of pharmacotherapy with clonazepam and cognitive-behavioral group therapy (CBGT) for treating social phobia. In addition, we examined potential predictors of differential treatment response. Outpatients meeting Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised) criteria for social phobia were randomly assigned to treatment. Clinician-rated and patient-rated symptom severity was examined at baseline and after 4, 8, and 12 weeks of treatment. All clinician-rated assessments were completed by individuals blind to treatment condition. Patients in both conditions improved significantly, and differences between treatment conditions were absent, except for greater improvement on clonazepam on several measures at the 12-week assessment. Symptom severity was negatively associated with treatment success for both methods of treatment, and additional predictors-sex, comorbidity with other anxiety or mood disorders, fear of anxiety symptoms, and dysfunctional attitudes-failed to predict treatment outcome above and beyond severity measures. In summary, we found that patients randomized to clinical care with clonazepam or CBGT were equally likely to respond to acute treatment, and pretreatment measures of symptom severity provided no guidance for the selection of one treatment over another.     

Social phobia with somatic symptoms including nausea and urgency of micturition]

The common symptoms of the social anxiety response include blushing, trembling, feelings of muscular tension of the face, and fear of eye contact. However, the ICD-10 mentions other less familiar symptoms such as nausea, urgency of micturition or defecation, gastrointestinal discomfort, and diarrhea as symptoms of social phobia. Since some of these somatic symptoms are classified as panic-like symptoms in the DSM-IV, it is sometimes difficult to distinguish between social phobia and agoraphobia when these somatic symptoms appear in situations usually associated with agoraphobia. We investigated whether social phobic patients with familiar symptoms (classical group; N = 24) and those with unfamiliar symptoms such as nausea, urgency of micturition or defecation (N/U group; N = 13) could be distinguished on the basis of several selected demographic and psychological tests. Fear of negative evaluation (FNE), social avoidance and distress (SAD), brief social phobia scale (BSPS), and Rosenberg's self esteem score (Se) were compared among these two groups and 82 controls. We also investigated whether they have "fears of making other people feel uncomfortable" which is believed to be a characteristic symptom for what is known in Japanese as "taijin-kyofu-sho." Both groups had higher scores on FNE, SAD, fear and avoidance scores of BSPS, and lower scores on Se as compared with controls. However, neither group differed in demographic variables or results of psychological tests, except for higher scores on the performance score of BSPS and increased rate of "fears of making other people feel uncomfortable" in the classical group. It is suggested that social phobia patients had common social phobic symptomatology and psychopathology irrespective of their somatic symptoms.     

A prospective examination of predictors of post-event processing following videotaped exposures in group cognitive behavioural therapy for individuals with social phobia

Following social events, individuals with social phobia engage in post-event processing (PEP), namely a post-mortem detailed analysis of a social situation. This study aimed to examine cognitive and symptom correlates of PEP, as well as stability of PEP, in the context of videotaped exposures that occurred during treatment at sessions four and eight. Before treatment, 75 individuals with DSM-IV diagnosed social phobia completed measures of social anxiety, anxious rumination, fear of causing discomfort to others, and negative interpretation of positive social events. They rated their peak anxiety during the taped exposure. Then, they completed a measure of PEP one week after each videotaped exposure exercise. Results revealed that baseline social anxiety symptoms, state anxiety during the videotaping, anxious rumination, fear of causing discomfort to others, and negative interpretation of positive social events were all positively associated with PEP for the first taped exposure. Regression analyses demonstrated that unique predictors of PEP over and above baseline social anxiety were state social anxiety during the exposure, and anxious coping-focused rumination. This was largely replicated in the second taped exposure. In addition, PEP following two videotaped exposures separated by four weeks showed a moderate-to-large positive correlation. These findings highlight symptom and cognitive correlates of PEP, and underscore importance of state anxiety in social situations, as well as general anxiety focused rumination in social phobia.     

The association between social phobia, social anxiety cognitions and paranoid symptoms

Schutters SIJ, Dominguez M‐d‐G, Knappe S, Lieb R, van Os J, Schruers KRJ, Wittchen H‐U. The association between social phobia, social anxiety cognitions and paranoid symptoms. Objective: Previous research suggests high levels of comorbidity between social phobia and paranoid symptoms, although the nature of this association remains unclear. Method: Data were derived from the Early Developmental Stages of Psychopathology study, a 10‐year longitudinal study in a representative German community sample of 3021 participants aged 14–24 years at baseline. The Munich‐Composite International Diagnostic Interview was used to assess social phobia and paranoid symptoms, along with data on social phobia features. Cross‐sectional and longitudinal analyses were conducted. Differential associations with environmental risk factors and temperamental traits were investigated. Results: Lifetime social phobia and paranoid symptoms were associated with each other cross‐sectionally (OR = 1.80, 95% CI = 1.31–2.47). Lifetime paranoid symptoms were associated specifically with social anxiety cognitions. Lifetime cognitions of negative evaluation predicted later onset of paranoid symptoms, whereas onset of social phobia was predicted by cognitions of loss of control and fear/avoidance of social situations. Lifetime social phobia and paranoid symptoms shared temperamental traits of behavioural inhibition, but differed in environmental risks. Conclusions: The present study showed that paranoid symptoms and social phobia share similarities in cognitive profile and inhibited temperament. Avoidance appears to be important in the development of social phobia, whereas cannabis use and traumatic experiences may drive paranoid thinking in vulnerable individuals.