Putative clinical subtypes of social phobia: a factor-analytical study

Higher- and lower-order personality traits and cluster subtypes in social anxiety disorder

Social anxiety disorder (SAD) can come in different forms, presenting problems for diagnostic classification. Here, we examined personality traits in a large sample of patients (N = 265) diagnosed with SAD in comparison to healthy controls (N = 164) by use of the Revised NEO Personality Inventory (NEO-PI-R) and Karolinska Scales of Personality (KSP). In addition, we identified subtypes of SAD based on cluster analysis of the NEO-PI-R Big Five personality dimensions. Significant group differences in personality traits between patients and controls were noted on all Big Five dimensions except agreeableness. Group differences were further noted on most lower-order facets of NEO-PI-R, and nearly all KSP variables. A logistic regression analysis showed, however, that only neuroticism and extraversion remained significant independent predictors of patient/control group when controlling for the effects of the other Big Five dimensions. Also, only neuroticism and extraversion yielded large effect sizes when SAD patients were compared to Swedish normative data for the NEO-PI-R. A two-step cluster analysis resulted in three separate clusters labelled Prototypical (33%), Introvert-Conscientious (29%), and Instable-Open (38%) SAD. Individuals in the Prototypical cluster deviated most on the Big Five dimensions and they were at the most severe end in profile analyses of social anxiety, self-rated fear during public speaking, trait anxiety, and anxiety-related KSP variables. While additional studies are needed to determine if personality subtypes in SAD differ in etiological and treatment-related factors, the present results demonstrate considerable personality heterogeneity in socially anxious individuals, further underscoring that SAD is a multidimensional disorder.

Psychometric properties of the Liebowitz Social Anxiety Scale in a large cross-cultural Spanish and Portuguese speaking sample

Objective:

To examine the psychometric properties of the Liebowitz Social Anxiety Scale-Self Report (LSAS-SR) based on a large sample recruited from 16 Latin American countries, Spain, and Portugal.

Methods:

Two groups of participants were included: a non-clinical sample involving 31,243 community subjects and a clinical sample comprising 529 patients with a diagnosis of social anxiety disorder (SAD). Exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and exploratory structural equation modeling (ESEM) were used in order to determine the psychometric properties of the LSAS-SR.

Results:

EFA identified five factors with eigenvalues greater than 1.00 explaining 50.78% of the cumulative variance. CFA and ESEM supported this 5-factor structure of the LSAS-SR. The factors included: 1) speaking in public; 2) eating/drinking in front of other people; 3) assertive behaviors; 4) working/writing while being observed; and 5) interactions with strangers. Other psychometric properties such as inter-factor correlations, invariance, reliability, and validity of the scale were also found.

Conclusion:

Psychometric data support the internal consistency and convergent validity of the LSAS-SR. It seems to be a valid and reliable measure of global social anxiety for Spanish and Portuguese-speaking countries, although when considering a multidimensional approach (factor-based assessment) it seems to be lacking some relevant social situations that are feared in those countries.

Test Anxiety and the Americans With Disabilities Act

Test anxiety leads to requests for accommodations under the Americans With Disabilities Act (ADA), but many testing entities have expressed skepticism about whether test anxiety qualifies as a disability. This article addresses three legal issues raised by the inclusion of test anxiety under ADA: whether test anxiety is a mental impairment, whether test-taking is a major life activity, and whether test anxiety substantially limits test-taking. The article then turns to questions of policy: How should ADA claims for test anxiety be handled by educational institutions, independent testing agencies, and employers? A review of scientific research and legal authorities are used to answer these questions. Most individuals with high test anxiety levels will not qualify as disabled under ADA, although there will be exceptions to that general rule, and testing entities should always conduct an individualized inquiry into each claim.

Attachment styles in patients with avoidant personality disorder compared with social phobia

OBJECTIVES

Avoidant personality disorder (AvPD) and social phobia (SP) are common, closely related conditions. Little is known about the underlying processes related to the social discomfort of subjects with AvPD and SP. Both disorders are associated with interpersonal problems. An attachment perspective may shed light on similarities and differences in close relationships between the disorders. The aim of the study was to compare self-reported attachment styles in patients with AvPD and SP. We expected that patients with AvPD would have more attachment anxiety and avoidance and more often a Fearful attachment style, compared with SP.

DESIGN

This is a cross-sectional multisite study of 90 adult patients with AvPD and SP. Patients with AvPD with and without SP (AvPD group) were compared with patients with SP without AvPD (SP group).

METHODS

Patients were assessed using structured diagnostic interviews and self-reporting questionnaires, including Experiences in Close Relationships (ECR). The ECR dimensions, Anxiety and Avoidance, and the new described five factors of the ECR were used.

RESULTS

The AvPD group had higher levels of attachment anxiety than the SP group, especially for the sub-factors Anxiety for abandonment and Separation frustration. The diagnostic groups did not differ in levels of avoidance. Anxiety for abandonment was still associated with AvPD after controlling for symptom disorders and the criteria of other personality disorders. A Fearful attachment style was more frequent among patients with AvPD.

CONCLUSIONS

The results indicate AvPD is associated with more attachment anxiety than SP. Fear of abandonment may play a significant role in the AvPD pathology.

PRACTITIONER POINTS

This is the first study to compare attachment styles in patients with avoidant personality disorder (AvPD) and social phobia (SP). The AvPD group had higher attachment-related anxiety than the SP group, and anxiety was most pronounced for the fear of abandonment. Fear of abandonment may play an important role in the AvPD pathology.

Recent Insight Into the Subtypes of Social Anxiety Disorder

Systems for subtyping individuals with social anxiety disorder have been the focus of much research attention as a means to improve assessment and treatment of the disorder. This article highlights recent revisions to social anxiety disorder (SAD) subtypes from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to DSM-V, reviewing empirical evidence that served as the impetus for the revisions. Recent research examining the validity of the DSM-V system and alternative subtyping systems is reviewed. Overall, there appears to be greater empirical support for a dimensional subtyping system. Concerns therefore remain with the DSM-V system, which retained a categorical system but replaced the previous subtypes with a subtype of individuals fearing only performance situations. Recommendations for future research are discussed, as well as alternate options for capturing the variability in SAD presentations, including the possibility of eliminating subtyping altogether.

Interoceptive exposure exercises for social anxiety

Individuals with social anxiety disorder (SAD) commonly experience panic attacks and evidence increased anxiety sensitivity (AS) specific to noticeable anxiety sensations. Interoceptive exposure (IE) is an effective treatment for reducing AS, but few IE tasks target fears of blushing, sweating, or trembling, which are incorporated within AS social concerns and especially feared by individuals with SAD. The primary study aims were trifold: (1) identify novel IE tasks that produce blushing, sweating, and/or trembling; (2) assess the intensity of sensations and anxiety produced by a series of novel and validated IE tasks; and (3) evaluate the incremental validity of combining an IE task and a speech task. Individuals (N = 55) with heightened fear of noticeably blushing, sweating, and/or trembling completed a control task and 8 IE tasks (e.g., hot sauce, hyperventilation). All tasks produced greater intensity of anxiety and sensations compared to the control task (ps < .001; range of η(p)(2) = .20-.50). Responses to the combination of an IE task and social task compared to a social task alone did not differ significantly. Future directions for research and clinical implications of the findings are discussed.

Differentiating the subtypes of social anxiety disorder

Since the inclusion of subtypes of social anxiety disorder (SAD) in the DSM-III-R, the most studied have been generalized versus specific subtypes. Previous research indicated that the generalized subtype was associated with greater severity, comorbidity and functional impairment compared to the specific subtype, but more recent evidence supports a dimensional conceptualization of SAD. Earlier studies also possessed limitations, such as heterogeneity in definitions of generalized SAD. Based on the more recent findings and the limitations of the earlier studies, the DSM-5 eliminated the generalized specifier. However, it also retained a categorical system by including a performance-based fear specifier, thus leaving an open debate on whether or not a dimensional or categorical system best describes SAD. Future research could examine other, more recent concepts as potential subtypes (e.g., attentional biases), or perhaps the larger question of the overall utility in subtyping SAD.

The factor structure of the Liebowitz Social Anxiety Scale for Children and Adolescents: development of a brief version

The Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA-SR) is a validated instrument for the assessment of social anxiety in youth. The three main objectives of the present study were to (a) examine the factor structure of the LSAS-CA-SR; (b) to validate the factors against relevant personality measures, and (c) to create a brief and reliable version of the questionnaire. A total of 1,362 adolescents completed self-report measures of social anxiety, temperament, character and personality traits. The factor structure was examined using a combination of confirmatory and exploratory factor analysis. The analysis was conducted on both the anxiety and avoidance sub-scales, and identical items for both sub-scales were maintained. Two factors emerged: social interaction and school performance. These factors demonstrated high internal consistency and a significant correlation with relevant self-report measures. A brief version comprised of 14 items was highly correlated (0.96) with the full version. The new factor structure represents advancement over the previous efforts, and holds promise for efficient utilization of the LSAS-CA.

Latent structure of social fears and social anxiety disorders

BACKGROUND

Despite its high prevalence and associated levels of impairment, the latent structure of social anxiety disorder (SAD) is not well understood, with published studies reporting inconsistent results. Furthermore, it is unknown whether the latent structure of social fears in individuals with and without SAD is the same.

METHOD

Exploratory factor analysis (EFA) and confirmatory factor analysis followed by multiple indicators multiple causes (MIMIC) analysis were conducted on 13 commonly feared social situations assessed in a nationally representative sample including individuals with SAD and those with social fears but who did not meet DSM-IV criteria for SAD.

RESULTS

An EFA conducted in the full sample, including individuals with no social fears (88% of the sample), yielded only one factor. When the sample was restricted to those with at least one social fear, the EFA yielded three factors, in both the subsample with at least one social fear but no SAD and the subsample with SAD. The three factors represented feared situations related to public performance, close scrutiny and social interaction. The MIMIC analyses further indicated that the three-factor structure was able to explain differences in prevalence of social fears across a broad range of sociodemographic covariates.

CONCLUSIONS

Among individuals with at least one social fear and those with DSM-IV SAD the latent structure of social fears appears to be best described by three factors, although this may partially depend on how the sample is specified. These results may help reconcile the findings of different numbers of factors identified in previous studies.

Avoidant personality disorder in individuals with generalized social anxiety disorder: what does it add?

Avoidant personality disorder (AvPD) has a high level of symptom overlap and comorbidity with generalized social anxiety disorder (GSAD). We examined whether the presence of comorbid AvPD adds significant clinically relevant information for individuals seeking treatment for GSAD. Results suggested that AvPD was significantly associated with poorer quality of life and greater disability in univariate, but not multivariate analyses. Endorsement of more AvPD symptoms was associated with increased disability, increased risk of intimacy, and lower social support, even after covariate adjustment. Specifically, AvPD item 3, hard to be "open" even with people you are close to, was most strongly correlated with quality of life and disability. A binary diagnosis of AvPD alone adds little beyond a marker of greater GSAD severity and depression among patients with GSAD, while a specific feature of AvPD not captured by the GSAD diagnosis, namely emotional guardedness, may be associated with greater impairment.

Self-Discrepancies and the Situational Domains of Social Phobia

The present study explored whether particular discrepancies among an individual's self-beliefs, as described by Higgins’ (1987) Self-Discrepancy Theory, were differentially related to the two broad situational domains of social anxiety: performance and social interaction anxiety. Fifteen people (4 males) with a primary diagnosis of GSP from Macquarie University's Emotional Health Clinic, and 25 undergraduate psychology students from Macquarie University (8 males) with mean chronological ages of 31.7 and 20.6 years respectively, participated in the study. As predicted, the study found that the ‘actual/other:ought/other’ self-discrepancy was uniquely related to performance anxiety, the ‘actual/own:ought/other’ self-discrepancy was uniquely associated with social interaction anxiety, and the ‘actual/own:ideal/own’ self-discrepancy was uniquely associated with depression. The results are discussed in terms of their unique contribution to Self-Discrepancy Theory research, the current empirical debate regarding the existence of subtypes within social phobia, and their implications for the cognitive models and treatment of social anxiety.

Admixture analysis of the diagnostic subtypes of social anxiety disorder: implications for the DSM-V

BACKGROUND AND OBJECTIVES

Much controversy exists regarding diagnostic subtypes of social anxiety disorder (SAD). The present study used admixture analysis to examine whether individuals with generalized and nongeneralized SAD belong to the same or different populations of origin. This can inform diagnostic subtyping of SAD in the forthcoming DSM-V.

METHODS

Treatment-seeking individuals with generalized SAD (n = 154) and nongeneralized SAD (n = 48) completed a battery of questionnaires. Based on participants' responses to the Liebowitz Social Anxiety Scale (LSAS), we estimated log likelihood and chi-square goodness-of-fit for models with 1, 2, 3, or 4 populations of origin, and compared models using forward stepwise estimation and maximum likelihood ratio tests.

RESULTS

Admixture analyses suggested that the two diagnostic subtypes of SAD belong to the same underlying population of origin. In addition, observable differences in depression, general anxiety, and comorbidity were no longer significant when controlling for social anxiety severity.

LIMITATIONS

Our sample was recruited in the U.S. and was a treatment-seeking sample. Future studies should examine whether our results generalize to different cultures, and community samples.

CONCLUSIONS

Support for qualitative differences between SAD subtypes was not found. Rather, our findings support the notion that the diagnostic subtypes of SAD differ quantitatively, and that SAD exists on a continuum of severity. This finding informs diagnostic subtyping of SAD in the forthcoming DSM-V.

Validation of the diagnoses of panic disorder and phobic disorders in the US National Comorbidity Survey Replication Adolescent (NCS-A) supplement

Validity of the adolescent version of the World Health Organization Composite International Diagnostic Interview (CIDI) Version 3.0, a fully-structured research diagnostic interview designed to be used by trained lay interviewers, is assessed in comparison to independent clinical diagnoses based on the Schedule for Affective Disorders and Schizophrenia for School-age Children (K-SADS). This assessment is carried out in the clinical reappraisal sub-sample (n = 347) of the US National Comorbidity Survey Adolescent (NCS-A) supplement, a large (n = 10,148) community epidemiological survey of the prevalence and correlates of adolescent mental disorders in the United States. The diagnoses considered are panic disorder and phobic disorders (social phobia, specific phobia, agoraphobia). CIDI diagnoses are found to have good concordance with K-SADS diagnoses [area under the receiver operating characteristic curve (AUC) = 0.81-0.94], although the CIDI diagnoses are consistency somewhat higher than the K-SADS diagnoses. Data are also presented on criterion-level concordance in an effort to pinpoint CIDI question series that might be improved in future modifications of the instrument. Finally, data are presented on the factor structure of the fears associated with social phobia, the only disorder in this series where substantial controversy exists about disorder subtypes.

Social fear and social phobia types among community youth: differential clinical features and vulnerability factors

OBJECTIVE

To compare different social fears and social phobia subtypes with regard to clinical (age of onset, avoidance, impairment, comorbidities) and vulnerability factors (behavioural inhibition (BI), parental psychopathology and parental rearing) among community youth.

METHODS

Fears of 6 social situations and Social Phobia (SP), along with their clinical features, were assessed using the Munich-Composite International Diagnostic Interview (DIA-X/M-CIDI) in a population-based sample of N = 3021 14-24 year olds that were followed up for 10 years. BI and parental rearing were assessed using self-report questionnaires. Parental psychopathology was assessed directly in parents via DIA-X/M-CIDI, supplemented by offsprings' family history reports.

RESULTS

In the total sample, 20.0%, 11.6%, 11.7% reported fear of 1, 2, 3 or more social situations, respectively; rates were 24.2%, 18.7%, and 57.1% in SP-cases (6.6% of the total sample). Exploring the factorial structure indicated rather unidimensionality of social fears than mutual distinction of social fears by interaction vs. performance situations. Except for fear of taking tests and public speaking, social fears rarely occurred in isolation. Social fears of both interaction and performance situations were associated with severe avoidance (vs. fear of either situation; Odds Ratios, OR = 1.5, 95%CI: 1.1-1.9) and impairment (OR = 3.6, 95%CI: 2.6-4.9), and more comorbid anxiety and depressive disorders (OR range 3.2-5.8, p > .001). Fear of interaction situations was associated with higher BI (vs. performance-related fears, OR range 1.2-2.1, p < .05). Associations with parental psychopathology and unfavourable parental rearing were less consistent, albeit stronger for fear of interaction situations (vs. performance-related fears). Interactions with time indicated an earlier onset of SP for higher BI, but not for parental psychopathology or unfavourable parental rearing.

CONCLUSIONS

Interaction-related social fears differ in their clinical and vulnerability factors from performance-related social fears. The current DSM-IV specifier of "generalized" SP may fall short of adequately denoting these differences. Fear of taking tests appears to be conceptually and, possibly, etiologically distinct from other social fears, and may be better placed in another category (e.g., as a type of specific phobia).

Social anxiety disorder: what are we losing with the current diagnostic criteria?

OBJECTIVE

To assess the rate of comorbidities and the functional impairment associated with the social anxiety disorder (SAD), with an emphasis on the so-called subthreshold clinical signs and symptoms.

METHOD

Psychiatric comorbidities and psychosocial functioning were evaluated in 355 volunteers (college students) who had been diagnosed as SAD (n = 141), Subthreshold SAD (n = 92) or Controls (n = 122).

RESULTS

The rate of comorbidities was 71.6% in the SAD group and 50% in subjects with Subthreshold SAD, both significantly greater than Controls (28.7%). Concerning psychosocial functioning, the SAD group had higher impairment than the other two groups in all domains evaluated, and subjects with Subthreshold SAD presented intermediate values.

CONCLUSION

The rates of psychiatric comorbidities and the impairment of psychosocial functioning increase progressively along the spectrum of social anxiety. The fact that Subthreshold SAD causes considerable disability and suffering in comparison with control subjects justifies a review of the validity of the diagnostic criteria.

Social anxiety disorder: questions and answers for the DSM-V

BACKGROUND

This review evaluates the DSM-IV criteria of social anxiety disorder (SAD), with a focus on the generalized specifier and alternative specifiers, the considerable overlap between the DSM-IV diagnostic criteria for SAD and avoidant personality disorder, and developmental issues.

METHOD

A literature review was conducted, using the validators provided by the DSM-V Spectrum Study Group. This review presents a number of options and preliminary recommendations to be considered for DSM-V.

RESULTS/CONCLUSIONS

Little supporting evidence was found for the current specifier, generalized SAD. Rather, the symptoms of individuals with SAD appear to fall along a continuum of severity based on the number of fears. Available evidence suggested the utility of a specifier indicating a "predominantly performance" variety of SAD. A specifier based on "fear of showing anxiety symptoms" (e.g., blushing) was considered. However, a tendency to show anxiety symptoms is a core fear in SAD, similar to acting or appearing in a certain way. More research is needed before considering subtyping SAD based on core fears. SAD was found to be a valid diagnosis in children and adolescents. Selective mutism could be considered in part as a young child's avoidance response to social fears. Pervasive test anxiety may belong not only to SAD, but also to generalized anxiety disorder. The data are equivocal regarding whether to consider avoidant personality disorder simply a severe form of SAD. Secondary data analyses, field trials, and validity tests are needed to investigate the recommendations and options.

The relation between public speaking anxiety and social anxiety: a review

This article reviewed the literature on public speaking anxiety in the context of social phobia subtyping. In total, 18 empirical studies on subtype issues related to public speaking anxiety were analyzed. Results of the reviewed studies are discussed in relation to their research method, that is, whether it focused on qualitative or quantitative aspects of subtype differences and whether it used a clinical or community sample. Evidence supported the premise that public speaking anxiety is a distinct subtype, qualitatively and quantitatively different from other subtypes of social phobia. The significance of this finding for social phobia studies using speech tasks to assess participants' state anxiety and behavioral performance is discussed.

Entwicklungspsychopathologie Sozialer Angststörungen

Die Soziale Phobie (oder Soziale Angststörung) stellt eine häufige psychische Störung dar, die insbesondere aufgrund ihres chronischen Verlaufs mit umfassenden Beeinträchtigungen einhergeht. Voraussetzung für die langfristig wirksame Behandlung oder Prävention der Störung ist ein umfassendes Verständnis bedingender und aufrecht erhaltender Faktoren. Mittlerweile liegen neben einer Reihe deskriptiver Störungsmodelle zur Entstehung und Aufrechterhaltung eine Vielfalt empirischer Ergebnisse zu Risikofaktoren sozialer Ängste vor. Neben einem Überblick über Phänomenologie und Epidemiologie Sozialer Angststörungen liegt der Schwerpunkt der Arbeit auf der Diskussion möglicher Einflussfaktoren in einer Entwicklungspsychopathologie der Sozialen Phobie. Dabei werden internale Faktoren, wie Familiengenetik, Temperament, kognitive Stile und soziale Fertigkeiten, sowie externe Faktoren, wie Erziehungsverhalten der Eltern und Erfahrungen mit der sozialen Umwelt, berücksichtigt. Zur Integration dieser Befunde werden differenzierte Modelle zur Ausbildung und zu differenziellen Entwicklungsverläufen generalisierter und isolierter sozialer Ängste vorgeschlagen.

A new proposal for the subtypes of social phobia in a sample of Spanish adolescents

The present study aimed to analyze validity of a new proposal of delimitation and operationalization of the social phobia subtypes in the adolescence. The sample consisted of 971 Spanish adolescents ranged between 14 and 18 years, attending 59 high schools in rural and urban areas of the south-east of Spain. Principal component and cluster analyses were conducted. Results indicated that the principal components analysis revealed two factors, which could be categorized as interaction and performance anxiety, whereas the cluster analysis delimited four subtypes: specific social phobia, mild generalized social phobia, moderate generalized social phobia and severe generalized social phobia. Subsequently, comparisons in psychopathological and demographic variables showed statistically significant differences among the four subtypes. The emerging multidimensional structure was consistent with the differential psychopathological and demographic features of each group. The current study establishes preliminary support for a new proposal of subdivision and operationalization of the construct social phobia in adolescence.

Subtypes of social phobia: are they of any use?

This study investigated the existence of DSM-IV social phobia subtype models in the community. Data came from the Dresden Predictor Study of a representative sample of 1877 German women (aged 18-24 years) who completed a diagnostic interview and filled out various self-report questionnaires. The number of feared social situations was distributed continuously without a clear-cut for delineation of subtypes and significantly increased functional impairment, comorbidity, subjective need for psychotherapy, seeking psychotherapeutic help and dysfunctional attitudes, and decreased social support and mental health. Subtype models based on the number (1, 2-4 and >4) and type ('formal speaking fear' versus 'other fears') of social fear did not have extra value above the continuum model of social phobia. The heterogeneity within social phobia has to be seen as a continuum of severity of social phobia, with a greater number of feared situations associated with more functional, social and psychological disability.

Internal consistency and factor structure of the Portuguese version of the Liebowitz Social Anxiety Scale among alcoholic patients

OBJECTIVE: Liebowitz Social Anxiety Scale is an instrument used to evaluate the severity of social phobia. It has been widely used in different contexts and cultures, presenting variable psychometric properties. The objective of this article is to investigate the internal consistency and the factor structure of this scale. METHOD: In a sample of 300 alcoholic patients hospitalized in 3 mental clinics in Southern Brazil, 74 of them were social phobics (24.6%). The Structured Clinical Interview for DSM-IV-Axis I Disorders - Patient Edition, a semi-structured clinical interview based on DSM-IV, was used to check for the diagnosis of social phobia. The internal consistency was measured by Cronbach's alpha. Data were subjected to a factor analysis with the principal component method of parameter estimation. Questionnaire items loading at 0.35 or above were considered in the final factor solution. RESULTS: The coefficient of internal consistency was 0.95. All items showed corrected item-total correlation coefficient above 0.15, considered the minimum requested index. The factor analysis resulted in 5 dimensions which corresponded to 52.9% of the total variance. The five factors extracted were: factor I - speaking in a group, factor II - activity in public, factor III - social interaction with unknown person, factor IV - attitude of disagreement or disapproval and factor V - social interaction in leisure activity. CONCLUSIONS: The scale proved to be reliable and structurally valid instrument for use in a population of alcoholic patients. The possibility of screening for social phobia through the use of the instrument may be helpful in identifying probable cases of the disorder among alcoholics.

Escitalopram versus paroxetine for social anxiety disorder: an analysis of efficacy for different symptom dimensions

BACKGROUND

A previous factor analysis of pooled data demonstrated that the Liebowitz Social Anxiety Scale (LSAS) can be divided into six subscales. This paper examines data from a fixed-dose trial of escitalopram versus paroxetine, in order to determine the differential effects of these agents on symptom dimensions in social anxiety disorder (SAD).

METHODS

Data from a 24-week randomised, placebo-controlled, comparative study of fixed doses of escitalopram (5 mg, 10 mg, 20 mg) versus paroxetine (20 mg) in SAD were examined. The six factors identified in a previous factor analysis of baseline data from escitalopram studies on the primary efficacy scale, the LSAS, were used to compute subscale scores. These were analysed using analysis of covariance (ANCOVA), and standardised effect sizes were calculated.

RESULTS

The combined escitalopram data and the paroxetine data both demonstrated significant superiority to placebo on each of the 6 LSAS factors at week 24 (OC analysis). Escitalopram doses of 5 mg, 10 mg, and 20 mg were generally more effective than placebo for each of the factors. Escitalopram 20 mg was significantly more effective than paroxetine 20 mg on 5 of the 6 symptom dimensions.

CONCLUSION

Factor analysis of the LSAS allows for useful secondary analyses that support and extend the primary efficacy analysis of this instrument. The analysis here indicates that different escitalopram doses are effective across the various symptom dimensions of SAD.

Is "relationship fear" unique to Japan? Symptom factors and patient clusters of social anxiety disorder among the Japanese clinical population

BACKGROUND

There have been only a limited number of cross-cultural studies of social anxiety disorder (SAD), especially as diagnosed with modern operationalized diagnostic criteria and as measured with recently developed assessment instruments. We examined the symptomatological structure and clinical subtypes of patients with DSM-IV SAD among the Japanese clinical population.

METHODS

We performed confirmatory and exploratory factor analyses of the joint Social Interaction Anxiety Scale and Social Phobia Scale from 149 psychiatric patients diagnosed with SAD. Based on the derived symptom factors, we further ran cluster analysis to identify patient subgroups.

RESULTS

Factor analyses revealed three factors which were named "scrutiny fears", "conversation fears" and "relationship fears". The first two appeared common to Western clinical populations but the third appeared unique to the Japanese. Cluster analysis based on these three factor scores yielded three subgroups, which were externally validated and which overall corresponded with mild, moderate and pervasive subtypes of social phobia.

LIMITATIONS

Both factor analysis and cluster analysis employed in the present study are exploratory in nature. Further empirical examination in different settings and cultures is necessary to provide definitive answers.

CONCLUSIONS

It is suggested that we may need three symptom subscales and three subtypes in order to better account for cultural variations in the presentation of SAD.

Escitalopram in the treatment of social anxiety disorder: analysis of efficacy for different clinical subgroups and symptom dimensions

Escitalopram has demonstrated efficacy for the acute treatment of social anxiety disorder (SAD) in two placebo-controlled trials and for long-term treatment in a relapse-prevention study. Social anxiety disorder is a heterogeneous disorder. This study questions whether this new selective serotonin reuptake inhibitor is effective across different subgroups of patients. Data from two randomised, placebo-controlled, 12-week escitalopram SAD trials were pooled. General linear models were used to determine the efficacy of escitalopram in different patient subgroups. Furthermore, a factor analysis of the primary efficacy scale, the Liebowitz Social Anxiety Scale (LSAS), was undertaken, and a determination made of whether treatment effects were similar for the different symptom dimensions. Escitalopram was effective in both younger and older patients, in male and female patients, and in patients with more and less severe social anxiety symptoms. The LSAS factor analysis showed six factors, which were differentially associated with different areas of disability. Escitalopram was significantly superior to placebo for all six symptom dimensions. The treatment effects of escitalopram were independent of gender, symptom severity and chronicity, and comorbid depressive symptoms. A six-factor model of social anxiety symptoms is supported by the distinctive association between these symptom dimensions and different areas of disability, but did not predict differential response to escitalopram.

In search of social phobia subtypes: similarity of feared social situations

The existence of subtypes of social phobia has been questioned. Although cluster analytic methods have been used to support various subtype models, a continuous model based on total number of feared social situations seems equally plausible. In a community sample, we calculated mean similarity measures for combinations of item pairs of feared social situations. Speaking fear items were significantly more similar to each other than to other items. There was also a trend for interaction fear items to be more similar to each other than to other items. These findings suggest that fear of speaking and interactional situations may represent distinct domains of socially feared situations. They should be considered separately in delineation of treatment response and may, if replicated in clinical samples, help identify meaningful subtypes of social phobia.