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.

Non-pharmacologic treatments for social anxiety disorder

OBJECTIVE

The purpose of this paper is to present a review of research on the efficacy of psychotherapeutic interventions for children, adolescents and adults with social anxiety disorder. Data are presented on the relative efficacy of cognitive-behavioral therapies (CBTs), pharmacotherapy and combination treatments. We also discuss research on specific clinical conditions that are likely to influence treatment success.

METHOD

Relevant studies were identified through literature searches, reference lists and research databases.

RESULTS

Non-pharmacologic treatments for social anxiety disorder, particularly CBTs, have gained substantial empirical support over the last two decades. However, questions remain about how to maximize the benefit of available treatments.

CONCLUSION

New directions for future research in this area are discussed.

Evaluation of the clinical global impression scale among individuals with social anxiety disorder

BACKGROUND

The clinical Global Impression Scale (CGI) is commonly used as a primary outcome measure in studies evaluating the efficacy of treatments for anxiety disorders. The current study evaluated the psychometric properties and predictors of clinicians' ratings on an adapted version of the CGI among individuals with social anxiety disorders.

METHOD

An independent assessor administered the CGI Severity of Illness and Improvement ratings to 123 patients at baseline and the subset of treated patients again mid- and post-treatment.

RESULTS

Improvement ratings were strongly related to both concurrent Severity of Illness and changes in Severity of Illness ratings from baseline. Additionally, both CGI ratings were positively correlated with both self-report and clinician-administered measures of social anxiety, depression, impairment and quality of life. Measures of social anxiety symptoms accounted for a large portion of the variance in Severity of Illness ratings, with significant additional variance accounted for by measures of impairment and depression. Changes in social anxiety symptoms from baseline accounted for significant variance in Improvement ratings, but no significant additional variance was accounted for by changes in impairment and depressive symptoms.

CONCLUSIONS

Our findings support the utility of the CGI as an index of global severity and symptom-specific improvement among individuals with social anxiety disorder.

The psychometric properties of the Interpersonal Sensitivity Measure in social anxiety disorder

The Interpersonal Sensitivity Measure (IPSM) was developed to assess hypersensitivity to interpersonal rejection, a suggested trait of depression-prone personality (Aust NZ J Psychiatry 23 (1989) 341). Although studies of the IPSM and interpersonal rejection sensitivity have primarily been conducted in depressed populations, it is important to investigate interpersonal rejection sensitivity as a relevant construct in the assessment of social anxiety. This study examined the psychometric properties of the IPSM in treatment-seeking individuals with social anxiety disorder. The results of this investigation support the convergent and divergent validity and internal consistency of the IPSM in socially anxious individuals. An exploratory factor analysis of the scale was also conducted after the original factor and subscale structure was shown to be a poor fit for the present data. Three factors emerged (Interpersonal Worry and Dependency, Low Self-Esteem, and Unassertive Interpersonal Behavior), and 29 items were retained. Because they demonstrated negative factor loadings on Factor 2, it is suggested that the scoring for four items of the original IPSM be reversed. In summary, the revised IPSM assesses three aspects of interpersonal rejection sensitivity and appears to be a valid and reliable instrument for its assessment in social anxiety disorder.

Psychometric evaluation of the Beck Depression Inventory in adults with social anxiety disorder

Although the Beck Depression Inventory (BDI) is commonly used to assess levels of depressive symptoms in socially anxious adults, its psychometric properties in this context have never been formally examined. Therefore, we examined the psychometrics of the BDI in a sample of adults with a principal diagnosis of social anxiety disorder (N = 113). The BDI exhibited good internal consistency and re-test reliability. It also correlated significantly more strongly with other measures of depression than with measures of either social or non-social anxiety. Thus, the BDI appears to be a valid tool for the assessment of depressive symptoms in adults with social anxiety disorder.

Cognitive-behavioral models of social anxiety disorder

In 1985, Liebowitz et al labeled SAD the "neglected anxiety disorder." Clearly, times have changed. Although it took 10 years after this pronouncement for the first cognitive-behavioral model of SAD to be introduced, a great deal of research has been carried out and a great deal has been learned since then. The core features of these models seem to hold a great deal of validity. Perhaps the greatest "learning curve" has been seen in work done on the processing of the self as social object, a component of both cognitive-behavioral models of SAD. A great deal of empiric evidence now suggests that people with SAD see themselves as they believe they are seen by others. Unfortunately, their perception of how they are seen by others is often grossly distorted, likely contributing to the distress they feel about social situations and their concomitant avoidance of them. Recent work by Hirsch and Mathews has gone so far as to suggest that people with the disorder may not attend at all to social information while social events are ongoing but rather may judge them later based on preexisting notions about themselves as social beings. In Rapee and Heimberg's model, preferential allocation of attentional resources is emphasized, and this has been another great area of progress over the past few years. While people with SAD may be hypervigilant to social threat in their environments, once they find it, they tend to divert their attention away from it--as has been most clearly demonstrated in the studies of processing of facial expressions. The data suggest that both angry and happy faces may be perceived as threatening and attention is diverted as a means of avoiding them--again having important implications for social behavior and for maintenance of the disorder over time. Important strides have also been made in understanding judgment biases in SAD. Studies on this issue have suggested that individuals with the disorder see positive social outcomes as unlikely and see negative social outcomes as highly likely. When presented with ambiguous scenarios, people with SAD are more likely to select negative interpretations for them, even when they are given the option of selecting positive interpretations and neutral interpretations that they could find at least somewhat believable. Furthermore, people with SAD see both negative social outcomes and positive social outcomes as coming at a higher emotional cost than do people without the disorder. Hirsch and Mathews suggest that the core of social anxiety may be a failure to (over-)emphasize the positive. However, people with the disorder may not adequately distinguish between positive and negative cues, seeing them as equal in valence. Gilboa-Schechtman et al and Wallace and Alden, using very different approaches, have also suggested that both positive and negative outcomes in social situations come at a great emotional cost for people with SAD. Studies of facial expressions suggest that positive and negative faces are perceived as threatening, leading people with SAD to divert attention away from both. Finally, the studies on the observer perspective suggest, also in line with the research of Hirsch and Mathews, that people with SAD do not pay sufficient attention to what is going on around them in social situations. In effect, they are looking at the wrong thing (or through the wrong eyes) and missing important social cues, both positive and negative. Perhaps, as suggested by Hirsh and Mathews, people with the disorder come away from social situations with very little information at all (this notion is supported by older studies that asked socially anxious people what they remembered from social situations after they had participated in them), forcing them to draw conclusions about their performance based on blanket assumptions about themselves as social beings rather than about what actually occurred during that single event. These conclusions have very important implications for treatment. First, it is clear that clinicians need to help their patients learn to pay attention in social situations and, furthermore, to attend to the "right" things. Studies that have included that manipulations of attention suggest that this is a positive direction to pursue. Furthermore, clinicians have to help their patients to make judgments based on what really occurred in a single situation, rather than drawing blanket conclusions for all situations based on preconceived notions of the self as social being. Again, some very preliminary evidence suggests that this approach (through the use of video feedback and other techniques) could be of great benefit.

Attachment in individuals with social anxiety disorder: the relationship among adult attachment styles, social anxiety, and depression

Despite their apparent implications for social functioning, adult attachment styles have never been specifically explored among persons with social anxiety disorder. In the current study, a cluster analysis of the Revised Adult Attachment Scale (N. L. Collins, 1996) revealed that 118 patients with social anxiety were best represented by anxious and secure attachment style clusters. Members of the anxious attachment cluster exhibited more severe social anxiety and avoidance, greater depression, greater impairment, and lower life satisfaction than members of the secure attachment cluster. This pattern was replicated in a separate sample of 56 patients and compared with the pattern found in 36 control participants. Social anxiety mediated the association between attachment insecurity and depression. Findings are discussed in the context of their relevance to the etiology, maintenance, and cognitive-behavioral treatment of social anxiety disorder.

Effects of writing about rape: evaluating Pennebaker's paradigm with a severe trauma

We examined the effect of disclosing to others an attempted or completed rape. Eighty-five undergraduate women who acknowledged attempted or completed rape wrote about their experience and read their narratives. In a 2 x 2 design, we examined the value of writing only factual information versus factual plus emotional information, and reading to oneself versus reading aloud to another woman. Before and 1-month after the task, symptoms of dysphoria, social anxiety and posttraumatic stress disorder were assessed. Greater detail and a moderate level of personalization in the description of the trauma were associated with decreased symptoms of dysphoria and social anxiety. Neither the nature of the writing task nor the presence of another woman predicted degree of symptom reduction.

The Liebowitz Social Anxiety Scale: a comparison of the psychometric properties of self-report and clinician-administered formats

BACKGROUND

The clinician-administered version of the Liebowitz Social Anxiety Scale (LSAS-CA) is a commonly used assessment device for the evaluation of social anxiety disorder and has been shown to have strong psychometric characteristics. Because of its apparently straightforward rating format and potential savings in time and effort, interest in the use of the LSAS as a self-report (LSAS-SR) measure has increased, and the LSAS-SR has been used in a number of studies. However, the psychometric properties of the LSAS-SR have not been well established.

METHODS

This study examined the psychometric properties of the LSAS-SR in comparison to the LSAS-CA in a sample of 99 individuals with a primary diagnosis of social anxiety disorder and 53 individuals with no current psychiatric disorder.

RESULTS

There was little difference between the two versions of the LSAS on any scale or subscale score. Both forms were internally consistent and the subscale intercorrelations for the two forms were essentially identical. Correlations of each LSAS-SR index with its LSAS-CA counterpart were all highly significant. Finally, the convergent and discriminant validity of the two forms of the LSAS was shown to be strong.

CONCLUSION

Results of this study suggest that the self-report version of the LSAS compares well to the clinician-administered version and may be validly employed in the assessment of social anxiety disorder.

Distinguishing obsessive features and worries: the role of thought-action fusion

Obsessions are a key feature of obsessive-compulsive disorder (OCD), and chronic worry is the cardinal feature of generalized anxiety disorder (GAD). However, these two cognitive processes are conceptually very similar, and there is a need to determine how they differ. Recent studies have attempted to identify cognitive processes that may be differentially related to obsessive features and worry. In the current study we proposed that (1) obsessive features and worry could be differentiated and that (2) a measure of the cognitive process thought-action fusion would distinguish between obsessive features and worry, being strongly related to obsessive features after controlling for the effects of worry. These hypotheses were supported in a sample of 173 undergraduate students. Thought-action fusion may be a valuable construct in differentiating between obsessive features and worry.

Screening for anxiety and depression in early adolescence

OBJECTIVE

To examine the level of diagnostic and discriminative accuracy of three dimensional rating scales for detecting anxiety and depressive disorders in a school-based survey of 9th grade youths.

METHOD

Classroom screening instruments, the Center for Epidemiologic Studies-Depression Scale (CES-D), the Revised Children's Manifest Anxiety Scale (RCMAS), and the Multidimensional Anxiety Scale for Children (MASC) were administered to 632 youths from three sites in 1998. On the basis of rating scale results, samples of high-scoring and non-high-scoring youths were invited to participate in a diagnostic interview conducted within 2 months of the screening sessions.

RESULTS

MASC scores were most strongly associated with individual anxiety disorders, particularly among females, whereas the CES-D composite score was associated with a diagnosis of major depression, after controlling for comorbid disorders. The RCMAS was least successful in discriminating anxiety and depression. When receiver operator characteristic curves were examined, diagnostic accuracy was moderate.

CONCLUSIONS

The ability of the MASC and CES-D to discriminate within and between categorically defined diagnostic groups has important implications for the accurate identification of youths in need of services.

Effects of varying levels of anxiety within social situations: relationship to memory perspective and attributions in social phobia

Cognitive-behavioral theorists (Clark & Wells, 1995: Clark, D. M. & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69-93). New York: Guilford Press; Rapee & Heimberg, 1997: Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35, 741-756.) propose that individuals with social phobia form mental images of themselves as if from an external point of view. Research by Wells and colleagues has shown that, when recalling anxiety-provoking social situations, individuals with social phobia are more likely to take an observer perspective (seeing oneself as if from an external point of view) whereas control subjects are more likely to take a field perspective (as if looking out through one's own eyes). Furthermore, this pattern is specific to social events, as both groups recall non-social events from a field perspective (see Wells, Clark & Ahmad, 1998: Wells, A., Clark, D. M., & Ahmad, S. (1998). How do I look with my minds eye: perspective taking in social phobic imagery. Behaviour Research and Therapy, 36, 631-634; Wells & Papageorigou, 1999: Wells, A. & Papageorgiou, C. (1999). The observer perspective: Biased imagery in social phobia, agoraphobia, and blood/injury phobia. Behaviour Research and Therapy, 37, 653-658). In the current study, individuals with social phobia took more of an observer perspective than non-anxious controls when recalling high anxiety social situations. However, both groups took a predominantly field perspective for memories of medium or low anxiety social situations. As memory perspective has also been shown to be related to causal attributions, we examined this relationship in our sample. Memories of low, medium, and high anxiety social situations were differentially related to attributions for each group. Patients' attributions for their performance became more internal, stable, and global as the anxiety level of the situation increased, while the attributions of control subjects showed the opposite pattern.

Presenting problems among treatment-seeking gay, lesbian, and bisexual youth

Gay, lesbian, and bisexual youth are at risk for a variety of clinical problems amenable to psychotherapeutic intervention. However, many psychotherapists may be unaware of the difficulties faced by this population. The purpose of this article is to familiarize therapists with presenting complaints common to psychotherapy-seeking gay, lesbian, and bisexual youth. Some of these problems include homophobia among family, peers, and authority figures (often expressed at school or at work), depression, suicidality, social anxiety, and body image disturbance. We illustrate these important issues via four case examples.

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.

Current status of psychotherapeutic interventions for social phobia

Psychotherapeutic interventions, especially the cognitive-behavioral psychotherapies, have been well studied as treatments for social phobia. The purposes of this article are to (1) enumerate and describe the varieties of cognitive-behavioral therapy (CBT) that have been applied to the treatment of social phobia, (2) provide a meta-analytic overview of the efficacy of these approaches, (3) examine the relative utility of CBT versus that of pharmacotherapy for social phobia, (4) examine the potential utility of multidisciplinary approaches to treatment, and (5) discuss possible future directions in the development of psychotherapeutic strategies for the treatment of social phobia, including the use of computers as adjunctive tools.

An empirical approach to subtype identification in individuals with social phobia

BACKGROUND

The present study used cluster analysis procedures to identify empirically subgroups of patients with social phobia in a large clinical sample.

METHOD

The Liebowitz Social Anxiety Scale (LSAS) was administered to 382 patients from several studies of the treatment of social phobia. LSAS fear ratings were summed into four subscale scores (social interaction, public speaking, observation by others, eating and drinking in public) based on a previous factor analytical study of the LSAS. In order to produce a stable and robust solution, these factor scores were submitted to a two-stage clustering procedure consisting of an agglomerative-hierarchical clustering method followed by an iterative non-hierarchical clustering method.

RESULTS

Three patient subgroups were identified based on their pattern of feared social situations on the LSAS. These groups were labelled: (1) pervasive social anxiety; (2) moderate social interaction anxiety; and (3) dominant public speaking anxiety. Clusters differed significantly on age and age of social phobia onset, as well as on measures of social anxiety, general anxiety and depressive symptomatology. Clusters also differed in the percentage of assigned patients who met criteria for the generalized subtype of social phobia and avoidant personality disorder.

CONCLUSIONS

The results provide empirical support for the existence of three subgroups in a clinical sample of individuals with social phobia and contribute to the growing evidence for the heterogeneity of social phobia. Further study of the conceptual, clinical and aetiological significance of these subgroups is needed.

Subtypes of social phobia in adolescents

Thirty-three social phobic adolescents were asked to name their ten most feared social situations. Two independent judges classified each situation reported by the participants into one of four situational domains: formal speaking/interactions, informal speaking/interactions, observation by others, and assertion. Fifteen participants (45.5%) were assigned a generalized subtype of social phobia because they endorsed at least moderate anxiety in all four situational domains. This subgroup scored higher on self-report measures of anxiety and depression than the rest of the sample. These results provide empirical support for the existence of subtypes of social phobia in adolescents.

Cognitive-behavioral group therapy versus phenelzine in social phobia: long-term outcome

To evaluate the effects of maintenance treatment and durability of gains after treatment discontinuation, responders to either phenelzine (PZ) or cognitive-behavioral group therapy (CBGT) from an acute trial comparing these two treatments as well as pill placebo and a psychotherapy control (educational supportive group therapy) were enrolled into maintenance and treatment-free follow-up phases.

EXPERIMENTAL DESIGN

Responders to an acute trial contrasting PZ and CBGT entered a six-month maintenance phase. Patients who continued to respond through the maintenance phase entered a six-month treatment free phase. Patients receiving pill placebo or educational supportive group therapy in the acute trial did not enter the long term study.

PRINCIPAL OBSERVATIONS

PZ patients entered maintenance more improved than CBGT patients, and nonrelapsing PZ patients maintained their superior gains throughout the study. Relapse during maintenance did not differ between treatments. However, PZ patients showed a trend toward greater relapse during treatment-free follow-up. There was a greater relapse among patients with generalized social phobia with phenelzine.

CONCLUSIONS

PZ and cognitive-behavioral group therapy may differ in their long term effects. The superiority seen with PZ on some measures in the acute study persisted in patients who maintained their gains over the course of maintenance and treatment-free follow-up. However, CBGT may lead to a greater likelihood of maintaining response after treatment has terminated. Replication with larger samples is needed, as is a study of the acute and long-term efficacy of combined PZ and CBGT.

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.

Comorbid generalized anxiety disorder in primary social phobia: symptom severity, functional impairment, and treatment response

As many as 50% of patients with a primary anxiety disorder may meet criteria for an additional anxiety disorder. However, there is insufficient research on the cooccurrence of the anxiety disorders, although investigations of this nature may facilitate our understanding of their cause, phenomenology, and treatment. The present study examined the occurrence of generalized anxiety disorder (GAD) among patients with social phobia (SP) compared with SP patients without GAD. Of 122 treatment-seeking patients meeting DSM-III-R criteria for SP, 29 (23.8%) also met criteria for an additional diagnosis of GAD. SP patients with comorbid GAD demonstrated greater severity on measures of social anxiety and avoidance, general anxiety, cognitive (but not somatic) symptoms of anxiety, depressed mood, functional impairment, and overall psychopathology. Group differences remained significant when comorbidity with other anxiety and mood disorders was controlled. The content of worry among the SP patients with GAD was not specific to social concerns and appeared similar to the reported content of worry in samples of patients with primary GAD. Nevertheless, SP patients with and without GAD responded similarly to cognitive-behavioral group therapy for social phobia. Implications for the understanding and treatment of comorbid SP and GAD are discussed.

Patterns of anxious arousal during exposure to feared situations in individuals with social phobia

Behavioral assessment tests (BATs) are commonly used in studies of social phobia (SP). While previous studies have examined subjective anxiety during BATs, they have usually reported only mean or peak ratings. The current study examined whether there are different patterns of anxious arousal in anticipation of, and during exposure to, feared situations among individuals seeking treatment for SP (N = 153). A four cluster solution was judged to best describe the data, and the four clusters were labeled 'high anxiety,' 'increasing/high anxiety', 'moderate anxiety' and 'mild anxiety'. Before treatment, the cluster groups did not differ on person characteristics, subtype of social phobia, or levels of depressive symptoms. However, they did differ in terms of the severity of social phobia symptoms and the emotional valence of thoughts reported at the conclusion of the BAT. While members of all clusters benefited from cognitive-behavioral group therapy for social phobia, the clusters showed some differential response in amount of symptom reduction and likelihood of continuing to meet diagnostic criteria following treatment. The different emotional experiences of clients in the various clusters are explored and implications for cognitive-behavioral therapy are proposed. Finally, limitations of this study and future directions are discussed.

Anxiety in ethnic minority youth. Methodological and conceptual issues and review of the literature

Although current research has documented a relatively high prevalence of anxiety disorders in American youth, this research has been conducted mainly with nonminority samples. Fair treatment and increasing numbers of ethnic minority persons in the United States require that more should be known about minority youth. However, research with majority youth cannot be safely generalized to minority youth for several reasons, such as potential differences in the manifestation of anxiety, differences in style of response to assessment devices, and different life circumstances. This review is presented in two major sections. First, the authors address definition of terms and fully examine the significance of studying anxiety in ethnic minority youth. Also considered are methodological issues such as sampling and participation biases. Second, the authors review anxiety in ethnic minority children and adolescents in the United States including studies addressing fears, worries, trait anxiety, test anxiety, and anxiety disorders.

The impact of comorbid mood and personality disorders in the cognitive-behavioral treatment of panic disorder

The present review examined the effect of comorbid major depressive disorder and personality disorder on the outcome of cognitive-behavioral interventions for panic disorder. Panic disorder patients often present with these comorbid conditions, but for the most part, treatment studies have paid little attention to them. Most studies on the effects of comorbidity on treatment outcome address pharmacological treatment. However, there is a growing literature on the effect of additional disorders on the outcome of cognitive-behavioral interventions for panic disorder. Findings from the studies of comorbidity with depression are equivocal, possibly reflecting inconsistencies in measurement methodology across studies. However, personality psychopathology was found to exert a detrimental effect on the outcome of cognitive-behavioral treatment for panic disorder. Further research is necessary to elucidate the impact of these concurrent conditions on cognitive-behavioral treatment for panic disorder. It is suggested that studies utilizing cognitive-behavioral treatment routinely examine the influence of comorbid conditions on treatment outcome.

Trends in the prevalence of social phobia in the United States: a synthetic cohort analysis of changes over four decades

Previous analysis of data from the U.S. National Comorbidity Survey (NCS) [24] suggested that the lifetime prevalence of social phobia in the community has increased significantly in recent cohorts. Furthermore, a latent class analysis of NCS data [21] revealed two primary classes of persons with social phobia: those with exclusive speaking fears and those with one or more other social-evaluative fears. Social phobia in the other social fear group is more persistent, more impairing, and more highly co-morbid with other DSM-III-R disorders. The current report presents data on whether the cohort effect is a general aspect of social phobia or is specific to one of the NCS social phobia subtypes, and whether the cohort effect varies as a function of socio-demographic characteristics. Data were drawn from the NCS. Social phobia was assessed with a revised version of the Composite International Diagnostic Interview. Retrospective age of onset reports were used to estimate Kaplan-Meier survival curves for first onset of social phobia in each cohort represented in the survey. Comparison of these curves allowed us to make synthetic estimates based on retrospective reports of intercohort trends in lifetime prevalence. The lifetime prevalence of social phobia appears to have increased in recent cohorts. However, this increase does not exist among social phobics with exclusive fears of speaking. The increase is most pronounced among white, educated, and married persons, and it is not explained by increased co-morbidity with other mental disorders. The fact that the cohort effect is more pronounced for social phobia with one or more non-speaking fears is important in that this is generally a more severe form of the disorder with an earlier age of onset than social phobia with pure speaking fears. The fact that the cohort effect is most pronounced among people with social and economic advantage (i.e., white, married, well-educated) is intriguing and raises questions about the etiologic process that warrant further study in future research.

Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents

In the present study, the researchers examined factors related to depression, hopelessness, and suicidality in gay, lesbian, and bisexual adolescents, compared with demographically similar heterosexual adolescents. Sexual minority adolescents reported greater depression, hopelessness, and past and present suicidality than did heterosexual adolescents. However, when controlling for other psychosocial predictors of present distress, significant differences between the 2 samples disappeared. For past suicidality scores, the effects of sexual orientation were reduced, but still significant, when accounting for the other predictor variables. These results suggest that environmental factors associated with sexual orientation, which can be targeted and changed through prevention and intervention efforts, play a major role in predicting distress in this population.

Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents

In the present study, the researchers examined factors related to depression, hopelessness, and suicidality in gay, lesbian, and bisexual adolescents, compared with demographically similar heterosexual adolescents. Sexual minority adolescents reported greater depression, hopelessness, and past and present suicidality than did heterosexual adolescents. However, when controlling for other psychosocial predictors of present distress, significant differences between the 2 samples disappeared. For past suicidality scores, the effects of sexual orientation were reduced, but still significant, when accounting for the other predictor variables. These results suggest that environmental factors associated with sexual orientation, which can be targeted and changed through prevention and intervention efforts, play a major role in predicting distress in this population.

Factor structure of social fears: The Liebowitz Social Anxiety Scale

In the assessment of social anxiety, investigators often differentiate between social interactional anxiety and performance anxiety. The Liebowitz Social Anxiety Scale (LSAS), a clinician-administered measure of social anxiety and avoidance, was originally developed with separate subscales for the assessment of fear and avoidance of situations involving social interaction and performance/observation by others. Separate confirmatory factor analyses of the LSAS fear and avoidance ratings demonstrated that this two-factor model did not provide an adequate fit to the data, suggesting the need to further investigate the underlying structure of the LSAS. Separate exploratory common factor analyses of the fear and avoidance ratings yielded four similar factors for each: (1) social interaction, (2) public speaking, (3) observation by others, and (4) eating and drinking in public, which demonstrated convergent and discriminant validity with other measures of social anxiety. These findings suggest that there are four global categories of social fear assessed by the LSAS, and that while social interaction anxiety appears to be unifactorial, fear of performance/observation situations may be multifactorial.

Shyness and sociotropy: additive and interactive relations in predicting interpersonal concerns

Sociotropy (an aspect of interpersonal dependence) and sociability (affiliative need) were examined as moderator variables of the relationship between shyness and interpersonal concerns in two studies. In Study 1, sociotropy, but not sociability, predicted unique variance in three indices of interpersonal concerns through both direct and interactive relations with shyness. An initial analysis in Study 2 showed that sociotropy, but not sociability, was predictive of participants' perceived competence in situations that involved initiation of conversations and assertion. In the second part of Study 2, sociotropy accounted for significant increments in variance when predicting cognitive and affective manifestations of distress related to simulated conversation and assertion situations, while sociability did not. Study 2 results suggest that sociotropy operates primarily in an additive manner with shyness in predicting interpersonal concerns, rather than moderating the relation between shyness and interpersonal concerns. Differences in the results of the two studies and implications for future research are discussed.

Differentiating anxious and depressive self-statements in youth: factor structure of the Negative Affect Self-Statement Questionnaire among youth referred to an anxiety disorders clinic

Conducted a factor analysis on the items from the Negative Affect Self-Statement Questionnaire (NASSQ; Ronan, Kendall, & Rowe, 1994). This analysis yielded 4 factors (Depressive Self-Statements, Anxiety/Somatic Self-Statements, Negative Affect Self-Statements, and Positive Affect Self-Statements) broadly consistent with both the content-specificity hypothesis (Beck & Clark, 1988) and L. A. Clark and Watson's (1991b) tripartite model of anxiety and depression. The association between children's self-talk and measures of trait anxiety and depression was also examined. Self-statements with content theoretically specific to depression were the best predictors of self-reported depressive symptoms, but the results were less clear for trait anxiety. Overall, these results provide evidence for the discriminability of anxious and depressive self-talk in youth and for the utility of the NASSQ as a cognitive assessment instrument.

Psychometric properties of the Liebowitz Social Anxiety Scale

BACKGROUND

The present study provides data on the reliability, validity and treatment sensitivity of the Liebowitz Social Anxiety Scale (LSAS), one of the most commonly used clinician-administered scales for the assessment of social phobia.

METHOD

Three hundred and eighty-two patients from several studies of the treatment of social phobia were evaluated. An independent assessor administered the LSAS to each patient prior to the initiation of treatment. Patients also completed other measures of social anxiety and avoidance, although the specific measures varied across samples.

RESULTS

The LSAS and its subscales were normally distributed and demonstrated excellent internal consistency. The convergent validity of the LSAS was demonstrated via significant correlations with other commonly-used measures of social anxiety and avoidance. These correlations also tended to be larger than correlations with measures of depression, especially after treatment. However, the pattern of correlations of LSAS subscales with one another and with the other measures suggest that the fear subscales and the avoidance subscales may not be sufficiently distinct in clinical samples. The LSAS was also demonstrated to be sensitive to the effects of pharmacological treatments of social phobia over time and in comparison to double-blind pill placebo.

CONCLUSION

The LSAS appears to be a reliable, valid and treatment sensitive measure of social phobia. Further study of the LSAS, both in samples with severe social phobia and in community samples, is needed.

Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome

BACKGROUND

This article presents results of the acute treatment phase of a 2-site study comparing cognitive behavioral group therapy (CBGT) and treatment with the monoamine oxidase inhibitor phenelzine sulfate for social phobia.

METHODS

One hundred thirty-three patients from 2 sites received 12 weeks of CBGT, phenelzine therapy, pill placebo administration, or educational-supportive group therapy (an attention-placebo treatment of equal credibility to CBGT). The "allegiance effect," ie, the tendency for treatments to seem most efficacious in settings of similar theoretical orientation and less efficacious in theoretically divergent settings, was also examined by comparing responses to the treatment conditions at both sites: 1 known for pharmacological treatment of anxiety disorders and the other for cognitive behavioral treatment.

RESULTS

After 12 weeks, phenelzine therapy and CBGT led to superior response rates and greater change on dimensional measures than did either control condition. However, response to phenelzine therapy was more evident after 6 weeks, and phenelzine therapy was also superior to CBGT after 12 weeks on some measures. There were few differences between sites, suggesting that these treatments can be efficacious at facilities with differing theoretical allegiances.

CONCLUSIONS

After 12 weeks, both phenelzine therapy and CBGT were associated with marked positive response. Although phenelzine therapy was superior to CBGT on some measures, both were more efficacious than the control conditions. More extended cognitive behavioral treatment and the combination of modalities may enhance treatment effect.

Assessment of contemporary social phobia verbal report instruments

The Social Phobia Scale (SPS), the Social Interaction Anxiety Scale (SIAS) and the Social Phobia and Anxiety Inventory (SPAI) were compared to each other and evaluated in patients with social phobia. We examined the relationship of these three contemporary social phobia verbal report instruments with each other, as well as with behavioral and self-report cognitive criteria. As expected, the three social phobia scales were significantly intercorrelated, although they differed in their relationship to the behavioral and cognitive measures. Specifically, the SPS had a significant negative relationship with time spent in a speech behavioral assessment test. The higher the anxiety scores were on the SPS, the less time patients spent giving an impromptu speech in front of a small audience. The SIAS was consistently related to negative and positive self-reported thoughts in speech and conversation behavioral assessment tests. All instruments differentiated patients with speech phobia from those having both generalized social phobia and avoidant personality disorder; on the SPAI and the SIAS, however, distinguished the former group from individuals with generalized social phobia but not without avoidant personality disorder. All three social phobia instruments were sensitive to treatment changes. Results are discussed in terms of the relative utility of each of these measures' total sores and any and their subscales.

Cross-informant agreement in the assessment of social phobia in youth

In the present study involving children and adolescents with a principal diagnosis of social phobia, we measured parent-child agreement regarding social anxiety symptoms. Additionally, we examined variables related to the severity of the children's social phobia symptoms as reported by children and as rated by clinicians. Examination of cross-informant agreement indicated little difference between mean parent and children ratings of the children's social fears. In contrast, there was a significant difference in parent and children ratings of the children's avoidance, with parents endorsing greater degrees of social avoidance. Children's report of social avoidance was negatively related to scores on a measure of self-presentational concerns (i.e., social desirability). Clinicians' determination of the severity of the children's social phobia was also influenced by the children's self-presentation as well as parent report of social avoidance and children's depression scores. Thus, this differential weighting by the clinician of parent versus child report may be related to the finding that children's self-reported social avoidance was negatively related to their concerns regarding positive self-presentation. Results suggest the need to consider the impact of social desirability when examining clinical characteristics of children and adolescents with social phobia.

An investigation of gender differences in social phobia

The present study was an exploratory investigation of gender differences in a large sample of persons with social phobia. Potential differences in demographic characteristics, comorbidity, severity of fear, and situations feared were examined. No differences were found on history of social phobia, social phobia subtype, or comorbidity of additional anxiety disorders, mood disorders, or avoidant personality disorder. However, women exhibited more severe social fears as indexed by several assessment instruments. Some differences between men and women also emerged in their report of severity of fear in specific situations. Women reported significantly greater fear than men while talking to authority, acting/performing/giving a talk in front of an audience, working while being observed, entering a room when others are already seated, being the center of attention, speaking up at a meeting, expressing disagreement or disapproval to people they do not know very well, giving a report to a group, and giving a party. Men reported significantly more fear than women regarding urinating in public bathrooms and returning goods to a store. Additionally, there were some differences in the proportion of men and women reporting fear in different situations. Specifically, more women than men reported fear of going to a party, and more men than women reported fear of urinating in a public restroom. Gender differences among patients with social phobia are discussed in the context of traditional sex-role expectations.

Stressful life events and personality styles: relation to impairment and treatment outcome in patients with social phobia

Forty-five patients with social phobia and 15 individuals with no mental disorder were compared on number and type of life events experienced. Social phobia patients were further examined to evaluate the effect of negative life events and of the interaction between personality style and life events on severity of impairment and reactions to cognitive-behavioral group therapy. Patients with social phobia reported more negative life events than participants with no mental disorder. Among patients with social phobia, more frequent negative life events were associated with higher scores on measures of depression and general anxiety. Patients high on autonomy who reported more negative autonomous (i.e., achievement-oriented) life events also scored higher on measures of social anxiety and general anxiety. There were no significant interactions between sociotropy and the frequency of reported socially oriented negative life events. However, patients high on sociotropy scored higher on measures of social anxiety, depression, and general anxiety. Patients who had experienced more negative life events improved more after treatment on measures of social anxiety than did those who had experienced fewer negative life events. Implications of these findings and recommendations for future research are discussed.

Factor structure of the Social Interaction Anxiety Scale and the Social Phobia Scale

In the study of social anxiety, it is common to differentiate between social interaction versus performance anxiety. The Social Interaction Anxiety Scale was designed to assess social interaction anxiety, and the Social Phobia Scale to assess fear of scrutiny by others (Mattick and Clarke, 1989). In common use, these scales are typically administered together and treated as subscales of a larger measure. However, the joint factor structure of these instruments has never been examined; therefore, it is unclear whether or not the items on these scales actually represent distinct aspects of social anxiety. In the present study, a confirmatory factor analysis of the pooled items from the SIAS and SPS failed to adequately fit the data. An exploratory factor analysis yielded three factors: (1) interaction anxiety, (2) anxiety about being observed by others, and (3) fear that others will notice anxiety symptoms. However, hierarchical factor analysis suggested that these factors all load on a single higher-order factor, social anxiety. Relationships of the first-order factors to other measures of social and performance fear and avoidance are examined, and implications of our findings for the assessment of social phobia are discussed.

Clients' expectancies and their relationship to pretreatment symptomatology and outcome of cognitive-behavioral group treatment for social phobia

The present study examined the expectancies of clients with social phobia that they would benefit from cognitive-behavioral group treatment. Lower expectancies for positive outcome were related to greater severity of social phobia, duration of social phobia, and depression. Lower expectancies were also reported by individuals with the generalized subtype of social phobia, but expectancies were not further influenced by the presence of other Axis I disorders. Expectancy ratings did not differ between clients who dropped out of treatment and those who did not, but, after pretreatment severity of social phobia was accounted for, expectancies significantly predicted improvement among treatment completers. Clients' expectancy beliefs may be an important factor to address in the prediction of who will benefit from a cognitive-behavioral treatment, even when that treatment has demonstrated specific efficacy.

A cognitive-behavioral model of anxiety in social phobia

The current paper presents a model of the experience of anxiety in social/evaluative situations in people with social phobia. The model describes the manner in which people with social phobia perceive and process information related to potential evaluation and the way in which these processes differ between people high and low in social anxiety. It is argued that distortions and biases in the processing of social/evaluative information lead to heightened anxiety in social situations and, in turn, help to maintain social phobia. Potential etiological factors as well as treatment implications are also discussed.

Clients' expectancies and their relationship to pretreatment symptomatology and outcome of cognitive-behavioral group treatment for social phobia

The present study examined the expectancies of clients with social phobia that they would benefit from cognitive-behavioral group treatment. Lower expectancies for positive outcome were related to greater severity of social phobia, duration of social phobia, and depression. Lower expectancies were also reported by individuals with the generalized subtype of social phobia, but expectancies were not further influenced by the presence of other Axis I disorders. Expectancy ratings did not differ between clients who dropped out of treatment and those who did not, but, after pretreatment severity of social phobia was accounted for, expectancies significantly predicted improvement among treatment completers. Clients' expectancy beliefs may be an important factor to address in the prediction of who will benefit from a cognitive-behavioral treatment, even when that treatment has demonstrated specific efficacy.

A systematic replication of the prescriptive treatment of school refusal behavior in a single subject

We employed a multiple-baseline design to test the efficacy of a recently developed approach for reducing school refusal behavior. This approach uses a systematic method for conducting a functional analysis for the target behaviors and suggests specific intervention strategies based upon this analysis. To maximize external validity, the intervention was tested using a systematic replication strategy, whereby only the major conceptual elements of the intervention were retained from previous applications. The subject was a 10 year old girl who attended school with great difficulty and resistance and who was assigned DSM-III-R diagnoses of separation anxiety disorder and social phobia prior to treatment. Following 8 weeks of treatment, she showed marked reductions in problem behavior and no longer met criteria for any anxiety disorder diagnoses. The results highlight the importance of the use of functional analytic strategies to effect behavior change.

Issues in the design of trials for the evaluation of psychosocial treatments for social phobia

Scientific evaluation of the efficacy of treatments for mental disorders is an undertaking of critical importance. However, the design of trials evaluating psychosocial treatments may determine whether or not they will ultimately provide meaningful data that may guide further treatment development. In this paper, we address areas of methodological concern in the evaluation of psychosocial treatments. These are discussed in the context of psychosocial treatments for social phobia, whether they be the sole focus of an outcome trial, compared to other psychosocial or pharmacological treatments, or combined with pharmacotherapies. We address issues of patient representativeness, adequacy of treatment as conducted, selection and design of control conditions, and assessment of change over the course of treatment for social phobia. Most of these issues have implications for the evaluation of pharmacotherapies for social phobia as well.

Issues in the design of trials for the evaluation of psychopharmacological treatments for social phobia

Social phobia was neglected by psychopharmacologically oriented researchers until the past decade. Benefitting from the experience with other anxiety and other affective disorders, however, and also from unique interdisciplinary collaborative arrangements between psychopharmacological and cognitive behavioral investigators, treatment research in social phobia has made remarkable progress in the past few years. Not only has the field itself advanced, but investigative models have been created that are now being adopted and adapted for other disorders.

Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia

This study examined the relationship of compliance with homework assignments and posttreatment anxiety in patients who received cognitive-behavioral group therapy (CBGT) for social phobia. Greater homework compliance measured in the first and latter periods of CBGT was associated with lower levels of social interactional anxiety after treatment. Surprisingly, homework compliance during the middle sessions of CBGT was positively related to posttreatment fears of scrutiny and criticism. Perceptions of control in social phobia and their potential effect on homework compliance and the homework compliance/treatment outcome relationship were also examined using the Levenson (Journal of Consulting and Clinical Psychology, 41, 397-404, 1973) Locus of Control Scale. Social phobics were less likely to believe in their own control over events than a comparison sample of community subjects but attributed greater control over events to other powerful persons. Among patients, higher Internality and lower Powerful Others subscale scores were associated with higher levels of pretreatment anxiety. However, neither subscale was significantly related to measures of homework compliance. Furthermore, when included in multiple regression analyses, neither subscale or its interaction with homework compliance added to the prediction of posttreatment anxiety. Limitations of this study and future research to improve assessment of homework compliance and perceptions of control among social phobic patients are discussed.

Social phobia and PTSD in Vietnam veterans

Posttraumatic stress disorder (PTSD) is the most prevalent psychological disorder experienced by Vietnam veterans. However, there are many other disorders and problems of adjustment, like social anxiety and social phobia, that have not been fully investigated in this population. This study examined the prevalence of social phobia and the comorbidity of social phobia and PTSD, and tested out a theory of the etiology of social anxiety in trauma victims. Forty one Vietnam combat veterans were interviewed and completed self-report measures assessing PTSD and social phobia. Adversity of homecoming was also assessed. Using a conservative multi-method assessment approach, 32% of the sample were found to be positive for both social phobia and PTSD. Veterans with PTSD were significantly more likely to carry an additional diagnosis of social phobia as compared to veterans without PTSD. Adversity of homecoming and shame about one's experience in Vietnam were significant predictors of current level of social anxiety over and above the effects of pre-military anxiety and severity of combat exposure. These observations suggest that social anxiety and social phobia may be significant problems among individuals with PTSD. Further, these findings offer preliminary support for the theory that posttrauma environment may impact upon the later development of social anxiety.

Relationship between ADIS clinician's severity rating and self-report measures among social phobics

Although global clinical rating scales have been a mainstay of clinical research, little is known about the relationship between these measures and other assessment modalities. The present study examined the Clinician's Severity Rating (CSR) from the Anxiety Disorders Interview Schedule in a sample of 186 social phobics. It was hypothesized that the CSR would be related to higher fear of negative evaluation, behavioral avoidance, social anxiety, and dysphoria, and that four self-report measures reflecting each of these common features of social phobia would contribute individually to predict clinicians' judgments of clinical severity using the CSR. Multiple regression analyses supported these hypotheses, accounting for nearly 33% of the variance in the CSR. The role of subtype of social phobia was also investigated. Overall, these results support the utility of the CSR for use with social phobics, but the relatively low proportion of variance accounted for raises further questions. Directions for future research are also discussed.