Delays in referral of patients with social phobia, panic disorder and generalized anxiety disorder attending a specialist anxiety clinic

Correlates of treatment seeking in individuals with social anxiety disorder: Findings from a nationally representative sample

Despite the availability of well-established and efficacious treatments for social anxiety disorder, most socially anxious individuals do not seek treatment and those who do often suffer for years before seeking treatment. A more comprehensive understanding of the factors related to treatment seeking for social anxiety disorder is needed. This study utilized the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a large representative U.S. adult sample, to examine the relationships between treatment seeking for social anxiety disorder and demographic characteristics, psychiatric comorbidities, social anxiety disorder symptomatology, and specific feared situations. Socially anxious individuals (n = 1,255) were identified using DSM-V criteria and treatment seeking was measured by either seeking help from a professional or being prescribed medication for social anxiety disorder symptoms. Results indicate key relationships between treatment seeking and age as well as comorbid anxiety disorders. Importantly, this study found that specific feared situations such as fear of small groups (AOR = 1.78) and speaking in social gatherings (AOR = 1.66), and specific social anxiety disorder symptoms such as panic attacks (AOR = 2.92) were significantly and uniquely associated with increased treatment seeking for social anxiety disorder.

A Brief Online and Offline (Paper-and-Pencil) Screening Tool for Generalized Anxiety Disorder: The Final Phase in the Development and Validation of the Mental Health Screening Tool for Anxiety Disorders (MHS: A)

Generalized anxiety disorder (GAD) can cause significant socioeconomic burden and daily life dysfunction; hence, therapeutic intervention through early detection is important. This study was the final stage of a 3-year anxiety screening tool development project that evaluated the psychometric properties and diagnostic screening utility of the Mental Health Screening Tool for Anxiety Disorders (MHS: A), which measures GAD. A total of 527 Koreans completed online and offline (i.e., paper-and pencil) versions of the MHS: A, Beck Anxiety Inventory (BAI), Generalized Anxiety Disorder-7 (GAD-7), and Penn State Worry Questionnaire (PSWQ). The participants had an average age of 38.6 years and included 340 (64.5%) females. Participants were also administered the Mini-International Neuropsychiatric Interview (MINI). Internal consistency, convergent/criterion validity, item characteristics, and test information were assessed based on the item response theory (IRT), and a factor analysis and cut-off score analyses were conducted. The MHS: A had good internal consistency and good convergent validity with other anxiety scales. The two versions (online/offline) of the MHS: A were nearly identical (r = 0.908). It had a one-factor structure and showed better diagnostic accuracy (online/offline: sensitivity = 0.98/0.90, specificity = 0.80/0.83) for GAD detection than the GAD-7 and BAI. The IRT analysis indicated that the MHS: A was most informative as a screening tool for GAD. The MHS: A can serve as a clinically useful screening tool for GAD in Korea. Furthermore, it can be administered both online and offline and can be flexibly used as a brief mental health screener, especially with the current rise in telehealth.

Duration of untreated illness in a cross-diagnostic sample of obsessive-compulsive disorder, panic disorder, and social anxiety disorder

OBJECTIVE

In this study, we compared duration of untreated illness (DUI) in obsessive-compulsive disorder (OCD), panic disorder (PD), and social anxiety disorder (SAD) patients and investigated its correlates, both within specific diagnoses and across the whole sample.

METHODS

Eighty-eight patients (33 OCD, 24 SAD, and 31 PD) had their diagnosis confirmed by the Mini International Neuropsychiatric Interview, were assessed for treatment-seeking variables, and were evaluated with instruments aimed at quantifying transdiagnostic features (i.e., the Cause subscale of the Illness Perception Questionnaire-Mental Health and the Anxiety Sensitivity Index-Revised) and severity of illness (i.e., Beck Depression and Anxiety Inventories, the Dimensional Obsessive-Compulsive Scale, the Panic and Agoraphobia Scale, and the Social Phobia Inventory).

RESULTS

The only differences between groups with short (<2 years) versus long (>2 years) DUI were greater fear of public display of anxiety in the first group and greater social avoidance in the second group. The DUI was significantly different between groups that sought treatment after the onset of illness, with OCD patients having longer DUI than PD patients and shorter DUI than SAD patients. Further, DUI correlated negatively with the perception of OCD being caused by stress and positively with severity of panic-related disability in SAD patients, but not in PD or OCD patients.

CONCLUSION

There was substantial delay in treatment seeking among the anxiety and obsessive-compulsive disorder patients, particularly those with OCD or SAD. Perception of stress as a cause of OCD prompted treatment seeking, while severity of panic symptoms delayed treatment seeking.

Does initial use of benzodiazepines delay an adequate pharmacological treatment? A multicentre analysis in patients with psychotic and affective disorders

It is established that delayed effective pharmacotherapy plays a significant role in the overall burden of psychiatric disorders, which are often treated with symptomatic drugs, that is benzodiazepines (BZDs), in relation to their rapid onset of action and safety, despite long-term side effects. We aimed to assess the influence of initial treatment with BZDs on the duration of untreated illness (DUI) and whether specific sociodemographic and clinical factors could influence the choice of BZDs as first treatment in 545 patients affected by schizophrenia, mood and anxiety spectrum disorders. Statistical analyses (one-way analysis of variance and χ) were carried out to compare patients who used BZDs as first treatment (BZD w/) and those who did not (BZD w/o). The overall DUI, irrespective of diagnosis, resulted in significantly longer in BZD w/ versus w/o patients, who also experienced more frequently anxious/depressive symptoms at onset. Furthermore, BZD w/ patients more frequently autonomously decided to look for treatment (mainly refering to psychologists or general practitioners) and experimented more frequently phobias, than BZD w/o ones. The present findings suggest that initial BZDs treatment may prolong the overall DUI, although their prescription seems to be influenced by specific sociodemographic and clinical factors. Further studies are needed to confirm the present findings.

Suicidal Risk, Psychopathology, and Quality of Life in a Clinical Population of Adolescents

BACKGROUND

According to literature data, psychopathology is associated with both quality of life (QoL) and suicidal risk in adolescents, but the literature does not fully support a direct association between psychopathology and suicidal thoughts and behaviors. The aim of this study was to investigate the possible mediational role of QoL in the relationship between psychopathology and level of suicidal risk in a clinical sample of adolescents.

METHOD

The authors examined a clinical population of 134 adolescents, aged 13-18 years. Suicidal risk-having any current suicidal ideations and/or previous suicide attempt-was assessed by the Mini International Neuropsychiatric Interview. QoL was evaluated by the adolescent self-rated versions of "Das Intervertar zur Erfassung der Lebensqualität Kindern und Jugendlichen" (ILK: Measure of Quality of Life for Children and Adolescents) and psychopathology was measured by adolescent self-rated versions of the Strengths and Difficulties Questionnaire (SDQ). A mediational model, in which QoL mediated the relationship between psychopathology and suicidal risk controlling for gender and age, was tested by means of regression analyses.

RESULTS

Gender and age were both associated with suicidal risk. Self-reported QoL significantly mediated the relationships between emotional problems (=1.846; 95% BCa CI: 0.731-2.577), as well as peer problems (=0.883; 95% BCa CI: 0.055-1.561) and suicidal risk: more emotional and peer problems were associated with lower QoL, which in turn was related to higher level of suicidal risk.

CONCLUSION

Based on this study, which aims to make further steps in suicidal prevention, our findings suggest that clinicians should routinely screen the QoL of their patients, especially in adolescents with emotional and peer problems. Furthermore, it is important to focus intervention and treatment efforts on improving the QoL of adolescents with emotional and peer problems.

Reduced duration of untreated illness over time in patients with schizophrenia spectrum, mood and anxiety disorders

AIMS

Psychiatric disorders represent highly impairing conditions, often underdiagnosed and undertreated, with a conspicuous duration of untreated illness (DUI). Given that social and cultural factors influence the DUI and assuming that progress in diagnosis and treatment determines a reduced latency to pharmacotherapy, we assessed and compared DUI and related variables in a large sample of psychiatric patients (n = 562) whose onset occurred within three different a priori-defined epochs.

METHODS

Two temporal cut-offs were established - the year 1978, when Law 180 (redefining standards for mental care) was introduced in Italy, and the year 2000 - in order to divide patients into three subgroups: onset before 1978, onset 1978-2000 and onset after 2000.

RESULTS

A significant difference in terms of age at onset, age at first diagnosis and age at first treatment was observed in patients with onset 1978-2000 and in those with onset after 2000. In addition, a significant reduction of the DUI was found across epochs (onset before 1978: 192.25 ± 184.52 months; onset 1978-2000: 77.00 ± 96.63 months; and onset after 2000: 19.00 ± 31.67 months; P < 0.001). Furthermore, the proportion of patients with onset-related stressful events, use of benzodiazepines and neurological referral was found to be significantly different between the three epochs (χ(2) = 23.4, P < 0.001; χ(2) = 9.92, P = 0.007; χ(2) = 16.50, P = 0.011).

CONCLUSIONS

Present data indicate a progressive, statistically significant reduction of latency to treatment and other related changes across subsequent epochs of onset in patients with different psychiatric disorders. Future studies will assess specific changes within homogeneous diagnostic subgroups.

Generalized social anxiety disorder: A still-neglected anxiety disorder 3 decades since Liebowitz's review

In the 3 decades since Liebowitz's review of 'a neglected anxiety disorder,' controversy and challenges have remained in the study of social anxiety disorder (SAD). This review examines evidence around the classification and subtyping of SAD, focusing on generalized SAD. Substantial discrepancies and variation in definition, epidemiology, assessment, and treatment of generalized SAD exist as the international literature on it has grown. In East Asian cultures in particular, study of taijin kyofusho has been important to a broadened conceptualization of SAD into generalized SAD. Despite important progress with biological and other studies, many challenges in the understanding of generalized SAD will remain in the years to come.

Why are children and adolescents referred for psychiatric assessment without fulfiling diagnostic criteria for any psychiatric disorder?

BACKGROUND

Clinicians often experience that children are referred for psychiatric evaluation without fulfiling the diagnostic criteria of any psychiatric disorders. This study investigates factors that might lead children to psychiatric referral without any psychiatric disorder.

METHOD

Children/adolescents who were referred for psychiatric assessment (referred group) (n = 418, mean age = 10.82 years, SD = 3.81) and a control group (n = 48, mean age = 10.38 years, SD = 3.77) were evaluated by the Mini International Neuropsychiatric Interview Kid (MINI Kid) and the Erfassung der Lebensqualität Kindern und Jugendlichen (Measure of Quality of Life for Children and Adolescents). The referred group was further divided into two subgroups: referred subgroup without MINI Kid diagnosis (n = 61) and referred subgroup with MINI Kid diagnosis (n = 357). Subjects less than 18 years old were included and there was no lower age limit.

RESULTS

Attention-deficit/hyperactivity disorder (ADHD) symptoms significantly increased the odds for referral as social phobia symptoms significantly decreased the odds for psychiatric referral. Regarding quality of life (QoL), the control group showed significantly less impairment when compared with the referred group; the two referred subgroup with and without diagnosis did not differ significantly.

CONCLUSIONS

ADHD symptoms, even in a subthreshold level and impaired QoL represent risk factors for psychiatric referral in children. Secondary prevention of children should target to screen subthreshold ADHD symptoms and QoL.

Social anxiety disorder, a lifelong disorder? A review of the spontaneous remission and its predictors

OBJECTIVE

Based on clinical observations, social anxiety disorder (SAD) is usually described as a chronic disorder. Its natural course in the community is less clear.

METHOD

The present review summarises prospective and retrospective spontaneous remission rates of SAD in the community and its predictors that were published after 1987. Remission rates were specified as partial, defined as still having social fears, but not fulfilling the diagnostic criteria, and full, defined as having no social fears anymore.

RESULTS

In prospective studies, remission rates of SAD varied between 36% and 93% and in retrospective studies between 3% and 80%. The estimated average remission rate in prospective studies was 50% for full remission and 79% when including partial remission. In retrospective studies, the average remission rate was 26% during the last year and 56% over the lifetime. Diverse predictors of remission of SAD have been found that can be clustered into less severe anxiety, less additional psychopathology, less stress, employment, and mental health.

CONCLUSION

The enormous variation in remission rates indicates that SAD might have different course types (short, fluctuating, and chronic) and is not necessarily a chronic disorder. Prevention and treatment should be focused on enhancing positive and reducing negative factors.

Social anxiety disorder in DSM-5

With the publication of DSM-5, the diagnostic criteria for social anxiety disorder (SAD, also known as social phobia) have undergone several changes, which have important conceptual and clinical implications. In this paper, we first provide a brief history of the diagnosis. We then review a number of these changes, including (1) the primary name of the disorder, (2) the increased emphasis on fear of negative evaluation, (3) the importance of sociocultural context in determining whether an anxious response to a social situation is out of proportion to the actual threat, (4) the diagnosis of SAD in the context of a medical condition, and (5) the way in which we think about variations in the presentation of SAD (the specifier issue). We then consider the clinical implications of changes in DSM-5 related to these issues.

Differences in latency to first pharmacological treatment (duration of untreated illness) in anxiety disorders: a study on patients with panic disorder, generalized anxiety disorder and obsessive-compulsive disorder

AIM

The latency to first pharmacological treatment (duration of untreated illness or 'DUI') is supposed to play a major role in terms of outcome in psychotic conditions. Interest in the field of affective disorders and, in particular, of duration of untreated anxiety, has been recently registered as well. However, a preliminary epidemiologic investigation of the phenomenon is necessary. The present study was aimed to investigate and compare age at onset, age at first pharmacological treatment and DUI in a sample of patients affected by different anxiety disorders. DUI was defined as the interval between the onset of the specific anxiety disorder and the administration of the first adequate pharmacological treatment in compliant subjects.

METHODS

Study sample included 350 patients, of both sexes, with a DSM-IV-TR diagnosis of panic disorder (n = 138), generalized anxiety disorder (n = 127) and obsessive-compulsive disorder (n = 85).

RESULTS

Panic disorder was associated with the shortest DUI (39.5 months), whereas obsessive-compulsive disorder was associated with the longest latency to treatment (94.5 months) (F = 13.333; P < 0.0001). Patients with generalized anxiety disorder showed a mean DUI of 81.6 months.

CONCLUSION

Present results indicate that patients with different anxiety disorders may wait for years (from 3 up to 8) before receiving a first adequate pharmacological treatment. Differences in terms of age at onset, age at the first pharmacological treatment and, ultimately, in DUI in specific anxiety disorders may depend on multiple clinical and environmental factors. Latency to non-pharmacological interventions (e.g. psychoeducation and different forms of psychotherapy) needs to be addressed and correlated with DUI in future studies.

A clinically useful social anxiety disorder outcome scale

Increasingly, emphasis is being placed on measurement-based care to improve the quality of treatment. Although much of the focus has been on depression, measurement-based care may be particularly applicable to social anxiety disorder (SAD) given its high prevalence, high comorbidity with other disorders, and association with significant functional impairment. Many self-report scales for SAD currently exist, but these scales possess limitations related to length and/or accessibility that may serve as barriers to their use in monitoring outcome in routine clinical practice. Therefore, the aim of the current study was to develop and validate the Clinically Useful Social Anxiety Disorder Outcome Scale (CUSADOS), a self-report measure of SAD. The CUSADOS was designed to be reliable, valid, sensitive to change, brief, easy to score, and easily accessible, to facilitate its use in routine clinical settings. The psychometric properties of the CUSADOS were examined in 2415 psychiatric outpatients who were presenting for treatment and had completed a semi-structured diagnostic interview. The CUSADOS demonstrated excellent internal consistency, and high item-total correlations and test-retest reliability. Within a sub-sample of 381 patients, the CUSADOS possessed good discriminant and convergent validity as it was more highly correlated with other measures of SAD than with other psychiatric disorders. Furthermore, scores were higher in outpatients with a current diagnosis of SAD compared to those without a SAD diagnosis. Preliminary support also was obtained for the sensitivity to change of the CUSADOS in a sample of 15 outpatients receiving treatment for comorbid SAD and depression. Results from this validation study in a large psychiatric sample show that the CUSADOS possesses good psychometric properties. Its brevity and ease of scoring also suggest that it is feasible to incorporate into routine clinical practice.

The best next drug in the course of generalized anxiety disorders: the "PN-GAD-algorithm"

OBJECTIVE

Today, there are many pharmacotherapeutic options for generalized anxiety disorder (GAD). The question is, which is the best medication for a particular patient at a particular moment? This is especially challenging because GAD is by definition a chronic disorder and new interventions should learn from earlier experiences. An algorithm which can help to use pretreatment information for drug selection is the "Pretreatment - Next Treatment (PN) - Algorithm". This article introduces an PN-algorithm for GAD.

METHODS AND RESULTS

For the development of a GAD-specific PN-algorithm, all possible pharmacological options for GAD are reviewed and brought into a rank order on the basis of scientific evidence regarding efficacy, tolerability, or price: (1) pregabalin, (2) venlafaxine XR, (3) selective serotonin reuptake inhibitors, (4) tricyclic antidepressants, (5) buspirone, (6) antipsychotics, (7) benzodiazepines, and (8) hydroxyzine. Based on this hierarchy and patient-specific information, a decision algorithm is derived, which allows to assess and evaluate pretreatment and to select the drug with no contraindications, limited negative or convincing positive effects, or the option which has not been used so far but which is the next compound in the hierarchy.

CONCLUSIONS

The "PN-GAD-algorithm" can be easily translated into a checklist to support clinical decision-making. It can also help to increase patient empowerment and cooperation in long-term treatment.

Issues and controversies surrounding the diagnosis and treatment of social anxiety disorder

Although much has been learned about social anxiety disorder (SAD) in recent decades, many questions and controversies surrounding its diagnosis and treatment have remained. Similar to the state of affairs with other psychiatric disorders, no clear pathophysiology has been identified for SAD, and the question of where to draw the line between shyness, SAD and even avoidant personality disorder continues to be debated. Much of the evidence to date suggests that among persons with SAD, it is under-recognized and undertreated; however, other researchers contend that it may be overdiagnosed in some individuals. Questions also remain as to how best treat these individuals, such as with pharmacotherapy, psychotherapy or a combination of the two. The aim of this review is to provide an overview of the controversies related to the diagnosis and treatment of SAD. In addition, suggestions for future research are provided that could perhaps clarify these remaining questions, such as maximizing treatment efficacy by targeting broader outcomes such as quality of life and addressing common comorbidities that occur with SAD.

Can long-term outcomes be improved by shortening the duration of untreated illness in psychiatric disorders? A conceptual framework

The duration of untreated illness (DUI), meaning the latency to the pharmacological treatment, has been increasingly investigated in the last decade as a predictor of outcome across different psychiatric conditions, particularly in psychotic disorders. DUI is essentially computed by subtracting the age of onset of a specific disorder from the age at which the first adequate pharmacological treatment is administered. Assessment of the latency to treatment represents one of the first steps in planning early interventions. This review examines the role of the DUI in psychotic and affective disorders, focusing on neuropathological, epidemiologic, clinical and prognostic factors related to a longer latency to treatment. Through a Medline and Cochrane Library search, relevant studies up to June 2011 and other pertinent articles including meta-analyses, randomized controlled trials, naturalistic studies and clinical reviews were identified. Converging evidence indicates that a prolonged DUI negatively influences the outcome of first-episode psychosis and schizophrenia in different ways, and increasing data point toward a similar conclusion in affective disorders. Even though methodological limitations related to investigation of the DUI need to be considered, research and interventions aimed to reduce latency to treatments are object of increasing implementation worldwide. The assessment of the DUI represents one of the most important parameters to consider in this perspective, in order to quantify different latency to treatment in specific disorders and to plan related, targeted interventions.

Self-Disclosure and Mental Health Service Use in Socially Anxious Adolescents

Social anxiety disorder is highly prevalent in adolescence, persistent into adulthood, and associated with multiple impairments. Despite the development of efficacious treatments for socially anxious youth, few affected adolescents receive such treatment. This study examined service use in a sample of high school students (n = 1,574), as well as predictors of treatment delay and factors associated with adolescents' disclosure of social difficulties. Self-report measures of social anxiety and service utilization were administered by study staff to 10th- and 11th-grade classrooms across three public high schools. Consistent with the literature, results indicated low treatment utilization (14 %) and lengthy delays in treatment initiation. Symptom severity, impairment, and disclosing anxiety to school personnel were significant predictors of service utilization. Several demographic and illness-specific factors were associated with a higher likelihood of disclosing social discomfort. These findings underscore the important role of school personnel in identifying and referring youth with anxiety disorders. Implications are discussed for increasing access to services, including school-wide screenings and training of school personnel to recognize and provide intervention for anxious youth.

Treatment-seeking for social anxiety disorder in a general outpatient psychiatry setting

Many individuals with social anxiety disorder (SAD) seek treatment principally for another psychiatric disorder, but when directly asked, a majority of these individuals also desire treatment for SAD. Several reasons may exist for why individuals with SAD do not seek treatment for it, such as the severity or functional impairment related to SAD. The aim of the current study was to examine factors related to SAD severity, impairment, and comorbidity, to gain a better understanding of what factors may be related to treatment-seeking for SAD. In 819 psychiatric outpatients with SAD, initial results showed that age, duration of SAD illness, number of social fears endorsed, Clinical Global Impression score, Sheehan Disability Scale ratings for social life and distress, presence of major depressive disorder, and presence of depressive disorder not otherwise specified (DDNOS) were associated with treatment-seeking for SAD status. However, a regression analysis found that DDNOS was the most robust predictor of treatment-seeking for SAD status, followed by the number of feared social situations. Other factors should be examined in the future, such as knowledge of SAD and available treatment options.

Characteristics and predictors of social phobia course in a longitudinal study of primary-care patients

BACKGROUND

Social Phobia (SP) is a prevalent disorder in primary-care settings. To date, few researchers have examined the natural course of SP in primary care. We examined the natural course and predictors of recovery in a large sample of primary-care patients.

METHODS

Data are obtained from the Primary Care Anxiety Project, a naturalistic, longitudinal study of anxiety disorders in primary-care patients. This report pertains to 182 patients with SP at intake. We examined intake demographic and clinical variables as predictors of recovery within the 5 years of follow-up.

RESULTS

The probability of recovery from SP during the 5-year follow-up period was .40. At intake, a longer duration of SP episode, comorbid Panic Disorder with Agoraphobia, and lower psychosocial functioning predicted lower rates of recovery.

CONCLUSIONS

These findings highlight the chronicity of SP, as well as factors that may affect its naturalistic course. It is imperative that primary-care physicians and mental health specialists assess for and treat SP in their practices. Future research is warranted to further examine the effect of medical and psychiatric comorbidity on SP course.

Age at onset and latency to treatment (duration of untreated illness) in patients with mood and anxiety disorders: a naturalistic study

This study was designed to investigate and compare demographic and clinical features with specific emphasis on age at onset, age at first treatment and, in particular, on duration of untreated illness (DUI), in patients with different mood and anxiety disorders. Study sample included 729 outpatients with the following diagnoses: major depressive disorder (n=181), bipolar disorder type I (BD I, n=115) and II (BD II, n=186), generalized anxiety disorder (n=100), panic disorder (n=96), and obsessive-compulsive disorder (n=51). Main demographic and clinical variables of the sample were compared among the diagnostic groups using one-way analysis of variance or chi tests. The diagnostic groups showed significant differences in relation to age at onset and age at first pharmacological treatment and in relation to latency to treatment. In particular, patients with major depressive disorder showed the shortest DUI (39.08 months), whereas patient with BD II showed the longest DUI (97.2 months) in comparison with the other groups. Within the group with anxiety disorders (F=7.512, P<0.001), patients with panic disorder showed the shortest DUI (44.35 months), whereas patients with obsessive-compulsive disorder showed the longest DUI (90.57 months). The present findings suggest that patients with different mood and anxiety disorders show significant differences in terms of age at onset, age at first treatment and, consequently, DUI, which potentially reflect different reasons influencing treatment delay.

Duration of untreated psychosis and duration of untreated illness: new vistas

The duration of untreated illness (DUI), defined as the interval between the onset of a psychiatric disorder and the administration of the first pharmacological treatment, has been increasingly investigated in the last decade as a predictor of outcome across different psychiatric conditions including schizophrenia and psychotic disorders (duration of untreated psychosis), and mood and anxiety disorders. Converging evidence indicates that a prolonged DUI may be viewed as a negative prognostic factor in schizophrenia and increasing data point toward a similar conclusion in mood and anxiety disorders. Through a Medline search, the present article highlights the role of the DUI in this group of psychiatric disorders, focusing on social and psychopathological determinants of the DUI, as well as the clinical consequences related to a longer DUI in terms of outcome. Hypotheses on neurobiological mechanisms underpinning outcome differences in relation to a prolonged DUI are provided and methodological limitations related to the assessment of the DUI in published studies and clinical practice discussed. Finally, given that DUI is supposed to be a potentially modifiable prognostic factor, intervention programs aimed to reduce this variable are briefly considered and discussed.

The prevalence and correlates of adult separation anxiety disorder in an anxiety clinic

BACKGROUND

Adult separation anxiety disorder (ASAD) has been identified recently, but there is a paucity of data about its prevalence and associated characteristics amongst anxiety patients. This study assessed the prevalence and risk factor profile associated with ASAD in an anxiety clinic.

METHODS

Clinical psychologists assigned 520 consecutive patients to DSM-IV adult anxiety subcategories using the SCID. We also measured demographic factors and reports of early separation anxiety (the Separation Anxiety Symptom Inventory and a retrospective diagnosis of childhood separation anxiety disorder). Other self-report measures included the Adult Separation Anxiety Symptom Questionnaire (ASA-27), the Depression, Anxiety, Stress Scales (DASS-21), personality traits measured by the NEO PI-R and the Work and Social Adjustment Scale. These measures were included in three models examining for overall differences and then by gender: Model 1 compared the conventional SCID anxiety subtypes (excluding PTSD and OCD because of insufficient numbers); Model 2 divided the sample into those with and without ASAD; Model 3 compared those with ASAD with the individual anxiety subtypes in the residual group.

RESULTS

Patients with ASAD had elevated early separation anxiety scores but this association was unique in females only. Except for social phobia in relation to some comparisons, those with ASAD recorded more severe symptoms of depression, anxiety and stress, higher neuroticism scores, and greater levels of disability.

CONCLUSIONS

Patients with ASAD attending an anxiety clinic are highly symptomatic and disabled. The findings have implications for the classification, clinical identification and treatment of adult anxiety disorders.

Social Anxiety Disorder: Recent Developments in Psychological Approaches to Conceptualization and Treatment

The aim of the present study was to identify and synthesize recent research findings in the aetiology and psychological treatment of social anxiety disorder and consider how these might improve outcome through more effective intervention. The electronic databases Medline, EMBASE and PsychInfo were searched for January 2000–December 2008. Publications of interest referred to in relevant articles were also reviewed. Case reports and publications not in English were excluded. The greatest variance in social anxiety disorder is accounted for by temperamental and personality factors and these may be associated with significant heritability. The environmental contribution is smaller and mainly due to non-shared factors, with a small contribution from shared environmental factors. Epidemiological research confirms that social anxiety disorder is chronic, and among the anxiety disorders has the lowest rates of treatment seeking, receipt of evidence-based treatments and recovery. Effective psychological treatments have been available for some time, and the research emphasis is on increasing the efficacy of treatments through innovations in programme content and delivery. Cognitive science research has contributed a better understanding of cognitive factors that maintain social anxiety disorder and informed enhancement of the cognitive elements of therapy. Internet-based programmes show promise as a novel way to deliver and improve access to effective therapy. Genetic, personality and temperamental factors contribute to the risk for social anxiety disorder. Given the associated comorbidity and disability, energy needs to be directed towards early recognition and treatment, and to increasing engagement and retention in effective therapy. Ongoing professional education is required to ensure that the disorder is recognized and evidence-based treatments received by patients who do seek help. Current cognitive behavioural treatments are being enhanced as the results of cognitive science research are being applied, and novel forms of treatment delivery show promise in increasing access.

Social anxiety and cognitive biases in non-referred children: The interaction of self-focused attention and threat interpretation biases

Cognitive-behavioral models of social phobia emphasize the combined effects of cognitive biases in the maintenance of the condition, and recent findings in adults implicate self-focused attention as one such bias. However, research examining self-focus in youth is limited. This investigation examined the causal role of self-focused attention on threat interpretation biases in a community sample of 175 socially anxious children. Self-focused attention was experimentally induced via a mirror manipulation procedure and self-focused attention was assessed before and after mirror exposure. Social interpretation biases were examined via an ambiguous stories task with half of the children completing the task in front of a mirror and the other half without a mirror. Social anxiety predicted self-focus and threat interpretation bias. The mirror manipulation did not have an effect on focus of attention or on threat interpretation bias, nor did it interact with social anxiety. Implications and future research directions are discussed.

Screening for social fears and social anxiety disorder in psychiatric outpatients

The ability of a diagnostic interview to identify all individuals with a particular psychiatric disorder depends, in part, on the performance of the interview's initial screening questions. The Structured Clinical Interview for the Diagnostic and Statistical Manual, Fourth Edition (SCID) is the most widely used research diagnostic interview, yet little research has examined the performance of the SCID screening questions. Because social anxiety disorder (SAD) is one of the most frequent psychiatric disorders, we examined the performance of the SCID screening question in the SAD module to detect social fears and SAD. The incremental validity of a more comprehensive list of social fears was examined by determining how many patients were diagnosed with SAD in those who were originally missed by the SCID screening question. Five percent of those originally missed by the SCID screening question subsequently received a lifetime diagnosis of SAD, and there was a significant increase in the prevalence of social fears after patients were cued by the social fears list. The most commonly reported fears missed by the SCID screening question included speaking in a group, with sexually attractive others, and with authority figures. Results suggest that perhaps these fears could be added to the SCID screening question to capture individuals missed by the SCID screening question and to provide more comprehensive information for treatment purposes.

Recovery from social phobia in the community and its predictors: data from a longitudinal epidemiological study

The present longitudinal study aimed to determine rate of natural recovery from DSM-IV social phobia in the community and to examine predictors of recovery. Data were derived from the Dresden Predictor Study of a representative sample of 1396 young German women. The participants completed a diagnostic interview and self-report questionnaires at two survey points approximately 1.5 years apart. Of the 91 women with social phobia at baseline 64% were at least partially recovered and 36% showed full recovery from social phobia at follow-up, defined as absence of any of the DSM-IV criteria of social phobia. Predictors of recovery from social phobia were: being employed, no lifetime depression, fewer than three lifetime psychiatric disorders, less psychopathology, less anxiety sensitivity, fewer daily hassles, and better mental health. These results show that rates of recovery from social phobia are relatively high in community and that less stress and internal psychological problems play an important role in recovery from social phobia.

Does comorbid Social Anxiety Disorder impact the clinical presentation of principal Major Depressive Disorder?

BACKGROUND

Although previous research has examined comorbidity in principal Social Anxiety Disorder (SAD), few studies have examined the disorders for which those with comorbid SAD seek treatment. Further, studies have shown that depressive disorders often are associated with SAD, but few have examined the clinical characteristics of patients with this particular comorbidity.

METHOD

The current study examined the prevalence of various principal Axis I disorders in 577 individuals diagnosed with comorbid SAD.

RESULTS

Consistent with previous research, Major Depressive Disorder (MDD) was the most frequent principal diagnosis in patients with comorbid SAD. Those with principal MDD and comorbid SAD (MDD-SAD) were compared to those with MDD without SAD (MDD) on demographic and clinical characteristics. Patients with MDD-SAD versus those with MDD were more severe in terms of social functioning, duration of depressive episode, suicidal ideation, time out of work, presence of current alcohol abuse/dependence, and age of onset of MDD. Social functioning, duration of episode, suicidal ideation, and age of onset of MDD remained significant even after controlling for additional comorbid disorders.

CONCLUSIONS

Findings suggest the need for future research to determine how treatments could be adapted for this commonly occurring comorbidity.

Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder

Mindfulness-based stress reduction (MBSR) has been reported to reduce anxiety in a broad range of clinical populations. However, its efficacy in alleviating core symptoms of specific anxiety disorders is not well established. We conducted a randomized trial to evaluate how well MBSR compared to a first-line psychological intervention for social anxiety disorder (SAD). Fifty-three patients with DSM-IV generalized SAD were randomized to an 8-week course of MBSR or 12 weekly sessions of cognitive-behavioral group therapy (CBGT). Although patients in both treatment groups improved, patients receiving CBGT had significantly lower scores on clinician- and patient-rated measures of social anxiety. Response and remission rates were also significantly greater with CBGT. Both interventions were comparable in improving mood, functionality and quality of life. The results confirm that CBGT is the treatment of choice of generalized SAD and suggest that MBSR may have some benefit in the treatment of generalized SAD.