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

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

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

Evaluating the interplay between subclinical levels of mental health symptoms and coordination dynamics

Viewed under the broad theoretical umbrella of an embodied-embedded approach to psychological activity, body movements can be seen to play an essential role in shaping social interaction. Of note, research concerning the embodiment of social cognition has documented key differences in non-verbal behaviour during social interaction for individuals diagnosed with a range of disorders, including social anxiety disorder and autism spectrum disorder. The present work sets out to extend these findings by better understanding the interplay between subclinical variation in psychopathology and social-motor coordination, a key component of effective interaction. We asked participants, in pairs, to swing hand-held pendula that varied in their intrinsic movement characteristics. Extending previous clinically oriented work (Varlet et al., 2014, Frontiers in Behavioral Neuroscience, 8, 29), our results indicated that subclinical variation in mental health status was predictive of disruption to the patterns of coordination dynamics that characterize effective social exchange. This work provides further evidence for the utility of theorizing social interaction as a self-organizing dynamical system and strengthens support for the claim that disruption to interpersonal coordination may act as an embodied-embedded marker of variation in mental health.

Exploring the role of the DSM-5 performance-only specifier in adolescents with social anxiety disorder

The DSM-5 social anxiety disorder section has recently added the performance-only specifier for individuals whose anxiety is limited to speaking or performing in public. The impact of the DSM-5 performance-only specifier remains a neglected area. The sample comprised 44 healthy controls and 50 adolescents with a clinical diagnosis of SAD (20% met criteria for the performance-only specifier). Findings revealed that adolescents with the specifier had a later age of onset; lower levels of depression, social anxiety symptomatology and clinical severity; and a lesser degree of comorbidity relative to adolescents with SAD but excluding the performance-only specifier. Specifiers only evidenced higher (cognitive) social anxiety symptomatology compared to healthy controls. Results of this study also suggested that the performance-only specifier may correspond to a mild form of social anxiety disorder. Data also revealed that SAD exists on a continuum of severity among healthy controls, specifier participants, and those with both interactional and performance fears, which is consistent with a dimensional structure for SAD. Finally, findings suggested a unique comorbid pattern for specifiers and those adolescents with SAD but excluding the performance-only specifier. The implications of these findings for the etiology, assessment, classification, and treatment of social anxiety in youth are discussed.

Optimal Cut-Off Score of Social Phobia and Anxiety Inventory-Brief Form

Abstract. No cut-off scores for the Social Phobia and Anxiety Inventory-Brief (SPAI-B) are available to screen for young adults with and without social anxiety disorder (SAD). In addition, there is a currently heated debate on the utility of the performance-only specifier in DSM-5. The present study is aimed at covering these gaps. Participants included 124 young adults in higher education with a clinical diagnosis of SAD and 81 healthy controls. The SPAI-B scores revealed a continuum of severity among the nonclinical population, performance-only specifier participants, and those with both performance and social interactional fears. Data suggested to use a rounded cut-off of 24 to screen for patients with both performance and interactional fears, and a rounded cut-off score of 23 for young adults with performance-only specifier. Findings demonstrated that the SPAI-B is particularly useful as a screening measure among young adults in higher education, but the limited discriminative capacity of the performance-only specifier may call into question the clinical utility of this recently established specifier.

The Role of Shame and Self-Criticism in Social Anxiety: A Daily-Diary Study in a Nonclinical Sample

We sought to explore the daily association between shame and self-criticism, and the extent to which this association varies as a function of social anxiety symptoms. Fifty-nine undergraduate students completed a measure of social anxiety symptoms at a baseline meeting and then completed measures of shame experienced during significant social interactions and self-criticism following those interactions twice daily for 10 days. Social anxiety symptoms predicted more shame during daily social interactions and more self-criticism following them. Additionally, shame predicted subsequent self-criticism. This relationship was moderated by levels of social anxiety symptoms, such that those with higher levels of social anxiety symptoms exhibited high levels of self-criticism following daily social interactions characterized by both high and low shame, whereas those with lower levels of social anxiety symptoms showed high levels of self-criticism only after interactions with high levels of shame. These findings are consistent with the notion that self-criticism may serve as a regulatory coping method when experiencing shame, and that social anxiety difficulties are related to an inflexibly high level of self-criticism.

Admixture analysis of age of onset in generalized anxiety disorder

Age of onset is a marker of clinically relevant subtypes in various medical and psychiatric disorders. Past research has also reported that age of onset in generalized anxiety disorder (GAD) is clinically significant; but, in research to date, arbitrary cut-off ages have been used. In the present study, admixture analysis was used to determine the best fitting model for age of onset distribution in GAD. Data were derived from 459 adults with a diagnosis of GAD who took part in the Netherlands Study of Depression and Anxiety (NESDA). Associations between age of onset subtypes, identified by admixture analysis, and sociodemographic, clinical, and vulnerability factors were examined using univariate tests and multivariate logistic regression analyses. Two age of onset distributions were identified: an early-onset group (24 years of age and younger) and a late-onset group (greater than 24 years of age). Multivariate analysis revealed that early-onset GAD was associated with female gender (OR 2.1 (95%CI 1.4-3.2)), higher education (OR 1.1 (95%CI 1.0-1.2)), and higher neuroticism (OR 1.4 (95%CI 1.1-1.7)), while late-onset GAD was associated with physical illnesses (OR 1.3 (95%CI 1.1-1.7)). Study limitations include the possibility of recall bias given that age of onset was assessed retrospectively, and an inability to detect a possible very-late-onset GAD subtype. Collectively, the results of the study indicate that GAD is characterized by a bimodal age of onset distribution with an objectively determined early cut-off at 24 years of age. Early-onset GAD is associated with unique factors that may contribute to its aetiology; but, it does not constitute a more severe subtype compared to late-onset GAD. Future research should use 24 years of age as the cut-off for early-onset GAD to when examining the clinical relevance of age of onset for treatment efficacy and illness course.

Subtyping social anxiety in youth

Few empirical studies have examined subtypes of social anxiety disorder (SAD) in youth, and limited consensus resides on the nature of potential subtypes. Identifying subtypes, based on both fear and avoidance patterns, can help improve assessment and treatment of SAD. Subtypes of fear and avoidance were examined in a sample comprising 131 youth (age 8-15 years) diagnosed with SAD using the Anxiety Disorders Interview Schedule for children and parents (ADIS-C/P). Exploratory factor analysis of fear responses revealed three factors, defining fear subtypes linked to: (1) performance, (2) observation, and (3) interaction situations, respectively. Exploratory factor analysis of avoidance responses showed these were best represented by one avoidance factor. Few youth qualified exclusively for either of the fear subtypes, thus calling into question the clinical utility of these subtypes. Nevertheless, the findings indicate distinct contributions of fear and avoidance in SAD presentation. This finding might help clinicians target and improve treatment of the disorder.

Taxonicity and network structure of generalized anxiety disorder and major depressive disorder: An admixture analysis and complex network analysis

BACKGROUND

Recent years have witnessed sustained efforts to delineate the nosology of generalized anxiety disorder (GAD), especially in light of its substantial comorbidity with major depressive disorder (MDD). Traditional diagnostic conceptualizations regard these disorders as categorically distinct; however, extant literature attests to appreciable similarities. The application of admixture analyses and complex network analyses has become more prevalent in recent years to investigate the presence of meaningful subgroups in mental disorders and to address qualitative similarity in network structure across disorders. To date, no studies have extended these analytic techniques to determine whether GAD and MDD constitute independent syndromes. The current study used a clinical sample comprising individuals diagnosed with primary GAD or primary MDD to examine potential subgroups and network structure using symptoms of each disorder as indicators.

METHODS

The current sample comprised 111 individuals who received primary diagnoses of either GAD or MDD and completed a battery of assessments related to anxiety and depression.

RESULTS

Results of the admixture analyses converged on a single class solution, suggesting that individuals with GAD derive from the same population as those with MDD. Furthermore, results of the complex network analyses did not reveal differences in centrality parameters across disorders, suggesting qualitative similarity.

LIMITATIONS

The cross-sectional nature of this study precludes conclusions about the temporal and causal dynamics of these disorders

CONCLUSION

GAD and MDD exhibit robust similarities, as evidenced by the converging results of the admixture analyses and complex network analyses. This conclusion complements the findings of transdiagnostic research, which has identified common mechanisms underlying multiple emotional disorders.

Eating disorders: What age at onset?

Age at onset (AAO) of eating disorders has classically been described in adolescence. We analyzed data from 806 subjects with anorexia nervosa (AN) or bulimia nervosa (BN) and performed a normal distribution admixture analysis to determine their AAO. No significant differences were found concerning the AAO functions of AN and BN subjects. Both groups had a mean AAO of about 18 years. Most of the subjects with AN (75.3%) and BN (83.3%) belonged to the early onset group. The definition of AAO for ED may be crucial for planning treatment modalities, with specific consideration of their clinical history and course.

Admixture analysis of age at symptom onset and age at disorder onset in a large sample of patients with obsessive-compulsive disorder

BACKGROUND

A number of studies tested for the presence of different homogeneous subgroups of obsessive-compulsive disorder (OCD) patients depending on the age at onset (AAO). However, none of the various thresholds of AAO have been validated. No study examined whether age at symptoms onset (ASO) and age at disorder onset (ADO) each define specific and diverse OCD subgroups.

METHODS

We used normal distribution mixture analysis in a sample of 483 OCD patients to test whether we could identify subgroups of patients according to the AAO. We tested whether ASO and ADO had different distributions and identified different subgroups of OCD patients, and whether clinical correlates had similar patterns of associations with patients subgroups identified with ASO or ADO.

RESULTS

The mixture analysis showed a trimodal distribution for ASO (mean ASO: 6.9 years for the early onset, 14.99 years for the intermediate onset, and 27.7 years for the late onset component), and confirmed a bimodal distribution for ADO (mean ADO: 18.0 and 29.5 years). Significant differences in the clinical profile of the subgroups emerged, particularly when identified using ASO.

LIMITATIONS

Limitations of our study are the retrospective investigation of AAO, and the fact that our sample may not represent the OCD population, as we enrolled patients referring to a tertiary center specialized in the treatment of OCD. Our findings need to be confirmed in community samples. Another limitation is the lack of information on medication status at enrollment.

CONCLUSIONS

Age at symptom onset and ADO showed distinct patterns of distributions. Similarly, phenotypic delineation was specific for ASO and ADO identified subgroups. Accurate clinical and biological profiling of ADO and ASO subgroups might show distinct genetic liabilities, ultimately leading to better nosological models and possibly to improved treatment decision making of OCD patients.

Validation and Diagnostic Efficiency of the Mini-SPIN in Spanish-Speaking Adolescents

OBJECTIVES

Social Anxiety Disorder (SAD) is one of the most common mental disorders in adolescence. Many validated psychometric tools are available to diagnose individuals with SAD efficaciously. However, there is a demand for shortened self-report instruments that identify adolescents at risk of developing SAD. We validate the Mini-SPIN and its diagnostic efficiency in overcoming this problem in Spanish-speaking adolescents in Spain.

METHODS

The psychometric properties of the 3-item Mini-SPIN scale for adolescents were assessed in a community (study 1) and clinical sample (study 2).

RESULTS

Study 1 consisted of 573 adolescents, and found the Mini-SPIN to have appropriate internal consistency and high construct validity. Study 2 consisted of 354 adolescents (147 participants diagnosed with SAD and 207 healthy controls). Data revealed that the Mini-SPIN has good internal consistency, high construct validity and adequate diagnostic efficiency.

CONCLUSIONS

Our findings suggest that the Mini-SPIN has good psychometric properties on clinical and healthy control adolescents and general population, which indicates that it can be used as a screening tool in Spanish-speaking adolescents. Cut-off scores are provided.

An admixture analysis of age of onset in agoraphobia

BACKGROUND

Age of onset is an important epidemiological indicator in characterizing disorders׳ subtypes according to demographic, clinical and psychosocial determinants. While investigated in various psychiatric conditions, age of onset and related characteristics in agoraphobia have yet to be examined. In light of the new diagnostic status in the DSM-5 edition of agoraphobia as independent from panic disorder, research on agoraphobia as a stand-alone disorder is needed.

METHODS

Admixture analysis was used to determine the best-fitting model for the observed ages at onset of 507 agoraphobia patients participating in the Netherlands Study of Depression and Anxiety (age range 18-65). Associations between agoraphobia age of onset and different demographic, clinical and psychosocial determinants were examined using multivariate logistic regression analysis.

RESULTS

Admixture analyses identified two distributions of age of onset, with 27 as the cutoff age (≤27; early onset, >27; late onset). Early onset agoraphobia was only independently associated with family history of anxiety disorders (p<0.01) LIMITATIONS: Age of onset was assessed retrospectively, and analyses were based on cross-sectional data.

CONCLUSION

The best distinguishing age of onset cutoff of agoraphobia was found to be 27. Early onset agoraphobia might constitute of a familial subtype. As opposed to other psychiatric disorders, early onset in agoraphobia does not indicate for increased clinical severity and/or disability.

Differentiating the subtypes of social anxiety disorder

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

Difficulty leading interpersonal coordination: towards an embodied signature of social anxiety disorder

Defined by a persistent fear of embarrassment or negative evaluation while engaged in social interaction or public performance, social anxiety disorder (SAD) is one of the most common psychiatric syndromes. Previous research has made a considerable effort to better understand and assess this mental disorder. However, little attention has been paid to social motor behavior of patients with SAD despite its crucial importance in daily social interactions. Previous research has shown that the coordination of arm, head or postural movements of interacting people can reflect their mental states or feelings such as social connectedness and social motives, suggesting that interpersonal movement coordination may be impaired in patients suffering from SAD. The current study was specifically aimed at determining whether SAD affects the dynamics of social motor coordination. We compared the unintentional and intentional rhythmic coordination of a SAD group (19 patients paired with control participants) with the rhythmic coordination of a control group (19 control pairs) in an interpersonal pendulum coordination task. The results demonstrated that unintentional social motor coordination was preserved with SAD while intentional coordination was impaired. More specifically, intentional coordination became impaired when patients with SAD had to lead the coordination as indicated by poorer (i.e., more variable) coordination. These differences between intentional and unintentional coordination as well as between follower and leader roles reveal an impaired coordination dynamics that is specific to SAD, and thus, opens promising research directions to better understand, assess and treat this mental disorder.

Age of onset in obsessive-compulsive disorder: admixture analysis with a large sample

BACKGROUND

Research into age of onset in obsessive-compulsive disorder (OCD) has indicated significant differences between patients with early and late onset of the disorder. However, multiple criteria have been used arbitrarily for differentiating between early- and late-onset OCD, rendering inconsistent results that are difficult to interpret.

METHOD

In the current study, admixture analysis was conducted in a sample of 377 OC patients to determine the number of underlying populations of age of onset and associated demographic and clinical characteristics. Various measures of anxiety, depression, co-morbidity, autism, OCD, tics and attention deficit hyperactivity disorder (ADHD) symptoms were administered.

RESULTS

A bimodal age of onset was established and the best-fitting cut-off score between early and late age of onset was 20 years (early age of onset ≤19 years). Patients with early age of onset were more likely to be single. Early age of onset patients demonstrated higher levels of OCD severity and increased symptoms on all OCD dimensions along with increased ADHD symptoms and higher rates of bipolar disorder.

CONCLUSIONS

It is suggested that 20 years is the recommended cut-off age for the determination of early versus late age of onset in OCD. Early age of onset is associated with a generally graver OCD clinical picture and increased ADHD symptoms and bipolar disorder rates, which may be related to greater functional implications of the disorder. We propose that age of onset could be an important marker for the subtyping of OCD.

Examining determinants of early and late age at onset in panic disorder: an admixture analysis

Past research demonstrated that age at onset might account for different clinical and etiological characteristics in panic disorder (PD). However, prior research relied on arbitrary choices of age cut-offs. Using a data-driven validated method, this study aimed to examine differences between early and late onset PD in various determinants. Admixture analysis was used to determine the best fitting model of age at onset distribution in PD. Data was collected from 511 individuals (ages 18-65) with PD diagnoses, who participated in the Netherlands Study of Depression and Anxiety (NESDA). DSM-IV comorbidities and various measures of childhood adversities, suicidal behavior, anxiety and depressive symptoms were assessed. The best fitting cut-off score between early and late age at onset groups was 27 years (early age at onset ≤ 27 years). Univariate tests showed that participants with early onset PD were younger and more likely to be female. Early onset PD was associated with agoraphobia, higher frequency of childhood trauma and life events, and higher rates of suicide attempts as compared to late onset PD. Multivariate logistic regression analysis demonstrated that only current age, childhood trauma and agoraphobia remained significantly associated with early onset PD. Findings suggest that 27 years marks two onset groups in PD, which are slightly distinct. Early onset PD is independently associated with exposure to childhood trauma and increased avoidance. This highlights the importance of subtyping age of onset in PD. Clinical implications are further discussed.

Neuroanatomical deficits in drug-naïve adult patients with generalized social anxiety disorder: a voxel-based morphometry study

Little is known, so far, about the cerebral structural deficits in drug-naïve adult social anxiety disorder (SAD) patients. The present study aimed to explore the cerebral anatomic deficits in drug-naïve adult generalized SAD patients using voxel-based morphometric analysis with DARTEL. High-resolution T1-weighted images were acquired from 20 drug-naïve adult SAD patients and 19 age-, sex- and education-matched controls. The volumes of gray matter, white matter, cerebrospinal fluid, and total intracranial volume were compared between groups using two-sample t-tests with age and gender as covariates. Gray matter density (GMD) was compared between groups using voxel-wise two-sample t-test analysis. Correlation analysis was used to identify any associations between regional GMD and clinical symptoms. Compared with healthy controls, SAD patients showed significantly lower GMD in the bilateral thalami, right amygdala, and right precuneus. Furthermore, the GMD in the right amygdala was negatively related to the disease duration, but positively correlated with age of onset. Our findings demonstrated that cerebral anatomic deficits could be found within limbic and thalamic areas in drug-naïve SAD patients, which provides structural information to complement the functional alterations observed in the same regions.

Informant discrepancies in adult social anxiety disorder assessments: links with contextual variations in observed behavior

Multi-informant assessments of adult psychopathology often result in discrepancies among informants' reports. Among 157 adults meeting criteria for either the generalized (n = 106) or nongeneralized (n = 51) social anxiety disorder (SAD) subtype, we examined whether discrepancies between patients' and clinicians' reports of patients' symptoms related to variations in both SAD subtype and expressions of social skills deficits across multiple social interaction tasks. Latent class analyses revealed two behavioral patterns: (a) context-specific social skills deficits and (b) cross-context social skills deficits. Similarly, patients' symptom reports could be characterized by concordance or discordance with clinicians' reports. Patient-clinician concordance on relatively high levels of patients' symptoms related to an increased likelihood of the patient meeting criteria for the generalized relative to nongeneralized subtype. Further, patient-clinician concordance on relatively high levels of patients' symptoms related to an increased likelihood of consistently exhibiting social skills deficits across social interaction tasks (relative to context-specific social skills deficits). These relations were robust in accounting for patient age, clinical severity, and Axis I and II comorbidity. Further, clinical severity did not completely explain variability in patients' behavior on laboratory tasks or discrepancies between patient and clinician reports. Findings provide the first laboratory-based support for the ability of informant discrepancies to indicate cross-contextual variability in clinical adult assessments, and the first of any developmental period to indicate this for SAD assessments. These findings have important implications for clinical assessment and developmental psychopathology research.