Characteristics of patients with social phobia and their treatment in specialized clinics for anxiety disorders in the Netherlands

Not intended, still embarrassed: Social anxiety is related to increased levels of embarrassment in response to unintentional social norm violations

Background:

Social anxiety disorder (SAD) is associated with altered social norm (SN) processing: SAD-patients rate stories on SN violations as more inappropriate and more embarrassing than healthy participants, with the most prominent effect for stories on unintentional SN violations (i.e. committing a blunder). Until now it’s unknown how levels of social anxiety (SA) are related to ratings of SN violations in the general population, in which SA-symptoms are present at a continuum. More insight in this relationship could improve our understanding of the symptom profile of SAD. Therefore, we investigated the relation between ratings of SN violations and SA-levels in the general population.

Methods:

Adults and adolescents (n = 87) performed the revised Social Norm Processing Task (SNPT-R) and completed self-report questionnaires on social anxiety. Repeated-measures ANCOVAs were used to investigate the effect of SA on the ratings of inappropriateness and embarrassment.

Results:

As hypothesized, participants with higher SA-levels rated SN violations as more inappropriate and more embarrassing. Whereas participants with low-to-intermediate SA-levels rated unintentional SN violations as less embarrassing than intentional SN violations, participants with high SA-levels (z-score SA ≥ 1.6) rated unintentional SN violations as equally embarrassing as intentional SN violations.

Conclusion:

These findings indicate that increased embarrassment for unintentional SN violations is an important characteristic of social anxiety. These high levels of embarrassment are likely related to the debilitating concern of socially-anxious people that their skills and behavior do not meet expectations of others, and to their fear of blundering. This concern might be an important target for future therapeutic interventions.

The Leiden Family Lab study on Social Anxiety Disorder: A multiplex, multigenerational family study on neurocognitive endophenotypes

OBJECTIVES

Social anxiety disorder (SAD) is a serious and prevalent psychiatric condition, with a heritable component. However, little is known about the characteristics that are associated with the genetic component of SAD, the so-called "endophenotypes". These endophenotypes could advance our insight in the genetic susceptibility to SAD, as they are on the pathway from genotype to phenotype. The Leiden Family Lab study on Social Anxiety Disorder (LFLSAD) is the first multiplex, multigenerational study aimed to identify neurocognitive endophenotypes of social anxiety.

METHODS

The LFLSAD is characterized by a multidisciplinary approach and encompasses a variety of measurements, including a clinical interview, functional and structural magnetic resonance imaging and an electroencephalography experiment. Participants are family members from 2 generations, from families genetically enriched for SAD.

RESULTS

The sample (n = 132 participants, from 9 families) was characterized by a high prevalence of SAD, in both generations (prevalence (sub)clinical SAD: 38.3%). Furthermore, (sub)clinical SAD was positively related to self-reported social anxiety, fear of negative evaluation, trait anxiety, behavioral inhibition, negative affect, and the level of depressive symptoms.

CONCLUSIONS

By the multidimensional character of the measurements and thorough characterization of the sample, the LFLSAD offers unique opportunities to investigate candidate neurocognitive endophenotypes of SAD.

Delta-beta correlation as a candidate endophenotype of social anxiety: A two-generation family study

BACKGROUND

Social anxiety disorder (SAD) is characterized by an extreme and intense fear and avoidance of social situations. In this two-generation family study we examined delta-beta correlation during a social performance task as candidate endophenotype of SAD.

METHODS

Nine families with a target participant (diagnosed with SAD), their spouse and children, as well as target's siblings with spouse and children performed a social performance task in which they gave a speech in front of a camera. EEG was measured during resting state, anticipation, and recovery. Our analyses focused on two criteria for endophenotypes: co-segregation within families and heritability.

RESULTS

Co-segregation analyses revealed increased negative delta-low beta correlation during anticipation in participants with (sub)clinical SAD compared to participants without (sub)clinical SAD. Heritability analyses revealed that delta-low beta and delta-high beta correlation during anticipation were heritable. Delta-beta correlation did not differ between participants with and without (sub)clinical SAD during resting state or recovery, nor between participants with and without SAD during all phases of the task.

LIMITATIONS

It should be noted that participants were seen only once, they all performed the EEG tasks in the same order, and some participants were too anxious to give a speech.

CONCLUSIONS

Delta-low beta correlation during anticipation of giving a speech might be a candidate endophenotype of SAD, possibly reflecting increased crosstalk between cortical and subcortical regions. If validated as endophenotype, delta-beta correlation during anticipation could be useful in studying the genetic basis, as well as improving treatment and early detection of persons at risk for developing SAD.

Short-term effectiveness of web-based guided self-help for phobic outpatients: randomized controlled trial

Background

Internet-based guided self-help has been successfully used in the general population, but it is unknown whether this method can be effectively used in outpatient clinics for patients waiting for face-to-face psychotherapy for phobias.

Objective

The aim was to assess the clinical effectiveness of Phobias Under Control, an Internet-based intervention based on exposure therapy with weekly guidance.

Methods

We conducted a randomized controlled trial, recruiting 212 outpatients scheduled to receive face-to-face psychotherapy for any type of phobia at an outpatient clinic. Participants suffering from at least 1 DSM-IV or ICD-10 classified phobia (social phobia, agoraphobia with or without panic disorder, and/or specific phobia as ascertained by a telephone interview at baseline) were randomly allocated to either a 5-week Internet-based guided self-help program based on exposure therapy with weekly student support followed by face-to-face psychotherapy (n=105) or a wait-list control group followed by face-to-face psychotherapy (n=107). Primary outcome was the Fear Questionnaire (FQ). Secondary outcomes were the Beck Anxiety Inventory (BAI) and Center of Epidemiological Studies-Depression scale (CES-D). Assessments took place by telephone at baseline (T0) and on the Internet at posttest (T1, self-assessment at 5 weeks after baseline). Missing data at T1 were imputed.

Results

At posttest, analysis of covariance on the intention-to-treat sample showed significant but small effect sizes between intervention and control groups on the FQ (d=0.35, P=.02), CES-D (d=0.34, P=.03), and a nonsignificant effect size on the BAI (d=0.28. P=.05). Although initial acceptance was good, high nonresponse was observed, with 86 of 212 participants (40.5%) lost to follow-up at T1 and only 14 of 105 (13.3%) intervention participants finishing all 5 weeks.

Conclusions

Phobias Under Control is modestly effective in lowering phobic and depressive symptoms in a relatively short period and may be clinically beneficial when implemented in routine outpatient practice.

Trial Registration

Netherlands Trial Register NTR2233; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2233 (Archived by WebCite at http://www.webcitation.org/6O2ioOQSs).

Severity of anxiety in mental health versus addiction treatment settings when social anxiety and substance abuse are comorbid

There is increasing interest in the co-occurrence of social anxiety and addiction. Each investigation has a specific vantage point, e.g., the effect social anxiety has in a population with addiction or that of addiction in a population with social anxiety, which could create unique findings. Among comorbid individuals, is social anxiety more severe in people seeking treatment for anxiety, as compared to those seeking treatment for addiction? This report compares social anxiety severity between subjects in two studies--one involving socially anxious individuals (n=38) seeking treatment for addictions; the other (n=41) subjects with social anxiety and an alcohol use disorder, seeking treatment for social anxiety. Baseline severity scores on the Liebowitz Social Anxiety Scale for social anxiety were compared between the groups. No significant differences were found. For both groups, social anxiety was largely in the severe range. The results suggest that clinicians should attend to social anxiety symptom severity in patients with co-occurring social anxiety and addiction, regardless of the condition for which treatment is sought.

Effectiveness and cost-effectiveness of web-based treatment for phobic outpatients on a waiting list for psychotherapy: protocol of a randomised controlled trial

BACKGROUND

Phobic disorders are highly prevalent and constitute a considerable burden for patients and society. As patients wait for face-to-face psychotherapy for phobic disorders in outpatient clinics, this time can be used for guided self-help interventions. The aim of this study is to investigate a five week internet-based guided self-help programme of exposure therapy in terms of clinical effectiveness and impact on speed of recovery in psychiatric outpatients, as well as the cost-effectiveness of this pre-treatment waiting list intervention.

METHODS/DESIGN

A randomised controlled trial will be conducted among 244 Dutch adult patients recruited from waiting lists of outpatient clinics for face-to-face psychotherapy for phobic disorders. Patients suffering from at least one DSM-IV classified phobic disorder (social phobia, agoraphobia or specific phobia) are randomly allocated (at a 1:1 ratio) to either a five-week internet-based guided self-help program followed by face-to-face psychotherapy, or a control group followed by face-to-face psychotherapy. Waiting list status and duration are unchanged and actual need for further treatment is evaluated prior to face-to-face psychotherapy. Clinical and economic self-assessment measurements take place at baseline, post-test (five weeks after baseline) and at 3, 6, 9 and 12 months after baseline.

DISCUSSION

Offering pre-treatment internet-based guided self-help efficiently uses time otherwise lost on a waiting list and may increase patient satisfaction. Patients are expected to need fewer face-to-face sessions, reducing total treatment cost and increasing speed of recovery. Internet-delivered treatment for phobias may be a valuable addition to psychotherapy as demand for outpatient treatment increases while budgets decrease.

TRIAL REGISTRATION

Netherlands Trial Register NTR2233.

Correlations between the offensive subtype of social anxiety disorder and personality disorders

AIMS

Recent studies have revealed the possibility that the offensive subtype of social anxiety disorder (SAD) may no longer be a culture-bound syndrome; however, detailed clinical pictures have never been reported. This study investigated the differences between the offensive and non-offensive subtypes of SAD in terms of the background and axis I and II comorbidity.

METHODS

A total of 139 patients with SAD based on DSM-IV criteria were studied by conducting a semi-structured interview including the Structured Clinical Interview for DSM-IV axis I and II disorders, and the Liebowitz Social Anxiety Scale.

RESULTS

Fifty-two (37%) patients were classified with the offensive subtype. There were no significant differences in most demographic variables and axis I lifetime comorbidity between offensive and non-offensive subtype patients. On logistic regression analysis, offensive subtype patients showed a more frequent history of parental physical abuse, higher Liebowitz Social Anxiety Scale scores, and more frequently exhibited obsessive--compulsive personality disorders than non-offensive subtype patients.

CONCLUSION

Yamashita (1977) reported that the majority of offensive subtype patients were doted on by their parents, although current offensive subtype patients are more likely to have had a troubled childhood, show severer forms of SAD, and more frequently exhibit an inflexible personality. This study suggested that the offensive subtype might not be essentially different from the non-offensive subtype (quantitative rather than qualitative).

Neuropsychological effects of stress on social phobia with and without comorbid depression

BACKGROUND

The influence of stress on neuropsychological functioning was assessed in socially phobic (SP), comorbid socially phobic/major depression (CM), and asymptomatic control subjects (AC) under baseline and stressor conditions.

METHODS

Subjects were 33 clinically diagnosed undergraduates aged 18 to 41 years. Neuropsychological measures included the Trail Making Test, Wisconsin Card Sorting Test (WCST), Spatial Span, and Digit Span administered during a baseline condition and a psychosocial stress condition (videotaping).

RESULTS

Spatial Span scores were reduced for SP during stress, improved for AC, and showed no change for CM. TMT B times showed an interaction effect, with completion time improving significantly less for SP than for AC and CM during stress. Analyses of the normative data for WCST total errors indicated that AC and CM improved significantly during stress, while SP performance declined during stress.

CONCLUSIONS

The present findings suggest that comorbid depressed versus non-depressed SP subjects respond uniquely to stress in terms of their neuropsychological functioning and self-reported mood and experiences; generalized social phobia may be associated with spatial working memory disturbance during social stress. Therefore, situations involving potential social and personal evaluation (e.g., examinations or presentations) may have a significant impact on the neuropsychological functioning of SP individuals.

Social anxiety disorder in 300 patients hospitalized for alcoholism in Brazil: high prevalence and undertreatment

BACKGROUND

Although the frequency of social phobia is high among alcoholic patients, this anxiety disorder is often neglected because treatment tends to be focused exclusively on alcohol dependence.

METHODS

A total of 300 hospitalized alcoholic patients were interviewed using Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and Liebowitz Social Anxiety Scale as well a questionnaire to check the use of medication for social phobia among alcoholics and the relationship between social phobia and alcohol use.

RESULTS

A prevalence of 30.6% was found for specific phobia, 24.7% for social phobia, 22.2% for anxiety disorder induced by alcohol, 19.3% for generalized anxiety disorder, 5% for obsessive-compulsive disorder, 4.6% for posttraumatic stress disorder, and 2% for panic disorder with agoraphobia. Social phobia preceded alcohol dependence in 90.2% of the patients. The frequency of the use of medication for social phobia among social phobic alcoholics was 20.3%.

CONCLUSIONS

The study confirms the high prevalence of anxiety disorders among alcoholics, particularly of social phobia. It also suggests that social phobia precedes alcohol dependence but shows that the use of medication for social phobia is still infrequent. Further studies are required to check if the failure to identify this comorbidity can make the recovery of alcoholics even more difficult.

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

Individuals with anxiety disorders experience substantial delays in obtaining treatment, but little is known about whether people with specific anxiety subcategories are differentially affected. The present study used a modified Encounter Form to examine the cause and length of delays in reaching primary care and specialist services amongst patients with panic disorder (PD/PD-Ag), social phobia (SP), and generalized anxiety disorder (GAD). Participants were 142 consecutive patients attending a specialist anxiety clinic in South Western Sydney. On average, participants with SP took much longer to consult a primary health care provider. Primary care assessments of those with SP often failed to detect anxiety as the key problem, and subsequently, those with SP reported longer delays in reaching specialist care (>9 years). It is not possible to extrapolate the findings to all individuals with SP, as the study was based on specialist service attenders. Nevertheless, the data supports previous findings in suggesting that SP may not be well-recognized as a disorder needing treatment, either by the patient or the primary health care provider. Appropriate educational programs seem warranted to ensure appropriate treatment for this condition.

Reliability of the Social Phobia and Anxiety Inventory (SPAI) Portuguese version in a heterogeneous sample of Brazilian university students

OBJECTIVE: To evaluate internal consistency and temporal stability trough test re-test reliability of the Portuguese version of the Social Phobia and Anxiety Inventory (SPAI) in a heterogeneous Brazilian sample. METHODS: After informed consent, the translated and adapted version of the SPAI Portuguese was tested and re-tested at a 14-day interval in a sample of 225 university students, both genders, from 4 different undergraduate courses. After double data entry, statistical analysis included Cronbach's alphas, Pearson and intra-class correlation coefficients. RESULTS: The studied sample consisted of 213 students from 4 sub-samples: 95 law students, 31 social communication students, 54 civil engineering students and 33 dental medicine students. The mean age was 23 (±6) years and 110 (51.6%) were female. The Cronbach' alpha was 0.96, no difference for both genders. The differential (total) score of the SPAI Portuguese showed Pearson coefficient 0.83 (95% CI 0.78-0.87) and Intra-class coefficient 0.83 (95% CI 0.78-0.86). There was no statistical difference in Pearson coefficients between genders (p = 0.121) and the 4 sub-samples (p = 0.258). CONCLUSION: The results do not ensure validity, however, the SPAI Portuguese version presented a good content homogeneity with satisfactory level of internal consistency. The temporal stability evaluated was substantial. The results showed that the Portuguese SPAI presents perfectly acceptable reliability for both genders and suggest that it can be used in Brazilian populations