Social anxiety disorders in clinical practice: differentiating social phobia from avoidant personality disorder

Estimating the prevalence and characteristics of people in severe social isolation in 29 European countries: A secondary analysis of data from the European Social Survey round 9 (2018-2020)

The main aim of the present study was to estimate the prevalence of people in severe social isolation as a proxy for high risk of hikikomori using data from 29 European countries. The relationship between the presence/absence of severe social isolation and demographic and psychosocial variables was also investigated. Publicly available data from the European Social Survey (ESS) round 9 collected between August 2018 and January 2020 were used. Data from the ESS round 1 (September 2002 -December 2003) and round 10 (September 2020 -May 2022) were also examined to investigate changes in the prevalence of severe social isolation over time. Analyses were restricted to the working-age population (15-64 years). A complex sampling design to obtain weighted prevalence and results was used. The study protocol was preregistered online on the Open Science Framework (https://osf.io/6a7br/). The weighted prevalence of severe social isolation was 2.01% for the sample from the ESS 1, 1.77% for the sample from the ESS 9, and 1.71% for the sample from the ESS 10, indicating a decrease over time, mainly in males. Logistic regression models showed that different sociodemographic factors (e.g., being retired, being permanently sick or disabled, doing housework, living in Central and Eastern Europe, living uncomfortably on household income, having no income) were associated with severe social isolation. Further, feeling unsafe when walking alone in the neighbourhood after dark, low social trust, and support, decreased happiness and lack of future planning correlated with severe social isolation after adjustment for the effect of sociodemographic factors was made. In this study, the prevalence of severe social isolation as a proxy for hikikomori in European countries is in line with that found by previous representative studies conducted in Asian countries. The novelty of the findings as well as implications for hikikomori research are discussed according to recent scientific literature.

Research Review: The relationship between social anxiety and social cognition in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Childhood Social Anxiety Disorder (SAD) is common and impairing. The recommended treatment is a disorder specific form of cognitive behavioural therapy (CBT) that includes social skills training and, whilst they appear to be more effective than more general treatments, it is not clear whether social skills training is the critical component involved in improved outcomes, particularly given that evidence for the relationship between social anxiety and social skills deficits in children is inconsistent. This may be partly due to an overlap in their observable features, and because the nature of the association may vary in different contexts (e.g. according to child age). An alternative approach is to examine the association between social anxiety and the social cognitive capacities that underpin social skills. This paper aims to examine the association between social anxiety and social cognition in children and adolescents, and examine conceptual and methodological moderators of this relationship.

METHODS

Papers published between 1980 and 2019 were screened systematically. Fifty studies were identified from which an effect size could be calculated for the relationship between social anxiety and social cognition, including 15,411 children and adolescents.

RESULTS

An overall significant, but moderate effect (r = -.15) was identified, where increased social anxiety was associated with lower social cognitive ability. Moderation analyses revealed specific associations within studies examining social anxiety among participants with and without ASD who were older than 7 years old, and studies assessing the relationship between social anxiety and specific aspects of Theory of Mind (ToM). No significant association was identified between social anxiety and emotion recognition.

CONCLUSIONS

Significant associations between social anxiety and social cognitive abilities appear to be accounted for by elevated social anxiety among children with ASD, and those with difficulties in specific aspects of ToM but not broader social skills, such as emotion recognition. This reinforces the importance of accurately identifying and treating social anxiety within ASD populations. In addition, treatments for social anxiety among neurotypical populations may benefit from targeting particular aspects of ToM rather than emotion recognition and other broad social skills.

Social anxiety disorder and avoidant personality disorder from an interpersonal perspective

OBJECTIVES

The general objective of this article is to study the unclear and overlapping relationship between social anxiety disorder (SAD) and avoidant personality disorder (AvPD) from an interpersonal perspective. The first specific objective is to compare the disorders with regard to interpersonal problems and general symptom distress. The second specific objective is to examine interpersonal subgroups and pathoplasticity.

DESIGN

In a cross-sectional design, patients from an outpatient psychotherapy clinic diagnosed with social anxiety disorder (SAD, n = 299), avoidant personality disorder (AvPD, n = 180), or the comorbid condition of both disorders (AvPD + SAD, n = 29) were assessed before treatment.

METHODS

Patients filled out the Inventory of Interpersonal Problems (IIP-64) and the Symptom Checklist-Revised (SCL-R-90) before treatment.

RESULTS AND CONCLUSIONS

From an interpersonal perspective, the relationship between the diagnostic groups is well described by the severity continuum hypothesis, with similar interpersonal problems related to Nonassertiveness and lower levels of general interpersonal stress in the SAD group compared to the two AvPD groups. However, other differences in severity do not fit the severity continuum hypothesis, as there are no differences in severity on the global severity index, and, moreover, the SAD group has the most severe problems on the SCL-90 phobic anxiety scale. Interpersonal pathoplasticity is not found in the diagnostic groups or in the full sample. However, three interpersonal subgroups are identified in the full sample, designated as Nonassertive, Friendly-submissive, and Cold-submissive. Implications for treatment are discussed.

PRACTITIONER POINTS

SAD is characterized by a lower level of interpersonal distress compared to AvPD, but the two disorders are similar in having Nonassertiveness as their general interpersonal problem. Contrary to expectation, SAD and AvPD did not differ in general level of symptom severity, and patients with SAD reported more problems with phobic anxiety than AvPD patients did. When understanding SAD and AvPD as different conceptualizations of the same disorder and analysing all patients together, three distinct interpersonal subgroups emerge, which can be identified as Nonassertive, Friendly-submissive, and Cold-submissive.

The Differential Profile of Social Anxiety Disorder (SAD) and Avoidant Personality Disorder (APD) on the Basis of Criterion B of the DSM-5-AMPD in a College Sample

BACKGROUND

The present study was conducted to determine the differential profile of social anxiety disorder (SAD) and avoidant personality disorder (APD) based on dimensional diagnosis in criterion B of the DSM-5 Alternative Model for Personality Disorders (DSM-5-AMPD) in a college sample.

METHODS

Samples of this cross-sectional study included 320 (23.08 ± 2.66 years; 57% female) college students in western Iran during February 2015 to December 2017. Liebowitz-social anxiety scale, PID-5, SCID-II, SCID-II-SQ and diagnostic interview for SAD were the tools. The data were analysed using Pearson correlation and multiple linear regression analysis.

RESULTS

Forty-three and 38 participants met criteria for SAD alone and APD, respectively. Five main domains of PID-5 could explain 29% and 54% of the variance of SAD and APD, respectively. Facets of negative affect, detachment, antagonism, disinhibition, and psychoticism could explain 25% versus 43%, 26% versus 54%, 7% versus 27%, 21% versus 41%, 13% versus 30% of the variance of SAD and APD, respectively.

CONCLUSION

SAD and APD probably refer to two distinct mental states having prominent anxiety, emotional instability, and interpersonal pattern of avoidance and detachment of challenge. SAD is a simple form of mental disturbances with anxiety in its core features; although, APD is possibly referring to more complicated psychopathology.

Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges

Comorbid disorders are highly prevalent in patients with social anxiety disorder, occurring in as many as 90% of patients. The presence of comorbidity may affect the course of the disease in several ways such as comorbidity in patients with social anxiety disorder (SAD) is related to earlier treatment-seeking behavior, increased symptom severity, treatment resistance and decreased functioning. Moreover, comorbidities cause significant difficulties in nosology and diagnosis, and may cause treatment challenges. In this review, major psychiatric comorbidities that can be encountered over the course of SAD as well as comorbidity associated diagnostic and therapeutic challenges will be discussed.

Avoidant personality disorder: current insights

Avoidant personality disorder (AVPD) is a relatively common disorder that is associated with significant distress, impairment, and disability. It is a chronic disorder with an early age at onset and a lifelong impact. Yet it is underrecognized and poorly studied. Little is known regarding the most effective treatment. The impetus for research into this condition has waxed and waned, possibly due to concerns regarding its distinctiveness from other disorders, especially social anxiety disorder (SAD), schizoid personality disorder, and dependent personality disorder. The prevailing paradigm subscribes to the "severity continuum hypothesis", in which AVPD is viewed essentially as a severe variant of SAD. However, areas of discontinuity have been described, and there is support for retaining AVPD as a distinct diagnostic category. Recent research has focused on the phenomenology of AVPD, factors of possible etiological significance such as early parenting experiences, attachment style, temperament, and cognitive processing. Self-concept, avoidant behavior, early attachments, and attachment style may represent points of difference from SAD that also have relevance to treatment. Additional areas of research not focused specifically on AVPD, including the literature on social cognition as it relates to attachment and personality style, report findings that are promising for future research aimed at better delineating AVPD and informing treatment.