Epidemiology and Prevalence of Somatic Symptom Disorder at the Primary Care Level in Muscat, Oman: A Cross-Sectional Study

OBJECTIVES

Somatic symptom disorder (SSD) is a diagnostic classification to describe the occurrence of physical symptoms without organic cause. This study aimed to identify prevalence rates and associated characteristics of SSD among adults in primary care settings.

METHODS

This cross-sectional study took place between July 2020 and March 2021 and included a random selection of 3383 Omani adults attending 12 primary healthcare centres in Muscat Governorate. Screening was conducted using an Arabic version of the Somatic Symptom Scale-8 (SSS-8).

RESULTS

A total of 2000 adults participated in the study (response rate: 67.3%), of which most were female (71.7%) and under 50 years old (86.2%). Based on their SSS-8 scores, 602 participants (17.8%) had SSD, resulting in an overall prevalence estimate of 30.1% (95% confidence interval: 28.13-32.15). Significant associations were observed between SSD and age (p = 0.002), gender (p < 0.001), marital status (p = 0.030) and chronic comorbidities (p = 0.001). In addition, adjusted odds ratio estimates revealed SSD to be significantly associated with gender (p < 0.001), education level (p < 0.001) and chronic comorbidities (p = 0.001).

CONCLUSION

The estimated prevalence of SSD in primary care settings is high compared to reports from elsewhere in the Gulf region. There is an urgent need to enhance the diagnosis of SSD at the primary care level in order to reduce healthcare service overutilisation and patient dissatisfaction. Moreover, healthcare practitioners should be aware of the effect of age, gender, educational status and chronic comorbidities on somatic symptoms.

Somatic symptom disorder: a scoping review on the empirical evidence of a new diagnosis

BACKGROUND

In 2013, the diagnosis of somatic symptom disorder (SSD) was introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This review aims to comprehensively synthesize contemporary evidence related to SSD.

METHODS

A scoping review was conducted using PubMed, PsycINFO, and Cochrane Library. The main inclusion criteria were SSD and publication in the English language between 01/2009 and 05/2020. Systematic search terms also included subheadings for the DSM-5 text sections; i.e., diagnostic features, prevalence, development and course, risk and prognostic factors, culture, gender, suicide risk, functional consequences, differential diagnosis, and comorbidity.

RESULTS

Eight hundred and eighty-two articles were identified, of which 59 full texts were included for analysis. Empirical evidence supports the reliability, validity, and clinical utility of SSD diagnostic criteria, but the further specification of the psychological SSD B-criteria criteria seems necessary. General population studies using self-report questionnaires reported mean frequencies for SSD of 12.9% [95% confidence interval (CI) 12.5-13.3%], while prevalence studies based on criterion standard interviews are lacking. SSD was associated with increased functional impairment, decreased quality of life, and high comorbidity with anxiety and depressive disorders. Relevant research gaps remain regarding developmental aspects, risk and prognostic factors, suicide risk as well as culture- and gender-associated issues.

CONCLUSIONS

Strengths of the SSD diagnosis are its good reliability, validity, and clinical utility, which substantially improved on its predecessors. SSD characterizes a specific patient population that is significantly impaired both physically and psychologically. However, substantial research gaps exist, e.g., regarding SSD prevalence assessed with criterion standard diagnostic interviews.

Post-traumatic stress disorder among Syrian refugees in Greece

BACKGROUND

Post-Traumatic Stress Disorder (PTSD) is a psychiatric entity developed by those who have been through a traumatic experience. The civil wars in Syria and neighboring countries during the past few years might trigger such experiences, and the same could be argued for the difficult journey from the actual war zones to Europe.

PURPOSE

To determine the level of PTSD among Arabic-speaking refugees in a Greek refugee camp, who originate primarily from Syria.

METHODS

This study involves (N = 73) Syrian refugees, all located in Greek camp. Data were gathered using the civilian version of PTSD CheckList (PCL-C). The Arabic version of the PCL-C was used. Individual scores were evaluated via use of DSM-IV criteria.

RESULTS

PTSD was found in 58 participants, afflicting both genders (72% of men and 45% of women). In addition, the severity score was recorded to be significantly elevated for the majority of the participants. Finally, the most vulnerable age group was the same for both genders, featuring those between the ages of 35 and 44 years.

CONCLUSIONS

The findings of this study demonstrated that the traumatic experiences, suffered by these refugees either before and/or on their journey to Greece, had a severe mental impact. It is imperative that all refugees suffering from this disorder be diagnosed in time and receive appropriate support.

Conceptual and historical evolution of psychiatric nosology

Psychiatric taxonomies exist within conceptual frameworks which presuppose certain conceptions of psychiatric distress and offer guiding principles. This article provides an overview of the historical development of psychiatric classifications with an emphasis on their methodological assumptions. After identifying roots of scientific psychiatric classifications in the works of Sydenham and Linnaeus and discussing early classification systems, our survey focuses on the Kahlbaum-Hecker-Kraepelin paradigm (with its emphasis on longitudinal course of illness), the Wernicke-Kleist-Leonhard tradition (with its emphasis on neural systems), the development of the ICD and the DSM classifications (with their roots in medical statistics, their pragmatic nature, and their emphasis on descriptive and operationalized criteria), psychodynamic and idiographic perspectives (e.g. the Psychodynamic Diagnostic Manual), and transdiagnostic approaches (e.g. Research Domain Criteria). The central philosophical questions of nosology (descriptive vs aetiological, symptoms vs course of illness, idiographic vs nomothetic, categorical vs dimensional, etc.) have appeared and reappeared throughout this evolution. Ongoing controversies reflect the epistemological and ontological difficulties inherent in defining and classifying mental illness. It may be that no single taxonomy can satisfy all clinical, research, and administrative needs, and that, echoing the ideas of Aubrey Lewis, multiple systems may be required to serve different needs.

Prevalence and Related Factors of Post-Traumatic Stress Disorder in Emergency Medical Technicians; a Cross-sectional Study

Introduction:

Ongoing exposure to a variety of Pre-hospital Emergencies (PE) has placed Emergency Medical Technicians (EMTs) at serious psychiatric compromise such as Post-Traumatic Stress Disorder (PTSD). The present study aimed to evaluate the prevalence and associated factors of PTSD among EMTs.

Methods:

This prospective cross-sectional study was conducted on EMTs in the Emergency Medical Services (EMS) in west of Iran. A baseline information questionnaire including personal work-related characteristics and the PTSD checklist of DSM-5 (PCL-5) were used for data collection. Non-parametric tests and multivariate linear regression were used to evaluate the associated factors of PTSD in these participants.

Results:

Among the participants, 22% of technicians had PTSD-diagnostic criteria. The mean total PCL-5 score was 21.60 ± 11.45, while the scores were 38.02 ± 6.08 and 17.47 ± 8.36 in the PTSD-diagnosed and undiagnosed groups, respectively. The most common symptom of the clusters was negative alterations in cognition with a mean score of 7.42 ± 4.63. After adjusting confounders, the number of missions (t= 2.50, P= 0.013), work experience (t= -3.24, P= 0.001) and number of shifts (t: 26.38, P < 0.001) were significantly corelated with PCL-5 score.

Conclusion:

The results indicated that the prevalence of PTSD among EMTs personnel of Hamedan province is high. EMTs with the age of ≤ 30 years, work experience of ≤ 10 years, married status, informal employment, emergency medical technician's degree, and more than 8 shifts per month, as well as no previous training history had a higher total PCL-5 score.

[Sex addiction: losing its taboo]

Sex addiction or dependency is a complex and debilitating pathology characterised by a disproportionate preoccupation with sex or sexual activity. The aim of scientific research carried out into this disorder is both nosographic, to establish which subtype of mental disorder it belongs to, and physiopathological, to explain its origin and develop potential therapies. A state of the science on sexual dependency is charted, in the world of psychiatry, based on its very first mention to the present day.

Deriving ICD-11 personality disorder domains from dsm-5 traits: initial attempt to harmonize two diagnostic systems

OBJECTIVE

The personality disorder domains proposed for the ICD-11 comprise Negative Affectivity, Detachment, Dissociality, Disinhibition, and Anankastia, which are reasonably concordant with the higher-order trait domains in the Alternative DSM-5 Model for Personality Disorders.

METHOD

We examined (i) whether designated DSM-5 trait facets can be used to describe the proposed ICD-11 trait domains, and (ii) how these ICD-11 trait features are hierarchically organized. A mixed Danish derivation sample (N = 1541) of 615 psychiatric out-patients and 925 community participants along with a US replication sample (N = 637) completed the Personality Inventory for DSM-5 (PID-5). Sixteen PID-5 traits were designated to cover features of the ICD-11 trait domains.

RESULTS

Exploratory structural equation modeling (ESEM) analyzes showed that the designated traits were meaningfully organized in the proposed ICD-11 five-domain structure as well as other recognizable higher-order models of personality and psychopathology. Model fits revealed that the five proposed ICD-11 personality disorder domains were satisfactorily resembled, and replicated in the independent US sample.

CONCLUSION

The proposed ICD-11 personality disorder domains can be accurately described using designated traits from the DSM-5 personality trait system. A scoring algorithm for the ICD-11 personality disorder domains is provided in appendix.

Historical Underpinnings of Bipolar Disorder Diagnostic Criteria

Mood is the changing expression of emotion and can be described as a spectrum. The outermost ends of this spectrum highlight two states, the lowest low, melancholia, and the highest high, mania. These mood extremes have been documented repeatedly in human history, being first systematically described by Hippocrates. Nineteenth century contemporaries Falret and Baillarger described two forms of an extreme mood disorder, with the validity and accuracy of both debated. Regardless, the concept of a cycling mood disease was accepted before the end of the 19th century. Kraepelin then described “manic depressive insanity” and presented his description of a full spectrum of mood dysfunction which could be exhibited through single episodes of mania or depression or a complement of many episodes of each. It was this concept which was incorporated into the first DSM and carried out until DSM-III, in which the description of episodic mood dysfunction was used to build a diagnosis of bipolar disorder. Criticism of this approach is explored through discussion of the bipolar spectrum concept and some recent examinations of the clinical validity of these DSM diagnoses are presented. The concept of bipolar disorder in children is also explored.

Depression sum-scores don't add up: why analyzing specific depression symptoms is essential

Most measures of depression severity are based on the number of reported symptoms, and threshold scores are often used to classify individuals as healthy or depressed. This method--and research results based on it--are valid if depression is a single condition, and all symptoms are equally good severity indicators. Here, we review a host of studies documenting that specific depressive symptoms like sad mood, insomnia, concentration problems, and suicidal ideation are distinct phenomena that differ from each other in important dimensions such as underlying biology, impact on impairment, and risk factors. Furthermore, specific life events predict increases in particular depression symptoms, and there is evidence for direct causal links among symptoms. We suggest that the pervasive use of sum-scores to estimate depression severity has obfuscated crucial insights and contributed to the lack of progress in key research areas such as identifying biomarkers and more efficacious antidepressants. The analysis of individual symptoms and their causal associations offers a way forward. We offer specific suggestions with practical implications for future research.

Chronic Pain, Psychopathology, and DSM-5 Somatic Symptom Disorder

Unlike acute pain that warns us of injury or disease, chronic or persistent pain serves no adaptive purpose. Though there is no agreed on definition of chronic pain, it is commonly referred to as pain that is without biological value, lasting longer than the typical healing time, not responsive to treatments based on specific remedies, and of a duration greater than 6 months. Chronic pain that is severe and intractable has detrimental consequences, including psychological distress, job loss, social isolation, and, not surprisingly, it is highly comorbid with depression and anxiety. Historically, pain without an apparent anatomical or neurophysiological origin was labelled as psychopathological. This approach is damaging to the patient and provider alike. It pollutes the therapeutic relationship by introducing an element of mutual distrust as well as implicit, if not explicit, blame. It is demoralizing to the patient who feels at fault, disbelieved, and alone. Moreover, many medically unexplained pains are now understood to involve an interplay between peripheral and central neurophysiological mechanisms that have gone awry. The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, somatic symptom disorder overpsychologizes people with chronic pain; it has low sensitivity and specificity, and it contributes to misdiagnosis, as well as unnecessary stigma. Adjustment disorder remains the most appropriate, accurate, and acceptable diagnosis for people who are overly concerned about their pain.

The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer

BACKGROUND

Delirium is a common and serious problem among acutely unwell persons. Although linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity.

DISCUSSION

Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises 'consciousness' as 'changes in attention'. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested.

SUMMARY

Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation.

Evaluation of the proposed social anxiety disorder specifier change for DSM-5 in a treatment-seeking sample of anxious youth

BACKGROUND

The current proposal for the DSM-5 definition of social anxiety disorder (SAD) is to replace the DSM-IV generalized subtype specifier with one that specifies fears in performance situations only. Relevant evaluations to support this change in youth samples are sparse.

METHODS

The present study examined rates and correlates of the DSM-IV and proposed DSM-5 specifiers in a sample of treatment-seeking children and adolescents with SAD (N = 204).

RESULTS

When applying DSM-IV subtypes, 64.2% of the sample was classified as having a generalized subtype of SAD, with the remaining 35.2% classifying as having a nongeneralized subtype SAD. Youth with generalized SAD, relative to those with nongeneralized SAD, were older, had more clinically severe SAD, showed greater depressive symptoms, and were more likely to have a comorbid depressive disorder. No children in the current sample endorsed discrete fear in performance situations only in the absence of fear in other social situations.

CONCLUSIONS

The present findings call into question the meaningfulness of the proposed changes in treatment-seeking youth with SAD.

Patient advocacy and DSM-5

The revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a useful opportunity to revisit debates about the nature of psychiatric classification. An important debate concerns the involvement of mental health consumers in revisions of the classification. One perspective argues that psychiatric classification is a scientific process undertaken by scientific experts and that including consumers in the revision process is merely pandering to political correctness. A contrasting perspective is that psychiatric classification is a process driven by a range of different values and that the involvement of patients and patient advocates would enhance this process. Here we draw on our experiences with input from the public during the deliberations of the Obsessive Compulsive-Spectrum Disorders subworkgroup of DSM-5, to help make the argument that psychiatric classification does require reasoned debate on a range of different facts and values, and that it is appropriate for scientist experts to review their nosological recommendations in the light of rigorous consideration of patient experience and feedback.

Phenomenology of bipolar disorder not otherwise specified in youth: a comparison of clinical characteristics across the spectrum of manic symptoms

OBJECTIVES

Controversy surrounds the diagnostic categorization of children with episodic moods that cause impairment, but do not meet DSM-IV criteria for bipolar I (BD-I) or bipolar II (BD-II) disorder. This study aimed to characterize the degree to which these children, who meet criteria for bipolar disorder not otherwise specified (BD-NOS), are similar to those with full syndromal BD, versus those with no bipolar spectrum diagnosis (no BSD).

METHODS

Children aged 6-12 years were recruited from nine outpatient clinics, preferentially selected for higher scores on a 10-item screen for manic symptoms. Interviews with the children and their primary caregivers assessed a wide array of clinical variables, as well as family history.

RESULTS

A total of 707 children [mean ± standard deviation (SD) 9.4 ± 1.9 years old] were evaluated at baseline, and were diagnosed with BD-I (n = 71), BD-II (n = 3), BD-NOS (including cyclothymia; n = 88), or no BSD (n = 545). Compared to BD-I, the BD-NOS group had less severe past functional impairment. However, current symptom severity and functional impairment did not differ between BD-NOS and BD-I, even though both groups were significantly more symptomatic and impaired than the no BSD group. Parental psychiatric history was similar for the BD-NOS and BD-I groups, and both were more likely than the no BSD group to have a parent with a history of mania. Rates of elated mood did not differ between BD-NOS and BD-I youth.

CONCLUSIONS

Children with BD-NOS and BD-I are quite similar, but different from the no BSD group, on many phenomenological measures. These findings support the hypothesis that BD-NOS is on the same spectrum as BD-I.

Specifying child anxiety disorders not otherwise specified in the DSM-IV

BACKGROUND

Anxiety disorder not otherwise specified (ADNOS) is one of the more common and impairing DSM-IV diagnoses assigned in child practice settings, but it is not clear what percentage of these assignments simply reflect poor diagnostic practices.

METHODS

The present study evaluated patterns and correlates of child ADNOS in a large outpatient treatment seeking sample of anxious youth (N = 650), utilizing structured diagnostic interviewing procedures.

RESULTS

Roughly, 15% of youth met diagnostic criteria for ADNOS. Overall, these youth exhibited comparable levels of clinical problems relative to youth with DSM-IV-specified anxiety disorders (AD), and roughly two-thirds of ADNOS cases exhibited symptom presentations closely resembling generalized anxiety disorder (GAD). Among ADNOS presentations resembling GAD, those failing to meet the "worries more days than not" or "worries across multiple domains" criteria showed lower internalizing symptoms than GAD youth, but comparable anxious/depressed symptoms, somatic symptoms, social problems, externalizing problems, and total problems as measured by the Child Behavior Checklist.

CONCLUSIONS

Childhood ADNOS cases are prevalent and warrant clinical attention. In many cases there are only a couple, if any, clinical differences between these disorders and the ADs they closely resemble. Future work is needed to improve upon the current taxonomy of childhood ADs to specify a larger proportion of affected youth needing care.

Generalized anxiety disorder and the proposed associated symptoms criterion change for DSM-5 in a treatment-seeking sample of anxious youth

BACKGROUND

A current proposal for the DSM-5 general anxiety disorder (GAD) definition is to remove fatigue, difficulty concentrating, irritability, and sleep disturbance from the list of associated symptoms, and to require the presence of one of two retained symptoms (restlessness or muscle tension) for diagnosis. Relevant evaluations in youth to support such a change are sparse.

METHODS

The present study evaluated patterns and correlates of the DSM-IV GAD associated symptoms in a large outpatient sample of anxious youth (N = 650) to empirically consider how the proposed diagnostic change might impact the prevalence and sample composition of GAD in children.

RESULTS

Logistic regression found irritability to be the most associated, and restlessness to be the least associated, with GAD diagnosis. Fatigue, difficulty concentrating, and sleep disturbances-which have each been suggested to be nonspecific to GAD due to their prevalence in depression-showed sizable associations with GAD even after accounting for depression and attention problems. Among GAD youth, 10.9% would not meet the proposed DSM-5 associated symptoms criterion. These children were comparable to GAD youth who would meet the proposed criteria with regard to clinical severity, symptomatology, and functioning.

CONCLUSIONS

A substantial proportion of youth with excessive, clinically impairing worry may be left unclassified by the DSM-5 if the proposed GAD associated symptoms criterion is adopted. Despite support for the proposed criterion change in adult samples, the present findings suggest that in children it may increase the false negative rate. This calls into question whether the proposed associated symptoms criterion is optimal for defining childhood GAD.

Understanding the neurobiology of fear conditioning and emergence of posttraumatic stress disorder psychobiology: commentary on Blanchard et al

In this article, we discuss the historical evolution of posttraumatic stress disorder (PTSD) after the Vietnam War, with a focus on an article by Blanchard, Kolb, Prins, Gates, and McCoy (J Nerv Ment Dis 179:371-373, 1991) published in this Journal in 1991 entitled Changes in Plasma Norepinephrine to Combat-Related Stimuli Among Vietnam Veterans With Posttraumatic Stress Disorder. In this commentary, we discuss the significance of this brief article and the developments in the PTSD field before, during, and after the Blanchard publication. Within this context, we discuss the eventual recognition in both the clinical and scientific fields that PTSD had a major neurobiological foundation. Finally, we examine the key implication of these discoveries from an epidemiological, a clinical, and a public health perspective.

PTSD in children and adolescents: toward an empirically based algorithma

In considering potential revisions for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), describing developmental influences on symptomatic expression is a high priority. This review presents a number of options and preliminary recommendations to be considered for DSM-V. Research conducted in the past 15 years is reviewed that pertains to expressions of posttraumatic stress disorder (PTSD) symptoms in preschool and school age children and in adolescents. This research has attempted to determine the usefulness of the DSM-IV criteria for PTSD in children and adolescents. Based on the studies of preschool children, evidence supports two sets of suggestions: first, we suggest that developmental manifestations are warranted in A-D criteria of PTSD; and second, we suggest that a developmental preschool PTSD subtype is warranted that lowers the C threshold from three to one symptom. For school-age children and young adolescents, the evidence is more limited. Nevertheless, there is also evidence suggesting that modifications in PTSD criteria A-D, including fewer Cluster C symptoms, may facilitate accurate diagnosis in this age group.

War exposure, 5-HTTLPR genotype and lifetime risk of depression

BACKGROUND

In 1962 approximately 1.5 million French people living in Algeria were repatriated to France in very poor and often life-threatening conditions. These people constitute a cohort for the study of the long-term impact of gene-environment interaction on depression.

AIMS

To examine the interaction between a highly stressful life event and subsequent depression, and its modulation by a length polymorphism of the serotonin transporter gene (5-HTTLPR).

METHOD

A community sample of people aged 65 years and over residing in the Montpellier region of the south of France was randomly recruited from electoral rolls. Genotyping was performed on 248 repatriated persons and 632 controls. Current and lifetime major and minor depressive disorders were assessed according to DSM-IV criteria.

RESULTS

A significant relationship was observed between exposure to repatriation and subsequent depression (P<0.002), but there was no significant effect of gene alone (P = 0.62). After controlling for age, gender, education, disability, recent life events and cognitive function, the gene-environment interaction (repatriation × 5-HTTLPR) was globally significant (P<0.002; OR = 3.21, 95% CI 2.48-5.12). Individuals carrying the two short (s) alleles of 5-HTTLPR were observed to be at higher risk (P<0.005; OR = 2.34, 95% CI 1.24-4.32), particularly when repatriation occurred before age 35 years (P<0.002; OR = 2.91, 95% CI 1.44-5.88), but this did not reach significance in those who were older at the time of the event (P = 0.067).

CONCLUSIONS

The association between depression and war repatriation was significantly modulated by 5-HTTLPR genotype but this appeared to occur only in people who were younger at the time of exposure.

New ways to classify bipolar disorders: going from categorical groups to symptom clusters or dimensions

Current psychiatric disorder classifications are based exclusively on categorical models, which were designed to increase the reliability of diagnoses. However, this system has some limitations, and various psychiatric disorders may be classified using a dimensional approach, which is more appropriate when no clear boundaries exist between entities or when examining various features on a continuum. Thus, the forthcoming DSM-5 appears to be undertaking a hybrid approach by including categorical models associated with dimensions. We aim to review examples of dimensions or symptom clusters associated with a categorical approach that could be useful in refining bipolar disorder classification. We selected predominant polarity, psychotic symptoms, inhibition/activation behavioral level, and emotional reactivity to define mood episodes, impulsivity/suicidality/substance misuse, and cognitive impairment. The selection was based on the fact that these dimensions or symptom clusters are currently being discussed to be implemented in the DSM-5 and/or may orientate toward the choice of specific treatments and represent more homogeneous and thus more appropriate subgroups for research purposes. In the future, there will be a need to identify biomarkers that can definitively validate the use of these criteria.

Cross-cultural study of conviction subtype Taijin Kyofu: proposal and reliability of Nagoya-Osaka diagnostic criteria for social anxiety disorder

Conviction subtype Taijin-Kyofu (c-TK) is a subgroup of mental disorder characterized by conviction and strong fear of offending others in social situations. Although the concept of c-TK overlaps with that of social anxiety disorder (SAD), patients with c-TK often may not be diagnosed as such within the current Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria. We propose the Nagoya-Osaka criteria to amend this situation. This study examined the cross-cultural interrater reliability of the proposed criteria. Eighteen case vignettes of patients with a variety of complaints focused around social anxieties were collected from 6 different countries, and diagnosed by 13 independent raters from various nationalities according to the original DSM-IV and the expanded criteria. The average agreement ratio for the most frequent diagnostic category in each case was 61.5% with DSM-IV and 87.6% with the modified DSM-IV with Nagoya-Osaka criteria (p < 0.001). These findings indicate that the Nagoya-Osaka criteria for SAD can improve interrater reliability of SAD.