Latent structure of social fears and social anxiety disorders.

BACKGROUND: Despite its high prevalence and associated levels of impairment, the latent structure of social anxiety disorder (SAD) is not well understood, with published studies reporting inconsistent results. Furthermore, it is unknown whether the latent structure of social fears in individuals with and without SAD is the same. METHOD: Exploratory factor analysis (EFA) and confirmatory factor analysis followed by multiple indicators multiple causes (MIMIC) analysis were conducted on 13 commonly feared social situations assessed in a nationally representative sample including individuals with SAD and those with social fears but who did not meet DSM-IV criteria for SAD. RESULTS: An EFA conducted in the full sample, including individuals with no social fears (88% of the sample), yielded only one factor. When the sample was restricted to those with at least one social fear, the EFA yielded three factors, in both the subsample with at least one social fear but no SAD and the subsample with SAD. The three factors represented feared situations related to public performance, close scrutiny and social interaction. The MIMIC analyses further indicated that the three-factor structure was able to explain differences in prevalence of social fears across a broad range of sociodemographic covariates. CONCLUSIONS: Among individuals with at least one social fear and those with DSM-IV SAD the latent structure of social fears appears to be best described by three factors, although this may partially depend on how the sample is specified. These results may help reconcile the findings of different numbers of factors identified in previous studies.

Social anxiety disorder and alcohol use disorder co-morbidity in the National Epidemiologic Survey on Alcohol and Related Conditions.

BACKGROUND: To assess the prevalence and clinical impact of co-morbid social anxiety disorder (SAD) and alcohol use disorders (AUD, i.e. alcohol abuse and alcohol dependence) in a nationally representative sample of adults in the United States. METHOD: Data came from a large representative sample of the US population. Face-to-face interviews of 43093 adults residing in households were conducted during 2001-2002. Diagnoses of mood, anxiety, alcohol and drug use disorders and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule - DSM-IV version. RESULTS: Lifetime prevalence of co-morbid AUD and SAD in the general population was 2.4%. SAD was associated with significantly increased rates of alcohol dependence [odds ratio (OR) 2.8] and alcohol abuse (OR 1.2). Among respondents with alcohol dependence, SAD was associated with significantly more mood, anxiety, psychotic and personality disorders. Among respondents with SAD, alcohol dependence and abuse were most strongly associated with more substance use disorders, pathological gambling and antisocial personality disorders. SAD occurred before alcohol dependence in 79.7% of co-morbid cases, but co-morbidity status did not influence age of onset for either disorder. Co-morbid SAD was associated with increased severity of alcohol dependence and abuse. Respondents with co-morbid SAD and alcohol dependence or abuse reported low rates of treatment-seeking. CONCLUSIONS: Co-morbid lifetime AUD and SAD is a prevalent dual diagnosis, associated with substantial rates of additional co-morbidity, but remaining largely untreated. Future research should clarify the etiology of this co-morbid presentation to better identify effective means of intervention.

Social phobia. Comorbidity and morbidity in an epidemiologic sample.

Selected sociodemographic and clinical features of social phobia were assessed in four US communities among more than 13,000 adults from the Epidemiologic Catchment Area study. Rates of social phobia were highest among women and persons who were younger (age, 18 to 29 years), less educated, single, and of lower socioeconomic class. Mean age at onset was 15.5 years, and first onsets after the age of 25 years were uncommon. Lifetime major comorbid disorders were present in 69% of subjects with social phobia and usually had onset after social phobia. When compared with persons with no psychiatric disorder, uncomplicated social phobia was associated with increased rates of suicidal ideation, financial dependency, and having sought medical treatment, but was not associated with higher rates of having made a suicide attempt or having sought treatment from a mental health professional. An increase in suicide attempts was found among subjects with social phobia overall, but this increase was mainly attributable to comorbid cases. Social phobia, in the absence of comorbidity, was associated with distress and impairment, yet was rarely treated by mental health professionals. The findings are compared and contrasted with prior reports from clinical samples.

Generalized social phobia. Reliability and validity.

OBJECTIVE: To investigate the reliability and validity of DSM-III-R "generalized" social phobia by examining interrater agreement and comparing patients with generalized and "nongeneralized" social phobia on demographic characteristics, clinical variables, and familial social phobia. DESIGN: Two senior clinicians classified 129 patients attending an anxiety clinic as having DSM-III-R social phobia that is generalized (fears most social situations) or nongeneralized (less than most) based on independent narrative review. RESULTS: Good reliability was achieved (kappa = 0.69). Patients with generalized social phobia were more often single, had earlier onsets of social phobia, had more interactional fears, and had higher rates of atypical depression and alcoholism. Familial social phobia was more common among patients with generalized social phobia than patients with nongeneralized social phobia and controls, with no difference between the latter two groups. CONCLUSIONS: Generalized social phobia (1) can be distinguished reliably from nongeneralized social phobia, (2) is a valid subtype, and (3) may characterize a familial form of the disorder.

Intravenous clomipramine for obsessive-compulsive disorder refractory to oral clomipramine: a placebo-controlled study.

BACKGROUND: Uncontrolled reports suggest that intravenous clomipramine hydrochloride may be effective for patients with obsessive-compulsive disorder (OCD) who are nonresponsive to oral clomipramine. METHODS: Fifty-four patients with oral clomipramine-refractory OCD were randomized to receive 14 infusions of either placebo or clomipramine hydrochloride, starting at 25 mg/d and increasing to 250 mg/d. Ratings were conducted double-blind after infusion 14 among 54 patients, single-blind 1 week later among 39 patients, and nonblind 1 month later among 31 patients. Response was based on a Clinical Global Impressions rating of at least "much improved." RESULTS: Six (21%) of 29 patients randomized to receive intravenous (i.v.) clomipramine vs 0 of 25 patients given i.v. placebo were responders after 14 infusions (df = 1, P<.02). Dimensional ratings after infusion 14 revealed significant (P = .007) improvement on the National Institute of Mental Health-Obsessive-Compulsive Scale and the Clinical Global Impressions Scale (P = .03), but not the Yale-Brown Obsessive Compulsive Scale. One week later, all dimensional measures of OCD showed significant improvement. At 1 week post-i.v., 9 (43%) of 21 patients initially randomized to i.v. clomipramine and treated subsequently with oral clomipramine were responders, whereas 0 of 18 patients initially randomized to receive i.v. placebo and treated subsequently with several days of open-label i.v. clomipramine responded (df = 1, P<.002). Of the 31 patients assessed 1 month after i.v. infusion (treatment not controlled), 18 (58.1%) were responders. Intravenous clomipramine treatment was safe with no serious adverse consequences. CONCLUSIONS: Intravenous clomipramine is more effective than i.v. placebo for patients with OCD with a history of inadequate response or intolerance to oral clomipramine. Further study of this promising treatment for refractory OCD is needed.

Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome.

BACKGROUND: This article presents results of the acute treatment phase of a 2-site study comparing cognitive behavioral group therapy (CBGT) and treatment with the monoamine oxidase inhibitor phenelzine sulfate for social phobia. METHODS: One hundred thirty-three patients from 2 sites received 12 weeks of CBGT, phenelzine therapy, pill placebo administration, or educational-supportive group therapy (an attention-placebo treatment of equal credibility to CBGT). The "allegiance effect," ie, the tendency for treatments to seem most efficacious in settings of similar theoretical orientation and less efficacious in theoretically divergent settings, was also examined by comparing responses to the treatment conditions at both sites: 1 known for pharmacological treatment of anxiety disorders and the other for cognitive behavioral treatment. RESULTS: After 12 weeks, phenelzine therapy and CBGT led to superior response rates and greater change on dimensional measures than did either control condition. However, response to phenelzine therapy was more evident after 6 weeks, and phenelzine therapy was also superior to CBGT after 12 weeks on some measures. There were few differences between sites, suggesting that these treatments can be efficacious at facilities with differing theoretical allegiances. CONCLUSIONS: After 12 weeks, both phenelzine therapy and CBGT were associated with marked positive response. Although phenelzine therapy was superior to CBGT on some measures, both were more efficacious than the control conditions. More extended cognitive behavioral treatment and the combination of modalities may enhance treatment effect.

Barriers to the treatment of social anxiety.

OBJECTIVE: This article evaluates barriers to treatment reported by adults with social anxiety who participated in the 1996 National Anxiety Disorders Screening Day. METHOD: The background characteristics of screening day participants with symptoms of social anxiety (N=6,130) were compared with those of participants without social anxiety (N=4,507). Barriers to previous mental health treatment reported by participants with and without symptoms of social anxiety were compared. RESULTS: Social anxiety was strongly associated with functional impairment, feelings of social isolation, and suicidal ideation. Compared to participants without social anxiety, those with social anxiety were significantly more likely to report that financial barriers, uncertainty over where to go for help, and fear of what others might think or say prevented them from seeking treatment. However, they were significantly less likely to report they avoided treatment because they did not believe they had an anxiety disorder. Roughly one-third (N=1,400 of 3,682, 38.0%) of the participants with symptoms of social anxiety who were referred for further evaluation were specifically referred for an evaluation for social phobia. CONCLUSIONS: Social anxiety is associated with a distinct pattern of treatment barriers. Treatment access may be improved by building public awareness of locally available services, easing the psychological and financial burden of entering treatment, and increasing health care professionals' awareness of its clinical significance.

Childhood trauma and dissociative symptoms in panic disorder.

OBJECTIVE: Childhood trauma has been associated with increased risk for both panic disorder and dissociative symptoms in adulthood. The authors hypothesized that among individuals with a primary diagnosis of panic disorder, those experiencing depersonalization/derealization during panic attacks would be more likely to have a history of childhood trauma. METHOD: Rates of traumatic events were compared between panic disorder patients with (N=34) and without (N=40) prominent depersonalization/derealization during panic attacks. Symptom severity in the two groups was also examined. RESULTS: Contrary to the authors' hypothesis, no evidence was found that depersonalization/derealization during panic attacks was associated with childhood trauma. Minimal differences in severity of illness were found between patients with dissociative symptoms and those without such symptoms. CONCLUSIONS: This finding is consistent with a multifactorial model of dissociation. Factors other than childhood trauma and general psychopathology may underlie vulnerability to dissociative symptoms in panic disorder.

Pharmacotherapy of four men with paruresis.

Four men with paruresis received trials of atenolol or phenelzine or both. Atenolol was effective in one patient. Three patients had a poor response to phenelzine, and they all experienced troublesome side effects.

Low dopamine D(2) receptor binding potential in social phobia.

OBJECTIVE: This study compared dopamine D(2) receptor binding potential in patients with social phobia and healthy comparison subjects. METHOD: Dopamine D(2) receptor binding potential was assessed in 10 unmedicated subjects with generalized social phobia and no significant lifetime psychiatric comorbidity and 10 healthy comparison subjects matched for age and sex. Binding potential was measured in the striatum by using single photon emission computerized tomography and constant infusion of the D(2) receptor radiotracer [(123)I]iodobenzamide ([(123)I]IBZM). RESULTS: Mean D(2) receptor binding potential was significantly lower in the subjects with social phobia than in the comparison subjects. Within the social phobia group, there was a nonsignificant correlation of binding potential with the Liebowitz Social Anxiety Scale score. CONCLUSIONS: Generalized social phobia may be associated with low binding of [(123)I]IBZM to D(2) receptors in the striatum.

Impact of generalized social anxiety disorder in managed care.

OBJECTIVE: The authors determined the costs associated with generalized social anxiety disorder in a managed care setting. METHOD: A three-phase mail and telephone survey was conducted from July to October 1998 in two outpatient clinics of a large health maintenance organization (HMO). The survey assessed direct costs, indirect costs, health-related quality of life, and clinical severity associated with generalized social anxiety disorder, both alone and with comorbid psychopathology. RESULTS: The weighted prevalence rate of current generalized social anxiety disorder was 8.2%. In the past year, only 0.5% of subjects with generalized social anxiety disorder had been accurately diagnosed. Yet 44.1% had a mental health specialty visit or had been prescribed an antidepressant, and psychiatric comorbidity was found in 43.6%. Noncomorbid generalized social anxiety disorder was associated with significantly lower health-related quality of life, work productivity, and earnings and greater utilization of health services; generalized social anxiety disorder with comorbid psychopathology was even more disabling. Suicide was attempted by 21.9% of subjects with noncomorbid generalized social anxiety disorder. Persons with average-severity generalized social anxiety disorder had probabilities of graduating from college that were 10 percentage points lower, earned wages that were 10% lower, and had probabilities of holding a technical, professional, or managerial job that were 14 percentage points lower than the comparison group. CONCLUSIONS: In a community cohort of HMO members, generalized social anxiety disorder was rarely diagnosed or treated despite being highly prevalent and associated with significant direct and indirect costs, comorbid depression, and impairment.

Treatment of social phobia with antidepressants.

This article reviews evidence for the utility of antidepressant medications in the treatment of social phobia. Monoamine oxidase inhibitors (MAOIs) were the first antidepressants shown to be effective for social phobia, but dietary restrictions and a relatively high rate of adverse effects often relegate MAOIs to use after other treatments have been found ineffective. Reversible inhibitors of monoamine oxidase (RIMAs) hold promise as safer alternatives to MAOIs, but RIMAs may be less effective and are currently unavailable in the United States. Selective serotonin reuptake inhibitors (SSRIs), of which paroxetine has been the best studied in social phobia to date, have recently emerged as a first-line treatment for the generalized subtype of social phobia. The SSRIs are well tolerated and consistently have been shown to be efficacious in controlled trials.

The offensive subtype of Taijin-kyofu-sho in New York City: the phenomenology and treatment of a social anxiety disorder.

BACKGROUND: Taijin-kyofu-sho (TKS) is thought to be a common, culture-bound disorder of social anxiety in Japan and Korea. Its phenomenology has been noted to overlap with that of social phobia. The "offensive type" of TKS, which has no direct parallel in Western classification, is characterized by a fear of offending others in social situations, which leads to social avoidance. There has been only one case of offensive-type TKS reported in the United States, and this case was not regarded as a variant of social phobia. METHOD: The phenomenology and treatment of six patients who presented to New York City anxiety disorders research clinic psychiatrists with the offensive type of TKS are described. Features of TKS are compared with those of social phobia, as described in Western countries. Treatment outcomes for four patients are discussed and compared with TKS treatment experience in Japan and Korea and with treatment outcome in social phobia. RESULTS: In this anxiety clinic sample, features of the offensive type of TKS showed much overlap with symptoms of social phobia. Only two of four treated patients in this TKS sample received adequate trials of medication known to be effective for social phobia, and one of the two improved significantly. CONCLUSION: The offensive type of TKS may not be as culture-bound as previously thought. Further study is needed to determine whether such cases respond to medications and to cognitive-behavioral approaches that are effective for social phobia. How to classify the offensive type of TKS is uncertain, but social phobia should be considered in the differential diagnosis.

Treatment outcome of obsessive compulsive disorder with comorbid social phobia.

BACKGROUND: Treatment of obsessive compulsive disorder (OCD) with serotonin reuptake blockers has been demonstrated effective in 50% to 60% of patients in open and placebo-controlled studies. However, some reports indicate that comorbid Axis II psychopathology, including avoidant personality disorder, and deficiency of social skills could be predictors of a poor response to treatment in OCD patients. METHOD: A retrospective review elicited 12 patients who met DSM-III-R diagnostic criteria for both OCD and social phobia and were treated in our clinic last year with adequate trials of serotonin reuptake blockers or MAOIs. RESULTS: Only 3 (27%) of the 11 patients treated with serotonin reuptake blockers had a substantial improvement of OCD symptoms. Among them, only 1 (11%) of 9 patients with generalized subtype of social phobia versus 2 (100%) of 2 patients with the nongeneralized subtype responded to serotonin reuptake blockers. Four (80%) of 5 patients with comorbid generalized social phobia receiving phenelzine had marked improvement of OCD symptoms. In general, response of social phobia occurred parallel to that of OCD. CONCLUSION: Comorbid generalized social phobia seems to be associated with a poor response to serotonin reuptake blockers in OCD patients. Deficient social skills, as well as distinct biological mechanisms, may be involved. MAOIs might be an effective alternative medication in refractory cases. Larger and controlled studies are needed to define the implications of the association of OCD and social phobia.

Medication therapy for social phobia.

Social phobia, though the third most common psychiatric disorder in the United States, has received little systematic attention until recently. Chronic and disabling symptoms usually precede other disorders in individuals with comorbidity, including alcohol abuse. Though about 80% of individuals do not seek treatment, controlled trials have demonstrated efficacy for several medications, of which phenelzine (an irreversible monoamine oxidase inhibitor [MAOI]) is the best studied. The benzodiazepines, clonazepam and alprazolam, also hold promise. New reversible MAOIs such as moclobemide and brofaromine are under investigation; fluoxetine and other serotonin selective reuptake inhibitors need further controlled study. The benefits of group cognitive-behavioral therapy also appear substantial. Issues for future investigation include long-term outcome, differential therapeutics, diagnostic subtyping, and combination treatments.

Characteristics of social phobia among persons with essential tremor.

BACKGROUND: Social phobia symptoms have been reported to be common among patients with essential tremor, but characteristics of this comorbidity have not been systematically described. METHOD: Cases with essential tremor (N = 94) and controls without essential tremor (N = 85), ascertained from movement disorder clinic and community samples, were evaluated for social phobia symptoms (using the social phobia module of the Structured Clinical Interview for DSM-IV Axis I Disorders and the Liebowitz Social Anxiety Scale), characteristics of tremor, and associated disability (via videotaped examination, performance test, and disability questionnaire). RESULTS: Lifetime combined prevalence of primary social phobia and clinically significant social phobia symptoms occurring secondary to essential tremor was 32.7% (16/49) among essential tremor patients in the clinic sample. Essential tremor cases with secondary social phobia symptoms reported a markedly later age at onset of clinically significant social phobia symptoms than essential tremor cases with primary social phobia (51.0 vs. 8.8 years). Cases with secondary social phobia also reported greater fear and avoidance of eating, drinking, and writing in public than essential tremor cases with primary social phobia and control subjects with social phobia. Essential tremor cases with secondary social phobia symptoms also demonstrated more severe tremor and tremor-related disability than essential tremor cases with primary social phobia and essential tremor cases without social phobia. Among all essential tremor cases, severity of social phobia symptoms and tremor independently contributed to disability. CONCLUSION: Social phobia appears to occur in a substantial minority of essential tremor patients, and severity of social phobia symptoms is associated with disability, independent of tremor severity. Persons with social phobia symptoms secondary to essential tremor evidence clinical characteristics that differ from those of persons with primary social phobia. Further research is needed to determine the efficacy of treatment of social phobia in essential tremor patients with significant social phobia symptoms.

Fenfluramine augmentation of serotonin reuptake blockade antiobsessional treatment.

Seven patients who met DSM-III-R criteria for obsessive compulsive disorder and had only a partial response to the serotonin reuptake blockers fluoxetine, fluvoxamine, or clomipramine or were unable to tolerate therapeutic doses of these agents due to side effects underwent open treatment with fenfluramine augmentation. Fenfluramine is a serotonin releaser and reuptake blocker which is marketed as an anorectic agent. In doses of 20 to 60 mg/day, fenfluramine augmentation was well tolerated and resulted in a further decrease in obsessions and compulsions in six of these patients. Larger controlled studies are needed to confirm this finding.

Serotonergic medications for sexual obsessions, sexual addictions, and paraphilias.

BACKGROUND: Paraphilias and related disorders have recently been thought of as sexual addictions. However, it has also been argued that these disorders are sexual compulsions. The question arises as to whether these disorders and obsessive compulsive disorder respond in the same way to pharmacotherapy. METHOD: We retrospectively reviewed outcome in 13 patients who presented with sexual symptoms and were treated with serotonin reuptake blockers. Symptoms were divided into paraphilias, nonparaphilic sexual addictions, and sexual obsessions. RESULTS: Paraphilias had the least improvement, while sexual obsessions had the best response to medication. CONCLUSION: Paraphilias and related disorders may be less responsive than sexual obsessions or compulsions to serotonin reuptake blockers. Perhaps paraphilias and related disorders are on the impulsive rather than the compulsive end of the spectrum of obsessive compulsive disorders. Controlled trials are, however, necessary to replicate these preliminary findings.

Treatment of social phobia with drugs other than benzodiazepines.

Social phobia is emerging as an important cause of psychiatric morbidity. Reasons for this are described, as are clinical issues of importance to social phobia, including the extensive associated distress and disability. The use of phenelzine, atenolol, buspirone, fluoxetine, and moclobemide are described. Diagnostic and transcultural aspects of social phobia are described.

Obsessive compulsive disorder, depression, and fluoxetine.

BACKGROUND: Fluoxetine, a selective serotonin reuptake blocker, is an antidepressant medication that has also been shown in open clinical trials and one controlled trial to be effective in the treatment of obsessive compulsive disorder (OCD). OCD is often complicated by depression, and depressive symptoms may interfere with response to both pharmacologic and behavioral treatments. METHOD: We describe pilot data from 10 outpatients who met DSM-III-R criteria for OCD in whom the possibility of a depressive reaction or lack of antidepressant response occurred during an open trial of fluoxetine. RESULTS: Rapid increase in fluoxetine dose to high doses was associated with depressive symptoms in 6 patients. In 8 patients, improvement in depression was associated with addition of a tricyclic antidepressant to fluoxetine treatment. In 5 patients, both OCD and depressive symptoms improved when the patient was switched to the partially selective serotonin reuptake blocker clomipramine. CONCLUSION: This paper serves to alert clinicians to the possibility of a depressive reaction, or lack of antidepressant response, to fluoxetine in OCD patients. This possibility can only be resolved scientifically by adequately controlled experimental trials. If depression occurs, combined fluoxetine and tricyclic treatment, or a switch to a partially selective serotonin reuptake inhibitor, may be helpful. Special considerations and side effects of combined fluoxetine-tricyclic treatment are described.