Generalized social anxiety disorder and avoidant personality disorder: structural analysis and treatment outcome.

There has been considerable controversy about whether generalized social phobia (GSP) and avoidant personality disorder (APD) are redundant diagnostic categories. In light of the ongoing controversy, more data are needed to help determine whether GSP and APD are independent constructs. Data were obtained from 335 people seeking treatment for GSP at a two site clinical trial. Indicators of GSP and APD were obtained along with assessments of demographic factors, level of functioning, and indicators of related psychopathology. Confirmatory factor analyses of indicators of GSP and APD suggested a somewhat better fit for a two-factor solution. Comparisons of GSP patients with and without APD suggested that in addition to having more severe social phobia symptoms, patients with APD were more depressed on a self-report measure and had more functional impairment, thereby suggesting potential utility of the diagnostic category of APD. Furthermore, the presence of APD predicted treatment response, in that patients with APD had more change early in treatment than those without APD. APD and GSP remain highly related constructs, and different aspects of these data support and dispute the utility of the diagnosis of APD in GSP. Possible new directions in conceptualizing APD are discussed.

Treating Comorbid Social Anxiety and Alcohol Use Disorders: Combining Motivation Enhancement Therapy With Cognitive-Behavioral Therapy.

Social anxiety disorder (SAD) and alcohol use disorders (AUD) co-occur at particularly high rates, resulting in greater impairment than either disorder alone. Thus, the development of effective treatments for patients with SAD and comorbid AUD is an important clinical and research aim. Yet little work has examined treatments for SAD with comorbid AUD. Given the efficacy of motivation enhancement therapy (MET) for AUD and cognitive-behavioral therapy (CBT) for SAD, combining MET with CBT may decrease symptoms of both AUD and SAD. The present case study outlines the successful use of combined MET-CBT to treat a 33-year-old man with a long history of generalized SAD with AUD. Following 19 sessions of MET-CBT, the patient was considered in remission for both disorders, with notable decreases in social anxiety and alcohol-related problems (with continued gains at 6-month follow-up). Although these data are preliminary, they indicate that the combination of MET and CBT may be a viable approach to the treatment for patients with SAD and comorbid AUD.

Robust dimensions of anxiety sensitivity: development and initial validation of the Anxiety Sensitivity Index-3.

Accumulating evidence suggests that anxiety sensitivity (fear of arousal-related sensations) plays an important role in many clinical conditions, particularly anxiety disorders. Research has increasingly focused on how the basic dimensions of anxiety sensitivity are related to various forms of psychopathology. Such work has been hampered because the original measure--the Anxiety Sensitivity Index (ASI)--was not designed to be multidimensional. Subsequently developed multidimensional measures have unstable factor structures or measure only a subset of the most widely replicated factors. Therefore, the authors developed, via factor analysis of responses from U.S. and Canadian nonclinical participants (n=2,361), an 18-item measure, the ASI-3, which assesses the 3 factors best replicated in previous research: Physical, Cognitive, and Social Concerns. Factorial validity of the ASI-3 was supported by confirmatory factor analyses of 6 replication samples, including nonclinical samples from the United States and Canada, France, Mexico, the Netherlands, and Spain (n=4,494) and a clinical sample from the United States and Canada (n=390). The ASI-3 displayed generally good performance on other indices of reliability and validity, along with evidence of improved psychometric properties over the original ASI.

Responses to symptom induction exercises in panic disorder.

Exposure to panic symptoms (interoceptive exposure) is often included as part of treatment for panic disorder (PD), although little is known about the relative effects of particular symptom induction exercises. This study describes responses of individuals with PD and nonclinical controls to 13 standard symptom induction exercises and 3 control exercises. Generally, individuals with PD responded more strongly to symptom induction exercises than did controls. The exercises producing the most fear included spinning, hyperventilation, breathing through a straw, and using a tongue depressor. This study also reports findings regarding specific symptoms triggered by each exercise, the percentage of participants reporting fear during each exercise, and predictors of fear.

Peer victimization in children with obsessive-compulsive disorder: relations with symptoms of psychopathology.

This study examined the frequency of peer victimization and psychological symptom correlates among youth with obsessive-compulsive disorder (OCD). The Schwartz Peer Victimization Scale, Children's Depression Inventory, and Asher Loneliness Scale were administered to 52 children and adolescents diagnosed with OCD. The child's parent or guardian completed the Child Behavior Checklist, and a trained clinician administered the Children's Yale-Brown Obsessive-Compulsive Scale (CY- BOCS). Fifty-two healthy controls and 52 children with Type 1 diabetes (T1D) who were administered the Schwartz Peer Victimization Scale as part of another study were included for comparison purposes. Greater rates of peer victimization were reported in youth with OCD relative to healthy controls and children with Type 1 diabetes (T1D). Peer victimization in the OCD sample was positively related to loneliness, child-reported depression, parent-reported internalizing and externalizing symptoms, and clinician-rated OCD severity. Peer victimization fully mediated the relation between OCD severity and both depression and parent reports of child externalizing behaviors and partially mediated the relation between OCD severity and loneliness. Recognition of the magnitude of the problem and contribution problematic peer relations may play in comorbid psychological conditions is important for clinicians who see children with OCD.

Peer victimization and psychosocial adjustment in children: current knowledge and future directions.

Childhood peer victimization is the experience of being a target of peers' aggressive behavior. Peer victimization is a common occurrence and has been concurrently and prospectively linked to significant psychological distress. This paper provides a review of the extant literature on the relationship between peer victimization and psychosocial adjustment in nonclinical and pediatric populations. Clinical applications of this literature, as well as directions for future study, are presented.

Separation anxiety disorder.

SAD is a disorder that can cause a great deal of distress and impairment. Children with the disorder often miss school, as well as many other important social opportunities like playing with friends and participating in extracurricular activities. It is quite likely that, if untreated, SAD can lead to numerous negative psychosocial outcomes. Luckily, effective treatments for SAD are available, including CBT and SSRI pharmacotherapy. Pediatricians can play an important role in identifying SAD and other anxiety disorders and providing parents with information about appropriate treatments.

Efficacy of a manualized and workbook-driven individual treatment for social anxiety disorder.

Social anxiety disorder is a prevalent and impairing disorder for which viable cognitive-behavioral therapies exist. However, these treatments have not been easily packaged for dissemination and may be underutilized as a result. The current study reports on the findings of a randomized controlled trial of a manualized and workbook-driven individual cognitive-behavioral treatment for social anxiety disorder (Hope, Heimberg, Juster, & Turk, 2000; Hope, Heimberg, & Turk, 2006). This treatment package was derived from an empirically supported group treatment for social anxiety disorder and intended for broad dissemination, but it has not previously been subjected to empirical examination on its own. As a first step in that examination, 38 clients seeking treatment for social anxiety disorder at either the Adult Anxiety Clinic of Temple University or the Anxiety Disorders Clinic of the University of Nebraska-Lincoln were randomly assigned to receive either immediate treatment with this cognitive-behavioral treatment package or treatment delayed for 20 weeks. Evaluation at the posttreatment/postdelay period revealed substantially greater improvements among immediate treatment clients on interviewer-rated and self-report measures of social anxiety and impairment. Three-month follow-up assessment revealed maintenance of gains. Clinical implications and directions for future research are discussed.

A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder.

OBJECTIVE: Although serotonin reuptake inhibitors (SRIs) are approved for the treatment of obsessive-compulsive disorder (OCD), most OCD patients who have received an adequate SRI trial continue to have clinically significant OCD symptoms. The purpose of this study was to examine the effects of augmenting SRIs with exposure and ritual prevention, an established cognitive-behavioral therapy (CBT) for OCD. METHOD: A randomized, controlled trial was conducted at two academic outpatient clinics to compare the effects of augmenting SRIs with exposure and ritual prevention versus stress management training, another form of CBT. Participants were adult outpatients (N=108) with primary OCD and a Yale-Brown Obsessive Compulsive Scale total score > or = 16 despite a therapeutic SRI dose for at least 12 weeks prior to entry. Participants received 17 sessions of CBT (either exposure and ritual prevention or stress management training) twice a week while continuing SRI pharmacotherapy. RESULTS: Exposure and ritual prevention was superior to stress management training in reducing OCD symptoms. At week 8, significantly more patients receiving exposure and ritual prevention than patients receiving stress management training had a decrease in symptom severity of at least 25% (based on Yale-Brown Obsessive Compulsive Scale scores) and achieved minimal symptoms (defined as a Yale-Brown Obsessive Compulsive Scale score < or = 12). CONCLUSIONS: Augmentation of SRI pharmacotherapy with exposure and ritual prevention is an effective strategy for reducing OCD symptoms. However, 17 sessions were not sufficient to help most of these patients achieve minimal symptoms.

Impact of depressive symptoms on the treatment of generalized social anxiety disorder.

Patients with depression are often excluded from studies on the treatment of social anxiety disorder (SAD), leaving gaps in our knowledge about the impact of depressive affect on treatment for SAD. Patients participated in a randomized, placebo-controlled study of treatment for SAD. As in previous studies, patients were excluded from the study if they met criteria for major depressive disorder in the past 6 months. This exclusion notwithstanding, patients who enrolled in the study exhibited a range of depressive symptoms, permitting an examination of the impact of depressive symptoms on treatment outcome for SAD. Assessment measures included the Clinical Global Impression Scale, Hamilton Rating Scale for Depression, Brief Social Phobia Scale, and Beck Depression Inventory. Higher levels of depressive symptoms were related to more severe social anxiety overall, and to less change in social anxiety symptoms over the course of the study. Patients who were deemed nonresponders to treatment had higher levels of depressive symptoms at pretreatment than those who responded. In addition, patients who dropped out of the study had higher levels of depressive symptoms at pretreatment than those who completed the study. These results suggest that modifications should be made to existing treatments to improve outcomes and decrease attrition in the substantial proportion of patients with SAD who also evidence depressive symptoms. Such modifications are likely to be more important when treating patients with SAD and comorbid major depressive disorder.