Social phobia: Axis I and II correlates.

The presence of Axis I and Axis II disorders in 71 social phobic patients was examined. Generalized anxiety disorder was the common secondary Axis I disorder, followed by simple phobia. Avoidant personality disorder and obsessive-compulsive personality disorder were the most common Axis II diagnoses, and 88% of the sample exhibited features of these 2 personality styles. Ss with additional Axis I diagnoses were more anxious and depressed than those with no additional Axis I disorder. Social phobics with additional Axis II disorders were more depressed but not more anxious than those with no Axis II diagnosis. Furthermore, those with an additional Axis I disorder had higher scores on measures of neuroticism, interpersonal sensitivity, and agoraphobia. The prevalence and impact of additional Axis I and II disorders on the etiology, maintenance, and treatment outcome for persons with social phobia are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comorbidity of DSM-III-R axis I and II disorders among female inpatients with eating disorders

Structured diagnostic interviews were used to determine DSM-III-R axis I and II diagnoses among 136 female psychiatric inpatients. To distinguish comorbidity of eating disorders with axis I and II disorders from simple diagnostic overlap, the frequency and distribution of diagnoses among the 31 patients with an eating disorder and the 105 without an eating disorder were compared. Social phobia, substance use disorders, borderline personality disorder, and avoidant personality disorder were diagnosed in a significantly larger proportion of the group with eating disorders. Future studies should focus on interpreting the meaning of the co-occurrence of these disorders in patients with eating disorders.     

A study of personality in eating disorders

Some evidence suggests that temperament and personality traits could influence the development and severity of eating disorders. This study was designed to study these aspects. METHODS: 72 patients with DSM-IV eating disorders including 25 anorexia nervosa restricting type, 17 with anorexia nervosa binge eating-purging type and 30 with bulimia nervosa were studied and compared with thirty healthy controls. Personality disorders and temperament were studied with the Eysenck's EPQ, Cloninger's TCI and SCID-II. Impulsive and clinical features were studied with specific rating scales. RESULTS: 61.8% of patients had at least one personality disorder. Avoidant personality disorder was the most commonly diagnosed in anorexia restricting type (25%). Borderline personality disorder was the most frequent in bulimia nervosa and in the binge eating-purging type of anorexia nervosa. Dimensionally, the group of eating disorders presented high scores in neuroticism and low scores in self-directedness. Higher harm avoidance was found in bulimic patients and higher persistence was associated with anorectic patients. Bulimic patients were significantly more impulsive than anorectic and controls. CONCLUSIONS: Temperament and personality traits differ in anorectic and bulimic patients. Bulimic symptoms are linked to impulsive temperament traits and to impulsive personality features. Anorectic symptoms are linked to persistent temperament traits and anxious personality features.     

Prevalence of comorbid anxiety disorders in primary care outpatients

OBJECTIVE: To estimate the extent to which anxiety disorders (eg, panic disorder, phobia, and generalized anxiety disorder [GAD]) co-occur in patients with major medical and psychiatric conditions. DESIGN: Observational study. SETTING: Offices of primary care providers in three US cities, with mental health specialty providers included for comparative purposes. PATIENTS: Adult patients (N = 2494) with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), current depressive disorder, or subthreshold depression. MEASURES: Current (past 12 months) and lifetime panic disorder, phobia, GAD, perceived need for help for emotional or family problems, and unmet need (ie, failure to get help that was needed). METHODS: Comparisons of the prevalence of anxiety comorbidity in medically ill nondepressed patients of primary care providers and in depressed patients of both primary care and mental health specialty providers. RESULTS: Among primary care patients, those with chronic medical illnesses or subthreshold depression had low rates of lifetime (1.5% to 3.5%) and current (1.0% to 1.7%) panic disorder, but those with current depressive disorder had much higher rates (10.9% lifetime and 9.4% current panic disorder). Concurrent phobia and GAD were more common (10.4% to 12.4% current GAD), especially among depressed patients (25% to 54% current GAD). Depending on the type of medical illness or depression, 14% to 66% of primary care patients had at least one concurrent anxiety disorder. Patient-perceived unmet need for care for personal or emotional problems was high among all primary care patients (54.6% to 72.9%). CONCLUSION: Primary care clinicians should be aware of the possible coexistence of anxiety disorders (especially GAD) among their patients with chronic medical conditions, but especially among those with current depressive disorder.     

Validation of the Social Interaction Anxiety Scale and the Social Phobia Scale across the anxiety disorders.

The psychometric adequacy of the Social Interaction Anxiety Scale (SIAS; R. P. Mattick & J. C. Clark, 1989), a measure of social interaction anxiety, and the Social Phobia Scale (SPS; R. P. Mattick & J. C. Clark, 1989), a measure of anxiety while being observed by others, was evaluated in anxious patients and normal controls. Social phobia patients scored higher on both scales and were more likely to be identified as having social phobia than other anxious patients (except for agoraphobic patients on the SPS) or controls. Clinician-rated severity of social phobia was moderately related to SIAS and SPS scores. Additional diagnoses of mood or panic disorder did not affect SIAS or SPS scores among social phobia patients, but an additional diagnosis of generalized anxiety disorder was associated with SIAS scores. Number of reported feared social interaction situations was more highly correlated with scores on the SIAS, whereas number of reported feared performance situations was more highly correlated with scores on the SPS. These scales appear to be useful in screening, designing individualized treatments, and evaluating the outcomes of treatments for social phobia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical study of the relation of borderline personality disorder to Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders

OBJECTIVE: The criteria for borderline personality disorder seem to select patients with very high rates of Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders. This study was undertaken to determine whether systematic assessment of patients with borderline personality disorder would reveal characteristic features of that condition which would distinguish it from these other disorders. METHOD: Eighty-seven white female patients (75 in St. Louis and 12 in Milan, Italy) who had borderline personality disorder according to both the DSM-III-R criteria and the Revised Diagnostic Interview for Borderlines were further examined with the DSM-III-R Checklist and the Perley-Guze Hysteria Checklist to determine their patterns of psychiatric comorbidity. RESULTS: Every patient had at least one additional DSM diagnosis. Patients in St. Louis and Milan averaged five and four additional diagnoses, respectively. Eighty-four percent of the patients in St. Louis met criteria for either somatization disorder, Briquet's syndrome, antisocial personality disorder, or substance abuse disorders. Patterns of comorbidity for panic (51%), generalized anxiety disorder (55%), and major depression (87%) in St. Louis were consistent with those in other studies. CONCLUSIONS: The data indicate that the boundaries for the borderline condition are not specific and identify a high percentage of patients with these other disorders. Furthermore, the comorbidity profiles closely resemble the psychiatric profiles of patients with these disorders. If the borderline syndrome is meant to include all of these disorders, its usefulness as a diagnosis is limited. Until the fundamental features of borderline personality disorder that distinguish it from the others are identified, it is recommended that clinicians carefully assess patients for these other diagnoses. Efforts should be made to change the borderline personality disorder criteria by shifting away from overlap with the criteria for the other disorders.     

Change in obsessive-compulsive and avoidant personality disorders following time-limited supportive-expressive therapy.

24 patients with avoidant personality disorder (AVPD) and 14 patients with obsessive-compulsive personality disorder (OCPD; all Ss 20–65 yrs old) were assigned to 52 sessions of time-limited Supportive-Expressive dynamic psychotherapy. At intake, most Ss had least 1 concurrent depressive and/or anxiety disorder. OCPD Ss lost their personality disorder diagnoses significantly faster than did AVPD Ss. By the end of treatment, 39% of AVPD Ss still retained their diagnosis while only 15% of OCPD did so. Using hierarchical linear modeling, both patient groups improved significantly across time on measures of personality disorders, depression, anxiety, general functioning, and interpersonal problems. OCPD Ss remained in treatment significantly longer and tended to improve more than did AVPD Ss. Alliance ratings from both Ss and therapists increased significantly over time, expect for those OCPD Ss who remained constant. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Morbidity of DSM-IV Axis I disorders in patients with noncardiac chest pain: Psychiatric morbidity linked with increased pain and health care utilization.

The present study examined current and lifetime psychiatric morbidity, chest pain, and health care utilization in 229 patients with noncardiac chest pain (NCCP), angina-like pain in the absence of cardiac etiology. Diagnostic interview findings based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) revealed a psychiatrically heterogeneous sample of whom 44% had a current Axis I psychiatric disorder. A total of 41% were diagnosed with a current anxiety disorder, and 13% were diagnosed with a mood disorder. Overall, 75% of patients had an Axis I clinical or subclinical disorder. Lifetime diagnoses of anxiety (55%) and mood disorders (44%) were also prevalent, including major depressive disorder (41%), social phobia (25%), and panic disorder (22%). Patients with an Axis I disorder reported more frequent and more painful chest pain compared with those without an Axis I disorder. Presence of an Axis I disorder was associated with increased life interference and health care utilization. Findings reveal that varied DSM-IV Axis I psychiatric disorders are prevalent among patients with NCCP, and this psychiatric morbidity is associated with a less favorable NCCP presentation. Implications for early identification of psychiatric disorders are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of personality disorders on behavioral treatment outcome for social phobia

The impact of personality disorders (PDs) on exposure in vivo treatment for social phobia was investigated in three groups of social phobics: social phobia without any PD (n = 30), social phobia with a single diagnosis of avoidant PD (n = 18) and social phobia with multiple PDs (n = 13). We hypothesized parallel change for social phobia with and without an avoidant PD with the latter group being more impaired before and after treatment. In order to test this hypothesis, confidence intervals for change were computed. In line with our hypothesis, social phobics in all three groups improved significantly during treatment and no interaction effects were found on the repeated MANOVAs. By using a confidence interval, parallel change was found on most measures. The impact of additional anxiety and mood disorders on treatment outcome was investigated separately. The analyses showed that an additional anxiety or mood disorder also did not predict outcome of exposure treatment.     

Personality traits in social phobia, II: Changes during drug treatment

BACKGROUND: Patients with social phobia often describe personality traits characterized by avoidant social behavior and more general depressive-anxious features. There is only sparse knowledge about the effects of drug treatment on these traits. METHOD: Fifty-seven patients with social phobia completed a 12-week double-blind, placebo-controlled trial with the reversible and selective monoamine oxidase A inhibitor brofaromine 150 mg/day. The Clinical Global Impressions-Improvement scale, Liebowitz Social Anxiety Scale, a questionnaire with 140 items regarding personality traits, and ratings on the presence or absence of diagnostic criteria for the DSM-III-R avoidant and dependent personality disorders were used for assessments at baseline and endpoint. Comparisons were made with a group of 58 healthy controls. RESULTS: Before treatment, there were no significant differences between the brofaromine and placebo groups in their ratings on situationally bound social anxiety or on personality traits that differed significantly from those of the controls. At endpoint, a marked normalization was noted in the brofaromine group. The changes that had occurred differed significantly from those in the placebo group. The normalization of traits seemed more marked than the normalization of anxiety in more specific social phobic situations. The number of brofaromine patients who fulfilled the criteria for avoidant personality disorder had diminished from 15 (60%) to 5 (20%). CONCLUSION: The results support the conclusion that the maladaptive personality traits characteristic of social phobia are at least as responsive to the monoamine oxidase inhibitor brofaromine as are the more circumscribed social anxiety responses.     

Peer social status of children with anxiety disorders.

The peer social status of 6–13-year-old children with anxiety disorders was investigated. Sixteen children who met Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria for anxiety disorders were compared with 26 children with conduct disorders and 45 nonreferred children. Anxiety-disorder children were liked significantly less than normal children, but anxious and conduct-disorder children did not differ from one another. The conduct-disorder group received more "like-least"" and "fight-most"" nominations than the anxious and nonreferred groups, which did not differ. Furthermore, the anxious group received the lowest social-impact scores (total like-most and like-least nominations) of any group and were most likely to fall in the socially neglected category of peer status. The lack of popularity of children with anxiety disorders may be limited to those with concurrent depression. Overall, these findings indicate that childhood anxiety disorders, at least when they coexist with depression, are associated with diminished peer popularity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Syndrome comorbidity in patients diagnosed with a DSM-III—R anxiety disorder.

One hundred thirty patients presenting at an anxiety disorders research clinic were administered a structured interview (i.e., Anxiety Disorders Interview Schedule—Revised). Diagnoses were made in accordance with Diagnostic and Statistical Manual of Mental Disorders-III—Revised (DSM-III—R) criteria. Seventy percent of patients received at least one additional but secondary Axis I diagnosis. The most common additional diagnoses were simple and social phobia, which were assigned to nearly one third of all patients. In addition, 33% of anxiety disorder patients received an additional diagnosis of a depressive mood disorder (i.e., dysthymia or major depression). The distribution of specific additional diagnoses are presented for each principal anxiety disorder category. The scientific and clinical implications of comorbidity are discussed while considering the relatively high patterns of syndrome comorbidity found in the present study, which is consistent with several earlier studies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social phobia: an update

The literature on social phobia is reviewed in this article. Social phobia has undergone considerable diagnostic evolution to reach its present form in DSM-IV. Its differential diagnosis includes panic disorder with agoraphobia, avoidant personality disorder, depression, and "shyness." Cross-cultural issues are important to consider because the disorder may manifest differently in different cultures and social settings. It is common, with a lifetime prevalence of 13.3% in the United States according to recent epidemiological studies. Underrecognition of social phobia remains an issue of concern. Comorbidity with other psychiatric disorders, including other anxiety disorders, depression, alcohol abuse, and personality disorders, frequently occurs. Current conceptualizations of the etiology of social phobia reflect psychodynamic theories and evidence from family and genetic studies, neurobiological research, and neuroimaging. Drugs such as monoamine oxidase inhibitors, selective serotonin-reuptake inhibitors, benzodiazepines, and beta3-adrenergic blockers have proven to be efficacious, as has cognitive-behavioral treatment, including group approaches.     

Drugs and the college athlete: an analysis of the attitudes of student athletes at risk

This study examines the degree to which untreated anxiety disorders and major depressive disorder, occurring either singly or in combination, reduce functioning and well-being among primary care patients. Adult patients were screened using the SCL-52 to identify those with clinically significant anxiety symptoms. They also completed the Rand Short-Form (SF-36) to measure self-reported patient functioning and well-being. Patients with untreated disorders were identified using the Q-DIS-III-R to diagnose six DIS-anxiety disorders (generalized anxiety disorder, post-traumatic stress disorder (PTSD), simple phobia, social phobia, panic/agoraphobia, obsessive/compulsive disorder) and major depression. Of 319 patients identified, 137 (43%) had a single disorder and 182 (57%) had multiple disorders. Regression models estimated the relative effects of these disorders on health status (SF-36) by comparing patients with the disorders to patients screened as being not-anxious. Estimates of these effects were consistent with available national norms. The estimated effect of each single disorder on all subscales for physical, social and emotional functioning was negative, often as much as a 20-30 point reduction on this 100-point scale. Major depression had the greatest negative impact, followed by PTSD and panic/ agoraphobia. For patients with multiple disorders, the presence of major depression was associated with the greatest reduction in functioning status. The impact of untreated anxiety disorders and major depressive disorder on functioning was comparable to, or greater than, the effects of medical conditions such as low back pain, arthritis, diabetes and heart disease.     

Co-morbidity and familial aggregation of alcoholism and anxiety disorders

BACKGROUND: This study examined the patterns of familial aggregation and co-morbidity of alcoholism and anxiety disorders in the relatives of 165 probands selected for alcoholism and/or anxiety disorders compared to those of 61 unaffected controls. METHODS: Probands were either selected from treatment settings or at random from the community. DSM-III-R diagnoses were obtained for all probands and their 1053 first-degree relatives, based on direct interview or family history information. RESULTS: The findings indicate that: (1) alcoholism was associated with anxiety disorders in the relatives, particularly among females; (2) both alcoholism and anxiety disorders were highly familial; (3) the familial aggregation of alcoholism was attributable to alcohol dependence rather than to alcohol abuse, particularly among male relatives; and (4) the the pattern of co-aggregation of alcohol dependence and anxiety disorders in families differed according to the subtype of anxiety disorder; there was evidence of a partly shared diathesis underlying panic and alcoholism, whereas social phobia and alcoholism tended to aggregate independently. CONCLUSIONS: The finding that the onset of social phobia tended to precede that of alcoholism, when taken together with the independence of familial aggregation of social phobia and alcoholism support a self-medication hypothesis as the explanation for the co-occurrence of social phobia and alcoholism. In contrast, the lack of a systematic pattern in the order of onset of panic and alcoholism among subjects with both disorders as well as evidence for shared underlying familial risk factors suggests that co-morbidity between panic disorder and alcoholism is not a consequence of self-medication of panic symptoms. The results of this study emphasize the importance of examining co-morbid disorders and subtypes thereof in identifying sources of heterogeneity in the pathogenesis of alcoholism.     

DSM-III-R personality disorders in a mood and anxiety disorders clinic: prevalence, comorbidity, and clinical correlates

This study examined the prevalence, comorbidity, and clinical correlates of personality disorders in an outpatient sample (N = 352) with anxiety and depression. Subjects were diagnosed using the Structured Clinical Interview for DSM-III-R (SCID) on Axes I and II, and they also completed interview and self-report measures of symptoms. Subjects with a personality disorder were less likely to be married, more likely to be single or divorced, had lower family incomes, had more severe symptoms of both anxiety and depression, and had a greater number of lifetime Axis I diagnoses. Subjects with dysthymic and bipolar disorders were more likely, and subjects with panic disorder uncomplicated by agoraphobia were less likely to have a personality disorder compared to the rest of the sample. The most prevalent personality disorders were Avoidant, Obsessive-Compulsive, Paranoid, and Borderline. Paranoid co-occurred with Narcissistic, and Borderline co-occurred with Histrionic personality disorder significantly more often than chance and base rates would predict.     

Psychopathology in the offspring of anxiety disorders patients.

Children of patients with an anxiety disorders diagnosis were assessed with a battery of self-report inventories and a semistructured interview schedule. The performance of these children was compared with that of children of patients with a diagnosis of dysthymic disorder, children of normal parents, and normal school children. Children of anxiety disorders patients were found to be more anxious and fearful; to report more school difficulties, more worries about family members and themselves, and more somatic complaints; and to spend more time engaged in solitary activities than children in either of the two normal groups. In addition, they were found to be more than 7 times as likely to meet criteria for an anxiety disorder than the two normal groups and to be twice as likely to have an anxiety disorder than the children of dysthymics. The resultant implications for familial factors in anxiety disorders are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders

BACKGROUND: The co-occurrence of anxiety disorders with other mental, addictive, and physical disorders has important implications for treatment and for prediction of clinical course and associated morbidity. METHOD: Cross-sectional and prospective data on 20,291 individuals from the Epidemiologic Catchment Area (ECA) study were analysed to determine one-month, current disorders, one-year incidence, and one-year and lifetime prevalence of anxiety, mood, and addictive disorders, and to identify the onset and offset of disorders within the one-year prospective period. RESULTS: Nearly half (47.2%) of those meeting lifetime criteria for major depression also have met criteria for a comorbid anxiety disorder. The average age of onset of any lifetime anxiety disorder (16.4 years) and social phobia (11.6 years) among those with major depression was much younger than the onset age for major depression (23.2 years) and panic disorder. CONCLUSIONS: Anxiety disorders, especially social and simple phobias, appear to have an early onset in adolescence with potentially severe consequences, predisposing those affected to greater vulnerability to major depression and addictive disorders.     

Psychopathology of social phobia and comparison to avoidant personality disorder.

Studied the clinical manifestations of social phobia in a diagnosed sample of 21 social phobics (aged 21–53 yrs). Social phobia was found to be a chronic and pervasive condition affecting a variety of life areas and producing significant emotional distress. In a 2nd study, individuals with a diagnosis of social phobia or avoidant personality disorder were compared using a subsample of 10 socially phobic Ss and a sample of 8 Ss with avoidant personality disorder (aged 30–60 yrs). Although physiological reactivity and cognitive content were essentially the same for both groups in a number of situational tasks, those Ss with a diagnosis of avoidant personality disorder were found to be more sensitive interpersonally, and exhibited significantly poorer social skill than did the social phobic Ss. Results are discussed in relation to Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria for social phobia, the significance of social phobia as a clinical syndrome, and the research and treatment implications of the difference found between individuals with a diagnosis of social phobia and those with avoidant personality disorders. (19 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Axis I comorbidity of borderline personality disorder

OBJECTIVE: The purpose of this study was to assess the lifetime rates of occurrence of a full range of DSM-III-R axis I disorders in a group of patients with criteria-defined borderline personality disorder and comparison subjects with other personality disorders. METHOD: The axis I comorbidity of 504 inpatients with personality disorders was assessed by interviewers who were blind to clinical diagnosis and who used a semistructured research interview of demonstrated reliability. RESULTS: Four new findings emerged from this study. First, anxiety disorders were found to be almost as common among borderline patients (N=379) as mood disorders but far more discriminating from axis II comparison subjects (N=125). Second, posttraumatic stress disorder (PTSD) was found to be a common but not universal comorbid disorder among borderline patients, a finding inconsistent with the view that borderline personality disorder is actually a form of chronic PTSD. Third, male and female borderline patients were found to differ in the type of disorder of impulse in which they "specialized." More specifically, substance use disorders were significantly more common among male borderline patients, while eating disorders were significantly more common among female borderline patients. Fourth, a lifetime pattern of complex comorbidity (i.e., met DSM-III-R criteria for both a disorder of affect and a disorder of impulse at some point before the patients' index admission) was found to have strong positive predictive power for the borderline diagnosis as well as a high degree of sensitivity and specificity. CONCLUSIONS: These results suggest that the lifetime pattern of axis I comorbidity characteristic of borderline patients and distinguishing for the disorder is a particularly good marker for borderline personality disorder.