Generalized social phobia versus avoidant personality disorder: a commentary on three studies.

The findings of Herbert, Hope, and Bellack (1992), Holt, Heimberg, and Hope (1992), and Turner, Beidel, and Townsley (1992) are largely consistent. Avoidant personality disorder and generalized social phobia appear to be overlapping constructs that have only minor differences with respect to severity of dysfunction. This commentary addresses the implications of the findings with respect to the validity of the categorical distinction in the Diagnostic and Statistical Manual of Mental Disorders (rev. 3rd ed.; American Psychiatric Association, 1987) between avoidant personality and generalized social phobia, revisions of their respective diagnostic criteria, and their reclassification as either an anxiety or a personality disorder. Methodological and substantive suggestions for future research are also discussed.     

Social phobia: a comparison of specific and generalized subtypes and avoidant personality disorder.

The validity of the social phobia subtype distinction was examined in a large sample of carefully diagnosed social phobics (N = 89). Generalized and specific subtypes were diagnosed reliably, and the generalized subtype showed a consistent pattern of greater symptom severity than did the specific subtype. In addition, generalized social phobics with and without avoidant personality disorder were compared, and a difference was found for only 1 of 4 parameters. The results are discussed in terms of the validity of subtyping in social phobia and the diagnostic boundary between social phobia and avoidant personality disorder.     

Validity of the distinction between generalized social phobia and avoidant personality disorder.

Disorders of pervasive social anxiety and inhibition are divided into 2 categories, generalized social phobia (GSP) and avoidant personality disorder (APD). We explored the discriminative validity of this categorization by examining the comorbidity of GSP and APD and by comparing these groups on anxiety level, social skills, dysfunctional cognitions, impairment in functioning, and presence of concurrent disorders. Results from 23 subjects showed high comorbidity of the 2 diagnoses: All subjects who met criteria for APD also met criteria for GSP. APD was associated with greater social anxiety, impairment in functioning, and comorbidity with other psychopathology, but no differences in social skills or performance on an impromptu speech. GSP and APD seem to represent quantitatively different variants of the same spectrum of psychopathology rather than qualitatively distinct disorders. We also investigated a proposed social phobia subtyping scheme.     

Use of a religious hymn in remission of symptoms of social phobia (social anxiety disorder): a case study

This case report described a veteran with social anxiety disorder who reported fears of negative evaluation by others, social avoidance, and accompanying physiological symptoms of heart palpitations, gastrointestinal discomfort, muscle tension and mental confusion. The symptoms of social anxiety disorder subsided with the use of a Christian hymn "Be Still My Soul" and its accompanying musical poem, in Finlandia. The veteran attributed the symptom remission to the feeling of stillness and surrender to God conveyed by the words and music of the hymn. Although previous studies have shown that both music and religious beliefs can affect mental health, the findings in this case cannot be generalized without conducting further prospective empirical studies.     

Avoidant personality disorder and the generalized subtype of social phobia.

Social phobia and avoidant personality disorder (APD) may be given as comorbid diagnoses. However, it is not known if the labels provide independent, useful diagnostic information. We classified social phobics by social phobia subtype and presence of APD. Generalized social phobics with and without APD (ns = 10 and 10) and nongeneralized social phobics without APD (n = 10) were distinguished on measures of phobic severity. The generalized groups also showed earlier age at onset and higher scores on measures of depression, fear of negative evaluation, and social anxiety and avoidance than did the nongeneralized group. APD criteria of general timidity and risk aversion were more frequently endorsed by social phobics with APD. The data suggest that both the generalized subtype of social phobia and the presence of APD do provide useful diagnostic information but the additional diagnosis of APD may simply identify a severe subgroup of social phobics.     

Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia

The relationship between co-occurring personality disorders and anxiety disorders (panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder) was examined, taking into account the effect of major depression. This article describes findings for 622 participants in the Harvard/Brown Anxiety Research Project, a longitudinal follow-up study of DSM-III-R-defined anxiety disorders. A total of 24% of participants had at least one personality disorder, with avoidant, obsessive compulsive, dependent, and borderline most common. Generalized anxiety disorder, social phobia, and major depression were positively associated with the occurrence of one or more personality disorders, whereas panic disorder with agoraphobia was not associated. Major depression was associated in particular with dependent, borderline, histrionic, and obsessive compulsive personality disorders and social phobia was associated with avoidant personality disorder. Whereas some of our findings confirm results from earlier studies, others are somewhat inconsistent with previous results and indicate the need for further investigation.     

Personality and mood correlates of avoidant personality disorder

Avoidant personality disorder (APD) has been recognized as prevalent and clinically important; however, it is not clear how APD maps onto established personality and mood dimensions. In this cross-sectional survey study, 365 college students completed questionnaires assessing APD features and theoretically relevant personality and mood dimensions. Based on these self-report data, 6.6% may meet DSM-IV criteria for APD. Hierarchical regression analyses showed that APD features were associated with introversion, neuroticism, low self-esteem, and pessimistic expectancies. Additionally, APD features were linked with self-reports of elevated emotional responsiveness to threats and reduced emotional responsiveness to incentives (the behavioral inhibition system and behavioral activation system scales). After controlling for the effects of other personality, temperament, and cognitive measures, affective distress (i.e., anger, anxiety, and depression) was no longer related to APD. Results are consistent with APD models that emphasize the joint influences of emotional vulnerability and social-cognitive triggering and sustaining factors.     

Social rank and affiliation in social anxiety disorder

The present study examined the interpersonal lives of individuals with social anxiety disorder (SAD). According to evolutionary and interpersonal theories, we construed the interpersonal world using the social rank and the affiliation psychological systems. Two studies assessed measures of social rank, affiliation, social anxiety and depression among a population of treatment-seeking individuals with SAD. In study 1, individuals with SAD without major depressive disorder (MDD; n=42) were compared to healthy controls (n=47). In study 2, individuals with SAD and MDD (n=45) were compared to individuals with other anxiety disorders and MDD (n=31). Results indicated that SAD was related to perceiving oneself as having low social rank, being inferior, and behaving submissively, as well as to low perceived intimacy and closeness among peer relations, friendships and romantic relations. SAD was distinctly associated with these perceptions above and beyond the symptomatic (study 1) and the syndrome-level (study 2) effects of depression. These findings were further supported by a path analysis of the SAD participants from both studies. Our findings highlight the need to address both social rank and affiliation issues in the assessment and treatment of SAD.     

Expectations and attributions in social anxiety disorder: diagnostic distinctions and relationship to general anxiety and depression

Contemporary cognitive models suggest that social anxiety disorder arises from a number of cognitive factors, including tendencies to form pessimistic (rather than optimistic) attributions and expectations for socially-related events. These models also assume that the strengths of such attributions and expectations are more closely linked with social anxiety than with general anxiety or depression. To test these assumptions, a battery of self-report measures was completed by participants with a primary diagnosis of generalized social anxiety disorder (n = 75), panic disorder with agoraphobia (n = 44), or post-traumatic stress disorder (n = 59). To examine differences on these cognitive variables, group comparisons were performed controlling for general anxiety, depression and medication status. Social anxiety disorder, compared with panic disorder with agoraphobia and post-traumatic stress disorder, was characterized by lower expectations for positive social events and higher expectations for negative social events. There was no difference among the groups on expectations for non-social positive or negative events. Stable and global attributions for social negative events were more closely associated with social anxiety disorder than with panic disorder with agoraphobia and post-traumatic stress disorder. Correlational analyses also revealed specific relationships among social-cognitive measures and social anxiety, even after controlling for general anxiety and depression. The results are consistent with cognitive models of social anxiety disorder.     

Predicting anxious response to a social challenge: the predictive utility of the social interaction anxiety scale and the social phobia scale in a college population

Trait anxiety is believed to be a hierarchical construct composed of several lower-order factors (Adv. Behav. Res. Therapy, 15 (1993) 147; J. Anxiety Disorders, 9 (1995) 163). Assessment devices such as the Social Interaction Anxiety Scale, the Social Phobia Scale (SIAS and SPS; Behav. Res. Therapy, 36 (4) (1998) 455), and the Anxiety Sensitivity Index (ASI; Behav. Res. Therapy, 24 (1986) 1) are good measures of the presumably separate lower-order factors. This study compared the effectiveness of the SIAS, SPS, ASI-physical scale and STAI-T (State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press (1970)) as predictors of anxious response to a social challenge (asking an aloof confederate out on a date). Consistent with the hierarchical model of anxiety, the measures of trait anxiety were moderately correlated with each other and each was a significant predictor of anxious response. The specific measures of trait social anxiety were slightly better predictors of anxious response to the social challenge than was either the ASI-physical scale or the STAI-T. The results provide evidence of the predictive validity of these social trait measures and some support for their specificity in the prediction of anxious response to a social challenge.     

Self-construal and social anxiety: Considering personality

Self-construal has been identified as a potential means to explain cultural differences in social anxiety. Yet, research findings suggest that self-construal is an individual difference as much as a cultural difference. We tested for mediation and moderation regarding self-construal, social anxiety, and other primary individual difference constructs. Our results indicated that the relation of extraversion and neuroticism to social anxiety was partially mediated by independent self-construal. In addition, the relationship between social anxiety and interdependent self-construal was moderated by neuroticism. These results suggest that personality traits play an important role in the relationship between social anxiety and self-construal. Clinical interventions that consider the interplay between self-construal and personality may be helpful in decreasing social anxiety.     

The social phobia and anxiety inventory: psychometric properties in a Spanish sample

This study is a validation of the Spanish version of the Social Phobia and Anxiety Inventory using a nonclinical sample (198 participants) and a clinical sample (72 participants with social phobia). The factor structure and concurrent validity with Fear of Negative Evaluation and Social Avoidance and Distress scales were analyzed. The Social Phobia and Anxiety Inventory demonstrated good concurrent validity, showing statistically significant relationships with Fear of Negative Evaluation and Social Avoidance and Distress. Results confirmed the rationale for the division of the SPAI into two subscales. Results also demonstrated the utility of the Social Phobia and Anxiety Inventory for differentiating between a nonclinical sample and participants with a social phobia, and its adequate reliability.     

Social phobia and interpretation of social events

It has been suggested that social phobia may be characterized by two interpretation biases. First, a tendency to interpret ambiguous social events in a negative fashion. Second, a tendency to interpret unambiguous but mildly negative social events in a catastrophic fashion. To assess this possibility, patients with generalized social phobia, equally anxious patients with another anxiety disorder, and non-patient controls were presented with ambiguous scenarios depicting social and non-social events, and with unambiguous scenarios depicting mildly negative social events. Interpretations were assessed by participants' answers to open-ended questions and by their rankings and belief ratings for experimenter-provided, alternative explanations. Compared to both control groups, patients with generalized social phobia were more likely to interpret ambiguous social events in a negative fashion and to catastrophize in response to unambiguous, mildly negative social events.     

Reaction time to threat stimuli in panic disorder and social phobia

Two studies assessed response time among clinically anxious subjects and normal controls when presented with threat, positive and neutral stimuli under perceptual (lexical decision) and semantic (category decision) task conditions. In Study 1, panic disorder subjects' (n = 14) performance was compared to that of matched normal controls (n = 14) while in Study 2 social phobic subjects (n = 24) were compared to matched normal controls (n = 24). Relative to matched normal controls, panic disorder subjects but not social phobics tended to show greater slowing in performance on the more cognitively complex (category) task. A second finding, consistent across both studies was that, compared to the normal control groups, both panic and social phobic groups showed significantly slowed responses to threat words in both the perceptual and semantic tasks. Such findings are directly counter to the predictions of a mood congruence hypothesis. This apparent contradiction is resolved by a review of the literature which indicates that mood-related facilitation effects are obtained only in tasks which tap awareness of threat information rather than speed of response. It is suggested that while anxiety may produce enhanced awareness of threat, it may inhibit responsiveness to it. The results of these studies are seen as consistent with ethological theories of inhibited motoric responses under certain threat conditions. Furthermore, the findings suggest that caution is indicated in interpreting slowed reaction time to threat stimuli in tasks such as the Stroop color naming task as purely the result of attentional processes.     

Public and private heart rate feedback in social phobia: a manipulation of anxiety visibility

According to cognitive behavioural models of social phobia, bodily symptoms are the main source of information concerning social evaluation for social phobics. Experience and perception of bodily symptoms therefore play an important role in social anxiety. In this study we evaluated the effects of anxiety visibility on patients and controls using feedback of veridical heart sounds. A total of 32 social phobics and 32 controls were asked twice to sit in a chair and appear relaxed while being evaluated. Half of the participants heard their heart sounds first via headphones and then via loudspeakers which were also audible to observers. The presentation order of the heart sound was reversed for the other half of the subjects. Social phobics reported substantially more anxiety than controls. Both groups showed habituation in heart rate from the first to the second presentation, and both groups reported perception of a higher heart rate, but only social phobics reported significantly more anxiety and were more worried about their heart rates in the public than in the private condition. These effects were in excess of actual heart rate differences. In conclusion, social phobics worried about the broadcast of a bodily anxiety symptom, whereas controls did not. Information about arousal made public has a strong potential to increase anxiety levels in social phobics.     

Public and private heart rate feedback in social phobia: a manipulation of anxiety visibility

According to cognitive behavioural models of social phobia, bodily symptoms are the main source of information concerning social evaluation for social phobics. Experience and perception of bodily symptoms therefore play an important role in social anxiety. In this study we evaluated the effects of anxiety visibility on patients and controls using feedback of veridical heart sounds. A total of 32 social phobics and 32 controls were asked twice to sit in a chair and appear relaxed while being evaluated. Half of the participants heard their heart sounds first via headphones and then via loudspeakers which were also audible to observers. The presentation order of the heart sound was reversed for the other half of the subjects. Social phobics reported substantially more anxiety than controls. Both groups showed habituation in heart rate from the first to the second presentation, and both groups reported perception of a higher heart rate, but only social phobics reported significantly more anxiety and were more worried about their heart rates in the public than in the private condition. These effects were in excess of actual heart rate differences. In conclusion, social phobics worried about the broadcast of a bodily anxiety symptom, whereas controls did not. Information about arousal made public has a strong potential to increase anxiety levels in social phobics.