Psychoanalytisch-orientierte Fokaltherapie der sozialen Phobie

Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy to treat anxiety disorders in clinical practice, evidence for the efficacy of psychodynamic therapy in anxiety disorders is unsatisfactory. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy in anxiety disorders. Psychodynamically oriented treatment manuals for anxiety disorders presently exist for generalized anxiety disorder and panic disorder. For social phobia (or social anxiety disorder), however, no manual for psychodynamic treatment has yet been published. Social phobia is a very frequent mental disorder characterized by an early onset, a chronic course, severe psychosocial impairments and high socio-economic costs and at the same time in spite of these facts one of the mental disorders which are scarcely diagnosed and treated. In this article, a manual for a 30-session (5 exploratory and 25 therapy sessions) short-term psychodynamic treatment of social phobia is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. In the first part, the general principles of SE therapy are presented. In the second part, a manual specifically adapted to the treatment of social phobia is described. This manual includes specific additional treatment elements that have clinically proved to be useful in the therapy of social phobia. The treatment manual is presently used in a large-scale randomized controlled multi-center study comparing short-term psychodynamic psychotherapy and cognitive-behavioral therapy in the treatment of social phobia.     

Mental imagery as an emotional amplifier: application to bipolar disorder

Cognitions in the form of mental images have a more powerful impact on emotion than their verbal counterparts. This review synthesizes the cognitive science of imagery and emotion with transdiagnostic clinical research, yielding novel predictions for the basis of emotional volatility in bipolar disorder. Anxiety is extremely common in patients with bipolar disorder and is associated with increased dysfunction and suicidality, yet it is poorly understood and rarely treated. Mental imagery is a neglected aspect of bipolar anxiety although in anxiety disorders such as posttraumatic stress disorder and social phobia focusing on imagery has been crucial for the development of cognitive behavior therapy (CBT).In this review we present a cognitive model of imagery and emotion applied to bipolar disorder. Within this model mental imagery amplifies emotion, drawing on Clark's cyclical panic model [(1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461–470]. We (1) emphasise imagery's amplification of anxiety (cycle one); (2) suggest that imagery amplifies the defining (hypo-) mania of bipolar disorder (cycle two), whereby the overly positive misinterpretation of triggers leads to mood elevation (escalated by imagery), increasing associated beliefs, goals, and action likelihood (all strengthened by imagery).Imagery suggests a unifying explanation for key unexplained features of bipolar disorder: ubiquitous anxiety, mood instability and creativity. Introducing imagery has novel implications for bipolar treatment innovation - an area where CBT improvements are much-needed.     

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.     

Social phobia features across the DSM-III-R anxiety disorders

One hundred sixty subjects meeting DSM-III-R criteria for the five major anxiety disorders were compared on the extent to which they reported features characteristic of social phobia. The results indicated that many patients in the anxiety disorder categories experience some degree of social anxiety. The differences between subjects with a primary diagnosis of social phobia and subjects with other anxiety disorders appear to be chiefly quantitative on this feature. Compared to the other anxiety disorders, social phobics report fear and avoidance in response to a greater number of social situations and report greater interference in their lives due to social phobic concerns. Among the anxiety disorders, generalized anxiety disorder appears to be associated with the greatest degree of social anxiety, and simple phobia with the least.     

Psychiatric correlates of childhood shyness in a nationally representative sample

Relations between adult anxiety and mood disorders and retrospective reports of excessive childhood shyness were investigated in the US National Comorbidity, Survey (n=5877). Results indicated that 26% of women and 19% of men described themselves as 'very shy' when they were growing up. Of these shy individuals, 53% of women and 40% of men met criteria for a lifetime diagnosis of one or more anxiety or mood disorders. Relations between excessive shyness and each of the anxiety and mood disorders were examined after adjusting for elevated neuroticism, self-criticism, and low maternal care. The largest odds ratios were found for social phobia in both men and women, particularly for the complex subtype of this disorder. Significant associations also emerged for posttraumatic stress disorder in women and for major depressive disorder in men. Childhood shyness remained significantly associated with a lifetime history of social phobia when individuals with current (past year) social phobia were excluded from the analysis. The results of this study suggest that childhood shyness is strongly related to the complex subtype of social phobia in the general population. Excessive shyness does not appear to be strongly associated with other anxiety and mood disorders when related psychosocial and developmental dimensions are statistically controlled. Finally, many individuals who report excessive childhood shyness do not meet criteria for any anxiety or mood disorder. In a similar fashion, approximately 50% of individuals with a lifetime history of complex social phobia did not view themselves as very shy when growing up.     

Preliminary Examination of the Relationship Between Anxiety Disorders in Adults and Self-Reported History of Teasing or Bullying Experiences

This preliminary study examined the relationship between anxiety disorders and self-reported history of teasing or bullying experiences, comparing individuals with social phobia, obsessive compulsive disorder, and panic disorder with or without agoraphobia. Given that aversive conditioning experiences, such as severe teasing, have been proposed to play a role in the development of social phobia and that the core feature of social phobia is a fear of social situations in which a person may be embarrassed or humiliated, we hypothesized that the social phobia group would have a higher rate of self-reported teasing history than would the obsessive compulsive disorder or panic disorder groups. Consistent with this hypothesis, a relationship between reported history of teasing and diagnosis was found. A significantly greater percentage of participants in the social phobia group (92%) reported a history of severe teasing experiences compared with the obsessive compulsive disorder (50%) and panic disorder (35%) groups. History of teasing experiences was also significantly related to an earlier age of onset for all 3 anxiety disorders, and to a greater number of self-reported additional problems in childhood. These findings suggest further directions for research in this area and highlight the significant link between perceptions of teasing in childhood and social phobia.     

Preliminary examination of the relationship between anxiety disorders in adults and self-reported history of teasing or bullying experiences

This preliminary study examined the relationship between anxiety disorders and self-reported history of teasing or bullying experiences, comparing individuals with social phobia, obsessive compulsive disorder, and panic disorder with or without agoraphobia. Given that aversive conditioning experiences, such as severe teasing, have been proposed to play a role in the development of social phobia and that the core feature of social phobia is a fear of social situations in which a person may be embarrassed or humiliated, we hypothesized that the social phobia group would have a higher rate of self-reported teasing history than would the obsessive compulsive disorder or panic disorder groups. Consistent with this hypothesis, a relationship between reported history of teasing and diagnosis was found. A significantly greater percentage of participants in the social phobia group (92%) reported a history of severe teasing experiences compared with the obsessive compulsive disorder (50%) and panic disorder (35%) groups. History of teasing experiences was also significantly related to an earlier age of onset for all 3 anxiety disorders, and to a greater number of self-reported additional problems in childhood. These findings suggest further directions for research in this area and highlight the significant link between perceptions of teasing in childhood and social phobia.     

Differences in reported symptom profile between panic disorder and other DSM-III-R anxiety disorders.

Previous research has indicated that reports of panic attacks are associated with a different set of symptoms to reports of generalized anxiety. The present two studies attempted to extend these findings to specific (situational) fears. In Study 1, 55 subjects with panic disorder were compared on their symptom profile during their panic attacks to 65 subjects with other anxiety disorders [simple phobia, social phobia and obsessive-compulsive disorder (OCD)] during response to their feared cue. The results indicated that, compared to subjects with other anxiety disorders, subjects with panic disorder were more likely to report parasthesias, dizziness, faintness, unreality, dyspnea, fear of dying and fear of going crazy/losing control. In Study 2, 90 subjects meeting diagnostic criteria for both panic disorder and another anxiety disorder (simple phobia, social phobia or OCD) were compared on the symptoms experienced during their unexpected panic attacks and their situationally-triggered fears respectively. Combining the symptoms found in Study 1 to differ between the groups into a linear combination, there was a significant interaction found between the type of fear reaction (panic attack vs cued fear response) and symptom group. Taken together, these findings suggest that reports of unexpected panic attacks associated with panic disorder are characterized by a different symptom profile to reports of specific fear reactions that are part of a phobic disorder or OCD.     

Sociodemographic, clinical and outcome differences among anxiety disorders

The aims of this paper are to analyze differences in sociodemographic and clinical characteristics among the various anxiety disorders treated in a Psychology Clinic, and the results of treatment in each anxiety disorder. Data from 282 patients of University Psychology Clinic at the Complutense University of Madrid, who had at least one diagnosis of anxiety according to DMS-IV-TR criteria, were analyzed. The most frequent anxiety disorders were nonspecific anxiety disorder (19.1%) and social phobia (18.8%). Significant differences were observed according to sex (in all disorders, the percentage of women was significantly higher than that of men, except for obsessive-compulsive disorder). Unspecific anxiety disorder required a smaller number of assessment and treatment sessions, whereas obsessive-compulsive disorder required a greater number of sessions. There were no significant differences between the percentage of patients who completed treatment and dropout rates in specific phobia, general anxiety disorder and obsessive-compulsive disorder. Differences between epidemiological and clinical data are discussed.     

Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample.

The comorbidity of current and lifetime DSM-IV anxiety and mood disorders was examined in 1,127 outpatients who were assessed with the Anxiety Disorders Interview Schedule for DSM-IV: Lifetime version (ADIS-IV-L). The current and lifetime prevalence of additional Axis I disorders in principal anxiety and mood disorders was found to be 57% and 81%, respectively. The principal diagnostic categories associated with the highest comorbidity rates were mood disorders, posttraumatic stress disorder (PTSD), and generalized anxiety disorder (GAD). A high rate of lifetime comorbidity was found between the anxiety and mood disorders; the lifetime association with mood disorders was particularly strong for PTSD, GAD, obsessive-compulsive disorder, and social phobia. The findings are discussed in regard to their implications for the classification of emotional disorders.     

Disgust sensitivity, trait anxiety and anxiety disorders symptoms in normal children.

There is evidence to suggest that disgust sensitivity plays a role in the development of small animal fears and phobias. Recently, Phillips, Senior, Fahy, and David (1998) [Phillips, M. L., Senior, C., Fahy, T., & David, A. S. (1998). Disgust: the forgotten emotion of psychiatry. British Journal of Psychiatry, 172, 373-375.] suggested that disgust sensitivity is also involved in various other anxiety-based symptoms (e.g. obsessive-compulsive complaints, social phobia). The present study sought to test this suggestion in a large sample of normal school children (N = 189). Children completed a measure of disgust sensitivity, the trait anxiety version of the Spielberger State-Trait Anxiety Inventory for Children and the Screen for Child Anxiety Related Emotional Disorders, an instrument that measures DSM-defined anxiety disorders symptoms. Disgust sensitivity was indeed found to be correlated with a broad range of anxiety disorders symptoms. However, results also indicated that these correlations were predominantly carried by trait anxiety. That is, when controlling for levels of trait anxiety, only specific phobia symptoms (including animal phobia, blood-injection-injury phobia and situational-environmental phobia) and separation anxiety disorder symptoms were significantly related to disgust sensitivity, although correlations were rather modest. Taken together, these findings cast doubts on the claim that disgust sensitivity is an unique and independent factor that contributes to a broad range of anxiety disorders.     

Perceived parental rearing behaviour and anxiety disorders symptoms in normal children

The present study examined the relationship between perceptions of parental rearing behaviours and anxiety disorders symptomatology in a sample of normal school children. 45 children, aged 8 to 12 years, completed the EMBU for children, a questionnaire that measures perceptions of parental rearing practices. Additionally, they filled in the Screen of Child Anxiety Related Emotional Disorders (SCARED), an index of DSM-defined anxiety disorders symptoms. Significant and positive relationships were found between anxious rearing behaviours and parental control, on the one hand, and anxiety disorders symptomatology, in particular symptoms of generalized anxiety disorder, separation anxiety disorder and environmental–situational phobia, on the other hand.     

Changes in Anxiety Control Beliefs Following a Brief CBT Treatment and Their Association With Anxiety Symptom Reduction

Anxiety control beliefs (i.e., beliefs regarding one’s ability to cope with external, fear-inducing threats and internal reactions to those perceived threats) have been found to negatively predict anxiety symptoms in children and adults and to be modifiable by cognitive-behavioral therapy for anxiety disorders. The current study examines whether changes in anxiety control beliefs were seen following a brief, intensive treatment for specific phobias, and whether those changes were associated with improvements in the targeted phobia and comorbid anxiety disorder symptoms. Participants were 135 children and adolescents (M age = 9.01 years, 49% male) who received one-session treatment (OST) with or without parental involvement for their primary specific phobia. Results indicated that self-reported anxiety control beliefs significantly increased following treatment and that these increases significantly predicted reductions in specific phobia severity and symptoms of comorbid anxiety disorders 6 months and 1 year following treatment. Findings illustrate that involvement in a single 3-hour OST was associated with changes in anxiety control beliefs and demonstrate the potential importance of targeting control beliefs in pediatric anxiety treatment.     

Comorbidity and Internet-Delivered Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders

Internet-delivered transdiagnostic anxiety interventions aim to reduce symptoms across several anxiety disorders using one treatment protocol. However, it is unclear whether comorbidity affects outcomes of such treatment. This study re-examined data from a recent randomised controlled trial (N = 129) that evaluated the efficacy of an Internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for participants with principal diagnoses of generalised anxiety disorder (GAD), social phobia (SP) panic disorder and agoraphobia (PDA), of whom 72% met criteria for a comorbid anxiety disorder or depression. Participants were divided into two groups based on whether or not they had a comorbid disorder before treatment. Participants with comorbid conditions reported higher symptom levels at pre-treatment, post-treatment, and follow-up across a range of measures. Both groups showed significant reductions in symptoms over treatment; however, participants with comorbid disorders showed greater reductions in measures of GAD, PDA, SP, depression, and neuroticism. In addition, treatment significantly reduced the number of comorbid diagnoses at follow-up. These results indicate transdiagnostic iCBT protocols have the potential to reduce comorbidity.     

The utility of screen for child anxiety related emotional disorders (scared) as a tool for identifying children at high risk for prevalent anxiety disorders

Abstract

The current study examined the utility of the Screen for Child Anxiety Related Emotional Disorders (SCARED) as a screening tool for the identification of children at high risk for prevalent childhood anxiety disorders. The child version of the Structured Clinical Interview for DSM (KSCID) was used as the diagnostic standard. It was investigated whether SCARED scores are indicative for the presence of generalized anxiety disorder, separation anxiety disorder, and social phobia. Five-hundred-and-thirty-seven children aged 7–14 years completed the SCARED. From this sample, 82 children were selected on the basis of their SCARED scores. A subgroup of these children scored relatively high on the generalized anxiety disorder, separation anxiety disorder, and/or social phobia scale(s) of the SCARED. A comparison group of children scored relatively low on these SCARED scales. Both groups of children then received the semi-structured interview to assess to what extent they fulfilled the DSM-IV criteria for the relevant anxiety disorders. Results provided some support for the predictive validity of the SCARED generalized anxiety disorder and separation anxiety disorder subscales. The implications of these findings for the detection of anxiety disorders in normal children are briefly discussed.     

Social phobia and avoidant personality disorder as related to parental history of social anxiety: a general population study

Using a validated and DSM-IV compatible questionnaire, the present study related family history of excessive social anxiety to social phobia and avoidant personality disorder (APD) in epidemiologically identified probands in the general population. Probands met diagnostic criteria for social phobia with or without APD and APD with or without social phobia. A two- to three-fold increased relative risk of social anxiety was observed for all diagnostic groups. Increasing severity in probands by varying diagnostic criteria did not affect the relative risk. Because familial aggregation of social anxiety was not modulated by Axis I or II diagnosis or diagnostic cut-off levels, data imply that social phobia and APD may represent a dimension of social anxiety rather than separate disorders. Thus, having an affected family member is associated with a two- to three-fold risk increase for both social phobia and APD.     

Examining a dimensional representation of depression and anxiety disorders' comorbidity in psychiatric outpatients with item response modeling

The current study replicated, in a sample of 2,300 outpatients seeking psychiatric treatment, a previous study (R. F. Krueger & M. S. Finger, 2001) that implemented an item response theory approach for modeling the comorbidity of common mood and anxiety disorders as indicators along the continuum of a shared latent factor (internalizing). The 5 disorders examined were major depressive disorder, social phobia, panic disorder/agoraphobia, specific phobia, and generalized anxiety disorder. The findings were consistent with the prior research. First, a confirmatory factor analysis yielded sufficient evidence for a nonspecific factor underlying the 5 diagnostic indicators. Second, a 2-parameter logistic item response model showed that the diagnoses were represented in the upper half of the internalizing continuum, and each was a strongly discriminating indicator of the factor. Third, the internalizing factor was significantly associated with 3 indexes of social burden: poorer social functioning, time missed from work, and lifetime hospitalizations. Rather than the categorical system of presumably discrete disorders presented in DSM-IV, these 5 mood and anxiety disorders may be alternatively viewed as higher end indicators of a common factor associated with social cost.     

Discriminant validity of the Social Phobia and Anxiety Inventory (SPAI), the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS)

Three measures commonly used in assessment of social phobia, the Social Phobia and Anxiety Inventory (SPAI [Turner, S. M., Beidel, D. C. & Dancu, C. V. (1996). Social phobia and anxiety inventory: manual. Toronto, Ont.: Multi-Health Systems Inc.), the Social Phobia Scale (SPS [Mattick, R. P. & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-470] and the Social Interaction Anxiety Scale (SIAS [Mattick, R. P. & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-470], were compared for their ability to discriminate between social phobia and other anxiety disorders (panic disorder with or without agoraphobia). Participants were 117 patients attending a specialized anxiety disorders unit for treatment. While all three measures were able to detect differences between social phobic patients and patients with panic disorder with or without agoraphobia, a logistic regression analysis showed that the SPAI, but not the SPS and SIAS, was a significant predictor of membership of the social phobia group. Receiver operating characteristic (ROC) analysis also showed that the SPAI was the better measure for discriminating between social phobia and panic disorder with and without agoraphobia. Analysis of the sensitivity, specificity and positive and negative predictive power of the measures at the optimum cutoff scores produced by the ROC analysis are presented.     

The Prevalence of Anxiety Disorders Among Adults with Asthma: A Meta-Analytic Review

Research estimating the comorbidity of asthma and anxiety disorders has produced highly disparate findings and little consensus. This study is a meta-analytic review of data from 15 independent studies of the co-occurrence of adult asthma and anxiety disorders and was conducted to provide more precise comorbidity estimates. Aggregating across studies, the average prevalence of any anxiety disorder among adults with asthma was 34%, indicating a strong relationship between the two conditions in general. More specifically, the prevalence of panic attacks (25%), panic disorder (12%), agoraphobia (12%), and generalized anxiety disorder (9%) were considerably higher among adults with asthma than in the general population. However, additional analyses yielded prevalence estimates for specific phobia (10%), social phobia (7%) and posttraumatic stress disorder (6%) comparable to or lower than rates observed in the population at large. Attention to psychiatric symptoms should be a crucial component of asthma management, as anxiety disorders appear to be highly prevalent among persons with asthma and may be associated with increased asthma morbidity.

Social phobia in youth: the diagnostic utility of feared social situations

The present study evaluated the utility of parent- and child-reported social fears for reaching a diagnosis of social phobia in youth. The diagnostic utility of (a) the number of fears and (b) specific feared social situations was examined. The sample included 140 youth and their parents: youth diagnosed with social phobia (n=50), youth diagnosed with generalized anxiety disorder or separation anxiety disorder but not social phobia (n=49), and youth without an anxiety disorder (n=41). Youth and their parents were interviewed separately using the Anxiety Disorders Interview Schedule for Children and Parents. Analyses indicate that a cut score of 4 parent-endorsed social fears optimally distinguished youth with and without social phobia. Analyses of child-reported fears did not identify a meaningful cut score. Conditional probability and odds ratio analyses indicated that several specific social fears have high diagnostic efficiency, and others were found to have limited diagnostic efficiency. Results are discussed with regard to informing diagnostic interviews and diagnostic systems for social phobia in youth.