Latent stability and change in subgroups of social anxiety and depressive symptoms in adolescence: A latent profile and transitional analysis.

BACKGROUND: Social anxiety and depressive symptoms increase markedly during adolescence. Most research examining the emergence of these symptoms has used a variable-centered approach providing little information about how these symptoms group together in individuals over time. METHOD: A person-centered approach utilizing latent profile and latent transitional analyses was applied to a large adolescent sample (N = 2742, Mage=13.65; SD=0.63; 47.9% girls). Subgroups differing in their expressions of social anxiety and depressive symptoms at each of four annual time points were identified and then change in membership of these groups was evaluated. RESULTS: Four subgroups were identified: 1. Low Distress, 2. Socially Anxious, 3. Dysphoric, and 4. Comorbid. The low distress group was the largest and most stable, followed by the socially anxious group, who most commonly transitioned into the comorbid group. In contrast, the dysphoric group were most likely to remit and move to the low distress group. The comorbid group was the smallest and least stable, although once in this group, three quarters of adolescents remained in this group over time. CONCLUSION: Early intervention is particularly imperative for socially anxious adolescents with or without comorbid depressive symptoms as they are the least likely to improve across the adolescent years.

Measuring associations between social anxiety and use of different types of social media using the Swedish Social Anxiety Scale for Social Media Users: A psychometric evaluation and cross-sectional study.

Research on the association between social anxiety and social media usage remains inconclusive: despite the preference for computer-mediated communication there is currently no clear empirical support for social anxiety being associated with longer duration of social media use. Self-report measures for social anxiety that are adapted for the context of social media could facilitate further research. The current study aimed to develop a Swedish version of the recently developed Social Anxiety Scale for Social Media Users (SAS-SMU), evaluate its psychometric properties, and explore associations between different uses of social media and social anxiety. Three factors were retained for SAS-SMU with excellent internal consistency. SAS-SMU evidenced convergent validity with measures of social anxiety, negative convergent validity with satisfaction with life, and divergent validity with measures of obsessive-compulsive disorder, depression and generalized anxiety disorder. Results indicated that higher levels of social anxiety were associated with passive and active use as well as longer duration of social media use in general, which is at odds with a previous study where passive use remained the only significant predictor for social anxiety.

Assessing depressive symptoms with the Borg centiMax Scale® in a Swedish sample of patients and students.

The Borg centiMax Scale, is a psychophysically composed general intensity ratio scale, which could enable more precise inter- and intraindividual comparisons of the intensity of depressive symptoms. In the present study, the properties of the centiMax scale were examined in 38 patients with clinical depression and 109 students. Additionally, preliminary centiMax cut-off scores for mild, moderate and severe depression were estimated. The psychometric properties of the centiMax were found to be satisfactory regarding internal consistency, convergent, discriminative and predictive validity. Moreover, the centiMax was demonstrated to provide meaningful comparisons of symptom intensity, which makes it possible to evaluate the relative importance of individual symptoms in a profile and make more precise comparisons within and between individuals. With regard to intraindividual comparisons, patients rated , for example, the intensity of feeling "guilt" twice as strong as feelings of "being punished," and the intensity of "loss of pleasure" almost three times as strong as "being punished." With regard to interindividual comparisons, patients rated e.g., the intensity of "being punished" as 12 times stronger than controls, and the intensity of "worthlessness" about nine times stronger. In conclusion, the centiMax was shown to be reliable and valid for assessing depressive symptoms. The centiMax with level anchored ratio data, appears to be highly advantageous as it permits rather precise values of symptom intensity for intra- and interindividual comparisons that could be useful in the diagnostic process and in treatment planning.

Psychometric Evaluation of the Social Phobia Inventory and the Mini-Social Phobia Inventory in a Swedish University Student Sample.

Social anxiety is common in the general population, as well as among students in higher education. For screening of social anxiety, there is a need for brief scales. In the present study, the psychometric properties were examined in a Swedish version of the Social Phobia Inventory (SPIN) and the Mini-Social Phobia Inventory (Mini-SPIN) in a university student sample ( n = 161). In addition to the SPIN and Mini-SPIN, participants completed measures of fear of public speaking, general anxiety, depression, and quality of life. Exploratory factor analyses were used to investigate the underlying dimensions of the SPIN, and reliability, convergent, and divergent validity of SPIN and Mini-SPIN were examined by Cronbach's alpha and correlation analyses. It was found that a shorter eight-item version of the SPIN was associated with two solid factors ( fear and avoidance of social interaction and fear and avoidance of criticism), and acceptable internal consistency, convergent, and divergent validity. In addition, the Mini-SPIN was associated with satisfactory convergent validity, but the reliability was not acceptable. It is concluded that the SPIN-8 is a viable screening tool for social anxiety in a university student population.

Psychometric Properties of the Personal Report of Public Speaking Anxiety (PRPSA) in a Sample of University Students in Sweden.

Existing measures for examining fear of public speaking are somewhat limited in content and there is a need for scales that assess a broader area including cognitive, behavioral, and physiological dimensions of the fear. This study examined the psychometric properties of the Personal Report of Public Speaking Anxiety (PRPSA) in a sample of university students (n, 273). Participants completed the PRPSA and measures of depression, social and general anxiety, and quality of life. A reduced version of the PRPSA, the PRPSA-18, was found to demonstrate satisfactory internal consistency as well as discriminant and convergent validity. The PRPSA-18 was associated with two solid factors, "Anticipatory anxiety and physiological symptoms during speech performance," and "Lack of control during speech performance." A PRPSA-18 score of 58 was found to discriminate participants with higher and lower fear of public speaking. It is concluded that the shorter and more easily administered PRPSA-18 is a credible option for assessing fear of public speaking among university students.

Factor solutions of the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS) in a Swedish population.

Culturally validated rating scales for social anxiety disorder (SAD) are of significant importance when screening for the disorder, as well as for evaluating treatment efficacy. This study examined construct validity and additional psychometric properties of two commonly used scales, the Social Phobia Scale and the Social Interaction Anxiety Scale, in a clinical SAD population (n = 180) and in a normal population (n = 614) in Sweden. Confirmatory factor analyses of previously reported factor solutions were tested but did not reveal acceptable fit. Exploratory factor analyses (EFA) of the joint structure of the scales in the total population yielded a two-factor model (performance anxiety and social interaction anxiety), whereas EFA in the clinical sample revealed a three-factor solution, a social interaction anxiety factor and two performance anxiety factors. The SPS and SIAS showed good to excellent internal consistency, and discriminated well between patients with SAD and a normal population sample. Both scales showed good convergent validity with an established measure of SAD, whereas the discriminant validity of symptoms of social anxiety and depression could not be confirmed. The optimal cut-off score for SPS and SIAS were 18 and 22 points, respectively. It is concluded that the factor structure and the additional psychometric properties of SPS and SIAS support the use of the scales for assessment in a Swedish population.

Shifting the focus of one's attention mediates improvement in cognitive therapy for social anxiety disorder.

BACKGROUND: Cognitive therapy is an effective treatment for social anxiety disorder but little is known about the mechanisms by which the treatment achieves its effects. AIMS: This study investigated the potential role of self-focused attention and social phobia related negative automatic thoughts as mediators of clinical improvement. METHOD: Twenty-nine patients with social phobia received individual cognitive therapy (ICT) in a randomized controlled trial. Weekly process and outcome measures were analysed using multilevel mediation models. RESULTS: Change from self-focused to externally focused attention mediated improvements in social anxiety one week later. In contrast, change in frequency of, or belief in, negative social phobia related negative automatic thoughts did not predict social anxiety one week later. CONCLUSIONS: Change in self-focused attention mediate therapeutic improvement in ICT. Therapists should therefore target self-focused attention.

Social anxiety in adult autism spectrum disorder.

A link has been suggested between Autism Spectrum Disorder (ASD) and anxiety disorders. The aim of the study was to examine the severity of social anxiety measured by the Liebowitz Social Anxiety Scale Self-Report and prevalence of Social Anxiety Disorder (SAD) in adults with ASD, with SAD and a non-ASD comparison group. Individuals with ASD showed significantly higher scores of social anxiety and social avoidance relative to the comparison group, but significantly lower scores relative to the SAD sample.

Working alliance in individual and group cognitive therapy for social anxiety disorder.

The tripartite model of working alliance, including the therapeutic bond and agreement on tasks and goals, was examined in 54 patients who received individual or group cognitive behavior therapy (CBT) for social anxiety disorder (SAD) in a randomized trial. Alliance was significantly stronger in individual relative to group CBT but generally not related to outcome.

An atypical anxious-impulsive pattern of social anxiety disorder in an adult clinical population.

An atypical subgroup of Social Anxiety Disorder (SAD) with impulsive rather than inhibited traits has recently been reported. The current study examined whether such an atypical subgroup could be identified in a clinical population of 84 adults with SAD. The temperament dimensions harm avoidance and novelty seeking of the Temperament and Character Inventory, and the Liebowitz Social Anxiety Scale were used in cluster analyses. The identified clusters were compared on depressive symptoms, the character dimension self-directedness, and treatment outcome. Among the six identified clusters, 24% of the sample had atypical characteristics, demonstrating mainly generalized SAD in combination with coexisting traits of inhibition and impulsivity. As additional signs of severity, this group showed low self-directedness and high levels of depressive symptoms. We also identified a typically inhibited subgroup comprising generalized SAD with high levels of harm avoidance and low levels of novelty seeking, with a similar clinical severity as the atypical subgroup. Thus, higher levels of harm avoidance and social anxiety in combination with higher or lower levels of novelty seeking and low self-directedness seem to contribute to a more severe clinical picture. Post hoc examination of the treatment outcome in these subgroups showed that only 20 to 30% achieved clinically significant change.

The Brief Obsessive-Compulsive Scale (BOCS): a self-report scale for OCD and obsessive-compulsive related disorders.

BACKGROUND: The Brief Obsessive Compulsive Scale (BOCS), derived from the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the children's version (CY-BOCS), is a short self-report tool used to aid in the assessment of obsessive-compulsive symptoms and diagnosis of obsessive-compulsive disorder (OCD). It is widely used throughout child, adolescent and adult psychiatry settings in Sweden but has not been validated up to date. AIM: The aim of the current study was to examine the psychometric properties of the BOCS amongst a psychiatric outpatient population. METHOD: The BOCS consists of a 15-item Symptom Checklist including three items (hoarding, dysmorphophobia and self-harm) related to the DSM-5 category "Obsessive-compulsive related disorders", accompanied by a single six-item Severity Scale for obsessions and compulsions combined. It encompasses the revisions made in the Y-BOCS-II severity scale by including obsessive-compulsive free intervals, extent of avoidance and excluding the resistance item. 402 adult psychiatric outpatients with OCD, attention-deficit/hyperactivity disorder, autism spectrum disorder and other psychiatric disorders completed the BOCS. RESULTS: Principal component factor analysis produced five subscales titled "Symmetry", "Forbidden thoughts", "Contamination", "Magical thoughts" and "Dysmorphic thoughts". The OCD group scored higher than the other diagnostic groups in all subscales (P < 0.001). Sensitivities, specificities and internal consistency for both the Symptom Checklist and the Severity Scale emerged high (Symptom Checklist: sensitivity = 85%, specificities = 62-70% Cronbach's α = 0.81; Severity Scale: sensitivity = 72%, specificities = 75-84%, Cronbach's α = 0.94). CONCLUSIONS: The BOCS has the ability to discriminate OCD from other non-OCD related psychiatric disorders. The current study provides strong support for the utility of the BOCS in the assessment of obsessive-compulsive symptoms in clinical psychiatry.

Predictors of response to individual and group cognitive behaviour therapy of social phobia.

OBJECTIVES: Increased knowledge of factors that predict treatment outcome is important for planning and individualizing of treatment. This study analysed predictors of response to individual cognitive therapy (ICT), and intensive (3-week) group cognitive treatment (IGCT) for social phobia. METHOD: Participants (n = 54) met diagnostic criteria for social phobia within a randomized controlled trial. Predictors assessed were fear of negative evaluation, anticipatory worry, self-directedness (SD) and cluster C personality disorder. Results were analysed by means of multiple regression analyses with both groups combined, and for each of the treatment groups. RESULTS: Anticipatory worry, an aspect of a harm-avoidance personality trait, was the strongest negative predictor of outcome in ICT and IGCT both at post-treatment and 1-year follow-up. Whereas low SD, signs of cluster C personality disorder and fear of negative evaluation were negative predictors of post-treatment outcome in ICT, the corresponding pattern of results was not to be found in IGCT. CONCLUSIONS: Anticipatory worry appears to be a particularly important trait for explaining variance in the outcome of social phobia. The finding is consistent with the assumed stability of such personality traits over time. Further studies are warranted to replicate the finding.

Mediators in psychological treatment of social anxiety disorder: individual cognitive therapy compared to cognitive behavioral group therapy.

According to cognitive-behavioral models of social anxiety disorder (SAD), four of the important maintaining mechanisms are avoidance, self-focused attention, anticipatory processing and post-event cognitive processing. Individual cognitive therapy (ICT) and cognitive behavioral group therapy (CBGT) both have substantial empirical support. However, it is unclear whether they achieve their effects by similar or different mechanisms. The aim of this study was to investigate whether changes in the four maintenance processes mediate clinical improvement in ICT and CBGT for SAD. We analyzed data from participants (N = 94) who received either ICT or CBGT in two separate RCTs. The results showed that ICT had larger effects than CBGT on social anxiety and each of the four potential mediators. More pertinently, moderated mediation analyses revealed significant between-treatment differences. Whereas improvement in ICT was mainly mediated by reductions in avoidance and self-focused attention, improvement in CBGT was mediated by changes in self-focused attention and in anticipatory and post-event processing. These results support the importance of the putative mediators, but suggest that their relative weights are moderated by treatment type.

Shame and guilt in social anxiety disorder: effects of cognitive behavior therapy and association with social anxiety and depressive symptoms.

Social anxiety disorder (SAD), characterized by fear of being scrutinized by others, has features that that are closely linked to the concept of shame. Despite this, it remains to be investigated whether shame is elevated in persons with SAD, and if cognitive behavior therapy (CBT) for SAD could reduce shame experience. In the present study, we focused on internal shame, i.e. the type of shame that pertains to how we judge ourselves. Although guilt is distinctly different from shame, we also viewed it as important to investigate its role in SAD as the two emotions are highly correlated. The aim of this study was to investigate: (I) if persons with SAD differ from healthy controls on shame and guilt, (II) if shame, guilt, depressive symptoms, and social anxiety are associated in persons with SAD, and (III) if CBT can reduce internal shame in patients with SAD. Firstly, we conducted a case-control study comparing a sample with SAD (n = 67) with two samples of healthy controls, a main sample (n = 72) and a replication sample (n = 22). Secondly, all participants with SAD were treated with CBT and shame, measured with the Test of Self-Conscious affect, was assessed before and after treatment. The results showed that shame was elevated in person with SAD compared to the control replication sample, but not to the main control sample. In addition, shame, social anxiety, and depressive symptoms were significantly associated among participants with SAD. After CBT, participants with SAD had significantly reduced their shame (Cohen's d = 0.44). Guilt was unrelated to social anxiety. We conclude that shame and social anxiety are associated and that it is likely that persons with SAD are more prone to experience shame than persons without SAD. Also, CBT is associated with shame reduction in the treatment of SAD.

Screening for ADHD in an adult social phobia sample.

OBJECTIVE: Recent studies have suggested a link between a primary anxiety disorder and ADHD. METHOD: A total of 39 participants with a primary diagnosis of social phobia were compared with 178 patients with ADHD and 88 patients with other psychiatric disorders on measures for childhood and adult ADHD (the Wender Utah Rating Scale and the Adult ADHD Self-Report Scale). RESULTS: Childhood symptoms of ADHD were reported by 7.8% of the social phobia participants, and 5.1% scored within the range of adult ADHD. The social phobia group reported significantly fewer ADHD symptoms than both of the comparison groups, who frequently reported social anxiety. CONCLUSION: Participants with social phobia recruited from the general population are less likely to suffer from ADHD. In contrast, patients with ADHD and patients with other psychiatric disorders appear to be likely to suffer from social anxiety.

Intensive group cognitive therapy and individual cognitive therapy for social phobia: sustained improvement at 5-year follow-up.

Little is known about the long-term outcome of treatments for social phobia. At 5 years post-treatment we contacted the 67 patients who had been treated with intensive group cognitive therapy (IGCT) or individual cognitive therapy (ICT) in a randomized controlled trial (Mörtberg, Clark, Sundin, & Åberg Wistedt, 2007) that originally compared IGCT, ICT, and treatment as usual (n=100 for the full trial). Seventy-two percent (48 patients) who received IGCT or ICT agreed to participate in the follow-up assessment. All re-completed the original self-report measures of symptoms and disability and a quality of life measure. A subset was also interviewed. Seventy-five percent (36 patients) had sought no further treatment for social phobia. Comparisons between post-treatment and 5-year follow-up indicated that patients who had received either treatment showed further improvement in social phobia symptoms and disability during the follow-up period. These improvements were present in patients who had no additional treatment, as well as in the total sample. In conclusion, it appears that the effects of IGCT and ICT are maintained and improved upon at 5 years post-treatment.

Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: a randomized controlled non-inferiority trial.

BACKGROUND AND AIMS: Cognitive behavioral group therapy (CBGT) is an effective, well-established, but not widely available treatment for social anxiety disorder (SAD). Internet-based cognitive behavior therapy (ICBT) has the potential to increase availability and facilitate dissemination of therapeutic services for SAD. However, ICBT for SAD has not been directly compared with in-person treatments such as CBGT and few studies investigating ICBT have been conducted in clinical settings. Our aim was to investigate if ICBT is at least as effective as CBGT for SAD when treatments are delivered in a psychiatric setting. METHODS: We conducted a randomized controlled non-inferiority trial with allocation to ICBT (n=64) or CBGT (n=62) with blinded assessment immediately following treatment and six months post-treatment. Participants were 126 individuals with SAD who received CBGT or ICBT for a duration of 15 weeks. The Liebowitz Social Anxiety Scale (LSAS) was the main outcome measure. The following non-inferiority margin was set: following treatment, the lower bound of the 95 % confidence interval (CI) of the mean difference between groups should be less than 10 LSAS-points. RESULTS: Both groups made large improvements. At follow-up, 41 (64%) participants in the ICBT group were classified as responders (95% CI, 52%-76%). In the CBGT group, 28 participants (45%) responded to the treatment (95% CI, 33%-58%). At post-treatment and follow-up respectively, the 95 % CI of the LSAS mean difference was 0.68-17.66 (Cohen's d between group=0.41) and -2.51-15.69 (Cohen's d between group=0.36) favoring ICBT, which was well within the non-inferiority margin. Mixed effects models analyses showed no significant interaction effect for LSAS, indicating similar improvement across treatments (F=1.58; df=2, 219; p=.21). CONCLUSIONS: ICBT delivered in a psychiatric setting can be as effective as CBGT in the treatment of SAD and could be used to increase availability to CBT. TRIAL REGISTRATION: ClinicalTrials.gov NCT00564967.

Temperament and character dimensions in patients with social phobia: patterns of change following treatments?

The aim of this study was to examine Temperament and Character Inventory (TCI) profiles in patients with social phobia (DSM-IV) and to outline patterns of change following intensive group cognitive therapy (IGCT), individual cognitive therapy (ICT) and treatment as usual (TAU). One hundred patients recruited by advertisements in local papers were randomized to IGCT, ICT and TAU. Patients (n=59) who completed diagnostic evaluation and TCI assessments at baseline and 1-year follow-up were examined in this study. Patients differed from healthy controls in novelty seeking (NS), harm avoidance (HA), self-directedness (SD), cooperativeness (C), and self-transcendence (ST). Treatments overall were associated with decrease in HA, while increase in SD was observed after psychotherapy only. Reduced social anxiety was correlated with decrease in HA and increase in SD. High HA at baseline was related to poor treatment outcome in all treatments. To conclude, patients with social phobia show a temperamental vulnerability for developing anxiety and character traits associated with personality disorders. Successful treatment is related to decrease in HA and increase in SD. High HA at baseline may suggest a need for extensive treatment in order to achieve remission.