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Background Evidence suggests that impulsive aggression and explosive anger are common among individuals with anxiety disorders; yet, the influence of intermittent explosive disorder (IED) on the onset, course, consequences, and patterns of comorbidity among those with anxiety disorders is unknown. Methods Data were drawn from the National Comorbidity Survey Replication (N = 9,282) and Adolescent Supplement (N = 9,632), nationally representative surveys conducted between 2001 and 2004. Diagnoses were based on structured lay-administered interviews. Lifetime diagnoses were assessed with structured instruments. Outcomes included comorbidity, functional and role impairment, and treatment utilization. Results Adolescents with a lifetime anxiety disorder had a higher prevalence of a lifetime anger attacks (68.5%) and IED (22.9%) than adolescents without a lifetime anxiety disorder (48.6 and 7.8%, respectively), especially social phobia and panic disorders. Similar elevation was found for adults. Age of onset and course of anxiety disorders did not differ by IED. Severe functional impairment associated with anxiety was higher among adolescents (39.3%) and adults (45.7%) with IED than those without IED (29.2 and 28.2%, respectively). Comorbidity for all other disorders was elevated. However, individuals with anxiety disorders and IED were no more likely to use treatment services than those with anxiety disorders without IED. Conclusions Individuals with IED concomitant to anxiety disorder, especially social phobia and panic, are at marked risk for worse functional impairment and a higher burden of comorbidity, but onset and course of anxiety disorder do not differ, and those with anxiety and IED are no more likely to utilize treatment services. Assessment, identification, and specialized treatment of anger in the context of anxiety disorders are critical to reducing burden.

BACKGROUND: Although CBT is efficacious for a wide variety of psychiatric conditions, relatively fewer GAD patients achieve high endstate functioning as compared to patients receiving CBTs for other disorders. Moreover, GAD trials that utilized patient samples without prominent depression have tended to report that effect sizes for depressive outcomes were small or diminished to pretreatment levels in the follow-up period. Emotion regulation therapy (ERT) integrates principles from traditional and contemporary cognitive behavioral treatments with basic and translational findings from affect science to offer a blueprint for improving intervention by focusing on motivational, regulatory, and contextual learning mechanisms. METHOD: The purpose of this investigation was to provide initial support for the efficacy of ERT in an open trial of patients with GAD and cooccurring depressive symptoms. Twenty-one patients received a 20-session version of ERT delivered in weekly individual sessions. Standardized clinician ratings and self-report measures were assessed at pre-, mid-, and posttreatment as well as at three- and nine-month follow-ups. Intent-to-treat analyzes were utilized. RESULTS: GAD patients, half with comorbid major depression, evidenced statistically, and clinically meaningful improvements in symptom severity, impairment, quality of life, and in model-related outcomes including emotional/motivational intensity, mindful attending/acceptance, decentering, and cognitive reappraisal. Patients maintained gains across the three and nine month follow-up periods. CONCLUSIONS: These findings, although preliminary, provide additional evidence for the role of emotion dysregulation in the onset, maintenance, and now treatment of conditions such as GAD and cooccurring depressive symptoms. Language: en

With the publication of DSM-5, the diagnostic criteria for social anxiety disorder (SAD, also known as social phobia) have undergone several changes, which have important conceptual and clinical implications. In this paper, we first provide a brief history of the diagnosis. We then review a number of these changes, including (1) the primary name of the disorder, (2) the increased emphasis on fear of negative evaluation, (3) the importance of sociocultural context in determining whether an anxious response to a social situation is out of proportion to the actual threat, (4) the diagnosis of SAD in the context of a medical condition, and (5) the way in which we think about variations in the presentation of SAD (the specifier issue). We then consider the clinical implications of changes in DSM-5 related to these issues.

Background Obsessive compulsive disorder (OCD) is a disabling condition associated with significant personal and societal burdens. Despite the availability of efficacious treatments, in most cases, the disorder remains unrecognized and untreated. Lack of knowledge (i.e. poor mental health literacy, MHL) regarding OCD may be an impediment to seeking treatment. Therefore, the current study assessed public knowledge and beliefs about OCD and examined factors influencing MHL. Methods Five hundred seventy-seven US adults participated in a telephone survey. After hearing a vignette describing someone with OCD, participants’ MHL for OCD was assessed across three domains as follows: recognition of OCD, knowledge and beliefs about available help, and concerns about being negatively evaluated for reporting symptoms. Results The majority of participants (90.9%) reported that the symptoms were a cause for concern and that the person in the vignette should seek professional help (89.5%). However, only one-third of respondents correctly labeled the disorder as OCD. More respondents were optimistic about the likely success of psychotherapy than medication, but primary care physicians were the most frequently reported source of professional help. Finally, less education, lower income, and being in an older cohort were associated with poorer recognition of OCD. Conclusions When presented with brief vignettes describing a person with OCD, most community members can recognize the benefits of seeking professional help. However, recognition of the disorder and knowledge of treatment options can be improved.

Background: The association between childhood maltreatment—particularly emotional maltreatment—and social anxiety disorder (SAD) has been established by research. Only recently have researchers begun to look at the impact of childhood maltreatment on treatment outcomes, and findings have been mixed. Because prior studies have focused on pharmacotherapy outcomes, or used global measures of childhood adversity or abuse, it is not clear how specific types of maltreatment impact outcomes in cognitive-behavioral therapy (CBT) for SAD. The currentstudyreportsonhowspecifictypesofchildhoodmaltreatmentsuchasphysical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect impact response to CBT in adults with SAD. Methods: Sixty-eight individuals with a primary diagnosis of SAD completed the childhood trauma questionnaire, along with measures of social anxiety, disability, and life satisfaction. Results: Childhood maltreatment did not affect the rate of response to CBT, but there is evidence for its negative impact. Patients with histories of emotional abuse and emotional neglect reported greater social anxiety, less satisfaction, and greater disability over the course of treatment. Sexual abuse also predicted greater social anxiety. Conclusions: Childhood abuse and/or neglect did not result in differential rates of improvement during CBT; however, those reporting histories of emotional and sexual forms of maltreatment evidenced greater symptoms and/or impairment at pre- and posttreatment. Additional attention to the role of traumatic experiences within CBT for SAD may be warranted. Depression and Anxiety 30:662–669, 2013. C � 2013 Wiley Periodicals, Inc.

Emerging prospective work suggests that individuals with social anxiety disorder (SAD) may be at particular risk for developing substance use disorders (SUD). Yet, little is known about why this may be so. Most research has utilized existing theories of substance use (e.g. tension reduction-based theories) to understand SAD-SUD relations. However, these theories do not address why individuals with social anxiety, in particular, experience such high rates of substance-related problems. A possible explanation may lie in the nature of social anxiety itself, which is characterized not only by chronically elevated negative affective states, but by low positive affect, fear of scrutiny, and social avoidance. These aspects of social anxiety may work in concert to place these especially vulnerable individuals at risk for SUD. The current paper presents a biopsychosocial model of SAD-SUD comorbidity that focuses on several specific facets of social anxiety that may be especially related to SUD risk. The utility of this model is evaluated via a review of the literature on the relations between SAD and substance-related behaviors.

Background: Recent evidence suggests that social anxiety disorder is best characterized as having a dimensional latent structure. Methods: In this study, we examined the latent structure of two cognitive components of social anxiety, fear of negative evaluation (FNE) and fear of positive evaluation (FPE), in a large undergraduate sample. Two taxometric procedures (MAMBAC, Mean Above Minus Below a Cut and MAXEIG, MAXimum EIGenvalue) were performed with indicator sets drawn from self-report measures of FNE and FPE. Results and conclusions: Taxometric analyses, as well as comparison analyses utilizing simulated dimensional and taxonic datasets, yielded converging evidence that both FNE and FPE have a dimensional latent structure. Depression and Anxiety, 2009. © 2008 Wiley-Liss, Inc.

Taijin-Kyofu-Sho (TKS), an East Asian syndrome of interpersonal fear and avoidance, that has been considered culture-bound, overlaps with social anxiety disorder to an unknown extent. The offensive subtype of TKS is characterized by two features considered atypical of social anxiety disorder: the belief that one displays physical defects and/or socially inappropriate behaviors (offensive TKS symptoms) and fear of offending others (allocentric focus), but no studies have systematically evaluated these two features in patients with social anxiety disorder. The purpose of this study was to assess offensive TKS symptoms and allocentric focus of fear in US (n = 181) and Korean (n = 64) patients with DSM-IV social anxiety disorder, using the newly developed TKS Questionnaire. Seventy-five percent of patients with social anxiety disorder in the US and Korea endorsed at least one of the five offensive TKS symptoms surveyed. The severity of features of offensive TKS was significantly associated with severity of social anxiety symptoms, depressive symptoms, and disability in both samples. These results suggest that features of the offensive subtype of TKS are not uncommon among US patients with social anxiety disorder and may not be as culturally specific as previously believed. They also suggest that Western clinicians should assess patients with social anxiety for features of offensive TKS, and they support further consideration of integrating TKS features into conceptualizations of social anxiety disorder.

The Mini-Social Phobia Inventory (Mini-SPIN) is a 3-item, self-rated screening instrument to assess social anxiety disorder, but its psychometric properties have not yet been examined in a sample seeking treatment for psychiatric disorders. We analyzed responses from 291 adults who telephoned the Adult Anxiety Clinic of Temple (AACT) seeking treatment for social anxiety or generalized anxiety and worry. The Mini-SPIN demonstrated strong internal consistency. Support for the convergent validity of the Mini-SPIN was provided by moderate correlations with several self-report measures and a clinician-administered measure of social anxiety completed by the subsample of callers who later came to the AACT for evaluation. Furthermore, the Mini-SPIN correlated significantly with two of three measures of functional disability, but not with a measure of life satisfaction. Correlations with measures of other constructs were nonsignificant, providing support for the discriminant validity of the Mini-SPIN. In addition, a cutoff score of 6 on the Mini-SPIN yielded strong sensitivity and diagnostic efficiency in the subsample of treatment seekers that later completed pretreatment evaluation, although the specificity of this cutoff score was not optimal in this sample. Overall, the Mini-SPIN demonstrated sound psychometric properties in this treatment-seeking sample.

Once considered to be a disorder associated with minimal impairment, the link between generalized anxiety disorder (GAD) and impairment across a broad constellation of domains is now well established. However, less is known about how comorbidity affects these relationships or how GAD impacts one's perceived life satisfaction or quality of life. To investigate these questions, data from 52 treatment-seeking individuals with GAD (33 with comorbid Axis I diagnoses) were compared to data from 55 nonanxious controls. Individuals with GAD reported more impairment at work and in their social functioning than they did with home and family responsibilities. They also reported lower quality of life than nonanxious controls, particularly in regard to self-esteem, goals and values, money, work, play, learning, creativity, friends, and relatives. Trait worry was positively correlated with impairment and inversely related to life satisfaction within the clinical sample. Individuals with GAD, with and without comorbid Axis I diagnoses, showed few differences on measures of impairment (differing only on impairment in social functioning). However, individuals with GAD and comorbid disorders perceived their lives as less satisfying than did individuals with GAD without comorbid diagnoses.

The present study examined ethnic differences in worry in a college student population. No differences were found between Caucasians, African Americans, and Asian Americans in pathological worry as measured by the Penn State Worry Questionnaire (PSWQ) or in the frequency with which they met self-report criteria for generalized anxiety disorder on the Generalized Anxiety Disorder Questionnaire for DSM-IV (GAD-Q-IV). Groups differed in Worry Domains Questionnaire (WDQ) total scores and on all WDQ domain subscales except for the Financial domain. Within ethnic groups, Caucasians and African Americans experienced variations in intensity of worry across the specific domains, but Asian Americans did not. These results suggest that ethnic groups may differ from each other in the degree to which they worry and in the breadth of their concerns. Further examination of ethnic differences and worry (and anxiety more generally) is suggested.

Although the Beck Depression Inventory (BDI) is commonly used to assess levels of depressive symptoms in socially anxious adults, its psychometric properties in this context have never been formally examined. Therefore, we examined the psychometrics of the BDI in a sample of adults with a principal diagnosis of social anxiety disorder (N = 113). The BDI exhibited good internal consistency and re-test reliability. It also correlated significantly more strongly with other measures of depression than with measures of either social or non-social anxiety. Thus, the BDI appears to be a valid tool for the assessment of depressive symptoms in adults with social anxiety disorder.

The current study examines levels of anxiety sensitivity among social phobic patients with and without panic attacks. Two-hundred fourteen individuals with a primary diagnosis of social phobia completed the Anxiety Sensitivity Index (ASI) prior to treatment. Social phobics who experienced panic attacks reported higher levels of anxiety sensitivity than those without panic attacks. Patterning of response to ASI items differed between panicking and non-panicking patients, with the panicking patients reporting greater fear of catastrophic consequences of bodily sensations. Individuals with an additional diagnosis of panic disorder did not differ from those with exclusively situational panic attacks. The findings suggest the importance of examining differences between anxiety-disordered individuals who experience panic attacks and their non-panicking counterparts.

To investigate the impact of situational panic attacks in social phobia, this study examined symptoms of social anxiety and avoidance, dysfunction, and associated psychopathology among individuals with social phobia who experience situational panic attacks, individuals meeting criteria for both social phobia and panic disorder, and individuals with social phobia but no report of panic attacks. One hundred thirty-three persons with a principal diagnosis of social phobia were evaluated. Fifty-seven individuals, who experienced panic attacks exclusively in the context of feared social situations, were compared to 15 individuals with social phobia who also experienced spontaneous panic attacks and met criteria for panic disorder and 61 social phobics who did not experience panic attacks. Compared to social phobics without panic, social phobics with situational panic attacks demonstrated greater fear and avoidance of social situations and higher ratings of somatic anxiety, were more distressed and impaired by their social phobias, and reported higher levels of anxiety sensitivity and hopelessness than social phobics without panic. Additionally, social phobia patients with situational panic but without panic disorder reported greater hopelessness than participants with comorbid panic disorder. In regression analyses, situational panic attacks accounted for significant unique variance beyond that contributed by the presence of comorbid panic disorder. Situational panic attacks are common in social phobia. They are associated with significant and unique disturbances compared either to the absence of panic attacks or to panic attacks in the context of comorbid panic disorder and deserve attention in both research and treatment of social phobia.

Thirty-three social phobic adolescents were asked to name their ten most feared social situations. Two independent judges classified each situation reported by the participants into one of four situational domains: formal speaking/interactions, informal speaking/interactions, observation by others, and assertion. Fifteen participants (45.5%) were assigned a generalized subtype of social phobia because they endorsed at least moderate anxiety in all four situational domains. This subgroup scored higher on self-report measures of anxiety and depression than the rest of the sample. These results provide empirical support for the existence of subtypes of social phobia in adolescents. Depression and Anxiety 9:15–18, 1999. © 1999 Wiley-Liss, Inc.

To evaluate the effects of maintenance treatment and durability of gains after treatment discontinuation, responders to either phenelzine (PZ) or cognitivebehavioral group therapy (CBGT) from an acute trial comparing these two treatments as well as pill placebo and a psychotherapy control (educational supportive group therapy) were enrolled into maintenance and treatment-free follow-up phases. Experimental design: Responders to an acute trial contrasting PZ and CBGT entered a six-month maintenance phase. Patients who continued to respond through the maintenance phase entered a six-month treatment free phase. Patients receiving pill placebo or educational supportive group therapy in the acute trial did not enter the long term study. Principal observations: PZ patients entered maintenance more improved than CBGT patients, and nonrelapsing PZ patients maintained their superior gains throughout the study. Relapse during maintenance did not differ between treatments. However, PZ patients showed a trend toward greater relapse during treatment-free follow-up. There was a greater relapse among patients with generalized social phobia with phenelzine. Conclusions: PZ and cognitive-behavioral group therapy may differ in their long term effects. The superiority seen with PZ on some measures in the acute study persisted in patients who maintained their gains over the course of maintenance and treatment-free follow-up. However, CBGT may lead to a greater likelihood of maintaining response after treatment has terminated. Replication with larger samples is needed, as is a study of the acute and long-term efficacy of combined PZ and CBGT. Depression and Anxiety 10:89‐98, 1999. © 1999 Wiley-Liss, Inc.

Columbia University and Anxiety Disorders Clinic of theNew York State Psychiatric Institute, New York, New YorkPortions of this study were presented at the 32nd Annual Meet-ing of the Association for Advancement of Behavior Therapy,Washington, DC, November 5–8, 1998.Contract grant sponsor: National Institute of Mental Health; Con-tract grant numbers: 44119, 40201.*Correspondence to: Richard G. Heimberg, Ph.D., Adult AnxietyClinic, Department of Psychology, Temple University, Weiss Hall,1701 N. 13th Street, Philadelphia, PA 19122-6085. E-mail:rheimber@nimbus.ocis.temple.eduReceived for publication 5 January 1999; Accepted 25 May 1999

The person's perception of his or her quality of life has been neglected in studies of mental health in general and anxiety disorders in particular. However, the judgement of the impact of a mental disorder based on symptomatic distress while ignoring one's overall quality of life is incomplete. In the present study, we examined social phobic patients' judgments of their satisfaction with various domains of life they deem important using the Quality of Life Inventory (QOLI; Frisch, unpublished). Social phobics judged their overall quality of life lower than Frisch's (unpublished) normative sample. Quality of life was inversely associated with various measures of severity of social phobia (especially social interaction anxiety), functional impairment, and depression. It was not, however, related to performance anxiety or trait anxiety. Quality of life also varied across combinations of subtype of social phobia and the presence/absence of avoidant personality disorder, and as a function of marital status. Patients showed significant improvement in quality of life scores after completion of cognitive-behavioral group therapy for social phobia.

Although global clinical rating scales have been a mainstay of clinical research, little is known about the relationship between these measures and other assessment modalities. The present study examined the Clinician's Severity Rating (CSR) from the Anxiety Disorders Interview Schedule in a sample of 186 social phobics. It was hypothesized that the CSR would be related to higher fear of negative evaluation, behavioral avoidance, social anxiety, and dysphoria, and that four self-report measures reflecting each of these common features of social phobia would contribute individually to predict clinicians' judgments of clinical severity using the CSR. Multiple regression analyses supported these hypotheses, accounting for nearly 33% of the variance in the CSR. The role of subtype of social phobia was also investigated. Overall, these results support the utility of the CSR for use with social phobics, but the relatively low proportion of variance accounted for raises further questions. Directions for future research are also discussed.