The spectrum of social phobia in the zurich cohort study of young adults
Introduction
There has been a dramatic increase in knowledge regarding the epidemiology, pathogenesis, risk factors, and treatment of social anxiety disorder during the past decade. Both community and clinical studies have shown that social phobia is associated with significant psychosocial impairment and has major public health significance in terms of its high prevalence, chronicity, and disability Brunello et al 2000, Kessler et al 1999. Below, we briefly review the results of community studies of social phobia as defined by contemporary diagnostic systems.
Social phobia is highly prevalent and ranks as the third most common mental health disorder after depression and alcoholism in the National Comorbidity Study (NCS; Kessler et al 1994). Lifetime prevalence rates of social phobia are available from numerous international community studies employing DSM-III, III-R, or IV criteria (Furmark 2000). There is a wide range of lifetime prevalence rates, with the lowest rates reported in Korea and Taiwan (0.5% and 0.6%, respectively; Hwu et al 1989, Lee et al 1990) and the highest rates reported in the United States (NCS) and Switzerland (13.3% and 16.0%, respectively; Kessler et al 1994, Wacker et al 1992). Lifetime prevalence rates of social phobia in children and adolescents range from about 1%–10% in community samples, with higher rates in studies that include older adolescents and young adults Anderson et al 1987, Newman et al 1996, Wittchen et al 1998.
The average gender ratio for social phobia in community studies is approximately 1.5 to 1 Chapman et al 1995, Moutier and Stein 1999. Although statistically significant gender differences have been reported in many studies Davidson et al 1993, Kessler et al 1994, Magee et al 1996, Schneier et al 1992, the female preponderance is only modest and is notably less than that of other anxiety subtypes and affective disorders. The onset of social phobia usually occurs in mid- to late adolescence Beidel 1998, Schneier et al 1992, Strauss and Last 1993, Wittchen et al 1999a.
Because social phobia is generally left untreated Magee et al 1996, Schneier et al 1992, Wittchen et al 1999b, it is associated with a number of negative outcomes, including poor school and work performance, increased risk of leaving school early, disability in major social roles, and dissatisfaction with friends, leisure activities, and income (Stein et al 1999, Turner et al 1986; Wittchen et al 199b).
A previous review concluded that an average of 80% of those with social phobia identified in community samples met diagnostic criteria for a comorbid lifetime disorder (Merikangas and Angst 1995). Social phobia is strongly associated with other types of anxiety disorders, affective disorders, and substance use disorders Davidson et al 1993, Kessler et al 1999, Magee et al 1996. Moreover, the onset of social anxiety typically precedes that of the majority of comorbid conditions, with the exception of specific phobia Angst 1993, Kessler et al 1999, Merikangas et al 1998a, Schneier et al 1992, Wittchen et al 1999a. Previous work on the comorbidity of social phobia and agoraphobia in the present study revealed that comorbidity was associated with poorer course and outcome (Degonda and Angst 1993), similar to that reported for comorbid depression and social phobia (Angst 1993).
One of the most potent risk factors for social phobia is a family history of anxiety and/or social phobia, which is associated with a two- to three-fold increased risk of social phobia among relatives Fyer 1993, Fyer et al 1995, Lieb et al 2000, Merikangas et al 1994, Stein et al 1998. The results of twin studies of female subjects reveal that approximately 30% of the variance underlying familial concordance is attributable to genetic influence Kendler et al 1992, Nelson et al 2000. Other frequently cited risk factors for social phobia include temperamental traits, such as childhood behavioral inhibition and anxiety sensitivity (Beidel 1998, Biederman et al 1990, Chorpita et al 1996, Cox et al 1999, Hayward et al 1998, Kagan et al 1990; Menkangal et al 1999; Pollock et al in press, Rosenbaum et al 1992).
Although the results of clinical and community studies suggest that the long-term course of social phobia is chronic and unremitting, these data have been primarily derived from retrospective reports Beidel 1998, Davidson et al 1993, DeWit et al 1999, Turner et al 1986. Two recent prospective reports demonstrated a substantial degree of stability of social phobia across short- (Wittchen et al 1999a) and long-term follow-up (Pine et al 1998).
There has been little empirical research on the boundaries and thresholds for the diagnostic criteria for social phobia in the community. Based on systematic increases in impairment as a function of the number of phobic situations, Stein et al (2000) concluded that social phobia may be better conceptualized as a continuum of severity rather than as a discrete disorder based on an arbitrarily derived threshold. The results of other community studies also support distinguishing social phobia based on severity rather than qualitative distinctions between phobic situations Furmark 2000, Kessler et al 1998.
The present article describes the prevalence, risk factors, course, and impact of social phobia in a prospective longitudinal community study of a cohort of young adults from Zurich, Switzerland. This study also evaluates an expanded conceptualization of social phobia with respect to clinical indicators of severity, as well as gender differences, personality traits, and stability over 15 years.
Section snippets
Sample
The Zurich Cohort Study is composed of a cohort of 4547 subjects (2201 male, 2346 female) representative of the canton of Zurich, Switzerland, who were screened in 1978 with the Symptom Checklist 90-R (SCL-90-R; Derogatis 1977). To increase the probability of psychiatric syndromes in this general population sample, a subsample of 591 subjects (292 male, 299 female) was selected for interview, with two thirds consisting of high scorers (defined by the 85th percentile and higher on the SCL-90)
Prevalence of social phobia spectrum
Participants were classified on the social phobia spectrum according to the criteria delineated above. Table 1 shows the weighted cumulative 1-year prevalence rates across the 15 years of the study. (Although these rates approximate lifetime prevalence because of the long period of observation, they are the maximum of the five 1-year prevalence rates derived from each interview.) Approximately 6% of participants met full diagnostic criteria for social anxiety disorder at least once during the
Social phobia as a spectrum
The major contribution of this work is the evidence for a spectrum of social phobia based on increasing severity of social anxiety symptoms in terms of all of the indicators of validity assessed herein. There was a direct association between the strictness of the diagnostic threshold and severity, family history, autonomic lability, and comorbidity. The basic findings with respect to the clinical validators, course, and risk factors remained similar when distress was substituted for avoidance
Acknowledgements
This study was supported by Grants MH46376, DA00293, AA12044, and K02-DA 00293 from the U.S. National Institutes of Health, and Grant No. 32-33980 from the Swiss National Foundation
Aspects of this work were presented at the conference, “Social Anxiety: From Laboratory Studies to Clinical Practice,” held March 22, 2001 in Atlanta, Georgia. The conference was supported by an unrestricted educational grant to the Anxiety Disorders Association of America (ADAA) from Wyeth-Ayerst Pharmaceuticals,
References (76)
- et al.
Premorbid personality of depressive, bipolar, and schizophrenic patients with special reference to suicidal issues
Compr Psychiatry
(1986) - et al.
The depressive spectrumDiagnostic classification and course
J Affect Disord
(1997) - et al.
Multi-dimensional criteria for the diagnosis of depression
J Affect Disord
(2001) - et al.
Depressive spectrum diagnoses
Compr Psychiatry
(2000) - et al.
At risk for anxietyI. Psychopathology in the offspring of anxious parents
J Am Acad Child Adolesc Psychiatry
(1997) - et al.
Social phobiaDiagnosis and epidemiology, neurobiology and pharmacology, comorbidity and treatment
J Affect Disord
(2000) - et al.
Linking self reported childhood behavioral inhibition to adolescent social phobia
J Am Acad Child Adolesc Psychiatry
(1998) - et al.
Comorbidity of alcohol and anxiety disorders among college studentsEffects of gender and family history of alcoholism
Addict Behav
(1993) - et al.
The relationship between major and subthreshold variants of unipolar depression
J Affect Disord
(1997) - et al.
Vulnerability factors among children at risk for anxiety disorders
Biol Psychiatry
(1999)
Comorbidity of substance use disorders with mood and anxiety disordersResults of the International Consortium in Psychiatric Epidemiology
Addict Behav
Social and simple phobias in children
J Anxiety Disord
Disability and quality of life in pure and comorbid social phobiaFindings from a controlled study
Eur Psychiatry
DSM-III disorders in preadolescent childrenPrevalence in a large sample from the general population
Arch Gen Psychiatry
Comorbidity of anxiety, phobia, compulsions, and depression
Int Clin Psychopharmacol
Modern epidemiology of anxietyResults of the Zurich cohort study
Hum Psychopharmacol
The Zurich Study—A prospective epidemiological study of depressive, neurotic and psychosomatic syndromes. I. Problem, methodology
Eur Arch Psychiatry Clin Neurosci
The Zurich StudyXIII. Recurrent brief anxiety
Eur Arch Psychiatry Clin Neurosci
Quality of life in anxiety and social phobia
Int Clin Psychopharmacol
Social anxiety disorderEtiology and early clinical presentation
J Clin Psychiatry
Psychiatric correlates of behavioral inhibition in young children of parents with and without psychiatric disorders
Arch Gen Psychiatry
Current and residual functional dis-ability associated w/psychopathologyFindings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)
Psychol Med
Lifetime prevalence of psychiatric disorders in Edmonton
Acta Psychiatr Scand Suppl
Epidemiology and family studies of social phobia
Social phobia and potential childhood risk factors in a community sample
Psychol Med
Child anxiety sensitivity indexConsiderations for children with anxiety disorders
J Clin Child Psychol
Anxiety sensitivity and emotional disordersPsychometric studies and their theoretical implications
The epidemiology of social phobiaFindings from the Duke Epidemiological Catchement Area Study
Psychol Med
The Zurich StudyXX. Social phobia and agoraphobia
Eur Arch Psychiatry Clin Neurosci
Symptom Checklist 90, R-Version Manual IScoring, Administration and Procedures for the SCL-90
Antecedents of the risk of recovery from DSM-III-R social phobia
Psychol Med
Two-phase epidemiological surveys in psychiatric research
Br J Psychiatry
Panic and phobia
A short questionnaire for the measurement of two dimensions of personality
J Applied Psychol
Das Freiburger Personlichkeitcinventar
The Analysis of Cross-Classified Categorical Data
Heritability of social anxietyA brief review
J Clin Psychiatry
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