Elsevier

Biological Psychiatry

Volume 51, Issue 1, 1 January 2002, Pages 81-91
Biological Psychiatry

The spectrum of social phobia in the zurich cohort study of young adults

https://doi.org/10.1016/S0006-3223(01)01309-9Get rights and content

Abstract

Background: The goals of the present study are to describe the prevalence, risk factors, course, and impact of social phobia in a 15-year prospective longitudinal community study; and to examine 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.

Methods: The sample is a cohort of 591 young adults aged 18–19 from the general population of Zurich, Switzerland at study entry who have been followed to age 35.

Results: Six percent of participants met lifetime criteria for social phobia at the diagnostic level, 12% at the subthreshold level, and 24% had social phobia symptoms alone. Women had higher lifetime rates of diagnostic and subthreshold-level social phobia, whereas there was an equal gender ratio of social phobia symptoms. There was a direct association between strictness of the diagnostic threshold and severity, such that work impairment, social impairment, treatment rate, medication use, and subjective distress decreased from the diagnostic to the symptom level. Similarly, family history of phobias, autonomic lability, and comorbidity decreased across the spectrum. Although there was a substantial degree of longitudinal stability at each level of the spectrum, significant oscillation across levels suggests that the spectrum concept better characterizes the longitudinal course of social phobia.

Conclusions: These findings demonstrate the utility of the social phobia spectrum. Application of the spectrum concept provides coverage of treated but undiagnosed cases of social phobia as well as those who vacillate across the diagnostic threshold over time.

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,

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