Elsevier

Comprehensive Psychiatry

Volume 55, Issue 2, February 2014, Pages 363-369
Comprehensive Psychiatry

The clinical impact of mood disorder comorbidity on social anxiety disorder

https://doi.org/10.1016/j.comppsych.2013.08.016Get rights and content

Abstract

Background

High comorbidity rates of mood disorders have been reported in patients with social anxiety disorder (SAD). Our study aims to identify the frequency of comorbid Axis I disorders in patients with SAD and to investigate the impact of psychiatric comorbidity on SAD.

Methods

The study included 247 patients with SAD. Thirty eight patients with bipolar depression (SAD-BD), 150 patients with major depressive disorder (SAD-MDD) and 25 patients who do not have any mood disorder comorbidity (SAD-NOMD) were compared.

Results

Around 90% of SAD patients had at least one comorbid disorder. Comorbidity rates of lifetime MDD and BD were 74.5% and 15.4%, respectively. There was no comorbidity in the SAD-NOMD group. Atypical depression, total number of depressive episodes and rate of PTSD comorbidity were higher in SAD-BD than in SAD-MDD. Additionally, OCD comorbidity was higher in SAD-BD than in SAD-NOMD. SAD-MDD group had higher social anxiety severity than SAD-NOMD.

Conclusions

Mood disorder comorbidity might be associated with increased severity and decreased functionality in patients with SAD.

Introduction

It is reported that annual prevalence of social anxiety disorder (SAD) is about 5–10% while lifetime prevalence is about 10–15% in general population [1], [2], [3], [4], [5]. Epidemiological studies have established that psychiatric comorbidity, particularly mood disorders, was frequent in SAD patients [1], [5], [6], [7], [8], [9], [10]. However, there is a scarcity of research on clinical samples and there might be great variance among the rates. According to the previous studies, the mood disorders comorbidity rates in SAD patients are 35–70% for major depressive disorder (MDD) [11], [12], [13], [14], and 3–21% for bipolar disorder [12], [13], [14].

SAD comorbidity is also frequent in patients with mood disorders. The prevalence of SAD comorbidity in MDD patients is reported to be 22–29.3% [7], [15], [16], [17]. The presence of SAD is found to be a predictor for the subsequent development of MDD [1], [7], [18], [19], [20], [21].

SAD comorbidity in bipolar patients is reported to be between 7.8% and 47.2% [7], [22], [23], [24], [25], [26], [27], [28], [29], [30]. Kessler and colleagues (1999) showed an association between bipolar disorder (odds ratio: 5.9) and SAD comorbidity [7]. Also, SAD was found to be related with severity and persistence of comorbid mood disorder [7], [19].

There are also studies that point to the association between SAD and bipolar disorder. It was reported that 18 of 32 SAD patients prescribed with a monoamin oxidase inhibitor benefited and hypomanic symptoms appeared in fourteen of those eighteen patients. In the study, it was speculated that a group of SAD patients might be within the bipolar spectrum and bipolar characteristics might appear with antidepressant treatment [31]. Because the increased rate of hypomanic shifts in MDD patients with SAD comorbidity as a result of antidepressant medication, an association between bipolar disorder and SAD was mentioned [32].

There are a limited number of studies investigating the clinical effects of mood disorder comorbidity on the course of disorder in patients with SAD. Bipolar disorder comorbidity was reported to be associated with severity and generalization of the social phobia symptoms, multiple comorbidity, and alcohol abuse in SAD patients [14]. The same study found that panic disorder with agoraphobia and obsessive compulsive disorder (OCD) comorbidity, functional impairment, phobic avoidance and overall severity scores of Liebowitz Social Phobic Disorders Rating Scale, Severity (LSPDRS) are higher in SAD patients with bipolar disorder or MDD comorbidity than in SAD patients with no mood disorder comorbidity. In general, bipolar disorder comorbidity has more negative effects than MDD comorbidity even though both have negative effects.

The aim of the present study is to identify the Axis I comorbidity rates in SAD patients and to examine the effects of current unipolar and bipolar depression on the clinical picture of SAD. Another aim is to test the hypothesis that symptomatology and course of the disorder would be significantly different in SAD patients with comorbid major depression or bipolar disorder than in patients without comorbid mood disorders. The groups of SAD patients were as follows: SAD with current major depressive disorder (SAD-MDD), SAD with bipolar disorder, current depressive episode (SAD-BD) and SAD without a history of mood disorder (SAD-non-mood disorder) (SAD-NOMD). The three groups were compared in terms of sociodemographic characteristics, symptom severity, course of illness and presence of other comorbid axis I disorders.

Section snippets

Materials and methods

A total of 247 consecutive SAD (generalized type) patients from the Outpatient Clinic of the Psychiatry Department of Bahat Group Hospitals (Bahat Hospital: 51 patients, Bati Bahat Hospital: 196 patients) were interviewed with the Structured Clinical Interview for DSM-IV/Clinical Version (SCID-I/CV) [33] between November 2008 and June 2011. These patients applied to the hospital through web searches and personal recommendations and referrals to the principal investigator (A.K.) who specifically

Results

Eighty five (34.4%) of 247 participants were female. 185 (74.9%) of the patients were single. Mean age was 27.61 (min: 18, max: 50, SD: 6.22) and mean years of education was 12.89 (min: 5, max: 18, SD: 2.84). The mean age at SAD onset was 13.64 (min: 6, max: 36, SD: 5.61), and mean age at first MD episode in patients who have comorbid mood disorder was 17.61 (min: 10, max: 43, SD: 5.12). There was no statistically significant difference among the three groups (SAD-BD, SAD-MDD and SAD-NOMD) in

Discussion

In the present study, the rate of mood disorders comorbidity was particularly high. The rate of MDD comorbidity was slightly higher than rates reported in previous clinical studies [11], [12], [13], [14], while the bipolar disorder comorbidity rate was in line with the literature [12], [13], [14]. However, alcohol-substance use rate was lower than expected. It might be a result of Turkey’s sociocultural characteristics. Also, the rate of any additional anxiety disorder comorbidity was high in

Conclusion

About ninety percent of the SAD patients have at least one comorbid disorder. The most frequent comorbidity was major depression. Also, bipolar disorder and any anxiety disorder comorbidity were high.

In the presence of mood disorder comorbidity, severity of major SAD symptoms (social anxiety and social avoidance) increased. Compared to the SAD-NOMD group, the statistical significance of this increase was found only in SAD-MDD group and this might be related with the limited number of patients

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