Predictors of persistence of social anxiety disorder: A national study

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Abstract

Social anxiety disorder (SAD) is highly prevalent and impairing. Little is known about rates and predictors of persistence of SAD in the community. The current study derived data from the National Epidemiologic Survey on Alcohol and Related Conditions, Wave 1 (2001–2002, n = 43,093) and Wave 2 (2004–2005, n = 34,653), a large survey of a representative sample of the United States adult population. Individuals with current DSM-IV SAD at Wave 1 were re-interviewed 3 years later at Wave 2 using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM IV Version (AUDADIS-IV). We found that in the community, 22.3% of respondents with SAD at the Wave 1 evaluation met DSM-IV criteria for SAD three years later, and endorsement of social interaction fears and a higher number of avoided social situations, treatment-seeking during past year, and comorbidity with mood disorders independently predicted persistence of SAD. These results suggest that persistence of SAD in the community is common and associated with symptom severity and comorbid mood disorders.

Introduction

Social anxiety disorder (SAD) is highly prevalent (Kessler et al., 1994, Kessler et al., 2005a, Kessler et al., 2005b, Stein et al., 1994, Magee et al., 1996, Grant et al., 2005, Stinson et al., 2007), associated with significant social and occupational impairment (Schneier et al., 1992, Davidson et al., 1993, Wittchen and Beloch, 1996, Keller, 2003, Kessler, 2003), and often co-occurs with other psychiatric disorders (Rapee et al., 1988, Reich et al., 1994). SAD generally has an onset during adolescence or early adulthood (Rapee et al., 1988, Reich et al., 1994, Chartier et al., 1998) and is typically considered to be chronic (Reich et al., 1994, Yonkers et al., 2003, Grant et al., 2005).

Data from clinical samples have suggested that SAD seldom remits (Reich et al., 1994, Massion et al., 2002, Yonkers et al., 2003). Initial short-term treatment studies suggested that early age of onset (Yonkers et al., 2003) and comorbid alcohol use disorders (Versiani et al., 1988) were associated with persistence of SAD, whereas gender (Cameron et al., 1986) and duration of illness (Mersch et al., 1991) did not seem to affect its chronicity. More recently, prospective data (Reich et al., 1994, Massion et al., 2002, Yonkers et al., 2003) from the Harvard/Brown Anxiety Research Program (HARP), which followed treatment-seeking patients with anxiety disorders for up to eight years, indicated that gender, age of onset, and comorbid anxiety and mood disorders did not predict persistence of SAD (Reich et al., 1994, Massion et al., 2002), but avoidant personality disorder (APD) did (Massion et al., 2002). In primary care settings, comorbid panic disorder and lower psychosocial functioning have also been found to predict the persistence of SAD (Beard et al., 2010).

Several studies using community samples have also examined persistence of SAD. Data from the Duke site of the Epidemiological Catchment Area study suggested that earlier age of onset and presence of psychiatric comorbidity were associated with the persistence of SAD (Davidson et al., 1993), whereas results from the National Comorbidity Survey indicated that endorsing more than one social fear predicted persistence of SAD (Kessler et al., 1998). Conflicting results have been reported from longitudinal studies. For instance, the Dresden Predictor Study found, in an 18-month follow-up of 91 young women with SAD, that having a lifetime history of depression, a higher number of comorbid psychiatric disorders, higher levels of stress, poorer mental status, and being unemployed at baseline predicted persistence of SAD (Vriends et al., 2007). However, data from the Early Developmental Stages of Psychopathology Study on 183 adolescents and young adults with SAD followed for up to 4 years indicated that most sociodemographic factors, clinical characteristics, comorbid psychiatric disorders, familial factors, and stressful life events did not predict the persistence of SAD (Müller, 2002).

Although these previous studies have advanced our knowledge of the course of SAD, they have been constrained by having modest sample size (Davidson et al., 1993, Vriends et al., 2007), use of cross-sectional data (Kessler et al., 1998, DeWit et al., 1999), or reliance on clinical samples (Beard et al., 2010), limiting the generalizability of their findings. Large prospective studies in the community are essential for the identification of predictors of persistence of SAD in the general population.

To expand current knowledge on this topic, we used data from a large and nationally representative community sample of United States (US) adults, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (n = 43,093) and its 3-year prospective follow-up (n = 34,653). In the NESARC, the 12-month prevalence of SAD at baseline (i.e., Wave 1) was 2.76% (Grant et al., 2005). The large size and representiveness of the NESARC sample and the longitudinal design of the study provide an unusual opportunity to simultaneously examine a broad range of variables that have been hypothesized to predict the course of SAD. Specifically, we sought to: 1) investigate differences in sociodemographic characteristics among individuals with persistent and remitted SAD; 2) compare rates of psychiatric comorbidity among individuals with persistent and remitted SAD; 3) examine clinical characteristics of SAD among individuals with persistent and remitted SAD; and, 4) examine childhood and adulthood risk factors among individuals with remitted and persistent SAD.

Section snippets

Sample

The NESARC is a longitudinal survey of a nationally representative sample of the US adult population conducted, as described elsewhere (Grant et al., 1995, Grant et al., 2004, Grant et al., 2005, Hasin et al., 1997, Canino et al., 1999, Grant et al., 2003a, Grant et al., 2004, Grant et al., 2005, Grant et al., 2009, Grant and Kaplan, 2005). The target population was the civilian non-institutionalized population 18 years and older, residing in households and group living quarters (Grant et al.,

Persistence rates

Among the 989 respondents who met criteria for SAD at Wave 1, 22.3% continued to meet criteria at Wave 2. Persistence rates were 47.5% and 17.4% among those who sought treatment during the past year (n = 149) and those who did not (n = 840), respectively.

Discussion

To our knowledge, this is the first prospective study using a national representative sample to examine predictors of persistence of SAD. We found that in the community 22.3% of individuals with SAD at the baseline evaluation met DSM-IV criteria for SAD three years later. In bivariate analyses, several sociodemographic correlates, psychiatric comorbidity, and clinical characteristics predicted persistence of SAD. However, results of the hierarchical stepwise regression indicated that only fear

Disclaimer

The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or the U.S. government.

Ethical considerations

All procedures, including informed consent, received full ethical review and approval from the U.S. Census Bureau and U.S. Office of Management and Budget.

Contributors

1. Conception and design, or acquisition of data, or analysis and interpretation of data (Carlos Blanco, Yang Xu, Shang-Min Liu).

2. Drafting the article or revising it critically for important intellectual content (Carlos Blanco, Yang Xu, Franklin Schneier, Mayumi Okuda, Richard G. Heimberg).

3. Final approval of the version to be published (Carlos Blanco, Yang Xu, Franklin Schneier, Mayumi Okuda, Shang-Min Liu, Richard G. Heimberg).

Role of funding source

Supported by NIH grants DA019606 DA019606, DA020783DA020783 and DA023200 (to Dr. Blanco) and by the New York State Psychiatric Institute (to Drs. Blanco and Schneier). The NESARC was funded by the National Institute on Alcoholism and Alcohol Abuse, with supplemental support from the National Institute on Drug Abuse.

Conflict of interest

All authors declare that they have no conflict of interest.

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