doi:10.1111/pcn.12327
Generalized social anxiety disorder: A still-neglected anxiety disorder 3 decades since Liebowitz’s review Toshihiko Nagata, MD, PhD,1* Futoshi Suzuki, MD, PhD2 and Alan R. Teo, MD, MS3 1 Mental Health Clinic of Dr Nagata in Nanba, Osaka, 2Department of Child and Adolescent Psychiatry, Nagoya University Hospital, Aichi, and 3VA Portland Health Care System and Oregon Health & Science University, Oregon, USA
In the 3 decades since Liebowitz’s review of ‘a neglected anxiety disorder,’ controversy and challenges have remained in the study of social anxiety disorder (SAD). This review examines evidence around the classification and subtyping of SAD, focusing on generalized SAD. Substantial discrepancies and variation in definition, epidemiology, assessment, and treatment of generalized SAD exist as the international literature on it has grown. In East Asian
cultures in particular, study of taijin kyofusho has been important to a broadened conceptualization of SAD into generalized SAD. Despite important progress with biological and other studies, many challenges in the understanding of generalized SAD will remain in the years to come.
OCIAL ANXIETY DISORDER (SAD)1 is one of the most common mental disorders, as shown by two recent general population surveys in the USA, which both found that almost one in 10 individuals suffers from SAD at some point in their lifetime.2,3 Onset typically occurs in childhood or early adolescence and takes a chronic course. SAD may cause significant distress and impairment in educational attainment, employment opportunities, the development of professional, peer and intimate relationships, and financial independence.4 The early onset and chronic course with rare spontaneous remission frequently causes secondary comorbidities, such as depression and alcohol-related problems.4 The conceptualization of SAD has rapidly altered and expanded during just the past few decades as progress has been made in SAD treatment strategies.
The disorder was initially considered as just a type of phobic reaction to a specific social situation akin to a specific phobia in DSM-III.5 With the advent of DSMIII-R,6 diagnostic criteria for the disorder underwent significant expansion. The specifier ‘generalized’ was introduced to the formal nosology in DSM-III-R6 to describe persons experiencing social fears in ‘most or all’ situations while allowing concurrent diagnosis of avoidant personality disorder. The label ‘social anxiety disorder’ was introduced in DSM-IV,7 and replaced ‘social phobia’ in DSM-5.1 Moreover, in the current version of DSM, typical fear and anxious situations are defined as: (i) social interaction fears; (ii) observation fears; and (iii) performance anxiety (in criterion A). Thus fear of performance in public was deprioritized compared to social interaction in DSM-5. This rapid expansion of concept was criticized as giving the diagnosis of SAD to individuals who have few social fears, overpathologizing the socially anxious8 and disease-mongering.9 Indeed, the distress of giving a speech in public is a normal reaction in
S
*Correspondence: Toshihiko Nagata, MD, PhD, Mental Health Clinic of Dr Nagata in Nanba, SAN-EI-Midosuji Bldg 3F, 3-5-8 Nanba, Chuo-Ku, Osaka 542-0076, Japan. Email: [email protected] Accepted 25 June 2015.
724
Key words: generalized, social anxiety disorder, taijin kyofusho, under-recognition, undertreatment.
© 2015 The Authors Psychiatry and Clinical Neurosciences © 2015 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2015; 69: 724–740
Generalized social anxiety disorder 725
human nature10 and psychosocial impairment from fear of public speech is much less than that from generalized SAD, which is characterized my multiple fears of social situations.11 On the other hand, SAD is still under-recognized even by mental health professionals,12 and undertreatment of SAD, especially generalized SAD, cannot be ignored.13 The ‘generalized’ specifier was removed in DSM-5 due to the dimensional nature of specific (just one or two public performances are feared), nongeneralized (more than a few but less than half of social situations are feared) and generalized (more than half of social situations are feared) SAD.14 However, the concept of generalized SAD remains clinically useful. The categorical15 and prototype approach16 is essential in treating patients in real world settings, regardless of whether SAD psychopathology is scientifically dimensional or not. This review focuses specifically on generalized SAD because it has received relatively little attention, continues to be clinically important, and provides insight into related phenomena, such as taijin kyofusho (TKS).
The social phobia section of DSM-III-R6 drastically shifted the paradigm to include broader social fears and reduced the diagnostic threshold such that avoidance of the fearful situation was not necessary anymore. Instead, the ‘generalized’ specifier (i.e., ‘the phobic situation includes most social situations’), first introduced into formal nosology the recommendation of consideration a concurrent diagnosis of avoidant personality disorder. No additional guideline or criteria were provided, and the definition was criticized for ambiguity and arbitrariness afterward.14 This establishment of generalized SAD enhanced numerous investigations, including its high prevalence rate within SAD, phenomenology of early onset, following a chronic and unremitting course, clinical trials of monoamine oxidase inhibitors (MAOI) and selective serotonin reuptake inhibitors (SSRI) and psychological interventions, such as cognitive behavioral therapy for this disorder.14 The label ‘social anxiety disorder’ was introduced in DSM-IV7 with quotation marks and in DSM-51 without quotation marks to mean a more pervasive and interfering condition than that implied by the label ‘social phobia’ and the limited DSM-III diagnostic definition. Despite documented distinctions in severity between generalized and non-generalized SAD,4 the validity and clinical utility of the generalized and non-generalized specifiers have been the subject of criticism.14 Because subtype definitions have been inconsistently applied across studies, there is no particular number of performance and interaction situations required.20,21 There was no clear distinction, such as clear nonlinearity or point-of-rarity, between generalized and non-generalized even in international studies22 suggesting a continuum (or dimensional model). Factor analysis in US and Canadian community samples23 as well as international community samples22 yielded a three-factor structure for SAD: (i) social interaction fears; (ii) observation fears; and (iii) public speaking fears.22 Thus, three and half decades since DSM-III,5 social interactional fear superseded public speaking fears as preeminent in SAD. However, the ‘generalized’ specifier has been replaced with a ‘performance-only’ specifier identifying significant social anxiety occurring only in public performance situations in DSM-5.1 The performanceonly specifier may instead be an indicator of mild or even sub-threshold SAD.
CONCEPT OF GENERALIZED SAD Emergence and evolution of the concept of generalized SAD A group of researchers at Columbia University led the development of the concept of generalized SAD. After Marks and Gelder17 suggested that social phobia was different from other phobias, social phobia was officially included in DSM-III.5 Social phobia in DSM-III was restricted to performance fears (fear of speaking, signing a check, or eating in public), although Marks’ original concept included more generalized forms of social anxiety (fears of initiating conversations or dating). At that time, patients with more generalized social anxiety were classified as having avoidant personality disorder in DSM-III, because these patients were believed to need social skill training for personality disorder while ‘social phobics’ responded well to exposure therapy.18 Liebowitz et al.19 re-introduced social phobia as a neglected anxiety disorder except among behavior therapists, and suggested that DSM-III too restrictively defined this disorder primarily as performance anxiety.5 They also showed that both psychopharmacological and behavioral treatment intervention were effective in this population.
© 2015 The Authors Psychiatry and Clinical Neurosciences © 2015 Japanese Society of Psychiatry and Neurology
726 T. Nagata et al.
Psychiatry and Clinical Neurosciences 2015; 69: 724–740
Definition of generalized SAD
fears of performance in public or in observation are essential to be classified as generalized SAD.
There is no consensus definition of generalized SAD. In early studies, subjects were classified into generalized and non-generalized based on ‘reviewing each subjects’ files and classified’,24 or ‘reviewing SADS-LA (Schedule for Affective Disorders and SchizophreniaLifetime Anxiety version) narratives’.25 Later investigators operationally defined generalized SAD with an indicated number of feared social situations. Hofmann et al.26 applied the ‘generalized’ subtype if the patients reported at least a moderate fear of situations from all four domains ([i] formal speaking/interaction; [ii] informal speaking/ interaction; [iii] observation by others; and [iv] assertion). Also, the Structured Clinical Interview for DSM-IV was modified to classify generalized and nongeneralized SAD. The modified version of the Structured Clinical Interview for DSM-IV27 lists nine social interaction situations and eight performance situations. To diagnose generalized SAD, patients are required to exhibit fear and/or avoidance of at least four social situations and at least two of these had to involve interpersonal interactions.28,29 A total score of >60 on the Liebowitz Social Anxiety Scale (LSAS) was also used to define the generalized subtype,30 although LSAS was designed to assess the symptom severity, not act as a diagnostic tool. Recent epidemiological studies operationalize generalized SAD as consisting of individuals who fear >50% of all social situations assessed and nongeneralized SAD as consisting of
Generalized social anxiety disorder: A still-neglected anxiety disorder 3 decades since Liebowitz’s review Toshihiko Nagata, MD, PhD,1* Futoshi Suzuki, MD, PhD2 and Alan R. Teo, MD, MS3 1 Mental Health Clinic of Dr Nagata in Nanba, Osaka, 2Department of Child and Adolescent Psychiatry, Nagoya University Hospital, Aichi, and 3VA Portland Health Care System and Oregon Health & Science University, Oregon, USA
In the 3 decades since Liebowitz’s review of ‘a neglected anxiety disorder,’ controversy and challenges have remained in the study of social anxiety disorder (SAD). This review examines evidence around the classification and subtyping of SAD, focusing on generalized SAD. Substantial discrepancies and variation in definition, epidemiology, assessment, and treatment of generalized SAD exist as the international literature on it has grown. In East Asian
cultures in particular, study of taijin kyofusho has been important to a broadened conceptualization of SAD into generalized SAD. Despite important progress with biological and other studies, many challenges in the understanding of generalized SAD will remain in the years to come.
OCIAL ANXIETY DISORDER (SAD)1 is one of the most common mental disorders, as shown by two recent general population surveys in the USA, which both found that almost one in 10 individuals suffers from SAD at some point in their lifetime.2,3 Onset typically occurs in childhood or early adolescence and takes a chronic course. SAD may cause significant distress and impairment in educational attainment, employment opportunities, the development of professional, peer and intimate relationships, and financial independence.4 The early onset and chronic course with rare spontaneous remission frequently causes secondary comorbidities, such as depression and alcohol-related problems.4 The conceptualization of SAD has rapidly altered and expanded during just the past few decades as progress has been made in SAD treatment strategies.
The disorder was initially considered as just a type of phobic reaction to a specific social situation akin to a specific phobia in DSM-III.5 With the advent of DSMIII-R,6 diagnostic criteria for the disorder underwent significant expansion. The specifier ‘generalized’ was introduced to the formal nosology in DSM-III-R6 to describe persons experiencing social fears in ‘most or all’ situations while allowing concurrent diagnosis of avoidant personality disorder. The label ‘social anxiety disorder’ was introduced in DSM-IV,7 and replaced ‘social phobia’ in DSM-5.1 Moreover, in the current version of DSM, typical fear and anxious situations are defined as: (i) social interaction fears; (ii) observation fears; and (iii) performance anxiety (in criterion A). Thus fear of performance in public was deprioritized compared to social interaction in DSM-5. This rapid expansion of concept was criticized as giving the diagnosis of SAD to individuals who have few social fears, overpathologizing the socially anxious8 and disease-mongering.9 Indeed, the distress of giving a speech in public is a normal reaction in
S
*Correspondence: Toshihiko Nagata, MD, PhD, Mental Health Clinic of Dr Nagata in Nanba, SAN-EI-Midosuji Bldg 3F, 3-5-8 Nanba, Chuo-Ku, Osaka 542-0076, Japan. Email: [email protected] Accepted 25 June 2015.
724
Key words: generalized, social anxiety disorder, taijin kyofusho, under-recognition, undertreatment.
© 2015 The Authors Psychiatry and Clinical Neurosciences © 2015 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2015; 69: 724–740
Generalized social anxiety disorder 725
human nature10 and psychosocial impairment from fear of public speech is much less than that from generalized SAD, which is characterized my multiple fears of social situations.11 On the other hand, SAD is still under-recognized even by mental health professionals,12 and undertreatment of SAD, especially generalized SAD, cannot be ignored.13 The ‘generalized’ specifier was removed in DSM-5 due to the dimensional nature of specific (just one or two public performances are feared), nongeneralized (more than a few but less than half of social situations are feared) and generalized (more than half of social situations are feared) SAD.14 However, the concept of generalized SAD remains clinically useful. The categorical15 and prototype approach16 is essential in treating patients in real world settings, regardless of whether SAD psychopathology is scientifically dimensional or not. This review focuses specifically on generalized SAD because it has received relatively little attention, continues to be clinically important, and provides insight into related phenomena, such as taijin kyofusho (TKS).
The social phobia section of DSM-III-R6 drastically shifted the paradigm to include broader social fears and reduced the diagnostic threshold such that avoidance of the fearful situation was not necessary anymore. Instead, the ‘generalized’ specifier (i.e., ‘the phobic situation includes most social situations’), first introduced into formal nosology the recommendation of consideration a concurrent diagnosis of avoidant personality disorder. No additional guideline or criteria were provided, and the definition was criticized for ambiguity and arbitrariness afterward.14 This establishment of generalized SAD enhanced numerous investigations, including its high prevalence rate within SAD, phenomenology of early onset, following a chronic and unremitting course, clinical trials of monoamine oxidase inhibitors (MAOI) and selective serotonin reuptake inhibitors (SSRI) and psychological interventions, such as cognitive behavioral therapy for this disorder.14 The label ‘social anxiety disorder’ was introduced in DSM-IV7 with quotation marks and in DSM-51 without quotation marks to mean a more pervasive and interfering condition than that implied by the label ‘social phobia’ and the limited DSM-III diagnostic definition. Despite documented distinctions in severity between generalized and non-generalized SAD,4 the validity and clinical utility of the generalized and non-generalized specifiers have been the subject of criticism.14 Because subtype definitions have been inconsistently applied across studies, there is no particular number of performance and interaction situations required.20,21 There was no clear distinction, such as clear nonlinearity or point-of-rarity, between generalized and non-generalized even in international studies22 suggesting a continuum (or dimensional model). Factor analysis in US and Canadian community samples23 as well as international community samples22 yielded a three-factor structure for SAD: (i) social interaction fears; (ii) observation fears; and (iii) public speaking fears.22 Thus, three and half decades since DSM-III,5 social interactional fear superseded public speaking fears as preeminent in SAD. However, the ‘generalized’ specifier has been replaced with a ‘performance-only’ specifier identifying significant social anxiety occurring only in public performance situations in DSM-5.1 The performanceonly specifier may instead be an indicator of mild or even sub-threshold SAD.
CONCEPT OF GENERALIZED SAD Emergence and evolution of the concept of generalized SAD A group of researchers at Columbia University led the development of the concept of generalized SAD. After Marks and Gelder17 suggested that social phobia was different from other phobias, social phobia was officially included in DSM-III.5 Social phobia in DSM-III was restricted to performance fears (fear of speaking, signing a check, or eating in public), although Marks’ original concept included more generalized forms of social anxiety (fears of initiating conversations or dating). At that time, patients with more generalized social anxiety were classified as having avoidant personality disorder in DSM-III, because these patients were believed to need social skill training for personality disorder while ‘social phobics’ responded well to exposure therapy.18 Liebowitz et al.19 re-introduced social phobia as a neglected anxiety disorder except among behavior therapists, and suggested that DSM-III too restrictively defined this disorder primarily as performance anxiety.5 They also showed that both psychopharmacological and behavioral treatment intervention were effective in this population.
© 2015 The Authors Psychiatry and Clinical Neurosciences © 2015 Japanese Society of Psychiatry and Neurology
726 T. Nagata et al.
Psychiatry and Clinical Neurosciences 2015; 69: 724–740
Definition of generalized SAD
fears of performance in public or in observation are essential to be classified as generalized SAD.
There is no consensus definition of generalized SAD. In early studies, subjects were classified into generalized and non-generalized based on ‘reviewing each subjects’ files and classified’,24 or ‘reviewing SADS-LA (Schedule for Affective Disorders and SchizophreniaLifetime Anxiety version) narratives’.25 Later investigators operationally defined generalized SAD with an indicated number of feared social situations. Hofmann et al.26 applied the ‘generalized’ subtype if the patients reported at least a moderate fear of situations from all four domains ([i] formal speaking/interaction; [ii] informal speaking/ interaction; [iii] observation by others; and [iv] assertion). Also, the Structured Clinical Interview for DSM-IV was modified to classify generalized and nongeneralized SAD. The modified version of the Structured Clinical Interview for DSM-IV27 lists nine social interaction situations and eight performance situations. To diagnose generalized SAD, patients are required to exhibit fear and/or avoidance of at least four social situations and at least two of these had to involve interpersonal interactions.28,29 A total score of >60 on the Liebowitz Social Anxiety Scale (LSAS) was also used to define the generalized subtype,30 although LSAS was designed to assess the symptom severity, not act as a diagnostic tool. Recent epidemiological studies operationalize generalized SAD as consisting of individuals who fear >50% of all social situations assessed and nongeneralized SAD as consisting of
