همبودی اختلال اضطراب اجتماعی و اختلال شخصیت ضد اجتماعی در بررسی ملی اپیدمیولوژیک در افراد الکلی و شرایط مرتبط (NESARC)

Abstract Social anxiety disorder (SAD) and antisocial personality disorder (ASPD) are not often thought of as being comorbid. However, recent research suggests the existence of a SAD subtype with characteristics atypical of SAD but common to ASPD. Thus, we explored two competing hypotheses: (1) SAD and ASPD represent opposite ends of a single dimension, or (2) SAD and ASPD exist on two separate dimensions that may be positively correlated. Data were obtained from the National Epidemiological Survey on Alcohol and Related Conditions. SAD–ASPD was related to greater impairment and psychiatric comorbidity than either disorder alone. The SAD–ASPD group was also more likely to seek treatment for their SAD symptoms and to drink before/during antisocial acts than the SAD only group. The presence of SAD for individuals with ASPD (and vice versa) does not appear to provide any “protective benefits.” SAD and ASPD appear to be two separate but correlated disorders.

. Introduction Social anxiety and antisocial behaviors are not typically conceptualized as co-occurring. Individuals with social anxiety are often characterized as shy, submissive, behaviorally inhibited, and risk-averse (Gilbert, 2001). However, recent research has shown that some socially anxious individuals exhibit characteristics quite different than the prototypical person with social anxiety disorder (SAD). For example, Kashdan, McKnight, Richey, and Hofmann (2009) demonstrated that some individuals with SAD exhibit a number of risk-prone behaviors, including aggression, sexual impulsivity, and problematic substance use. This atypical risk-prone pattern was evident in 21% of persons with SAD in their large community sample. Although previous research has shown that anxiety disorders, especially SAD and posttraumatic stress disorder (PTSD), are associated with antisocial personality disorder (ASPD) and engagement in antisocial behaviors in general (Goodwin and Hamilton, 2003 and Sareen et al., 2004), little is known about the co-occurrence of SAD and ASPD. However, examination of individuals with comorbid SAD–ASPD is important for several reasons. First, it provides an opportunity to increase our understanding of the prevalence and demographic characteristics of this understudied group. Second, it can enhance our knowledge of the clinical features of this comorbid group, including characterization of which ASPD criteria, antisocial behaviors, and feared social situations they tend to endorse. This would be valuable for increasing clinical recognition of such comorbidity. Third, it may help guide the development of interventions that specifically focus on SAD and ASPD. Conventional therapies directed at SAD or ASPD may need modification to be effective for this comorbid group. This work also has theoretical implications for conceptualizing dimensions of psychopathology. Two competing hypotheses may be useful for conceptualizing the co-occurrence of SAD and ASPD, its prevalence, and its impact: (1) SAD and ASPD may represent opposite ends of a single dimension. Consistent with this view, Hofmann, Korte, and Suvak (2009) found that social anxiety and psychopathic attributes were negatively associated and suggested that these traits may be on opposite ends of a spectrum related to adherence to social norms and concern for other people's approval. If so, symptoms/behaviors associated with each of these disorders would be negatively correlated. Accordingly, individuals with SAD–ASPD would be relatively rare, and the distress/interference they experience might be milder than that of individuals with either SAD or ASPD alone. (2) SAD and ASPD exist on two separate dimensions that may be positively correlated. According to this hypothesis, the presence of either SAD or ASPD should increase the likelihood of having the other diagnosis and comorbid SAD–ASPD would be associated with greater impairment/severity. This study sought to address several specific questions. For instance, do individuals with SAD–ASPD endorse different ASPD diagnostic criteria than individuals with ASPD alone? If SAD and ASPD exist on a single dimension, individuals with SAD–ASPD may endorse ASPD criteria that are less confrontational (e.g., consistent irresponsibility) rather than criteria that are associated with direct social interaction (e.g., physical aggressiveness). However, since individuals with the atypical, risk-prone subtype of SAD exhibited moderate to high levels of anger and aggression (Kashdan et al., 2009 and Kashdan and McKnight, 2010), it is plausible that individuals with SAD–ASPD may be more likely to endorse ASPD criteria for physical aggressiveness than individuals with ASPD alone (supporting the multi-dimensional conceptualization). Similar arguments can be made about the specific types of antisocial behaviors in which individuals with SAD–ASPD tend to engage compared to individuals with ASPD alone. In line with the multi-dimensional hypothesis, previous research has found that anxiety disorders comorbid with ASPD are associated with additional comorbid disorders, greater levels of distress and dysfunction, poorer quality of life, and a higher frequency of suicidal ideation than either diagnosis alone (Goodwin and Hamilton, 2003 and Sareen et al., 2004). However, few studies have investigated the specific impact of co-occurring SAD–ASPD on impairment across a wider range of social, occupational, and emotional/psychological outcomes. Given the results of these previous studies, SAD–ASPD individuals appear more likely to experience greater impairment across a variety of domains than individuals with SAD or ASPD alone. However, one study found higher levels of impairment in conduct-disordered boys without an anxiety disorder than boys with an anxiety disorder (Walker et al., 1991). Do individuals with SAD–ASPD differ in their treatment-seeking behavior for SAD compared to those with SAD alone? If individuals with SAD–ASPD tend to experience greater impairment than individuals with SAD or ASPD alone, they may be more likely to seek treatment for their SAD symptoms as a result of their heightened levels of distress and interference. However, ASPD has been shown to negatively affect treatment seeking behavior (Helzer & Pryzbeck, 1988). Therefore, individuals with SAD–ASPD may be less likely than individuals with SAD alone to seek treatment for their social anxiety. Are SAD–ASPD individuals more likely to drink heavily before/during their engagement in antisocial behaviors than individuals with ASPD alone? Sareen et al. (2004) demonstrated that there may be an additive effect of anxiety and ASPD on the odds of lifetime comorbidity for alcohol use disorder. Because drinking is sometimes used as a coping strategy and/or method of self-medication among individuals with SAD before, during, and after anxiety-provoking events (Abrams et al., 2001, Abrams et al., 2002, Buckner et al., 2013, de Boer et al., 1993 and Schneier et al., 2010), they may be more likely to use alcohol before/during antisocial acts since these particular types of behaviors often violate social norms and therefore should increase the likelihood that they will produce anxiety among individuals with SAD. The present study sought to fill these gaps in the literature using data from the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) National Epidemiological Survey on Alcohol and Related Conditions (NESARC), which consists of a large, representative sample of the U.S. population. First, we examined whether individuals with SAD–ASPD would differ from individuals with ASPD or SAD alone on the type and mean number of ASPD criteria and antisocial behaviors endorsed. Second, we examined whether individuals with SAD–ASPD would report greater impairment than individuals with SAD or ASPD alone. We examined a wide range of indicators, including measures of emotional/psychological well-being, psychiatric comorbidity, number of feared social situations, and various single-item questions used to assess social/interpersonal/occupational functioning and quality of life. Third, we examined whether individuals with SAD–ASPD would be less likely to seek treatment for their SAD symptoms than individuals with SAD alone. Finally, we examined whether individuals with SAD–ASPD would be more likely to drink heavily before and during their engagement in antisocial behaviors than individuals with ASPD or SAD alone.

. Results 3.1. Prevalence A total of 210 of the 3195 study participants met criteria for both SAD and ASPD (6.5%). SAD and ASPD were comorbid in 10.6% of respondents with SAD and 14.8% of respondents with ASPD. 3.2. Demographic characteristics Table 1 presents the demographic characteristics for the SAD–ASPD, SAD only, and ASPD only groups. Among those with SAD, individuals with comorbid ASPD were more likely to be male and have less than a high school education and were less likely to be over the age of 44 and earn between $35,000 and $69,000. Table 1. Demographic characteristics of individuals with lifetime social anxiety disorder (SAD), antisocial personality disorder (ASPD), and comorbid SAD–ASPD. SAD–ASPD n = 210 SAD no ASPDa n = 1773 OR 95% CI ASPD no SADa n = 1212 OR 95% CI % SE % SE % SE Sex Male 64.86 3.98 37.42 1.31 0.32 0.23 0.46 74.34 1.44 1.57 1.06 2.32 Female 35.14 3.98 62.58 1.31 1.00 1.00 1.00 25.66 1.44 1.00 1.00 1.00 Race/ethnicity White 75.02 3.38 78.75 1.51 1.00 1.00 1.00 69.69 2.20 1.00 1.00 1.00 Black 9.19 1.80 7.49 0.74 0.78 0.49 1.24 11.54 1.21 1.35 0.85 2.14 Native American 6.50 2.23 3.31 0.57 0.49 0.21 1.11 5.51 0.94 0.91 0.40 2.06 Asian 2.49 1.73 2.95 0.65 1.13 0.32 3.95 2.05 0.51 0.89 0.20 3.96 Hispanic 6.80 1.65 7.50 0.84 1.05 0.59 1.86 11.21 1.50 1.78 0.99 3.17 Age 18–29 34.87 4.55 20.35 1.18 1.00 1.00 1.00 37.91 1.76 1.00 1.00 1.00 30–44 33.82 4.57 33.22 1.41 1.68 1.02 2.78 35.76 1.65 0.97 0.59 1.61 45–64 27.75 3.88 35.97 1.34 2.22 1.38 3.59 23.80 1.52 0.79 0.49 1.27 65+ 3.57 2.10 10.46 0.71 5.02 1.41 17.95 2.54 0.54 0.66 0.18 2.45 Education Less than high school 30.95 4.13 12.98 0.97 0.29 0.19 0.44 21.75 1.60 0.57 0.37 0.88 High school 31.12 3.61 31.70 1.51 0.70 0.47 1.04 31.52 1.55 0.82 0.56 1.21 College or beyond 37.93 3.78 55.32 1.66 1.00 1.00 1.00 46.73 1.78 1.00 1.00 1.00 Individual income $0–19,999 58.77 4.47 51.82 1.63 1.00 1.00 1.00 48.03 1.95 1.00 1.00 1.00 $20,000–34,999 23.57 3.56 23.46 1.24 1.13 0.72 1.78 25.41 1.55 1.32 0.83 2.10 $35,000–69,999 12.84 2.52 19.43 1.40 1.72 1.05 2.80 20.12 1.37 1.92 1.15 3.19 ≥$70,000 4.83 1.94 5.29 0.74 1.24 0.49 3.15 6.44 0.90 1.63 0.64 4.14 Employment Employed 65.43 4.13 63.24 1.44 1.00 1.00 1.00 70.30 1.67 1.00 1.00 1.00 Unemployed 34.57 4.13 36.76 1.44 1.10 0.74 1.64 29.70 1.67 0.80 0.54 1.19 Marital status Married 53.84 4.29 60.81 1.34 1.00 1.00 1.00 50.47 1.75 1.00 1.00 1.00 Widowed/separated/divorced 17.87 3.16 17.93 0.92 0.89 0.56 1.41 16.93 1.33 1.01 0.63 1.63 Never married 28.30 4.12 21.25 1.26 0.66 0.43 1.02 32.60 1.79 1.23 0.79 1.92 Bolded adjusted odds ratios (AORs) and confidence intervals (CIs) illustrate significant relationships. a Compared to SAD–ASPD group. Table options Among those with ASPD, individuals with comorbid SAD were less likely to be male and earn between $35,000 and $69,000 and were more likely to have less than a high school education. 3.3. ASPD criteria endorsed Table 2 presents the percentage endorsement of ASPD criteria by the SAD–ASPD, SAD only, and ASPD only groups, adjusted for sex, age, education, and income. There were no significant differences between the SAD–ASPD group and the ASPD only group on percentage endorsement of any criterion. Similarly, there was no significant difference between the comorbid group and the ASPD only group on the average number of ASPD criteria endorsed (Table 3). Not surprisingly, the SAD–ASPD group and the SAD only group differed on percentage endorsement of every ASPD criterion (Table 2) as well as the average number of ASPD criteria endorsed (Table 3). Table 2. Percentages of lifetime antisocial personality disorder (ASPD), social anxiety disorder (SAD), and comorbid SAD–ASPD individuals who endorsed specific ASPD criteria and antisocial behaviors. SAD–ASPD n = 210 SAD no ASPDa n = 1773 AOR 95% CI ASPD no SADa n = 1212 AOR 95% CI % 95% CI % 95% CI % 95% CI ASPD criteria Failure to conform to social norms 100.00 N/A N/A 62.72 59.93 65.43 N/A N/A N/A 99.75 99.22 99.92 N/A N/A N/A Deception 60.20 51.38 68.40 12.29 10.53 14.31 0.11 0.08 0.17 56.74 53.01 60.41 0.95 0.63 1.42 Impulsiveness 68.94 60.23 76.49 26.89 24.42 29.52 0.18 0.12 0.26 61.60 57.74 65.32 0.81 0.55 1.19 Irritability and aggressiveness 81.27 73.14 87.37 17.15 14.94 19.61 0.06 0.03 0.10 84.36 81.85 86.59 1.09 0.67 1.79 Reckless disregard for safety 67.58 58.30 75.66 32.91 30.16 35.79 0.25 0.16 0.40 72.52 69.21 75.60 1.04 0.65 1.67 Consistent irresponsibility 62.86 53.53 71.31 24.62 22.15 27.28 0.25 0.16 0.37 54.60 50.90 58.25 0.77 0.52 1.15 Lack of remorse 62.71 53.58 71.02 16.58 14.52 18.88 0.14 0.09 0.22 57.78 54.54 60.95 0.78 0.52 1.17 Antisocial behaviors Cut class 77.67 70.21 83.69 29.32 26.85 31.92 0.16 0.10 0.24 74.13 70.75 77.25 0.93 0.60 1.44 Stay out late w/o permission 68.70 60.17 76.13 31.92 29.34 34.62 0.27 0.18 0.40 76.02 72.76 79.00 1.51 0.99 2.29 Bullied/pushed people around 47.72 39.69 55.86 8.09 6.67 9.77 0.12 0.08 0.19 49.86 46.35 53.38 1.06 0.73 1.53 Run away from home (at least 2×) 41.05 32.12 50.62 7.04 5.80 8.52 0.12 0.07 0.19 38.51 35.19 41.94 1.12 0.72 1.75 Absent from school a lot 46.46 37.90 55.25 13.98 12.11 16.09 0.24 0.16 0.38 39.70 36.22 43.29 0.82 0.57 1.18 Quit job w/o a plan 56.08 46.66 65.09 20.06 17.83 22.49 0.26 0.17 0.38 45.84 42.31 49.41 0.72 0.49 1.06 Quit school program w/o a plan 29.22 21.68 38.11 7.33 6.05 8.86 0.27 0.17 0.45 23.17 20.31 26.29 0.81 0.53 1.23 Travel around w/o a plan 25.55 18.94 33.51 5.28 4.25 6.55 0.17 0.11 0.29 23.37 20.55 26.46 1.00 0.65 1.52 Had no place to live (at least 1 mo.) 26.43 19.10 35.34 4.87 3.82 6.20 0.18 0.11 0.30 20.47 17.45 23.86 0.83 0.55 1.27 Lived w/family/friends due to not having a place to live (at least 1 mo.) 55.55 46.29 64.44 20.79 18.57 23.20 0.21 0.15 0.31 46.21 42.25 50.22 0.74 0.51 1.09 Lied a lot 55.05 45.95 63.82 10.82 9.14 12.77 0.12 0.08 0.18 43.57 40.01 47.20 0.68 0.45 1.03 Use false name/alias 17.87 11.94 25.88 2.53 1.88 3.40 0.13 0.07 0.23 20.33 17.51 23.47 1.30 0.77 2.22 Scam/con someone for money 16.92 11.39 24.41 1.18 0.72 1.95 0.09 0.04 0.19 19.49 16.79 22.50 1.22 0.76 1.97 Do things that could have easily hurt you/someone else 57.50 47.96 66.51 25.02 22.47 27.75 0.24 0.15 0.36 57.83 53.86 61.70 0.86 0.56 1.34 Get more than 3 traffic tickets for reckless driving/speeding/accidents 21.20 15.28 28.65 10.42 8.69 12.46 0.57 0.35 0.90 30.05 26.74 33.58 1.40 0.91 2.15 Have driver's license suspended for moving violations 28.98 21.78 37.43 8.12 6.55 10.03 0.34 0.21 0.56 28.63 25.73 31.71 0.97 0.63 1.49 Destroy/break/vandalize property 42.85 34.70 51.41 4.84 3.62 6.44 0.07 0.04 0.12 43.76 40.25 47.34 0.90 0.60 1.33 Start a fire on purpose 13.83 7.70 23.57 0.92 0.53 1.60 0.07 0.03 0.17 15.92 13.48 18.71 1.02 0.52 2.02 Fail to pay off your debts 32.10 23.86 41.63 7.14 5.90 8.62 0.17 0.11 0.28 25.61 22.45 29.05 0.77 0.49 1.21 Steal something when no one was around 61.01 51.65 69.62 15.85 13.91 18.00 0.14 0.09 0.21 60.50 56.70 64.19 0.88 0.56 1.39 Forge someone else's signature 13.31 8.33 20.61 2.90 2.11 3.97 0.19 0.09 0.38 16.59 14.26 19.21 1.40 0.81 2.41 Shoplift 67.13 57.41 75.57 19.33 17.02 21.87 0.15 0.10 0.23 66.71 63.25 70.01 0.92 0.60 1.41 Rob/mug someone 2.55 0.97 6.51 0.31 0.11 0.91 0.26 0.07 0.94 4.67 3.45 6.27 2.12 0.75 6.02 Make money illegally 28.27 20.44 37.68 3.37 2.39 4.74 0.12 0.07 0.23 26.93 23.85 30.25 0.89 0.57 1.41 Do things you could have been arrested for 75.39 66.87 82.30 24.68 22.15 27.40 0.13 0.08 0.19 75.28 72.22 78.11 0.81 0.53 1.23 Force someone to have sex with you 1.12 0.31 3.93 0.45 0.20 0.99 0.79 0.08 7.38 1.36 0.82 2.24 1.29 0.33 4.97 Get into a lot of fights that you started 32.48 23.81 42.55 3.23 2.44 4.26 0.08 0.05 0.13 32.58 29.24 36.11 1.07 0.69 1.68 Get into a fight that came to blows with a significant other 35.05 27.61 43.28 14.49 12.61 16.58 0.27 0.18 0.38 33.71 30.55 37.02 1.20 0.81 1.77 Use a weapon in a fight 22.27 16.18 29.83 3.56 2.65 4.76 0.16 0.09 0.29 25.84 22.92 29.00 1.32 0.85 2.04 Hit someone so hard you injured them 39.48 32.04 47.45 5.93 4.71 7.44 0.14 0.09 0.22 45.04 41.70 48.43 1.25 0.87 1.80 Harass/threaten/blackmail someone 23.93 17.75 31.43 2.28 1.56 3.34 0.09 0.05 0.17 21.86 18.94 25.10 0.91 0.59 1.39 Physically hurt another person on purpose 34.68 27.16 43.04 7.01 5.63 8.69 0.17 0.10 0.26 40.20 36.52 44.00 1.22 0.83 1.78 Hurt/be cruel to an animal/pet on purpose 23.07 16.54 31.22 2.67 1.91 3.73 0.12 0.07 0.20 16.60 14.18 19.34 0.55 0.33 0.91 Bolded adjusted odds ratios (AORs) and confidence intervals (CIs) illustrate significant relationships. Note. N/A = not applicable. AORs are adjusted for sex, age, education, and individual income. a Compared to SAD–ASPD group. Table options Table 3. Clinical features among individuals with social anxiety disorder (SAD), antisocial personality disorder (ASPD), and comorbid SAD–ASPD. SAD–ASPD n = 210 SAD no ASPDa n = 1773 F p ASPD no SADa n = 1212 F p Mean 95% CI Mean 95% CI Mean 95% CI No. of feared social situations 6.90 6.32 7.49 6.61 6.45 6.77 0.45 0.5049 4.08 3.56 4.61 59.14 <0.0001 No. of antisocial behaviors 12.20 11.56 12.85 3.26 3.05 3.46 608.63 <0.0001 11.90 11.56 12.25 0.28 0.6010 No. of ASPD criteria 5.04 4.81 5.26 1.93 1.83 2.03 537.65 <0.0001 4.87 4.79 4.96 2.18 0.1444 SF-12 subscales Social functioning scale 42.46 39.85 45.07 47.11 46.33 47.88 14.55 0.0003 48.73 47.88 49.58 16.95 0.0001 Role emotional scale 42.59 39.91 45.26 46.94 46.23 47.66 13.60 0.0005 48.54 47.71 49.37 14.93 0.0003 Mental health scale 41.58 39.43 43.74 46.25 45.53 46.96 25.66 <0.0001 48.38 47.56 49.21 31.95 <0.0001 SAD–ASPD n = 210 SAD no ASPDa n = 1773 AOR 95% CI ASPD no SADa n = 1212 AOR 95% CI % 95% CI % 95% CI % 95% CI Drinking heavily during antisocial behaviors Any? 38.44 29.56 48.18 24.69 20.60 29.30 0.54 0.34 0.86 33.68 30.40 37.14 0.81 0.52 1.26 All? 11.78 6.86 19.47 7.88 5.62 10.93 0.78 0.40 1.53 11.27 9.20 13.74 1.14 0.62 2.11 Treatment sought for SAD? 23.61 16.90 31.95 15.43 13.42 17.68 0.55 0.35 0.85 N/A N/A N/A N/A N/A N/A Perceived health status Excellent 13.38 8.58 20.28 21.38 18.83 24.17 1.00 1.00 1.00 23.25 20.39 26.37 1.00 1.00 1.00 Very good 27.24 20.10 35.79 30.62 28.02 33.36 0.73 0.38 1.39 30.41 27.34 33.65 0.65 0.35 1.21 Good 31.40 23.20 40.95 26.46 23.90 29.19 0.49 0.22 1.07 24.90 22.04 28.01 0.47 0.24 0.95 Fair 16.94 11.58 24.10 14.70 12.72 16.94 0.60 0.26 1.39 14.05 11.81 16.64 0.71 0.35 1.46 Poor 11.03 6.68 17.70 6.83 5.56 8.38 0.60 0.23 1.55 7.39 5.83 9.34 0.73 0.30 1.78 Interference with work/daily activities All of the time 11.14 6.61 18.16 4.82 3.77 6.16 0.23 0.12 0.47 4.71 3.41 6.49 0.36 0.18 0.71 Most of the time 9.95 6.46 15.03 8.52 6.98 10.36 0.60 0.33 1.10 6.62 5.04 8.65 0.50 0.27 0.92 Some of the time 20.29 13.31 29.68 15.21 13.39 17.23 0.47 0.27 0.83 10.27 8.38 12.52 0.31 0.17 0.55 A little of the time 17.48 11.04 26.54 16.08 14.09 18.29 0.59 0.31 1.13 14.93 12.48 17.77 0.58 0.32 1.07 None of the time 41.14 31.47 51.55 55.37 52.42 58.28 1.00 1.00 1.00 63.46 59.89 66.89 1.00 1.00 1.00 Felt downhearted and depressed All of the time 9.08 4.99 15.98 3.92 2.94 5.21 0.25 0.10 0.63 3.50 2.42 5.05 0.18 0.08 0.45 Most of the time 17.40 11.71 25.07 10.86 9.14 12.85 0.35 0.19 0.63 9.25 7.48 11.39 0.30 0.15 0.58 Some of the time 26.05 18.28 35.67 23.21 20.83 25.78 0.36 0.19 0.68 16.87 14.57 19.45 0.24 0.13 0.44 A little of the time 33.52 25.01 43.27 35.92 33.16 38.78 0.52 0.28 0.96 33.14 30.24 36.18 0.34 0.19 0.60 None of the time 13.94 9.14 20.68 26.08 23.71 28.61 1.00 1.00 1.00 37.24 33.76 40.85 1.00 1.00 1.00 Fired or laid off 15.63 10.25 23.11 8.14 6.69 9.88 0.65 0.40 1.06 18.07 15.62 20.80 1.29 0.80 2.08 Unemployed and looking for a job 21.58 14.21 31.39 10.51 9.04 12.17 0.57 0.32 1.02 22.18 19.56 25.04 1.23 0.70 2.16 Trouble with boss/coworker 29.34 21.79 38.23 15.48 13.42 17.78 0.44 0.28 0.68 22.11 19.20 25.32 0.64 0.41 0.99 Changed jobs/job responsibilities/hours 48.02 38.39 57.80 29.69 27.20 32.31 0.45 0.28 0.73 46.91 43.30 50.56 0.87 0.56 1.35 Separated or divorced or break off relationship 14.42 9.94 20.46 7.45 6.11 9.06 0.56 0.34 0.91 14.37 12.24 16.81 1.08 0.67 1.75 Serious problems with a neighbor/friend/relative 24.32 18.00 32.00 12.70 10.98 14.66 0.47 0.30 0.74 16.61 13.87 19.76 0.73 0.46 1.15 Bolded adjusted odds ratios (AORs) and confidence intervals (CIs) illustrate significant relationships. Note. N/A = not applicable. AORs and F tests are adjusted for sex, age, education, and individual income. a Compared to SAD–ASPD group. Table options 3.4. Antisocial behaviors endorsed Table 2 also presents the percentage of endorsement of specific antisocial behaviors by the SAD–ASPD, SAD only, and ASPD only groups, adjusted for sex, age, education, and income. Individuals with SAD–ASPD were more likely to hurt or be cruel to an animal/pet on purpose than those with ASPD alone. There were no other significant differences between the comorbid group and the ASPD only group. Individuals with SAD–ASPD did not endorse engaging in fewer antisocial behaviors (Table 3). As expected, there were significant differences between the SAD–ASPD group and the SAD only group on percentage endorsement of each of the specific antisocial behaviors, except for “Force someone to have sex with you,” which had a very low level of endorsement for both groups (Table 2). There was also a significant difference between these groups on the average number of antisocial behaviors endorsed (Table 3). 3.5. Functional impairment and comorbidity Among those with SAD, comorbid ASPD was related to interference with work/daily activities due to an emotional problem “some of the time” or “all of the time,” and feeling downhearted or depressed (Table 3). Additionally, individuals with SAD–ASPD were more likely to endorse the following experiences over the past 12 months than those with SAD alone: having trouble with a boss or coworker, changing jobs or job responsibilities/hours, being separated or divorced or breaking off a relationship, and having a serious problem with a neighbor, friend, or relative (Table 3). Among those with ASPD, comorbid SAD was related to a perceived health status of “good,” interference with work/daily activities due to an emotional problem “some of the time,” “most of the time,” or “all of the time,” and feeling downhearted or depressed. Individuals with SAD–ASPD were also more likely to endorse trouble with a boss or coworker over the past 12 months than those with ASPD alone (Table 3). For each of the SF-12 subscales (i.e., social functioning, role emotional, and mental health), individuals with SAD–ASPD had lower scores compared to those with either SAD or ASPD alone (Table 3). Table 4 presents the percentage of the SAD–ASPD, SAD only, and ASPD only groups who met criteria for other psychiatric disorders, adjusted for sex, age, education, and income. Among those with SAD, comorbid ASPD was related to having any other psychiatric disorder, having any Axis I or other Axis II disorders, substance use disorders (although not alcohol abuse), mood disorders (although not major depressive disorder and dysthymia), other anxiety disorders, and psychotic disorder. Among those with ASPD, comorbid SAD was related to having any other psychiatric disorder, having any other Axis I or Axis II disorders, substance use disorders (although not alcohol abuse and drug abuse), mood disorders (although not major depressive disorder and dysthymia), other anxiety disorders, and psychotic disorder. Table 4. Percentage of individuals with social anxiety disorder (SAD), antisocial personality disorder (ASPD), and comorbid SAD–ASPD who endorsed lifetime criteria for other psychiatric disorders. Comorbid disorders SAD–ASPD n = 210 SAD no ASPDa n = 1773 AOR 95% CI ASPD no SADa n = 1212 AOR 95% CI % SE % SE % SE Any psychiatric disorder 99.08 0.69 88.30 0.99 0.09 0.02 0.41 95.96 0.59 0.21 0.05 0.92 Any axis I disorder 98.38 0.82 83.99 1.09 0.10 0.04 0.28 93.22 0.82 0.22 0.08 0.61 Any substance use disorder 92.02 1.97 54.36 1.54 0.12 0.07 0.21 86.42 1.13 0.54 0.31 0.94 Nicotine dependence 65.58 4.25 28.85 1.32 0.24 0.15 0.36 52.68 1.94 0.62 0.42 0.94 Alcohol use disorder 82.88 3.78 43.84 1.54 0.17 0.10 0.29 74.87 1.51 0.57 0.33 0.99 Alcohol abuse 25.01 3.82 20.37 1.14 0.72 0.46 1.12 27.26 1.67 1.14 0.72 1.80 Alcohol dependence 57.86 4.55 23.47 1.35 0.27 0.18 0.41 47.61 1.79 0.62 0.41 0.95 Drug use disorder 57.20 4.47 17.87 1.20 0.22 0.15 0.32 51.13 2.00 0.77 0.52 1.13 Drug abuse 44.13 4.20 14.68 1.06 0.30 0.20 0.45 43.62 2.01 0.93 0.63 1.38 Drug dependence 36.38 4.71 6.43 0.75 0.16 0.10 0.24 21.05 1.55 0.48 0.31 0.74 Any mood disorder 72.30 4.33 52.58 1.52 0.37 0.24 0.58 45.03 1.79 0.32 0.20 0.50 Major depressive disorder 26.30 3.38 35.12 1.39 1.21 0.83 1.77 22.40 1.42 0.85 0.56 1.29 Bipolar I 35.75 4.79 13.25 1.03 0.32 0.20 0.51 16.75 1.31 0.37 0.23 0.60 Bipolar II 9.36 2.03 3.00 0.46 0.33 0.18 0.58 4.48 0.74 0.47 0.25 0.87 Dysthymia 9.77 2.26 11.73 0.89 0.95 0.55 1.65 7.56 0.90 0.85 0.46 1.60 Any anxiety Disorder 67.36 3.94 52.41 1.55 0.51 0.34 0.75 29.55 1.54 0.21 0.14 0.31 Panic disorder 32.34 3.90 20.73 1.16 0.48 0.32 0.74 13.27 1.21 0.35 0.24 0.53 Specific phobia 47.04 4.39 37.01 1.44 0.68 0.46 0.99 17.40 1.34 0.24 0.16 0.37 GAD 34.82 4.43 21.82 1.27 0.47 0.30 0.72 8.60 0.89 0.18 0.11 0.30 Psychotic disorder 10.66 2.77 2.61 0.39 0.29 0.13 0.61 3.25 0.68 0.32 0.16 0.62 Any other personality disorder 75.16 3.80 49.79 1.45 0.39 0.26 0.59 39.15 1.70 0.22 0.15 0.34 Avoidant 37.59 4.25 21.46 1.16 0.56 0.38 0.83 5.83 0.96 0.10 0.06 0.16 Dependent 13.26 3.40 3.40 0.53 0.30 0.17 0.54 2.07 0.45 0.15 0.07 0.33 Obsessive–compulsive 54.15 4.51 29.62 1.28 0.37 0.25 0.55 22.33 1.35 0.24 0.16 0.35 Paranoid 51.57 4.56 19.72 1.19 0.26 0.18 0.39 17.53 1.31 0.20 0.13 0.31 Schizoid 27.98 3.73 16.21 1.04 0.59 0.40 0.88 12.96 1.18 0.42 0.27 0.66 Histrionic 24.50 3.80 5.95 0.65 0.26 0.16 0.40 10.19 1.03 0.34 0.21 0.54 Bolded adjusted odds ratios (AORs) and confidence intervals (CIs) illustrate significant relationships. Note. AORs are adjusted for sex, age, education, and individual income. a Compared to SAD–ASPD group. Table options Table 5 presents the percentage of endorsement of significant fear in specific social situations for the SAD–ASPD, SAD only, and ASPD only groups, adjusted for sex, age, education, and income. Individuals with SAD–ASPD were more likely to experience significant fear in small groups than those with SAD alone. There were no significant differences between the SAD–ASPD group and the SAD only group for any other social situation or the average number of feared social situations endorsed (Table 3). Individuals in the SAD–ASPD group were more likely to endorse significant fear in all of the listed social situations and a greater number of feared situations than the ASPD only group. However, the ASPD only group reported that they feared an average of four social situations. Table 5. Percentages of individuals with lifetime social anxiety disorder (SAD), antisocial personality disorder (ASPD), and comorbid SAD–ASPD who endorsed significant fear in specific social situations. SAD–ASPD n = 210 SAD no ASPDa n = 1773 AOR 95% CI ASPD no SADa n = 1212 AOR 95% CI % 95% CI % 95% CI % 95% CI Conversing with strangers 62.88 53.88 71.06 56.12 53.43 58.78 0.82 0.55 1.23 43.09 34.79 51.79 0.38 0.24 0.62 Going to parties or social gatherings 53.24 43.58 62.67 53.45 50.53 56.34 0.99 0.66 1.49 25.94 19.97 32.96 0.29 0.17 0.50 Dating 34.98 27.68 43.06 24.21 21.79 26.80 0.72 0.49 1.05 17.55 12.01 24.92 0.35 0.20 0.61 Being interviewed 44.74 36.55 53.22 47.45 44.73 50.18 1.09 0.78 1.55 29.18 22.12 37.41 0.49 0.28 0.89 Being in a small group 28.96 21.52 37.74 17.29 15.22 19.57 0.56 0.37 0.85 10.47 6.22 17.10 0.25 0.13 0.50 Speaking to an authority figure 48.08 39.75 56.51 49.25 46.55 51.95 1.11 0.79 1.58 30.33 22.44 39.58 0.43 0.26 0.71 Speaking in front of other people 89.19 82.95 93.34 89.93 88.12 91.48 1.01 0.56 1.84 61.45 53.21 69.08 0.19 0.10 0.37 Speaking in class 76.79 67.61 83.98 80.72 78.52 82.74 1.33 0.82 2.17 52.71 43.98 61.28 0.32 0.18 0.58 Speaking at a meeting 69.39 60.64 76.93 73.59 70.99 76.04 1.12 0.75 1.66 36.07 28.18 44.79 0.26 0.15 0.43 Eating or drinking in front of people 21.82 15.34 30.06 17.74 15.71 19.96 0.95 0.61 1.48 9.73 6.14 15.07 0.34 0.16 0.72 Writing in front of someone 32.53 25.35 40.65 21.00 18.71 23.49 0.67 0.44 1.00 10.81 6.74 16.89 0.23 0.11 0.46 Performing in front of other people 78.92 69.82 85.83 80.34 77.92 82.56 0.97 0.57 1.66 44.00 35.89 52.45 0.23 0.12 0.41 Taking an important exam 51.39 43.32 59.39 51.51 48.75 54.27 0.96 0.67 1.39 37.95 30.79 45.68 0.54 0.34 0.86 Bolded adjusted odds ratios (AORs) and confidence intervals (CIs) illustrate significant relationships. Note. AORs are adjusted for sex, age, education, and individual income. a Compared to SAD–ASPD group. Table options 3.6. SAD treatment seeking Individuals with SAD–ASPD were more likely to seek treatment for their SAD symptoms compared to those with SAD only ( Table 3). 3.7. Heavy drinking before/during antisocial behaviors Individuals with SAD–ASPD were not more (or less) likely to drink heavily before/during any or all of their antisocial behaviors than those with ASPD only (Table 3). However, the SAD–ASPD group was more likely to drink heavily before/during engagement in antisocial behaviors than the SAD only group.