مقایسه چندوجهی زیر گروه های هراس اجتماعی و اختلال کناره گیری

The purpose of the present study was to further clarify the behavioral, physiological, and verbal response of patients with circumscribed social (speech) phobia, generalized social phobia without avoidant personality disorder, and generalized social phobia with avoidant personality disorder. Patients completed a battery of verbal report instruments and participated in two behavioral assessment tests. Measures of avoidance/escape behavior, cardiac response, level of behavioral skill, state anxiety, and positive and negative self-statements during performance were collected. Significant differences across response domains were found between the circumscribed social phobia and the generalized groups. Most of the distinctions were between individuals with circumscribed social phobia and those with both generalized social phobia and avoidant personality disorder, with the former group having less overall psychopathology. In addition, there was substantial overlap of problems between generalized social phobia individuals with and without avoidant personality disorder. Implications for the conceptualization of social phobia are discussed in terms of the differences among social phobia subtypes. According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994), social phobia is a disorder characterized by a marked and persistent fear of acting in a humiliating or embarrassing way in one or more social or performance situations in which an individual is confronted with unfamiliar people or possibly to scrutiny by others. This diagnostic classification system also allows for the specification of a “generalized” subtype if the fears include “most” situations (American Psychiatric Association, 1994). Some researchers have suggested the inclusion of additional subtypes, such as circumscribed and nongeneralized social phobia (e.g., Heimberg, Holt, Schneier, Spitzer, & Liebowitz, 1993). The circumscribed social phobia subtype is defined as fear in one or a limited number of discrete social situations (e.g., speaking, eating, or writing in public) and the nongeneralized social phobia subtype includes individuals who do not meet the criteria for the generalized subtype, but experience clinically significant social interaction anxiety in a wide range of situations (Heimberg et al., 1993). Circumscribed and nongeneralized subtypes are not included in the DSM-IV diagnostic scheme, and distinctions among subtypes remain unclear. Some research has been conducted to clarify the relation between the circumscribed and generalized subtypes of social phobia. Consistent with these categorizations, recent epidemiological data from interviews with a sample of 8,098 individuals (ages 15–54) from a general household survey in the United States (i.e., the National Comorbidity Study) identified two social phobia subtypes (Kessler, Stein, & Berglund, 1998). Approximately one third of the individuals with diagnosable social phobia had “pure” public-speaking fear, while two thirds were those with multiple social fears (e.g., performance and interactional fears). Additionally, initial studies Heimberg et al. 1990, Levin et al. 1993, McNeil & Lewin 1986 and Schneier, Spitzer, Gibbon, Fyer, & Liebowitz 1991 demonstrated that individuals diagnosed or otherwise classified with generalized social phobia report more anxiety and depression on verbal report instruments than those with circumscribed social phobia (e.g., public speaking), and are more likely to be diagnosed with avoidant personality disorder (APD). In addition, generalized social phobia groups demonstrate more anxiety, poorer skill, and less positive thinking during behavior tests (e.g., speeches and conversations). Individuals with circumscribed social phobia, however, report greater anticipatory anxiety and show higher heart rate elevation in response to behavior tests than individuals with generalized social phobia and controls. These studies provide preliminary data suggesting measurable differences between circumscribed (public speaking) phobia and generalized social phobia. Similar to social phobia, APD, which is a separate DSM-IV diagnosis on Axis II, is defined as an intense and widespread pattern of inhibition and inadequacy in a variety of social contexts, as well as extreme sensitivity to negative evaluation, beginning no later than early adulthood (American Psychiatric Association, 1994). All seven of the criteria for APD, with the exception of one, include a social interactional component, and researchers have reported comorbidity rates of social phobia and APD from 21 to 90% (Heimberg et al., 1993). Thus, the utility of maintaining both diagnostic categories has been questioned, and multiple studies have been conducted to examine the relation between social phobia and APD. A collection of three studies, published together with an independent commentary, indicated that there is substantial overlap between the constructs of generalized social phobia and APD Herbert et al. 1992, Holt, Heimberg, & Hope 1992, Turner et al. 1992 and Widiger 1992. Although there is some variability across investigations and specific variables, these studies found that generalized social phobia with APD, relative to generalized social phobia without APD, is associated with poorer overall psychosocial functioning, more concurrent Axis I and Axis II disorders, and greater social anxiety, trait anxiety, and depression, based on questionnaire and interview measures. No differences were found, however, between these two groups for social skills during behavioral assessment tests. Moreover, Turner et al. (1992) found no differences across groups for speech length or psychophysiological responsivity during role-play tests. While Herbert et al. (1992) showed that social phobia patients with APD indicated more distress during behavior tests of interactions (but not a speech), Holt, Heimberg, and Hope (1992) and Turner et al. (1992) found no differences in self-reported distress during social behavior tests. Conclusions from all three empirical investigations were that APD appears to be a quantitatively more severe type of social phobia; the status of generalized social phobia and APD as independent diagnostic entities also was questioned. Widiger’s (1992) commentary on these three investigations emphasized the overlap of these constructs, but suggested that future research is necessary for a conclusive decision about the most optimal diagnostic classification for problems currently conceptualized as generalized social phobia and APD. More recent studies also have investigated differences between social phobia and APD. First, McNeil et al. (1995) found that patients with generalized social phobia with and without APD demonstrated more interference than individuals with circumscribed social phobia on a General Social Stimuli Stroop Test; the former two groups did not differ. Also, no differences were found across groups in response to a Specific Speech Stimuli Stroop Test or a Negative Evaluative Stroop Test. Generalized social phobia patients with and without APD were similar in response, while the circumscribed speech phobia group was unique in demonstrating difficulties specific to public-speaking situations and not others of a more general social nature. Additionally, in an investigation by Hofmann, Newman, Ehlers, and Roth (1995), patients with social phobia and APD, compared to social phobia patients without APD and a control group, reported more anxiety and more fearful cognitions in response to a speech behavior test. Social phobia patients without APD, however, displayed more cardiac reactivity in response to public speaking than those with APD and controls, although no significant differences were found for respiratory measures. Both social phobia groups demonstrated more avoidance/escape behavior than controls. Finally, Tran and Chambless (1995) found that generalized social phobia groups with and without APD, as compared to a circumscribed (public speaking) social phobia group, were rated as more impaired in multiple social domains as indicated on the Global Impairment of Social Domains Scale, and reported greater fear of negative evaluation, and general social distress. APD participants reported more depression than any other patients. During a speech behavior task, individuals with circumscribed social phobia reported more anxiety than those with generalized social phobia without APD. In addition, there was a trend for the patients with generalized social phobia and APD to be rated as less socially skillful than the circumscribed social phobia group during both speech and conversation behavior tasks. Tran and Chambless (1995) concluded that subtype distinction and APD diagnosis were useful, and called for further investigation of possible qualitative differences between generalized social phobia with and without APD. While most findings described earlier are in agreement, some inconsistent results and limitations of these studies suggest areas for further investigation. First, most investigations in this area do not include three distinct groups (e.g., circumscribed social phobia, generalized social phobia without APD, and generalized social phobia with APD), and, therefore, interpretation of findings is hindered. For example, much of the research comparing circumscribed social phobia to generalized social phobia is unclear because individuals with APD might be included in the generalized social groups, and thus differences between groups might be due to the additional diagnosis of APD rather than to the separation of circumscribed and generalized subtypes. Currently, direct comparisons across diagnostic classifications using the same procedures are needed. A second area of ambiguity concerns the physiological responses of individuals with social phobia and/or APD. This uncertainty is due to the limited use of psychophysiological measures and the inconsistencies in existing physiological data. For instance, Hofmann, Newman, Ehlers, and Roth (1995) found significant cardiac differences between social phobia groups, while Turner et al. (1992) did not. Upon closer examination it appears that these discordant findings may simply be due to methodological differences across studies. That is, continuous assessment (Hofmann, Newman, Ehlers, & Roth, 1995) may allow the detection of differences in some response systems, while intermittent recording (e.g., at 2-minute intervals) may not (Turner et al., 1992). Thus, these and other results (e.g., Heimberg et al. 1990 and Levin et al. 1993) taken together suggest the possibility that circumscribed public-speaking phobia individuals have greater cardiac response in speech situations, relative to persons who have generalized social phobia with and without APD. Given the demonstrated similarity of the two generalized social phobia groups (i.e., those with and without APD), there is likely to be no cardiac differences between them. Investigations that include circumscribed and generalized social phobia patients with and without APD are necessary to comprehensively elucidate the physiological responses of social phobia subtypes. A third limitation is the minimal use of overt behavioral data. Although avoidance and escape behaviors have been found to be significant features of social phobia American Psychiatric Association 1987, American Psychiatric Association 1994, Scholing & Emmelkamp 1990 and Turner et al. 1986, relatively little attention has been given to measurement of avoidance and escape behavior (McNeil & Lewin, 1986). Finally, including more than one type of behavior test may allow a more complete and idiographic assessment. The purpose of the present study was to further clarify the behavioral and cardiac response differences among patients with circumscribed speech phobia, generalized social phobia without APD, and generalized social phobia with APD using assessment procedures similar to those of some previous investigations (e.g., Tran and Chambless 1995 and Turner et al. 1992; see also Clark et al. 1997 and McNeil, Ries, & Turk 1995). A comprehensive evaluation was conducted with certain social phobia subtypes, employing a multimodal and multimethod assessment with two simulated social situations (i.e., speech and conversation). In addition, the current investigation included measures of psychophysiological reactivity and self-statements. Finally, the use of a nonverbal method of signaling desire to avoid/escape is a contribution of the present study. It was predicted that generalized social phobia patients with and without APD would differ significantly on all dependent measures from patients with circumscribed social phobia, in the more pathological direction. One exception, however, was cardiac activity during a speech behavior test, in which it was predicted that the circumscribed social phobia group would demonstrate greater heart rate responsivity than the two generalized social phobia groups. Other variables (e.g., avoidance/escape time, verbal reports of distress) were expected to demonstrate a continuum of increasing severity, from circumscribed social phobia, to generalized social phobia without APD, to generalized social phobia with APD.