اختلالات اضطرابی و خلقی به همراه افراد مبتلا به اختلال اضطراب اجتماعی

Axis I comorbidity is associated with greater severity of social anxiety disorder. However, the differential effects of comorbid mood and anxiety disorders on symptom severity or treatment outcome have not been investigated. We evaluated 69 persons with uncomplicated social anxiety disorder, 39 persons with an additional anxiety disorder, and 33 persons with an additional mood disorder (with or without additional anxiety disorders). Those with comorbid mood disorders reported greater duration of social anxiety than those with uncomplicated social anxiety disorder. They were also judged, before and after 12 weeks of cognitive-behavioral group treatment and at follow-up, to be more severely impaired than those with no comorbid diagnosis. In contrast, persons with comorbid anxiety disorders were rated as more impaired than those with no comorbid diagnosis on only a single measure. Type of comorbid diagnosis did not result in differential rates of improvement of social anxiety disorder.

Social anxiety disorder is characterized by fear of embarrassment and humiliation in social and performance situations (American Psychiatric Association, 1994). It is one of the most common psychiatric disorders with a lifetime prevalence rate of 13.3% (Kessler et al., 1994). Social anxiety disorder is characterized by an early age of onset (Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992) and, in the absence of treatment, follows a chronic and unremitting course (Reich, Goldenberg, Vasile, Goisman, & Keller, 1994). Individuals with social anxiety disorder experience significant social, educational and vocational impairment (Schneier et al., 1994) and rate their quality of life very low (Safren, Heimberg, Brown, & Holle, 1997a). Cognitive-behavioral techniques are commonly used for the treatment of social anxiety disorder. Both qualitative (Juster & Heimberg, 1998) and meta-analytic reviews suggest that these interventions are efficacious treatments for social anxiety disorder (e.g., Feske & Chambless, 1995, Gould, Buckminster, Pollack, Otto, & Yap, 1997 and Taylor, 1996). One specific set of cognitive-behavioral techniques often employed in the treatment of social anxiety disorder is cognitive-behavioral group therapy (CBGT, Heimberg & Becker, 2001). CBGT is superior to a credible placebo therapy (Heimberg et al., 1990) and similar in efficacy to the monoamine oxidase inhibitor phenelzine (Heimberg et al., 1998). Further, CBGT patients maintained gains at 4.5–6.25-year follow-up (Heimberg, Salzman, Holt, & Blendell, 1993) and were less likely than phenelzine patients to relapse over the course of 6 months of maintenance treatment and 6 months of follow-up (Liebowitz et al., 1999). However, despite the demonstrated efficacy of CBGT and other cognitive-behavioral techniques for social anxiety disorder, a sizable percentage of patients do not achieve clinically significant improvement by the end of treatment. There is a strong need to determine who will and will not respond to cognitive-behavioral treatments for social anxiety disorder. Few predictors of treatment outcome for social anxiety disorder have yet been identified. Pretreatment level of depression (e.g., Chambless et al., 1997), subtype of social anxiety disorder (e.g., Brown, Heimberg, & Juster, 1995 and Hope, Herbert, & White, 1995), compliance with homework assignments (Leung & Heimberg, 1996), and expectancy for treatment outcome (e.g., Chambless, Tran, & Glass, 1997 and Safren, Heimberg, & Juster, 1997b) are among those variables that have been shown to predict treatment outcome. Social anxiety disorder is highly comorbid with other psychiatric disorders (Kessler et al., 1994 and Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992), particularly anxiety and mood disorders (Brown & Barlow, 1992). Persons with social anxiety disorder and another psychiatric disorder are at risk for greater distress and impairment than persons with uncomplicated social anxiety disorder (Schneier et al., 1992). While a minority (17.3%) of those with uncomplicated social anxiety disorder reported that this disorder interfered with their lives, caused them to seek professional help, or led them to take medication more than once to control their symptoms, this figure rose to 46.8–60% when a comorbid condition was present (Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996). Although comorbid disorders among persons with social anxiety disorder are common and associated with increased symptom severity, only a few studies have been conducted on the effect of comorbid conditions on the outcome of treatment for social anxiety disorder. In one study (Turner, Beidel, Wolff, Spaulding, & Jacob, 1996), persons with social anxiety disorder and a comorbid Axis I (dysthymia, generalized anxiety disorder, or simple phobia) or Axis II (avoidant, obsessive-compulsive, dependent, or histrionic) disorder responded to treatment similarly to those with uncomplicated social anxiety disorder. Whereas most analyses revealed non-significant differences, patients with social anxiety disorder and a comorbid diagnosis scored higher at posttreatment than those without a comorbid diagnosis on two measures of general anxiety and one measure of social anxiety disorder severity. Patients with a comorbid diagnosis also indicated that they were more troubled by their problems. However, the conclusions drawn from this study are limited by the small sample (n=8 uncomplicated social anxiety disorder; n=13 social anxiety disorder with comorbid diagnoses). A second study of the efficacy of cognitive and behavioral treatment for social anxiety disorder compared persons with uncomplicated social anxiety disorder to those with social anxiety disorder and an additional Axis I (anxiety or mood) disorder. Although those with an additional Axis I disorder reported more pretreatment depressive symptoms, both groups improved at the same rate and did not differ with regard to the percentage of patients demonstrating clinically significant change at posttreatment or 3-month follow-up (van Velzen, Emmelkamp, & Scholing, 1997). The studies by Turner et al. (1996) and van Velzen et al. (1997) and van Velzen, Emmelkamp, & Scholing (1997) suggest that comorbidity may not affect the rate at which patients improve. However, Chambless et al. (1997), examining predictors of improvement following CBGT, found higher self-reported depression to be associated with poorer treatment response. Although this study examined self-reported mood rather than presence or absence of mood disorder, it highlights the need to examine the differential effects of comorbid mood and anxiety disorders on symptom severity and treatment outcome. Furthermore, neither Turner et al. nor van Velzen et al. included a follow-up assessment. It is important to determine whether there is differential maintenance of treatment gains among persons with social anxiety disorder complicated by comorbid mood and anxiety disorders. The possible differential efficacy of CBGT in persons with social anxiety disorder and no other Axis I diagnosis, social anxiety disorder and another anxiety disorder, and social anxiety disorder and a mood disorder (regardless of whether additional anxiety disorders were present) was explored in the current study. Comparisons were made before treatment to examine differences in severity and after treatment to examine differences in outcome. Maintenance of gains after a 12-month follow-up period was also explored. Self-report, clinician-administered, and behavioral outcome measures were employed.