معیار پیآمد اختلال اضطراب اجتماعی بالینی مفید

Abstract Increasingly, emphasis is being placed on measurement-based care to improve the quality of treatment. Although much of the focus has been on depression, measurement-based care may be particularly applicable to social anxiety disorder (SAD) given its high prevalence, high comorbidity with other disorders, and association with significant functional impairment. Many self-report scales for SAD currently exist, but these scales possess limitations related to length and/or accessibility that may serve as barriers to their use in monitoring outcome in routine clinical practice. Therefore, the aim of the current study was to develop and validate the Clinically Useful Social Anxiety Disorder Outcome Scale (CUSADOS), a self-report measure of SAD. The CUSADOS was designed to be reliable, valid, sensitive to change, brief, easy to score, and easily accessible, to facilitate its use in routine clinical settings. The psychometric properties of the CUSADOS were examined in 2415 psychiatric outpatients who were presenting for treatment and had completed a semi-structured diagnostic interview. The CUSADOS demonstrated excellent internal consistency, and high item–total correlations and test–retest reliability. Within a sub-sample of 381 patients, the CUSADOS possessed good discriminant and convergent validity as it was more highly correlated with other measures of SAD than with other psychiatric disorders. Furthermore, scores were higher in outpatients with a current diagnosis of SAD compared to those without a SAD diagnosis. Preliminary support also was obtained for the sensitivity to change of the CUSADOS in a sample of 15 outpatients receiving treatment for comorbid SAD and depression. Results from this validation study in a large psychiatric sample show that the CUSADOS possesses good psychometric properties. Its brevity and ease of scoring also suggest that it is feasible to incorporate into routine clinical practice.

Introduction Surveys of psychiatrists in clinical practice in the United Kingdom and United States have found that the majority do not use symptom rating scales of depression or anxiety to monitor progress throughout treatment [1] and [2]. When outcomes are assessed, they typically are based on unstructured interactions rather than quantifiable assessments [3] and [4]. Although routine outcome assessment currently is not widely practiced, there is movement towards payor mandates to increase this behavior. For example, a law signed in 2006 (the Centers for Medicare and Medicaid Services’ Physician Quality Reporting Initiative; [5]) provides financial incentives to physicians to document outcomes reflecting best practices, in an effort to improve the quality of care. In addition, DSM-5 work groups are recommending the use of dimensional severity scales for various disorders (e.g., for social anxiety disorder [6]). Conducting reliable, valid, and informative outcome assessments on a routine basis can help to optimize delivery of care [3]. This is especially important for individuals with social anxiety disorder (SAD), as it is a chronic and significantly disabling disorder [7] and [8]. SAD often is under-recognized in clinical settings, especially when other disorders such as depression are present [9] and [10]. Therefore, it often is under-treated [11], [12] and [13] and tends to have the lowest proportion of met need for treatment compared to other psychiatric disorders [14]. Under-treated SAD may affect the treatment outcome of other conditions such as depression, in both pharmacologic and cognitive–behavioral treatments [15], [16], [17] and [18]. Therefore, routine monitoring of SAD symptoms over the course of treatment can aid in ensuring adequate and efficient treatment that perhaps could impact the treatment of comorbid disorders. One of the long-term aims of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project has been to develop a series of reliable, valid, and brief instruments for use in routine practice settings. In addition to being available to clinicians for personal use without cost, each measure is designed to have the same rating instructions to facilitate comparison across symptom domains. Most recently, measures of depression (the Clinically Useful Depression Outcome Scale, or CUDOS; [19]) and the general construct of anxiety (the Clinically Useful Anxiety Outcome Scale, or CUXOS; [3]) were validated. These measures are brief (so as to reduce respondent burden and allow for easy scoring), and they provide useful clinical information to monitor progress throughout treatment. The goal of the current report from the MIDAS Project is to validate a similar self-report measure specific to SAD, called the Clinically Useful Social Anxiety Disorder Outcome Scale (CUSADOS). As with its predecessors, the CUSADOS was designed to be clinically useful, reliable, valid, brief, quickly scored, and sensitive to change. It is acknowledged that many measures of SAD currently exist. However, some of these measures are lengthy and thus burdensome to complete (e.g., the Social Phobia and Anxiety Inventory (SPAI), administered in 20 to 30 min; [20]). Some measure only certain aspects of SAD, such as fear and avoidance in specific situations as in the Liebowitz Social Anxiety Scale (LSAS; [21]), or cognitions, as in the Social Interaction Self-Statement Test [22]. Others are in a true/false format rather than a Likert scale (e.g., Fear of Negative Evaluation Scale; [23]), and this is less useful as an outcome measure. Some are not readily available to clinicians and need to be purchased (e.g., the Social Phobia and Anxiety Inventory [20]), and some have reverse scoring that lengthens the amount of time required for scoring (e.g., the Fear of Negative Evaluation Scale [23]). Two other brief measures of SAD exist, with the intended purpose of screening for a SAD diagnosis: the Brief Social Phobia Scale (BSPS; [24]), and the Mini-Social Phobia Inventory (MINI-SPIN; [25]). However, the BSPS is an observer-rated measure consisting of three subscales, which the authors recommend using after completing a semi-structured diagnostic interview. It assesses fear and avoidance of a limited number of situations as well as a small number of physiological symptoms, but it does not assess cognitions commonly associated with SAD. Although it is brief, the fact that it is an observer-rated measure suggests that it may increase clinician burden relative to self-report scales. The MINI-SPIN is a self-report measure modeled after the BSPS, but it contains only three items. Therefore, the MINI-SPIN may not provide a large enough range of scores that would be sensitive to change, thus limiting its use as a symptom severity measure. In addition to their limited use as outcome measures, the brevity of these measures also may limit their utility as case-finding instruments. In contrast to the above measures, the CUSADOS is brief, yet has enough items to provide a broad range of scores. It also has straightforward scoring (sum of all items), and includes Likert scale ratings rather than true/false statements. In addition, it assesses a combination of different aspects of SAD, including affective (e.g., “I was extremely afraid of social situations”), cognitive (e.g., “I was worried that I would make a mistake in front of others and look foolish”), situational (“I was afraid of eating, drinking, or writing in front of other people”), and behavioral (e.g., “I avoided social situations where people might pay attention to me”). The aim of the present study was to examine the psychometric properties of the CUSADOS in a sample of psychiatric outpatients, as well as its operating characteristics to examine its potential use as a screening or case-finding instrument in addition to a symptom severity measure.

Results 3.1. Demographic characteristics Participants ranged in age from 18 to 85 years old (M = 39.0, SD = 13.4), and the majority were female, Caucasian, and either married or never married (see Table 1). Over half of the patients had a high school degree or equivalency, and nearly one third received a 2- or 4-year college degree ( Table 1). As shown in Table 2, more than one quarter (26.5%; n = 640) of the 2415 patients completing the CUSADOS met current criteria for SAD. Other than SAD, the most frequent current Axis I diagnoses were MDD, generalized anxiety disorder, panic disorder with or without agoraphobia, posttraumatic stress disorder, and specific phobia. Table 1. Demographic characteristics of 2415 psychiatric outpatients. Demographic Characteristic Frequency Percentage Gender Female 1430 59.2 Male 985 40.8 Marital Status Married 1001 41.4 Living as if married 147 6.1 Widowed 45 1.9 Separated 117 4.8 Divorced 341 14.1 Never Married 764 31.6 Education Less than high school 176 7.3 Graduated from high school 1490 61.7 College degree 749 31.0 Race Caucasian 2197 91.0 Black 105 4.3 Hispanic 64 2.7 Asian 24 1.0 Other 25 1.0 Table options Table 2. Current DSM-IV axis I diagnoses of 2415 psychiatric outpatients. DSM-IV Diagnosis Frequency Percentage Major depressive disorder 1005 41.6 Bipolar disorders 122 5.1 Dysthymic disorder 198 8.2 Generalized anxiety disorder 489 20.2 Panic disorder 401 16.6 Social anxiety disorder 640 26.5 Specific phobia 259 10.7 Obsessive–compulsive disorder 159 6.6 Posttraumatic stress disorder 267 11.1 Adjustment disorder 163 6.7 Schizophrenia 7 0.3 Eating disorder 159 6.6 Alcohol abuse/dependence 205 8.5 Drug abuse/dependence 127 5.3 Somatoform disorder 181 7.5 Attention deficit disorder 195 8.1 Impulse control disorder 143 5.9 Individuals could be given more than one diagnosis. Table options 3.2. Item redundancy An inter-item correlation matrix first was generated using the original 18 items of the scale. When two items similar in content were correlated at greater than 0.75, only one item in that pair was retained to reduce redundancy of items. The determination of which item to retain in the pair was based on the item–total correlations and test–retest reliability for each item. Using this method, the following 6 items were eliminated: “I was very afraid of embarrassing myself in front of others” (correlated 0.81 with the retained item “I was worried that I would make a mistake in front of others and look foolish”); “I was terrified that others may think badly of me” (correlated 0.83 with the retained item “I was very afraid of being judged by others”); “I avoided social situations that made me very nervous” (correlated 0.84 with the retained item “I avoided social situations where people might pay attention to me”); “I felt nervous in situations where people paid attention to me” (correlated 0.84 with the retained item “I avoided social situations where people might pay attention to me”); “I felt very anxious or nervous when entering social gatherings” (correlated 0.79 with the retained item “I was afraid to walk into a crowded room because everyone would look at me”); and “I was worried about being rejected by other people” (correlated 0.89 with the retained item “I was worried that other people may not like me”). This resulted in a 12-item measure, the items of which are presented in Table 3. The remaining psychometric analyses are based on this 12-item version. Table 3. Item–total correlations and test–retest reliability of individual CUSADOS items. CUSADOS Item Item–Total Correlations Test–Retest Reliability I was very afraid of being judged by others 0.74 0.77 I was extremely afraid of social situations 0.80 0.79 I was worried that I would make a mistake in front of others and look foolish 0.84 0.82 I avoided social situations where people might pay attention to me 0.80 0.75 I was afraid to walk into a crowded room because everyone would look at me 0.80 0.75 I was afraid of eating, drinking, or writing in front of other people 0.69 0.73 I was very concerned that people would notice that I was anxious 0.75 0.73 I avoided eating, drinking, or writing in front of people 0.67 0.76 I worried that I would say something stupid in front of other people 0.84 0.79 I was worried about being criticized by other people 0.84 0.79 I was worried that other people may not like me 0.80 0.80 After I was criticized, I thought about it for a long time 0.73 0.77 All correlations are significant at p < 0.001. CUSADOS = Clinically Useful Social Anxiety Disorder Outcome Scale. Table options 3.3. Reliability The mean total score on the CUSADOS across all participants was 13.4 (SD = 13.1). Internal consistency was excellent (Cronbach’s α = 0.96), and all item–scale correlations were statistically significant (ranging from 0.67 to 0.84, median r = 0.80; all ps < 0.001). Test–retest reliability of the overall measure (r = 0.89) and each item also was statistically significant (ranging from 0.73 to 0.82, median r = 0.77; all ps < 0.001; see Table 3). 3.4. Validity A total of 381 patients completed a packet of questionnaires at home an average of 1.2 days (SD = 16.9) following the initial intake evaluation. As shown in Table 4, the CUSADOS was significantly correlated with all of the other measures, with the highest correlations being with other measures of social anxiety (median r = 0.67) compared to measures of other symptom domains (median r = 0.39). As would be expected given the common comorbidity between SAD and mood and other anxiety disorders, the CUSADOS also was moderately and significantly correlated with the measures assessing depression and anxiety. Furthermore, the CUSADOS was negatively correlated with GAF scores (r = −0.35, p < 0.001), such that higher CUSADOS scores were associated with poorer functioning. Table 4. Discriminant and convergent validity of the Clinically Useful Social Anxiety Disorder Outcome Scale (CUSADOS). Scale Correlation with CUSADOS (r) Fear Questionnaire — social phobia subscale 0.68 Brief Fear of Negative Evaluation Scale 0.65 Symptom Rating Test — paranoia subscale 0.61 Social Phobia and Anxiety Inventory — agoraphobia subscale 0.59 Anxiety Control Questionnaire 0.57 Beck Depression Inventory 0.56 Obsessive Compulsive Inventory 0.53 Anxiety Sensitivity Index 0.51 Fear Questionnaire — agoraphobia subscale 0.48 Beck Anxiety Inventory 0.47 Penn State Worry Questionnaire 0.46 Somatic Symptom Index 0.41 State-Trait Anger Expression Inventory — Trait subscale 0.39 Self-Report Manic Inventory 0.38 Posttraumatic Stress Disorder Scale 0.37 State-Trait Anger Expression Inventory — State subscale 0.36 Eating Disorder Inventory — bulimia subscale 0.34 Whitely Index 0.29 Eating Disorder Inventory — anorexia subscale 0.28 Eating Disorder Inventory — body dissatisfaction subscale 0.24 Symptom Rating Test — psychosis subscale 0.21 Michigan Alcohol Screening Test 0.17 Drug Abuse Screening Test 0.17 All correlations are significant at p < 0.001. Due to missing data, sample sizes range from 270 to 381. Table options 3.5. Association with SAD diagnosis From the sample of 2415 outpatients with available CUSADOS data, 640 (26.5%) met current criteria for SAD. Patients with SAD scored significantly higher than the patients without SAD (23.27 ± 13.67 versus 9.81 ± 10.94, respectively; t = −22.5, p < 0.001). Although the primary purpose of the CUSADOS is to serve as a symptom severity measure, analyses were conducted on the operating characteristics to suggest cut-offs for its use as a screening measure or as a potential case-finding measure, depending on the intended purpose by the user. Fig. 1 shows the ROC curve comparing the diagnostic performance of the CUSADOS to the results from the SCID interview across cutoff scores. The AUC (0.78) was significant (p < 0.001). Results from this analysis indicated that cutoff scores ranging from 13 to 16 provided the maximum sum of sensitivity and specificity ( Table 5). A cutoff score of 16 performed best in terms of operating characteristics, with a diagnostic efficiency of 73%. When examining the performance of the CUSADOS as a screening instrument, it is most important to have high sensitivity at the expense of lower specificity [46]. This may result in a greater likelihood of false positives, but from a screening perspective it is best to have higher sensitivity to alert one to the possible presence of the disorder which then would prompt additional assessment. For such a purpose, a cut-off of 4 produces a sensitivity of 89.5% with a specificity of 41.5%. Receiver operating curve for the CUSADOS in detecting social anxiety disorder in ... Fig. 1. Receiver operating curve for the CUSADOS in detecting social anxiety disorder in 2415 psychiatric outpatients. Figure options Table 5. Operating characteristics of various cut-offs on the Clinically Useful Social Anxiety Disorder Outcome Scale (CUSADOS). Cut-off Value Sensitivity Specificity PPV NPV Efficiency 13 0.76 0.68 0.46 0.89 0.70 14 0.74 0.71 0.47 0.88 0.71 15 0.72 0.72 0.48 0.88 0.72 16 0.70 0.74 0.49 0.87 0.73 PPV = positive predictive value; NPV = negative predictive value; Efficiency = diagnostic efficiency. Table options 3.6. Sensitivity to change Preliminary sensitivity to change was examined by comparing pre- and post-treatment scores on the CUSADOS in 15 outpatients receiving acceptance-based behavior therapy adjunctive to medication for comorbid depression and SAD. Results from the paired samples t test showed that scores on the CUSADOS significantly decreased from pre- to post-treatment (20.43 ± 8.88 versus 11.36 ± 8.95, respectively; paired t = 3.46; p = 0.004).