یک مطالعه از بینش ضعیف در اختلال اضطراب اجتماعی

Abstract We investigated levels of insight among patients with Social Anxiety Disorder (SAD) as compared to patients with Obsessive−Compulsive Disorder (OCD) and evaluated whether levels of insight in SAD were related to specific sociodemographic and/or clinical features. Thirty-seven SAD patients and 51 OCD patients attending a tertiary obsessive−compulsive and anxiety disorders clinic were assessed with a sociodemographic and clinical questionnaire, a structured diagnostic interview, the Brown Assessment of Beliefs Scale (BABS), the Social Phobia Inventory (SPIN), the Beck Depression Inventory (BDI), the Sheehan Disability Scale (SDS), and the Treatment Adherence Survey-patient version (TAS-P). According to the BABS, SAD patients exhibited insight levels that were as low as those exhibited by OCD patients, with up to 29.7% of them being described as “poor insight” SAD. Although poor insight SAD patients were more frequently married, less depressed and displayed a statistical trend towards greater rates of early drop-out from cognitive-behavioral therapy, their insight levels were not associated with other variables of interest, including sex, age, employment, age at onset, duration of illness, associated psychiatric disorders, SPIN and SDS scores. Patients with poor insight SAD might perceive their symptoms as being less distressful and thus report fewer depressive symptoms and high rates of treatment non-adherence.

1. Introduction Insight is the human ability to critically appraise one׳s own mind state “from inside” (Oyebode, 2008). Poor levels of insight have been well documented in psychotic disorders (e.g. schizophrenia) and severe mood disorders (e.g. bipolar disorder), but have also been identified in patients with obsessive-compulsive disorder (OCD) (Fontenelle et al., 2010), body dysmorphic disorder (BDD) (Phillips et al., 2012), hoarding disorder (HD) (Dimauro et al., 2013), as well as other neuropsychiatric conditions (Konstantakopoulos et al., 2012 and Hartmann et al., 2013). Regardless of the primary syndrome, poor insight is generally associated with a more severe clinical presentation. In OCD, for instance, poor insight has been associated with an earlier age of onset (Ravi Kishore et al., 2004 and Catapano et al., 2010), higher rates of comorbid mood (Turksoy et al., 2002, Ravi Kishore et al., 2004, Alonso et al., 2008 and Catapano et al., 2010), anxiety (Turksoy et al., 2002), and personality disorders (Turksoy et al., 2002, Alonso et al., 2008 and Catapano et al., 2010); family history of psychosis (Catapano et al., 2010), poorer quality of life (Eisen et al., 2006) and functioning (Storch et al., 2008), and worse treatment response (Hantouche et al., 2000, Catapano et al., 2001, Erzegovesi et al., 2001, Ravi Kishore et al., 2004 and Himle et al., 2006). As patients with OCD and other OC-related disorders such as BDD and HD differ in their awareness of symptoms, developers of the DSM-5 added specifiers regarding levels of insight for each disorder (APA, 2013). These specifiers are intended to alert clinicians that patients with OC-related disorders should not be classified and treated as patients with other psychotic disorders generally managed with an antipsychotic monotherapy. Although there is evidence that antipsychotic augmentation therapy is beneficial in SRI-resistant OCD cases (Bloch et al., 2006), this strategy has been linked with potentially severe side effects (Meyer, 2007) and may not be effective when employed as a monotherapy in OCD-related disorders (Keuneman et al., 2005). Probably, a similar strategy can be adopted to prevent antipsychotic treatments being administered to poor insight patients with other disorders that are frequently comorbid with OCD, such as anxiety disorders. Social anxiety disorder (SAD) indeed has substantial overlap with several conditions that may present with poor insight, including OC-related disorders and eating disorders. Each of these conditions has an early age of onset, is highly comorbid with each other, and tend to respond to similar pharmacological treatments (e.g. serotonin reuptake inhibitors) (Schneier et al., 2002). In fact, when SAD is comorbid with other disorders, it tends to emerge first (McEvoy et al., 2011). The characteristic feature of SAD (i.e., fear of being negatively evaluated by others) is also evident in the clinical picture of these comorbid disorders – for example, in relation to sexual-religious obsessions in OCD (Assuncao et al., 2012), dysmorphic concerns in BDD (Fang and Hofmann, 2010), bizarre possessions in HD (Frost et al., 2011), and weight and shape in ED (Hinrichsen et al., 2003). Until DSM-IV-TR, only those patients who displayed insight into their social anxiety symptoms were qualified for a diagnosis of SAD (APA, 2000). However, a relevant change that has taken place with the DSM-5 conceptualization of SAD is that patients no longer need to recognize their symptoms as irrational (Bogels et al., 2010). Although in one study it was reported that less than 1% of patients with SAD failed to recognize that their fears as excessive or unreasonable (Zimmerman et al., 2010), we are not aware of any previous attempts to investigate levels of insight in SAD patients using standardized instruments to measure insight as a dimensional construct. Also, if some patients with poor insight SAD do exist, it is not clear whether they demonstrate specific sociodemographic or clinical features. Based on the findings described in other disorders, we hypothesized that poor insight SAD would likely be associated with an earlier age of onset, more severe SAD and depressive symptoms, greater rates of comorbid major depression, and a poorer adherence to treatment. In this study, we investigated the levels of insight among patients with SAD compared to OCD patients, and evaluated whether poorer insight was related to distinct sociodemographic features, comorbidity patterns, or clinical characteristics, including treatment adherence with particular focus on pharmacotherapy and cognitive-behavioral therapy.

. Results SAD patients were compared to OCD patients in terms of sociodemographic and clinical features (see Table 1). SAD patients were predominantly female, belonged to a higher socioeconomic stratum, displayed increased rates of alcohol dependence, had more unproductive days at school or work, and reported an earlier onset of symptoms. In contrast, OCD patients displayed higher rates of unemployment, greater religiosity, and a trend towards more frequent prescription of drug treatments. Table 1. Comparison of sociodemographic and clinical features presented by patients with social anxiety disorder and patients with Obsessive−Compulsive Disorder. Patients with SAD Patients with OCD Statistics Socio-demographic features Age (in years) 43.7 (13.5) 40.7 (13.7) t=1.02; d.f.=86; p=0.31 Sex χ2=3.65; d.f.=1; p=0.05 Female 12 (32.4%) 27 (52.9%) Male 25 (67.6%) 24 (47.1%) Marital status χ2=3.99; d.f.=1; p=0.53 Never married 23 (62.2%) 35 (68.6%) Ever married 14 (37.8%) 16 (31.4%) Religiosity χ2=9.35; d.f.=1; p=0.002 Yes 16 (48.5%) 41 (80.4%) No 17 (51.5%) 10 (19.6%) Occupation LR=3.65; d.f.=2; p=0.04 Unemployed or on medical leave 4 (11.1%) 14 (27.5%) Employed, retired or student 32 (88.9%) 35 (68.6%) Homemaker 0 (0.0%) 2 (3.9%) Social class LR=5.33; d.f.=2; p=0.03 Upper class 20 (54.1%) 18 (35.3%) Middle class 16 (43.2%) 26 (51.0%) Lower class 1 (2.7%) 7 (13.7%) Education LR=1.31; d.f.=2; p=0.52 Basic 4 (10.8%) 7 (13.7%) Intermediary 16 (43.2%) 16 (31.4%) High 17 (45.9%) 28 (54.9%) Course characteristics Age at onset 11.6 (5.1) 15.5 (7.0) t=−2.80; d.f.=80; p=0.006 Duration of illness 32.1 (14.7) 25.6 (15.1) t=1.94; d.f.=80; p=0.05 Insight features BABS I 9.1 (4.7) 2.7 (2.3) t=7.51; d.f.=85; p<0.001 BABS II 9.1 (4.7) 9.5 (5.9) t=−2.80; d.f.=86; p=0.78 Poor insight based on BABS I 10 (27.0%) 0 (0.0%) Fisher׳s test p<0.001 Poor insight based on BABS II 11 (29.7%) 18 (35.3%) χ2=0.30; d.f.=1; p=0.58 Severity of symptoms BDI 13.1 (9.8) 15.4 (11.1) t=−1.00; d.f.=86; p=0.31 SDS 11.4 (8.9) 9.9 (7.8) t=0.70; d.f.=59; p=0.49 Work/school work 4.4 (3.3) 2.8 (3.2) t=1.85; d.f.=60; p=0.07 Social life/leisure activities 4.5 (3.7) 4.4 (3.7) t=1.11; d.f.=86; p=0.91 Family life/home responsibilities 2.9 (3.0) 4.7 (3.7) t=−2.44; d.f.=83.3; p=0.02 Days lost 1.0 (2.1) 1.0 (2.4) Z=−1.12; p=0.26 Days unproductive 1.6 (2.3) 0.8 (2.0) Z=−2.0; p=0.05 Psychiatric comorbidity Major depressive episode (lifetime) 18 (50%) 20 (39.2%) χ2=1.00; d.f.=1; p=0.31 Dysthymia (current) 8 (22.2%) 6 (11.8%) χ2=1.70; d.f.=1; p=0.19 Bipolar disorder (lifetime) 0 (0.0%) 1 (2.0%) Fisher׳s test p=1.00 Bipolar II disorder (lifetime) 0 (0.0%) 5 (9.8%) Fisher׳s test p=0.07 Alcohol dependence (last year) 6 (16.7%) 0 (0.0%) Fisher׳s test p=0.004 Non-alcohol substance dependence (last year) 3 (8.3%) 0 (0.0%) Fisher׳s test p=0.06 Panic disorder (lifetime) 2 (5.6%) 10 (19.6%) Fisher׳s test p=0.11 Generalized anxiety disorder (current) 7 (19.4%) 14 (27.5%) χ2=0.73; d.f.=1; p=0.39 SAD: Social Anxiety Disorder; OCD: Obsessive−Compulsive Disorder; BABS: Brown Assessment of Beliefs Scale; BDI: Beck Depression Inventory; SDS: Sheehan Disability Scale. Table options As emphasized in Table 1 and described above, insight levels assessed using the BABS were analyzed according to two approaches. When compared to insight levels in OCD patients rated against their primary symptom domain, SAD patients demonstrated equivalent (low) insight levels. However, when compared to insight levels in OCD patients rated across all symptom domains, SAD patients demonstrated significantly lower insight levels. A comparison between SAD and OCD in terms of treatment adherence is depicted in Table 2. Table 2. Comparison of some treatment adherence features between patients with social anxiety disorder and patients with Obsessive−Compulsive Disorder. Patients with SAD Patients with OCD Statistics Has a doctor or other professional ever recommended that you receive CBT for SAD/OCD? 30 (81.1%) 40 (78.4%) Fisher׳s test p=0.79 Have you ever received CBT for SAD/OCD? 17 (45.9%) 25 (49%) Fisher׳s test p=0.83 Did you stop attending CBT before completing therapy? 10 (47.6%) 15 (62.5%) Fisher׳s test p=0.37 Have you ever decided not to participate in CBT despite its being recommended to you by your doctor or another professional? 13 (39.4%) 17 (47.2%) Fisher׳s test p=0.62 Has a doctor or other professional recommended that you take medication for SAD/OCD? 32 (86.5%) 50 (98%) Fisher׳s test p=0.07 Have you ever taken any medication for SAD/OCD? 33 (8.3%) 49 (96.1%) Fisher׳s test p=0.64 Did you ever take the medication less frequently or at a smaller dose than was prescribed, or stopped the medication on your own? 23 (43.2%) 31 (63.3%) Fisher׳s test p=1.00 Have you ever not taken medication for SAD/OCD, even though it was recommended to you? 16 (43.2%) 26 (52%) Fisher׳s test p=0.51 This table describes most, but not all items listed on treatment adherence survey-patient version. To avoid multiple comparisons, we have excluded, a priori, comparisons of (i) the number of cognitive behavioral therapy that sessions received, (ii) the total length of time medications were taken, (iii) the reasons why patients did not participate in or stopped attending cognitive-behavioral therapy and (iv) reasons why patients did not receive medication or have taken them less frequently or at a lesser dose than prescribed. Table options In relation to SAD, up to 29.7% of the sample (11 patients) exhibited poor insight, defined as a score of 13 or more on the BABS. Poor insight SAD patients were more frequently married and had lower BDI scores than good insight SAD patients (Table 3). There were no other distinct differences between the groups, although poor insight SAD patients displayed a statistical trend towards higher rates of CBT non-adherence (Table 4). Table 3. Comparison of sociodemographic and clinical features presented by patients with poor- vs. good-insight social anxiety disorder. Patients with poor insight SAD Patients with good insight SAD Statistics Socio-demographic features Age (in years) 49.4 (12.1) 41.7 (13.6) Z=−1.64; p=0.10 Sex Fisher׳s test p=0.44 Male 8 (80.0%) 17 (63.0%) Female 2 (20.0%) 10 (37.0%) Marital status Fisher׳s test p=0.02 Married 7 (70.0%) 7 (25.9%) Never married 3 (30.0%) 20 (74.1%) Religiosity Fisher׳s test p=0.08 Yes 1 (14.3%) 15 (57.7%) No 6 (85.7%) 11 (42.3%) Occupation Fisher׳s test p=1.00 Unemployed 1 (10.0%) 3 (11.5%) Employed 9 (90.0%) 23 (88.5%) Social class LR=0.81;d.f.=2;p=0.66 Upper class 5 (50.0%) 15 (55.6%) Middle class 5 (50.0%) 11 (40.7%) Lower class 0 (0.0%) 1 (3.7%) Education LR=1.59;d.f.=2;p=0.45 Basic 2 (20.0%) 2 (7.4%) Intermediary 3 (30.0%) 13 (48.1%) High 5 (50.0%) 12 (44.4%) Course characteristics Age at onset 13.7 (6.8) 10.8 (4.3) Z=−0.94; p=0,34 Duration of illness 35.7 (12.9) 30.8 (15.3) Z=−1.07; p=0.28 Severity of symptoms SPIN 27.5 (16.7) 43.2 (46.2) Z=−1.22; p=0.22 Fear 9.1 (5.4) 12.2 (6.9) Z=−1.34; p=0.18 Avoidance 12.7 (7.6) 15.8 (8.2) Z=−1.22; p=0.22 Physiological discomfort 5.6 (4.9) 8.4 (6.5) Z=−1.14; p=0.25 BDI 8.3 (8.3) 14.9 (9.8) Z=−1.92; p=0.05 SDS 10.2 (8.8) 11.8 (9.1) Z=−0.08; p=0.94 Work/school work 3.7 (3.1) 4.6 (3.4) Z=−0.61; p=0.54 Social life/leisure activities 4.6 (3.8) 4.5 (3.7) Z=−0.16; p=0.87 Family life/home responsibilities 2.6 (3.9) 2.9 (2.7) Z=−0.84; p=0.39 Days lost 0.3 (1.0) 1.3 (2.4) Z=−1.25; p=0.21 Days unproductive 1.7 (2.4) 1.6 (2.3) Z=−0.08; p=0.93 Psychiatric comorbidity Major depressive episode (lifetime) 4 (40.0%) 14 (53.8%) Fisher׳s test p=0.71 Dysthymia (current) 2 (20.0%) 6 (23.1%) Fisher׳s test p=1.00 Bipolar disorder (lifetime) 0 (0.0%) 0 (0.0%) Bipolar II disorder (lifetime) 0 (0.0%) 0 (0.0%) Alcohol dependence (last year) 3 (30.0%) 3 (11.5%) Fisher׳s test p=0.31 Non-alcohol substance dependence (last year) 1 (10.0%) 2 (7.7%) Fisher׳s test p=1.00 Panic disorder (lifetime) 2 (20%) 0 (0.0%) Fisher׳s test p=0.07 Generalized anxiety disorder (current) 0 (0.0%) 7 (26.9%) Fisher׳s test p=0.15 SAD: Social Anxiety Disorder; OCD: Obsessive−Compulsive Disorder; BABS: Brown Assessment of Beliefs Scale; BDI: Beck Depression Inventory; SDS: Sheehan Disability Scale. Table options Table 4. Comparison of some treatment adherence features between patients with poor- and good-insight social anxiety disorder. Patients with poorinsight SAD Patients with goodinsight SAD Statistics Has a doctor or other professional ever recommended that you receive CBT for SAD/OCD? Fisher׳s test p=1.00 No 2 (18.2%) 5 (19.2%) Yes 9 (81.8%) 21 (80.8%) Have you ever received CBT for SAD/OCD? Fisher׳s test p=1.00 No 6 (54.5%) 14 (53.8%) Yes 5 (45.5%) 12 (46.2%) Did you stop attending CBT before completing therapy? Fisher׳s test p=0.06 No 1 (16.7%) 10 (66.7%) Yes 5 (83.3%) 5 (33.3%) Have you ever decided not to participate in CBT despite its being recommended to you by your doctor or another professional? Fisher׳s test p=1.00 No 5 (55.6%) 15 (62.5%) Yes 4 (44.4%) 9 (37.5)% Has a doctor or other professional recommended that you take medication for SAD/OCD? Fisher׳s test p=1.00 No 1 (9.1%) 4 (15.4%) Yes 10 (90.9%) 23 (84.6%) Have you ever taken any medication for SAD/OCD? Fisher׳s test p=1.00 No 1 (10.0%) 2 (7.7%) Yes 9 (90.0%) 24 (92.3%) Did you ever take the medication less frequently or at a smaller dose than was prescribed, or stopped the medication on your own? Fisher׳s test p=1.00 No 4 (36.4%) 10 (38.5%) Yes 7 (63.6%) 16 (61.5%) Have you ever not taken medication for SAD/OCD, even though it was recommended to you? Fisher׳s test p=1.00 No 6 (54.5%) 15 (57.7%) Yes 5 (45.5%) 11 (42.3%) This table describes most, but not all items listed on treatment adherence survey-patient version. To avoid multiple comparisons, we have excluded, a priori, comparisons of (i) the number of cognitive behavioral therapy that sessions received, (ii) the total length of time medications were taken, (iii) the reasons why patients did not participate in or stopped attending cognitive-behavioral therapy and (iv) reasons why patients did not receive medication or have taken them less frequently or at a lesser dose than prescribed.