Epidemiology and Psychological Treatment of Social Phobia

Transcription

1 Epidemiology and Psychological Treatment of Social Phobia Zeynep Ceren Acartürk

2 Doctoral Committee: Prof. dr. A. van Balkom Prof. dr. M. van der Gaag Prof. dr. B. Penninx Prof. dr. J. Spijker Prof. dr. Ph. Spinhoven Prof. dr. J. Swinkels This thesis was prepared at the Department of Clinical Psychology of the Vrije Universiteit in Amsterdam in close cooperation with the Trimbos Institute, which is the Netherlands Institute of Mental Health and Addiction in Utrecht. Financial support for the printing of this thesis has been kindly provided by F.A. Acartürk. Cover design: Seda Welsh Printed by: Ipskamp Drukkers B.V., Amsterdam, NL Amsterdam. All rights reserved. No parts of this book may be produced, in any form, without prior written permission of the author. ii

3 VRIJE UNIVERSITEIT Epidemiology and Treatment of Social Phobia ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. L.M. Bouter, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de faculteit der Psychologie en Pedagogiek op donderdag 28 mei 2009 om uur in de aula van de universiteit, De Boelelaan 1105 door Zeynep Ceren Acartürk geboren te Istanbul, Turkije iii

4 promotor: copromotoren: prof.dr. W.J.M.J. Cuijpers dr. A. van Straten dr.ir. R. De Graaf iv

5 To my mother and father v

6 CONTENTS Chapter 1 Introduction 7 Chapter 2 Social Phobia and number of social fears, and their association 25 with comorbidity, health-related quality of life and help seeking: A population-based study Chapter 3 Economic costs of social phobia: a population-based study 43 Chapter 4 Incidence of social phobia and identification of its risk indicators: A 63 Model for Prevention Chapter 5 Psychological Treatment of Social Anxiety Disorder: A Meta- 82 Analysis Chapter 6 General Discussion 107 English summary 115 Dutch summary 118 Acknowledgement 121

7 Chapter 1 Introduction He dare not come in company, for fear he should be misused, disgraced, overshoot himself in gestures of speeches...he thinks every man observed him Hippocrates (unknown date) Preface Human beings are social animals. This implies that most of them want to be a member of social groups and to be accepted and valued by others of their group. Whether or not a person is accepted by a group, depends on the members of the group and is not fully under control by the individual. The uncertainty whether one is accepted or not, causes some form of social anxiety at any time in most individuals. Despite this social anxiety, however, most people are comfortable in most social situations, whereas some others are not. To a certain extent, social anxiety is normal and can be considered to be a part of human life. But in some cases this social anxiety is excessively high and is not related to the social situations this person is in. But where does social anxiety stop being normal and where does it start to become pathological? And what can be done to prevent the onset of social phobia and to treat existing social phobia? These are the questions at which this thesis will focus, and it will try to contribute to a further understanding of the epidemiology, the burden of disease of social phobia, the incidence, economic costs and effective treatments. In the following sections I will first describe the key concepts related to social phobia and then I will present the structure of this thesis. 1. Diagnosis of Social Phobia Although the category of anxiety disorders was included in the first edition of the American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders (DSM-I, 1952) (Murphy & Leighton, 2008), it took years to accept social phobia as a unique diagnose. A decade after Marks (1970) categorized the phobic disorders, social phobia became an official diagnose at DSM-III (APA, 1980). According to the current version of the DSM-IV- TR (APA, 2000) social phobia is characterized by a persistent fear of negative evaluation or 7

8 scrutiny by others in social or performance situations. Exposure to the feared social situation almost always leads to anxiety or to a panic attack. During these panic attacks the person experiences a number of somatic symptoms such as blushing, heart palpitations, tense muscles, and sweating. To be diagnosed as social phobia the following additional criteria need to be fulfilled: the person must realize that the fear is excessive, the person either avoids the feared situations or feel high levels of anxiety when exposed to it, and the fear must interfere significantly with the functions of the person in various domains of her or his life. All the symptoms have to be present for at least six months. Following the inclusion of social phobia as a diagnosis in the DSM, an effort was made by researchers to investigate the unique character and possible subtypes of social phobia (Heimberg, Hope, Dodge & Becker, 1990). As a result of those studies, two types of social phobia have been distinguished. One is called generalized social phobia and the other discrete, specific or nongeneralized phobia (Heimberg, Holt, Schneier, Spitzer, & Liebowitz, 1993). Generalized social phobia is characterized by fear for all or almost all social situations while nongeneralized phobia is limited to one or a few situations of which the most common is speaking in front of other people (Schneier et al., 1992; Stein & Chavira, 1998). However, this classification induced a debate which continues until today. A number of epidemiological and clinical studies have found some evidence for the existence of a generalized social phobia subtype but others have raised considerable criticism against this subtyping, especially because the meaning of most social situations remains unclear (Furmark et al., 2000; Vriends et al., 2006). Some researchers consider most social situations as a larger number of social situations, which implies that this is a quantitive distinction (Heimberg et al., 1993). Others, however, see it as a qualitative distinction (Turner et al., 1992) and label social fears related to the interactions with others as generalized social phobia. In the DSM-IV-TR, the subtypes of social phobia are not recognized as separate disorders. However, within the main diagnoses of social phobia there is an option to diagnose it as generalized phobia. Although full-blown social phobia is defined explicitly, the definition of subthreshold social phobia is not stated in diagnostic handbooks. However, some previous studies have tried to define it (Davidson et al., 1994; Wittchen et al., 2000). Subthreshold social phobia has been 8

9 defined in most studies as having one or more symptoms of social phobia but without experiencing significant functional impairment as stated in the E criterion of DSM-IV-TR (reference). Earlier studies have found evidence that persons with subthreshold social phobia have significantly decreased quality of life and increased functional impairments compared to persons with no social phobia (Davidson et al., 1994; Wittchen et al., 2000). 2. Etiology 2.1. Cognitive-Behavioral Model of Social Phobia After social phobia was defined as a distinct type of phobia (Marks, 1970), many theories such as neurobiological, behavioral, or cognitive behavioral tried to explain the origins of it. Although there are other models in clinical psychology, the cognitive behavioral model of social phobia is undoubtedly the most important model. The success of cognitive behavioral therapies in the treatment of social phobia has certainly resulted in a stronger focus of researchers on this theoretical model. In the cognitive behavioral model of social phobia by Rapee and Heimberg (1997), it is assumed that social phobia lies on a continuum from a low (shyness) to an extreme (avoidant personality disorder) degree of concern about social evaluation. According to this model, people with social phobia believe that other people are extremely critical and being appraised positively by others is considered to be very important. When a person with social phobia enters a social situation, he (or she) forms a mental representation of himself as seen by the audience (anybody in the social environment with which there is a possibility for social interaction). With this internal representation of the self in mind, the person is waiting for external indicators of any perceived threat in the social environment. The mental representation of the self is based on input from long-term memory (e.g. prior experiences), internal cues (e.g. physical symptoms), and external cues (e.g. feedback from audience). Then, the person rapidly compares the mental representation of the self as seen by the audience, with the appraisal of audience s expected standard. The discrepancy between these two determines the probability of negative evaluation from the audience and its possible consequences. When the person predicts negative evaluation, anxiety starts with its physiological (e.g. blushing), cognitive (e.g. negative thoughts about self), and behavioral (e.g. avoidance) symptoms. Subsequently, these perceived internal cues will influence the 9

10 person s mental representation of self as seen by the audience and the vicious cycle starts to work again (Rapee & Heimberg, 1997). Previous studies indicated that people with social phobia generally evaluate the external feedbacks in a negative way. They focus on and exaggerate negative feedback more than people without social phobia (Rapee & Heimberg, 1997). It has been found that people with social phobia underestimate their performance in social situations compared to nonclinical people (Rapee & Lim, 1992). It has also been found, however, that this underestimation can be successfully changed with interventions. Treatment studies have indicated that people with social phobia have more realistic perceptions of their own performance, after receiving cognitive behavioral therapy (Taylor, 1996) and video feedback of performance (Rapee & Hayman, 1996). On the other hand, it is possible that people with social phobia may actually perform poorly, because of their anxiety or because of social skills deficits. Recent research in this area has indicated that those people with social phobia actually have social performance deficits (Voncken, Bogels, 2008). The same study indicated that they perform worse in specific situations. Subjects with social phobia had performance problems not during a presentation for a group, but they did during a conversation with another individual. The researchers stated that during the presentation, the patient was in control of the situation. However, during the conversation, which requires interaction and more sensitive social behaviours such as listening, showing interest, smiling, or probing, the person might not have the feeling of being in control. These findings are important for treatments of the disorder. If the person with social phobia has real impairments in social behaviours, because of a lack of knowledge or experience, teaching those interpersonal skills might be one of the important elements of the treatment. However, it is still not clear whether these social deficits are be the cause or the consequence of social phobia, and more research is needed to establish which of the two is correct Etiological Factors While the cognitive model from Rapee and Heimberg (1997) can explain the cognitive processes which occur during the threat appraisal, it does not very well explain individual differences in threat appraisal. In a recent review, research findings on the etiology of social phobia were summarized (Rapee & Spence, 2004). Two main groups of factors which 10

11 contribute to the etiology of social phobia were distinguished: internal (genetic, temperament, cognitive and social skills deficits) and environmental factors (parent/child interaction, aversive social experiences and negative life events). It is generally accepted that genetic factors play an important role in the development of anxiety disorders. However, their importance for social phobia has only been examined recently. Although previous genetic studies have found an inherited genetic predisposition to anxiousness in general rather than specific to social phobia (Hudson & Rapee, 2000), more recent studies have indicated a moderate significant genetic contribution to the development of social phobia (Rapee & Spence, 2004). One area of research has focused on temperament styles and behavior inhibition, which was defined as reactions of withdrawal, avoidance and shyness in novel situations (Garcia et al., 1984). Findings of this research indicate that the prevalence rate of social phobia in parents of behaviorally inhibited children is significantly higher than in other people (Rosenbaum et al., 1991). Furthermore, behaviorally inhibited children have been found to have more social anxiety disorders compared to uninhibited children (Biederman et al., 1990). However, an anxious temperament, such as behavioral inhibition has not been found to be a specific risk factor for social phobia but rather for anxiety disorders in general. Environmental factors can also play an important role in the etiology of social phobia. Many studies have found an increased risk for social phobia in the relatives of people with social phobia (Fyer et al., 1995). This familial transmission of social phobia may be related to the shared family environment. Among the environment factors, parent-child interactions have been examined in several studies. These studies have suggested that parental overprotection, parental rejection, and emotional distance between parents and children may play a role in the etiology of social phobia (Neal & Edelmann, 2003; Rapee & Spence, 2004). Another environmental factor that has been examined in several studies is aversive social experiences. According to some studies, people with social phobia have experienced traumatic social experiences which have led to negative images of the self (Rapee and Spence, 2004). However, research in this area is scarce and is based on retrospective research, which may include biased reports of those early experiences (Rapee & Spencer, 2004). Moreover 11

12 these factors influence the development of many other mental health disorders, besides social phobia. Thus, more prospective research is needed to understand the origins of social phobia. 3. Epidemiology 3.1. Prevalence and Incidence Epidemiological studies estimate the lifetime prevalence of social phobia to be between 2.4% and 13% (Alonso et al., 2004; Kessler et al., 2005). Although there is no exact estimate, due to the use of different diagnostic criteria and different assessment instruments, (Turner et al., 1992) social phobia is generally recognized as being highly prevalent (Davidson et al., 1994; Kessler et al., 1994; Furmark et al., 1999). Social phobia is more prevalent in women than in men, in younger people than in older people, in people who have never been married or are separated than in people who are married, in people with little education than in people with high education, and in people with low income than in people with high income (Chalebly, 1987; Davidson et al, 1993; Fehm et al., 2005; Furmark et al., 1999; Grant et al., 2005; Heimberg et al., 2000; Schneier et al., 1992). In general, social phobia typically has an age of onset in the late childhood and early to middle adolescence (de Graaf, 2003; Ost, 1987; Kessler et al., 2005; Schneier et al., 1992). However, there are some studies that found earlier ages of onset, even as young as eight years (Turner & Beidel, 1989). People with social phobia commonly report a long duration of illness, ranging from 10 to 29 years (DeWitt et al., 1999; Chartier et al., 1998). Although social phobia tends to have a chronic course, there are studies which examine the recovery from social phobia. Reported recovery rates vary between 27% and 85% in community studies with an average duration of the disorder of 29 years (Degade & Angst, 1993; Chartier et al., 1998; DeWitt et al., 1999). However, in clinical settings long-term rate of recovery for social phobia was found to be only 35%, which is lower than those of other anxiety disorders (e.g. GAD: 50%; major depressive disorder: 72%; panic disorder without agoraphobia: 82%; Keller, 2006). Factors that predict recovery are high level of education, being brought up in a small town, having no more than one sibling, being employed, having an onset of social phobia after age seven, having three or less symptoms of the disorder, and not having a comorbid psychiatric disorder or another health problem (Chartier et al., 1998, DeWit et al., 1999). 12

13 There is a lack of studies examining the incidence of social phobia. To our knowledge, only three prospective community-based epidemiological studies have examined the incidence of social phobia: the Netherlands Mental Health Survey and Incidence Study (NEMESIS) (Bijl et al., 2002; de Graaf et al., 2002) the Epidemiologic Catchment Area Study (ECA) in the USA (Wells et al., 1994; Neufeld et al., 1999) and the Early Developmental Stages of Psychopathology (EDSP) study in Germany (Beesdo et al., 2007). According to the NEMESIS, social phobia has a 1.0% 12-month first incidence rate ( Bijl et al., 2002). The most recent ECA data report an incidence rate of 4-5 / 1000 life years (Neufeld et al., 1999). The EDSP reported a cumulative incidence rate of 11.0% for social phobia in the first three decades of life. The ECA study reported a number of risk factor factors associated with a higher incidence rate, including: being female, having little education, not being married, and having comorbid mental or physical symptoms (such as nervousness, headache, palpitations, other phobias, binge patterns of alcohol consumption, dysthymia, and schizophrenic symptoms). However, these predictive factors were not confirmed in the EDSP study. In this study only baseline depressive and panic disorders appeared to be significant predictors of social phobia (Neufeld et al., 1999). Knowledge about risk factors for social phobia can be very useful for the development of preventive interventions for social phobia. However, considering the lack of sufficient knowledge on this subject, more research is needed. 3.2.Comorbidity Social phobia without other comorbid mental disorders is rare and usually high rates of comorbidity are reported (Alonso et al., 2004; Chartier et al., 2003). Both epidemiological studies and clinical studies have shown that at least half of the social phobia patients had another DSM-IV disorder (Schneier et al., 1992; Kessler et al., 1999; Merikangas et al., 1995). The most reported comorbid disorders are: other anxiety disorders (about 33%), mood disorders (about 30-50%) and substance use disorders (about 25%; Schneier et al., 1992, Merikangas et al., 1995). Among the other anxiety disorders, generalized anxiety disorder appears to be the most common comorbid disorder (Mennin et al., 2000) although other phobic disorders such as agoraphobia (Schneier et al., 1992, Chartier et al., 2003), and simple phobia (Schneier et al., 1992) also occur frequently among people with social phobia. The association between social 13

14 phobia and substance abuse disorders is more complicated. Some studies showed substantial comorbidity rates (Morris, Stewart & Ham, 2005) while others indicated a moderate to low comorbidity with social phobia (Chartier et al., 2003; Davidson et al., 1993). Differences in methodology, population, diagnosis and the methods of dealing with missing data may contribute to this variation in comorbidity rates (Chartier et al., 2003). In addition, the definition of comorbidity and the considered time period may have contributed to this variation (Wittchen, 1996). However, in a recent review, it is stated that the presented comorbidity rates for alcohol use disorders in subjects with social phobia may be underestimated (Morris et al., 2005). The subjects with social phobia may not accept their problems due to alcohol use because of the fear of negative evaluation (Morris et al., 2005). Another factor contributing to the low comorbidity rate may be related to the group therapies for substance use disorders. As it lies in the definition of social phobia, people with social phobia would not be eager to participate in a group therapy in where they will be exposed to unfamiliar people (Marshall, 1994). As indicated earlier, social phobia has an early age of onset and therefore precedes the comorbid disorder in most cases (Graaf de et al. 2003; Kessler, et al., 1999, Magee et al., 1996; Ruiter, Rijken, Garssen, van Schaik, & Kraaimaat, 1989;). In a population study, social phobia was found to be the preceding disorder in 32% of comorbid anxiety disorders, 71% of comorbid mood disorders, and 80% of comorbid substance dependence and abuse disorders (Chartier et al., 2003). Moreover, in NEMESIS it is reported that among males with lifetime major depression, 62.7% developed social phobia before the onset of major depression while 54.9% of females with major depression had social phobia before major depression has started (Graaf de et al., 2003). This earlier onset of social phobia suggests that social phobia may be a risk factor for additional mental health disorders (Schneier et al., 1992; Chartier et al., 2003). 3.3 Burden of Social Phobia 3.3.1Functional Impairment and Quality of Life Anxiety disorders constitute a disabling group of disorders. In the Netherlands they cause serious disability and rank second in a list of 49 selected mental and physical disorders, directly after coronary heart disease (Bohn, Stafleu, Van Loghum, & Houten, 2002; Melse, Essink-Bot, Kramers, & Hoeymans, 2000). For social phobia substantial functional impairments have been reported in several major activities, including; work, school, 14

15 volunteering, childrearing, relationships with neighbours, volunteering and personal care (Stein & Kein, 2000). It is also reported that people with social phobia are more likely to have more dissatisfaction with their own functioning and as a result report a low quality of life (Ware & Sherbourne, 1992; Ware Snow, Kosinski, & Gandek, 1993). The disease burden of social phobia appears to be associated with the number of social fears. Subjects with higher numbers of feared social situations suffer more from social, functional and psychological disability (Vriends 2006). Consequently, the burden associated with the generalized social phobia subtype seem to be higher than that for the more isolated social fears (Stein & Kein, 2000; Kessler et al., 1998). Patients with the generalized subtype appear to be more anxious and depressed, have lower performance on behavioural and cognitive tasks, and report a lower quality of life compared to the non-generalized subgroup (Heimberg et al., 1990; Safren et al., 1996). In addition, comorbidity is also found to be related to the severity of the disorder and hence to the burden associated with it (Wittchen et al., 2000). Furthermore, suicidal ideation has been found to be more prevalent in social phobics with comoribid depression (Schneier et al, 1992; Davidson et al, 1993) Costs of Social Phobia With a lifetime prevalence of 16.6%, anxiety disorders are among the most prevalent psychiatric disorders (Somers et al., 2006). They are found to be associated with huge economic costs. In terms of total costs, panic disorder appeared to be the most expensive anxiety disorder (Konnopka et al., 2008). However, along with specific phobias and agoraphobia, social phobia has also been shown to be associated with substantial economic costs (Konnopka et al., 2008; Löthgren, 2004; Greenberg et al., 1999; Smit et al., 2006). The scarce research findings in this area suggest that social phobia is associated with more frequent use of prescribed medication (Patel et al., 2002), higher levels of GP visits (Patel et al, 2002), higher levels of unemployment (Patel, et al., 2002; Wittchen et al., 1996), more absenteeism from work (Lecrubier et al., 2000; Wittchen et al., 1996), increased financial dependency (Schneier et al., 1992; Leon et al., 1995), and decreased work productivity (Kessler et al., 1997; Wittchen et al., 2000). 15

16 Until now very few studies have examined the relationship between the different types of social fears and economic costs, nor between the number of social fears and economic costs (Wittchen et al., 2000, Stein et al., 2000). 5. Treatment 5.1. Help Seeking Behaviour Despite the increased functional impairment and decreased quality of life, many aspects of help-seeking behavior of social phobics remain unclear. Some studies report increased helpseeking behaviour in subjects with social phobia (Schneier et al., 1992), but there are also studies which report decreased help-seeking behaviour (Magee et al., 1996). It has also been suggested that subjects with social phobia who receive professional help, seek mainly help for their comorbid mental illnesses, but not for social phobia (Davidson, Hughes, George, & Blazer, 1993; Lepine, et al., 1995). In the National Comorbidity Survey, it was found that people with social phobia and a comorbid disorder seek help more often than those without a comorbid mental disorder (Magee et al., 1996). Several factors may contribute to decreased help seeking behaviour of people with social phobia. First of all, social phobics may attribute their symptoms to their personality (such as shyness) and do not consider the symptoms as part of a disorder. This is strengthened by the early onset of most cases of social phobia (Magee et al., 1996). Because they consider their social phobia as a part of their personality, they are less inclined to seek help. Second, people may not know that social phobia can be successfully treated by psychotherapy or pharmacotherapy (Feske & Chambless, 1995). Another related factor contributing to the decreased help seeking behaviour may be avoidance behaviour. A person with social phobia may view psychotherapy as a social interaction which induces anxiety and which is therefore avoided. Furthemore, they might be anxious about stigmatization (Davidson et al., 1993) Treatment Psychological interventions have been found to be effective in the treatment of social phobia (Rodebaugh et al., 2004), also at the longer term (Feske & Chambless, 1995). The most widely used psychological treatment for social phobia is cognitive behaviour therapy, which can include exposure, cognitive restructuring, applied relaxation, social skills training or a combination of them (Taylor, 1996; Federoff & Taylor, 2001). Several controlled studies 16

17 have indicated that all forms of cognitive behaviour therapy are effective in treating social phobia (Taylor, 1996). It is not yet clear whether or not one component of CBT is more effective than other (combinations of) components. While two earlier meta-analyses found that adding cognitive restructuring to exposure therapy did not improve the treatment outcome (Feske & Chambless, 1995; Gould et al., 1997), in another meta-analysis, Taylor (1996) it was found that adding cognitive restructuring to exposure did provide some benefit. Next to psychological treatments, the effectiveness of pharmacotherapy has also been demonstrated well. Most commonly prescribed are: benzodiazepines, monoamine oxidase inhibitors and selective serotonin reuptake inhibitors (SSRIs; Federoff & Taylor, 2001; Gould et al., 1997). Among them, benzodiazepines and SSRIs were found to be the most effective ones in the short-term (Federoff & Taylor, 2001; Gould et al., 1997). In conclusion, although social phobia is a debilitating disorder, cognitive behavioural interventions and pharmacological interventions have been found to be effective in the treatment of social phobia. 6. Aims and structure of this thesis Although social phobia is among the most common mental disorders (Kessler et al., 1994), more research is needed about incidence rates, risk factors associated with onset, and economic costs. The main aim of the present thesis is to contribute to this body of knowledge. First, we want to describe the demographic and clinical characteristics of the people with social phobia. We have used data from NEMESIS to examine the epidemiology of social phobia in the general Dutch population (Chapter 2). Based on previous research (Schneier et al., 1992; Kessler et al., 1999), we hypothesized that comorbidity with other DSM mental disorders would be significantly higher in subjects with social phobia, while the quality of life would be lower. Moreover, related to the high comorbidity rates and the decreased quality of life, we expected an increased service utilization. In this study, we also examined whether social phobia exits on a continuum of increasing severity with the number of social fears ranging from one social fear to multiple social fears. Apart from the disease burden of social phobia, previous research also indicated that social phobia is associated with increased economic costs. In order to examine whether people with social phobia have increased medical and non-medical costs compared to people without any mental disorder, we again used data of NEMESIS. Because we found that the different types 17

18 of social fears and the number of social fears were related to the level of disease burden, we also studied the relationship between the economic costs and the type and number of social fears. In addition, we explored the economic burden of subthreshold social phobia. These findings are discussed in chapter 3. As described above, only few studies have examined the incidence of social phobia. Therefore, we examined risk factors for the incidence of social phobia in the prospective data of NEMESIS. In order to identify high-risk groups for cost-effective prevention at the earliest stage, a methodology which is developed by Smith et al. (2004) was applied (Chapter 4). This chapter provides both the incidence of social phobia in the general Dutch population and a model for the prevention of social phobia. Up to here, in order to investigate these research questions we used the data from the NEMESIS (the Netherlands Mental Health Survey and Incidence Study; N=7076) which was based on a prospective, stratified, random sampling procedure. The data were collected in three waves (1996, 1997, and 1999). Social phobia was assessed according to DSM-III-R with the Composite International Diagnostic Interview (CIDI). The details about sample, instruments and analysis which are specific to each study are described in each of the chapters (chapter 2 to 4). Several meta-analyses have found evidence that psychological treatments such as exposure, cognitive restructuring, social skills training, and applied relaxation are effective in the treatment of social phobia. However, several of these earlier meta-analyses included nonrandomized and uncontrolled studies, which may have resulted in an overestimate the effect sizes of the treatments. In order to assess the effectiveness of psychological treatments, we conducted a new meta-analysis. This meta-analysis was limited to randomized controlled trials and several recent studies were included, which were not included in earlier metaanalyses. In order to explore possible sources of heterogeneity, we also conducted several series of subgroup analyses (which were not conducted in previous meta-analyses). We selected thirty studies which compared a psychological intervention to a control condition (Chapter 5). Finally, in chapter 6 the findings from these studies are discussed and suggestions for future research are given. 18

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25 Chapter 2 Social Phobia and number of social fears, and their association with comorbidity, health-related quality of life and help seeking: A populationbased study Abstract Objectives Community based data were used to examine the association between social phobia and comorbidity, quality of life and service utilization. In addition, the correlations of the number of social fears with these domains were. Method Data are from the Netherlands Mental Health Survey and Incidence Study (NEMESIS) (N=7076). Social phobia was assessed according to DSM-III-R with the Composite International Diagnostic Interview (CIDI); quality of life was assessed according to the Short-Form-36 Health Survey (SF-36). Results The 12-month prevalence of social phobia was 4.8%. Being female, young, low educated, a single parent, living alone, not having a paid job and having a somatic disorder are associated with 12-month social phobia. Mean and median ages of onset of social phobia were 19.3 and 16.0 years, respectively, and mean and median duration were 16.8 and 14.0 years, respectively. 66% of respondents with social phobia had at least one comorbid condition. 12-month social phobia was significantly related to lower quality of life and higher service utilization. The mean number of feared social situations was 2.73 out of the 6 assessed. As the number of social fears increases, comorbidity and service utilization increases, and the quality of life decreases. Conclusions These findings suggest as the number of feared social situations increases, the burden of social phobia rises. In other words, like comorbidity or decreased quality of life, the number of social fears is also an important indicator of the severity of social phobia. We conclude that from a public health perspective, mental health care givers should pay attention to the number of social fears in order to check the severity of social phobia. This chapter has been published as: Acarturk, C; de Graaf, R; van Straten, A; ten Have, M; Cuijpers, P (2008). Social phobia and number of social fears, and their association with comorbidity, health related quality of life and help seeking: a population-based study. Soc Psychiatry Psychiatr Epidemiol.43,

26 Introduction Social phobia is a highly prevalent disorder (Davidson, Hughes, George & Blazer, 1993; Furmark, 2002; Furmark et al., 1999;,Grant et al., 2005; Kessler et al., 2005; Kessler et al., 1994; Kringlen, Torgersen, & Cramer, 2001; Offord, et al., 1996), which is associated with huge loss in quality of life, (Stein & Kean, 2000; Wittchen, Fuetsch, Sonntag, Muller & Liebowitz, 2000) enormous economic costs, (Patel, Knapp, Henderson & Baldwin, 2002), high levels of service use, (Magee, Eaton, Wittchen, McGonagle & Kessler, 1996; Stein & Kean, 2000), serious functional impairments in the areas of education, social and occupational domains (Davidson et al., 1993; Kessler, Stein & Berglund, 1998), and high comorbidity rates with other anxiety and mood disorders (Chartier, Walker & Stein, 2003; Kessler, Stang, Wittchen, Stein & Walters, 1999). It is not yet clear whether specific subtypes of social phobia can be distinguished. In clinical samples, several types of social phobias have been found, with one group of patients suffering exclusively from performance fears (such as speaking in public), while others suffer from a broader range of fears, including both performance fears and interactional fears (such as meeting new people). (Kessler et al., 1998; Vriends, Becker, Meyer, Michael & Margraf, 2007) Generalized social phobia has been defined as a social phobia in which both performance fears and interactional fears occur together. (Safren, Heimberg, Brown & Holle, 1996). However, it has also been defined as a social phobia in which multiple social fears occur together. Although there is some evidence that different types of social phobia do indeed exist, it has also been suggested that there is stronger evidence that social phobia should be seen as a unidimensional condition, (Lepine & Lellouch, 1995; Safren et al., 1996; Stein et al., 2000) in which an increasing number of feared situations is related to increased functional impairments and psychological problems (Bijl, Ravelli & van Zessen, 1998; Furmark, Tillfors, Stattin, Ekselius & Fredrikson, 2000; Stein & Deutsch, 2003; Stein et al., 2000). This would suggest that social phobia exists on a continuum of severity. Whether social phobia exists on a continuum of increasing severity with the numbers of fears, however, has not been studied conclusively yet. Some studies have examined whether evidence could be found for such a continuum by examining the relationship between severity 26