Elsevier

Journal of Psychiatric Research

Volume 46, Issue 9, September 2012, Pages 1223-1230
Journal of Psychiatric Research

The multiple dimensions of the social anxiety spectrum in mood disorders

https://doi.org/10.1016/j.jpsychires.2012.06.002Get rights and content

Abstract

Major depressive disorder and bipolar spectrum disorders are debilitating conditions associated with severe impairment. The presence of co-occurring social phobia can make the clinical course of these disorders even more challenging. To better understand the nature of social anxiety in the context of ongoing mood disorders, we report the results of exploratory factor analyses of the Social Phobia Spectrum Self-Report Instrument (SHY), a 162-item measure designed to capture the full spectrum of manifestations and features associated with social anxiety experienced across the lifespan. We examined data from 359 adult outpatients diagnosed with major depressive disorder and 403 outpatients diagnosed with a bipolar spectrum disorder. The measure was divided into its two components: the SHY-General (SHY-G), reflecting general social anxiety features, and the SHY-Specific (SHY-S), reflecting anxiety in specific situations. Exploratory factor analyses were conducted for each using tetrachoric correlation matrices and an unweighted least squares estimator. Item invariance was evaluated for important patient subgroups. Five factors were identified for the SHY-G, representing general features of social anxiety: Fear of Social Disapproval, Childhood Social Anxiety, Somatic Social Anxiety, Excessive Agreeableness, and Behavioral Submission. Seven specific-situation factors were identified from the SHY-S: Writing in Public, Dating, Public Speaking, Eating in Public, Shopping Fears, Using Public Restrooms, and Unstructured Social Interactions. The identified dimensions provide clinically valuable information about the nature of the social fears experienced by individuals diagnosed with mood disorders and could help guide the development of tailored treatment strategies for individuals with co-occurring mood disorders and social anxiety.

Introduction

The co-occurrence of mood disorders and social phobia is not only common, but is associated with negative clinical outcomes (e.g., Dilsaver and Chen, 2003; Morris et al., 2009; Otto et al., 2006; Schneier et al., 2003). Currently, little is known regarding the nature of social anxiety experienced by individuals diagnosed with mood disorders. Using data from a sample of outpatients with unipolar depression or bipolar disorder, we report results of a factor analytic investigation of a measure of social anxiety designed to capture the full spectrum of manifestations and features of social anxiety experienced across the lifespan. Such data are needed to guide efforts to develop more effective treatments for this particularly difficult combination of pathologies.

Social phobia is frequently estimated to be the most commonly co-occurring anxiety disorder for both major depression and bipolar disorder (Fava et al., 2000; Kessler et al., 1999; Merikangas et al., 2007), and tends to precede the onset of these disorders when they co-occur (Fava et al., 2000; Pini et al., 2006). Such findings have been used to support the “social risk” theory of depression, which posits that depressive symptoms develop to mitigate risk of exclusion from survival-enhancing social contexts (Allen and Badcock, 2003). This theory suggests that many depressive features – such as hypersensitivity to social rejection cues, low self-esteem, and social withdrawal – represent an evolutionarily-adaptive response to reduce the risk of overt social exclusion when individuals perceive that the ratio between their social value and their social burden is diminishing to dangerously low levels. This theory, moreover, provides one framework for understanding why symptoms of depression may be particularly difficult to treat when they co-occur with symptoms of social phobia.

Indeed, co-occurring social phobia is associated with earlier onset, poorer prognosis, and increased suicidality among patients with unipolar depression (Frank et al., 2011; Morris et al., 2009; Schneier et al., 2003) and bipolar disorder (Boylan et al., 2004; Dilsaver et al., 2006; Dilsaver and Chen, 2003; Perroud et al., 2007; Perugi et al., 2001; Pini et al., 2006; Simon et al., 2007). In fact, a recent prospective analysis of the STEP-BD project, containing data from one-thousand outpatients diagnosed with bipolar disorder, revealed that co-occurring social phobia was the only anxiety disorder associated with all five of the negative outcomes observed: fewer well days, longer time to recovery of depressive symptoms, increased likelihood of relapse, poorer quality of life, and increased role dysfunction (Otto et al., 2006).

Little has been reported about the lifetime manifestations of social anxiety experienced by individuals with mood disorders. This may be the consequence of an overreliance on the categorical definitions of the disorders codified in the DSM. In contrast, recent taxometric studies have demonstrated that social fear (Kollman et al., 2006) and social anxiety (Ruscio, 2010) are best described by latent structures that exist on a continuous dimension from normal to abnormal functioning. In fact, Ruscio (2010) demonstrated that the dimensional conceptualization of social anxiety was a stronger predictor of future mood disorder onset, suicidal ideation, and suicide attempt than was categorical DSM-IV diagnosis.

Recognizing the need to develop a measure of social anxiety that captures the full range of manifestation experienced across the entire spectrum of illness, Cassano and colleagues developed the social phobia spectrum instrument (SHY). The SHY was developed explicitly to capture features and phenomena not adequately addressed in the standard diagnostic system. An important component of the spectrum model of psychopathology, from which the SHY was developed, is that it attempts to capture the broad range of manifestations of mental disorder from core symptoms to temperament, behavioral traits, and lifestyles – regardless of whether the full diagnostic criteria are met (Cassano et al., 1999). The model assumes that even subtle manifestations of illness can be clinically meaningful and may point to an underlying diathesis that is shared with patients who display more severe symptoms.

The SHY has strong psychometric properties and convergent validity (Dell'Osso et al., 2000; Dell'Osso et al., 2002), however, no investigation of the measure's underlying structure has been published. In the current study, we examine this structure using exploratory factor analysis in a sample of adult outpatients with either major depressive disorder or bipolar disorder. Given the importance of assessing social anxiety in patients with mood disorders, we aim to uncover the latent structure of lifetime social anxiety in this population. The results of this investigation could foster careful examinations into the role of specific dimensions of social anxiety in the clinical course and treatment outcomes of patients with primary mood disorders.

Section snippets

Sample characteristics

The sample consisted of adult outpatients whose data were drawn from two study cohorts: 359 outpatient participants from a two-site (Pittsburgh, PA and Pisa, Italy) RCT for unipolar depression (MH65376, E. Frank, PI), and 403 outpatient participants from a multi-center RCT for bipolar spectrum disorders (Fagiolini et al., 2005). Full descriptions of the studies' procedures have been published elsewhere (Fagiolini et al., 2005; Frank et al., 2011). All patients in both cohorts were screened

Results

Items from the SHY-G with the highest endorsement frequencies were: being very worried that people might be critical, often feeling more comfortable in small groups, and ever worrying about disapproval or hostility from others. From the SHY-S, the most frequently endorsed items were: feeling uncomfortable when speaking, singing or dancing in front of others, feeling uncomfortable when performing in front of others, and feeling uncomfortable when entering or leaving a room during a meeting or

Discussion

This study provides empirical factor structures of general and specific manifestations of social anxiety experienced by individuals diagnosed with mood disorders. These factors capture and extend current DSM-IV social anxiety disorder criteria. For example, among the general factors, Fear of Social Disapproval assesses the key DSM criterion involving fear of embarrassing and/or humiliating oneself in social situations. Yet, this factor also captures a broad array of fears regarding possible

Role of the funding source

This work was supported by National Institute of Mental Health grants MH065376 (Drs. Frank and Cassano), MH030915 (Dr. Frank) and MH085874 (Cyranowski), investigator-initiated grants from Forest Research Institute (Dr. Frank) and Fondazione IDEA (Dr. Cassano). The funding sources had no further role in the study design, data collection, analysis, interpretation of the data, drafting of the manuscript, or in the decision to submit the paper for publication.

Contributors

Jay Fournier contributed to the conceptualization of the current investigation and took the lead in conducting the statistical analysis, drafting the manuscript, and managing the revisions. Jill Cyranowski contributed to the initial conceptualization and design of the current investigation, and contributed to the interpretation of the results and the revision of the manuscript. Paola Rucci contributed to the data analyses, the interpretation of the results, and manuscript revision. Giovanni B.

Conflict of interest

Dr. Ellen Frank has served as a consultant to Servier and Vanda Pharmaceuticals, has received grant/research support from The Fine Foundation, The Pittsburgh Foundation, and Forest Research Institute, and has received royalties from Guilford Press and the American Psychological Association.

Dr. Cassano has served as a consultant to Aziende Chimiche Riunite Angelini Francesco ACRAF, Janssen Cilag, Abiogen Pharma, Pfizer Italy, Essex Italy, Eli Lilly Italy, GlaxoSmithKline, Boerhinger Ingelheim

Acknowledgments

None.

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