Predictors of persistence of social anxiety disorder: a national study.
ABSTRACT Social anxiety disorder (SAD) is highly prevalent and impairing. Little is known about rates and predictors of persistence of SAD in the community. The current study derived data from the National Epidemiologic Survey on Alcohol and Related Conditions, Wave 1 (2001-2002, n = 43,093) and Wave 2 (2004-2005, n = 34,653), a large survey of a representative sample of the United States adult population. Individuals with current DSM-IV SAD at Wave 1 were re-interviewed 3 years later at Wave 2 using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM IV Version (AUDADIS-IV). We found that in the community, 22.3% of respondents with SAD at the Wave 1 evaluation met DSM-IV criteria for SAD three years later, and endorsement of social interaction fears and a higher number of avoided social situations, treatment-seeking during past year, and comorbidity with mood disorders independently predicted persistence of SAD. These results suggest that persistence of SAD in the community is common and associated with symptom severity and comorbid mood disorders.
- SourceAvailable from: Chelsea Jin[Show abstract] [Hide abstract]
ABSTRACT: Anxiety disorders and major depressive disorder (MDD) often co-occur and share a broad range of risk factors. The goal of this study was to examine whether the co-occurrence of anxiety disorders and MDD could be explained by an underlying latent factor and whether the risk factors exert their effect exclusively through this factor, directly on each disorder, or through a combination of effects at both levels. Data were drawn from a large, nationally representative sample. Confirmatory factor analysis was used to identify the latent structure of anxiety disorders. A multiple indicators multiple causes (MIMIC) approach was used to assess the common and specific effects of risk factors for anxiety disorders. A one-factor model provided a good fit to the co-occurrence of anxiety disorders. Low self-esteem, family history of depression, female sex, childhood sexual abuse, White race, years of education, number of traumatic experiences, and disturbed family environment increased the risk of anxiety disorders and MDD through their effect on the latent factor. There were also several direct effects of the covariates on the disorders, indicating that the effect of the covariates differed across disorders. Risk for anxiety disorders and MDD appears to be mediated partially by a latent variable underlying anxiety disorders and MDD, and partially by disorder-specific effects. These findings may contribute to account for the high rates of comorbidity among disorders, identify commonalities in the etiologies of these disorders, and provide clues for the development of unified preventive interventions.Depression and Anxiety 02/2014; · 4.29 Impact Factor
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ABSTRACT: Chronic major depressive disorder (CMDD) is highly prevalent and associated with high personal and societal cost. Identifying risk factors for persistence and remission of CMDD may help in developing more effective treatment and prevention interventions. Prospective cohort study of individuals participating in the National Epidemiologic Survey on Alcohol and Related Conditions (Wave 1; n=43,093) and its 3-year follow-up (Wave 2; n=34,653) who met a diagnosis of CMDD at the Wave 1 assessment. Among the 504 respondents who met criteria for present CMDD at Wave 1, only 63 (11.52%) of them continued to meet criteria of CMDD. A history of childhood sexual abuse, earlier onset of MDD, presence of comorbidity and a history of treatment-seeking for depression predicted persistence of CMDD three years after the baseline evaluation. Our sample is limited to adults, our follow-up period was only three-years and the diagnosis of CMDD at baseline was retrospective. CMDD shows high rates of remission within three years of baseline assessment, although some specific risk factors predict a persistent course. Given the high personal and societal cost associated with CMDD, there is a need to develop and disseminate effective interventions for CMDD.Journal of Affective Disorders 07/2013; · 3.76 Impact Factor
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ABSTRACT: While we know that social anxiety disorder (SAD) is today's most common anxiety disorder knowledge on its prospective long-term course is sparse. We conducted a systematic literature search using databases Medline and PsycINFO for naturalistic and psychotherapy outcome studies with follow-up durations of at least 24 months. Four naturalistic cohorts and nine psychotherapy trials were included in the review. The naturalistic course in clinical was less favorable than in non-clinical samples (27% vs. 40% recovery rate after 5 years). Psychotherapy trials, all applying (cognitive) behavioral methods, yielded stable outcomes with overall large pre- to follow-up effect sizes on self-report scales. Observer rated remission rates varied considerably (36% to 100%) depending on study design and follow-up length. The results of psychotherapy trials and that of naturalistic studies can hardly be compared due to differences in methodology. More standardized remission and recovery criteria are needed to enhance the understanding of the longitudinal course.Journal of anxiety disorders 08/2013; 27(7):692-702. · 2.68 Impact Factor
Predictors of persistence of social anxiety disorder: A national study
Carlos Blancoa,*, Yang Xua, Franklin R. Schneiera, Mayumi Okudaa, Shang-Min Liua,
Richard G. Heimbergb
aDepartment of Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons, Columbia University,1051 Riverside Drive, unit 69, New York, NY 10032, USA
bAdult Anxiety Clinic, Department of Psychology, Temple University, Philadelphia, PA 19122, USA
a r t i c l e i n f o
Received 7 April 2011
Received in revised form
7 July 2011
Accepted 11 August 2011
Social anxiety disorder
Predictors of persistence
a b s t r a c t
Social anxiety disorder (SAD) is highly prevalent and impairing. Little is known about rates and
predictors of persistence of SAD in the community. The current study derived data from the National
Epidemiologic Survey on Alcohol and Related Conditions, Wave 1 (2001e2002, n ¼ 43,093) and Wave 2
(2004e2005, n ¼ 34,653), a large survey of a representative sample of the United States adult population.
Individuals with current DSM-IV SAD at Wave 1 were re-interviewed 3 years later at Wave 2 using the
Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM IV Version (AUDADIS-IV). We
found that in the community, 22.3% of respondents with SAD at the Wave 1 evaluation met DSM-IV
criteria for SAD three years later, and endorsement of social interaction fears and a higher number of
avoided social situations, treatment-seeking during past year, and comorbidity with mood disorders
independently predicted persistence of SAD. These results suggest that persistence of SAD in the
community is common and associated with symptom severity and comorbid mood disorders.
? 2011 Published by Elsevier Ltd.
Social anxiety disorder (SAD) is highly prevalent (Kessler et al.,
1994, 2005a, 2005b; Stein et al., 1994; Magee et al., 1996; Grant
et al., 2005; Stinson et al., 2007), associated with significant social
and occupational impairment (Schneier et al.,1992; Davidson et al.,
1993; Wittchen and Beloch, 1996; Keller, 2003; Kessler, 2003), and
often co-occurs with other psychiatric disorders (Rapee et al.,1988;
Reich et al.,1994). SAD generallyhas an onset during adolescence or
earlyadulthood (Rapee et al.,1988; Reich et al.,1994; Chartier et al.,
1998) and is typically considered to be chronic (Reich et al., 1994;
Yonkers et al., 2003; Grant et al., 2005).
Data from clinical samples have suggested that SAD seldom
remits (Reich et al.,1994; Massion et al., 2002; Yonkers et al., 2003).
Initial short-term treatment studies suggested that early age of
onset (Yonkers et al., 2003) and comorbid alcohol use disorders
(Versiani et al., 1988) were associated with persistence of SAD,
whereas gender (Cameron et al., 1986) and duration of illness
(Mersch et al., 1991) did not seem to affect its chronicity. More
recently, prospective data (Reich et al., 1994; Massion et al., 2002;
Yonkers et al., 2003) from the Harvard/Brown Anxiety Research
Program (HARP), which followed treatment-seeking patients with
anxiety disorders for up to eight years, indicated that gender, age of
onset, and comorbid anxiety and mood disorders did not predict
persistence of SAD (Reich et al., 1994; Massion et al., 2002), but
avoidant personality disorder (APD) did (Massion et al., 2002). In
primary care settings, comorbid panic disorder and lower psycho-
social functioning have also been found to predict the persistence
of SAD (Beard et al., 2010).
Several studies using community samples have also examined
persistence of SAD. Data from the Duke site of the Epidemiological
Catchment Area study suggested that earlier age of onset and
presence of psychiatric comorbidity were associated with the
persistence of SAD (Davidson et al.,1993), whereas results from the
National Comorbidity Survey indicated that endorsing more than
one social fear predicted persistence of SAD (Kessler et al., 1998).
Conflicting results have been reported from longitudinal studies.
For instance, the Dresden Predictor Study found, in an 18-month
follow-up of 91 young women with SAD, that having a lifetime
history of depression, a higher number of comorbid psychiatric
disorders, higher levels of stress, poorer mental status, and being
unemployed at baseline predicted persistence of SAD (Vriends
et al., 2007). However, data from the Early Developmental Stages
of Psychopathology Study on 183 adolescents and young adults
with SAD followed for up to 4 years indicated that most socio-
demographic factors, clinical characteristics, comorbid psychiatric
disorders, familial factors, and stressful life events did not predict
the persistence of SAD (Müller, 2002).
* Corresponding author. Tel.: þ1 212 543 6533; fax: þ1 212 543 6515.
Contents lists available at SciVerse ScienceDirect
Journal of Psychiatric Research
journal homepage: www.elsevier.com/locate/psychires
0022-3956/$ e see front matter ? 2011 Published by Elsevier Ltd.
Journal of Psychiatric Research 45 (2011) 1557e1563
Although these previous studies have advanced our knowledge
of the course of SAD, they have been constrained by having modest
sample size (Davidson et al., 1993; Vriends et al., 2007), use of
cross-sectional data (Kessler et al., 1998; DeWit et al., 1999), or
reliance on clinical samples (Beard et al., 2010), limiting the
generalizability of their findings. Large prospective studies in the
community are essential for the identification of predictors of
persistence of SAD in the general population.
To expand current knowledge on this topic, we used data from
a large and nationally representative community sample of United
States (US) adults, the National Epidemiologic Survey on Alcohol
and Related Conditions (NESARC) (n ¼ 43,093) and its 3-year
prospective follow-up (n ¼ 34,653). In the NESARC, the 12-month
prevalence of SAD at baseline (i.e., Wave 1) was 2.76% (Grant
et al., 2005). The large size and representiveness of the NESARC
sample and the longitudinal design of the study provide an unusual
opportunity to simultaneously examine a broad range of variables
that have been hypothesized to predict the course of SAD. Specifi-
cally, we sought to: 1) investigate differences in sociodemographic
characteristics among individuals with persistent and remitted
SAD; 2) compare rates of psychiatric comorbidity among individ-
uals with persistent and remitted SAD; 3) examine clinical char-
acteristics of SAD among individuals with persistent and remitted
SAD; and, 4) examine childhood and adulthood risk factors among
individuals with remitted and persistent SAD.
2. Materials and methods
(Grant et al.,1995, 2004, 2005; Hasin et al.,1997; Canino et al.,1999;
Grant et al., 2003a, 2004, 2005, 2009; Grant and Kaplan, 2005). The
target population was the civilian non-institutionalized population
18 years and older, residing in households and group living quarters
(Grant et al., 1995; Ruan et al., 2008). All procedures, including
U.S. Census Bureau and U.S. Office of Management and Budget.
The NESARC consisted of a first wave conducted in 2001e2002
(N ¼ 43,093) (Grant et al., 2003a, 2004) followed up by a second
wave in 2004e2005 (N ¼ 34,653) (Grant et al., 2005). In Wave 2,
attempts were made to conduct face-to-face re-interviews with all
43,093 respondents to the Wave 1 interview. Excluding respon-
dents ineligible for the Wave 2 interview (e.g. deceased) the Wave 2
response rate was 86.7%; thus, 34,653 respondents completed
Wave 2 interviews. The cumulative response rate from the two
waves was 70.2% and sample weights were developed to addi-
tionally adjust for Wave 2 non-response (Ruan et al., 2008).
At Wave 1, 1140 respondents met criteria for current DSM-IV
SAD. Of these, 989 also participated in Wave 2 and constitute the
present sample. The mean interval between Wave 1 and Wave 2
interviews was 36.6 (Standard Deviation (SD) ¼ 2.62) months.
2.2.1. Sociodemographic factors
Sociodemographic measures included age, sex, race-ethnicity,
nativity, education, marital status, urbanicity, employment status,
and insurance type.
2.2.2. DSM-IV diagnostic interview
All psychiatric diagnoses were made according to DSM-IV
criteria, using the Alcohol Use Disorder and Associated Disabil-
ities Interview Schedule-DSM IV Version (AUDADIS-IV) (Grant
et al., 1995), a valid and reliable fully structured diagnostic inter-
view designed for use by lay professional interviewers. Axis I
diagnoses are separated into three main groups: 1) substance use
disorders (including any alcohol abuse/dependence, any drug
abuse/dependence, and any nicotine dependence); 2) mood
disorders (including major depressive disorder, dysthymia, and
bipolar disorder); and 3) anxiety disorders (including SAD, panic
disorder, specific phobia, and generalized anxiety disorder). The
testetest reliability and validity of AUDADIS-IV of those DSM-IV
diagnoses in the general population and clinical settings range
from good to excellent (Grant et al., 1995, 2003b; Chatterji et al.,
1997; Canino et al., 1999; Ruan et al., 2008).
Personality disorders (PDs) assessed at Wave 1 (Bronisch and
Hecht, 1990; Chartier et al., 1998; The WHO World Mental Health
Survey Consortium, 2004; Karlsson et al., 2010) included avoidant,
dependent, obsessive-compulsive, paranoid, schizoid, histrionic
and antisocial PDs. Due to concerns about the validity of psychotic
diagnoses in general population surveys as well as the length of the
interview, a diagnosis of psychotic disorder was assigned if the
respondent answered affirmatively to a question about whether he
or she had ever been told by a doctor or other health professional
that he or she had schizophrenia or a psychotic disorder.
2.2.3. DSM-IV SAD
Diagnosis of SAD required a marked or persistent fear of social
or performance situations in which embarrassment or humiliation
may occur. The fear had to be recognized as excessive or unrea-
sonable, and the feared social situation must had been avoided or
endured with intense anxiety. All SAD diagnoses required that the
clinical significance criterion of DSM-IV be met (i.e., symptoms of
the disorder must have caused clinically significant distress and/or
impairment in social, occupational, or other areas of functioning).
The test-retest reliability of the diagnosis of SAD was fair
(k ¼ 0.42e0.46) (Grant et al., 2005, 2009), similar to other instru-
ments used in epidemiological studies (Ruscio et al., 2008).
2.2.4. Remission and persistence
Consistent with prior community studies (Kessler et al., 1998;
Wang et al., 2005), individuals who met DSM-IV criteria for
persistent cases, whereas respondents who met criteria for DSM-IV
SAD in Wave 1 but not in Wave 2 were considered remitters.
In view of the greater severity of disorders among treatment-
seeking populations (The WHO World Mental Health Survey
Consortium, 2004) and the particular importance of that informa-
tion for clinicians and policy-makers, we also computed the
persistence rates among the subgroups of individuals with SAD
who reported having sought treatment during the year before their
Wave 1 interview and those who did not.
2.2.5. Clinical characteristics
Variables describing clinical characteristics of SAD were
measured at Wave 1, including subtype of SAD (generalized vs. non-
generalized), presence of panic attacks in social situations, types
and number of feared social situations, and whether the respon-
dent ever used alcohol or illicit or non-prescribed drugs to help
relieve symptoms of SAD. In DSM-IV, the generalized subtype of
SAD is assigned when an individual endorses fear of “most social
situations”(American Psychiatric Association, 1994), although the
operationalization of that definition has not been standardized
(Heimberg et al., 1995). Consistent with our prior work (Schneier
et al., 2010), in the present study, the generalized subtype of SAD
was operationalized as fear of more than seven of the 14 situations
queried, with the remainder of SAD respondents classified as
having the non-generalized subtype.
C. Blanco et al. / Journal of Psychiatric Research 45 (2011) 1557e1563
Variables describing the course of SAD included age of onset,
duration of the disorder, duration of the longest and most recent
episodes, and number of episodes.
Respondents were classified as having received treatment for
SAD if, due to their symptoms of SAD, they ever: (1) visited a physi-
cian, psychologist, or any other professional; (2) were a patient in
a hospital for at least one night; (3) visited an emergency room; or
(4) were prescribed medications.
2.2.7. Other measures
Some studies (Chartier et al., 1998; DeWit et al., 1999) have
suggested that childhood family environment and current mental
and physical well-being affect the course of SAD. To examine the
effect of these features in predicting persistence of SAD, we also
incorporated measures of childhood risk factors. These included
a vulnerable family environment (as in prior studies (Vesga-López
et al., 2008; Alegria et al., 2010) operationalized as parental
absence or separation from a biological parent before age 18),
parental loss before age of 18, parental history of Substance Use
Disorder and parental history of depression. Psychosocial func-
tioning was measured at Wave 1 with the role emotional, social
function, mental health, and physical health disability scores of the
Short Form-12 version 2 (SF-12), a valid and reliable measure of
current functioning used in large population surveys (Jenkinson
et al., 1997).
2.3. Statistical analyses
Weighted percentages and means were computed to describe
the characteristics of individuals with remitted and persistent SAD.
Odds ratios were used to assess the strength of bivariate associa-
tions between persistence of DSM-IV SAD and sociodemographic
characteristics, comorbid psychiatric disorders, clinical correlates,
childhood risk factors, and level of psychosocial functioning. Stan-
dard errors and 95% confidence intervals for all analyses were
estimated using SUDAAN (Research Triangle Institute, 2004) to
adjust for the design effects of the NESARC.
We conducted hierarchical stepwise regression to identify
predictors of persistence after adjusting for other covariates. Vari-
ables with a p-value ? 0.2 in bivariate analyses were selected as
covariates to be arranged into four sets: 1) Clinical features: fear of
social interaction situations, fear of performance situations, panic
attacks during social situations, number of avoided social situa-
tions, duration of SAD, use of alcohol to help relieve SAD symptoms
in the previous year, and past-year treatment seeking; 2) Comor-
bidity: other anxiety disorders, mood disorders, and personality
disorders; 3) Risk Factors: vulnerable family environment, parental
loss before age 18, SF-12 physical component summary, SF-12
mental component summary; and 4) Sociodemographic charac-
teristics: nativity, age, employment, marital status, insurance. Each
set was entered in the regression sequentially and retained only if
the set was statistically significant. Once the significant sets were
identified, we tested the individual significance of the variables
within each set. Thus, the final model was composed only of the
significant variables within the significant sets.
3.1. Persistence rates
Among the 989 respondents who met criteria for SAD at Wave 1,
22.3% continued to meet criteria at Wave 2. Persistence rates were
47.5% and 17.4% among thosewho sought treatment during the past
year (n ¼ 149) and those who did not (n ¼ 840), respectively.
3.1.1. Sociodemographic characteristics
Individuals with persistent SAD were more likely to be younger
than those who remitted from SAD. There were no differences in
nativity, gender, race-ethnicity, educational level, urbanicity or
insurance type between individuals with persistent and remitted
SAD (Table 1).
3.2. Psychiatric comorbidity
Individuals with persistent SAD were more likely to have any
psychiatric and any axis I disorder than individuals with remitted
SAD. Individuals with persistent SAD had higher odds of having all
other anxiety disorders and all mood disorders except bipolar II
disorder. The odds of having any personality disorder, and avoi-
dant, schizoid, and paranoid personality disorders were also
significantly higher among individuals with persistent SAD than
among those who remitted from SAD (Table 2).
3.3. Clinical characteristics and treatment-seeking
Compared with those who remitted, individuals with persistent
SAD had significantly higher odds of having generalized SAD,
fearing social interaction situations, having panic attacks during
social situations, and alsoreported avoidance of a greater numberof
Sociodemographic characteristics of individuals with persistent and remitted SAD.
n ¼ 221
n ¼ 768
Lower than high school
Employed or at school
Abbreviations. OR: Odds Ratio. SE: Standard Error. CI: Confidence Interval.
C. Blanco et al. / Journal of Psychiatric Research 45 (2011) 1557e1563
social situations. The odds of fearing performance situations did not
differ between individuals with persistent and remitted SAD. Indi-
viduals with persistent SAD were more likely to have used alcohol
to relieve SAD symptoms. Age of onset, duration of the disorder,
duration of the longest and most recent episodes, mean number of
episodes, and use of illicit drugs to relieve symptoms did not differ
significantly between individuals with persistent and remitted SAD.
Past 12-month treatment-seeking rates were significantly higher
among individuals with persistent SAD (Table 3).
3.4. Childhood risk factors and psychosocial functioning
There were no differences in any of the childhood risk factors
between individuals with persistent and remitted SAD. However,
individuals with persistent SAD had lower scores in the mental
component summary, social functioning scale, role emotional
functioning scale, and the mental health scale of the SF-12. There
were no differences in physical component summary score
3.5. Hierarchical stepwise regression
In the hierarchical stepwise regression, fearing social interaction
situations, endorsing a larger number of feared social situations,
having sought treatment during the past year, and having
a comorbid mood disorder were all unique predictors of the
persistence of SAD (Table 5).
To our knowledge, this is the first prospective study using
a national representative sample to examine predictors of persis-
tence of SAD. We found that in the community 22.3% of individuals
with SAD at the baseline evaluation met DSM-IV criteria for SAD
three years later. In bivariate analyses, several sociodemographic
correlates, psychiatric comorbidity, and clinical characteristics
predicted persistence of SAD. However, results of the hierarchical
stepwise regression indicated that only fear of social interaction
situations, number of avoided social situations, past-year treatment
seeking for SAD, and co-occurrence of any mood disorder uniquely
predicted persistence of SAD.
Consistent with results from a previous community studies
(Beard et al., 2010; Karlsson et al., 2010), rates of persistence of SAD
in the present study were lower than those in clinical samples
(Cameron et al.,1986; Reich et al.,1994). Moreover, consistent with
previous community data for SAD (Magee et al.,1996; DeWit et al.,
1999), treatment-seeking was associated with persistent SAD. The
association between past treatment-seeking with disorder persis-
tence has been documented previously in other psychiatric disor-
ders (The WHO World Mental Health Survey Consortium, 2004)
and may reflect that individuals with more severe forms of
a disorder are more motivated to seek treatment. Nevertheless,
rates of persistence in the present study were lower than those in
some previous studies (Davidson et al., 1993; Chartier et al., 1998;
Yonkers et al., 2001; Massion et al., 2002). The use of different
definitions diagnostic instruments and sampling frames (Cameron
et al., 1986; Rapee et al., 1988; Davidson et al., 1993; Nelson et al.,
2000), retrospective designs (Wang et al., 2005; Krueger and
Markon, 2006), non-national samples (Davidson et al., 1993;
Reich et al., 1994; Chartier et al., 1998; Yonkers et al., 2001;
Comorbidity among individuals with persistent and remitted SAD.
n ¼ 221
n ¼ 768
Any psychiatric disorder
Any axis I disorder
Any substance use disorder
Alcohol Use Disorder
Alcohol abuse disorder
Alcohol dependence disorder
Drug use disorder
Drug abuse disorder
Drug dependence disorder
Any mood disorder
Any anxiety disorder
Generalized anxiety disorder
Any psychotic disorder
Any Personality Disorder
Avoidant personality disorder
Dependant personality disorder
Paranoid personality disorder
Schizoid personality disorder
Histrionic personality disorder
Antisocial personality disorder
Clinical correlates among individuals with remitted and persistent SAD.
n ¼ 221
n ¼ 768
Generalized type of SAD
Fear of interaction situations
Fear of performance situations
Panic attacks during social situations
Number of avoided social situations (mean)
Course of SAD
Age of onset (mean)
Duration of SAD (mean, in years)
Use of alcohol to help relieve SAD symptoms (past year)
Use of drugs to help relieve SAD symptoms (past year)
bWald F test and p-value reported for continuous variables.
C. Blanco et al. / Journal of Psychiatric Research 45 (2011) 1557e1563
Massion et al., 2002), and lower 12-month prevalence than in other
studies (Kessler et al., 1994, 2005b) may have contributed to
differences in the rates of the persistence of SAD across time.
In accord with prior studies (Hecht et al., 1990; Widiger and
Shea, 1991), bivariate analyses indicated that larger number of
anxiety-provoking situations, fear of social interaction situations,
having the generalized subtype SAD, and experiencing panic
attacks during social situations predicted persistence of SAD
(Chambless et al., 1997). Comorbid panic disorder, as well as
comorbidity with other anxiety disorders (in this study, GAD and
specific phobia) may represent a higher baseline of fear or auto-
nomic arousal among persistent cases. However, the higher rate of
situationally predisposed panic attacks may have a more direct link
to the persistence of SAD across time. In a previous study by our
group (Jack et al., 1999), socially anxious patients with situational
panic attacks demonstrated greater fear and avoidance of social
situations, were more distressed and impaired by their fears, and
reported higher levels of anxiety sensitivity and hopelessness than
those without panic. Greater hopelessness, in particular, may
predict persistence of SAD, as it may be associated with a tendency
to withdraw from/avoid social situations, to become more isolated,
and to experience fewer events that could help the person become
desensitized to feared stimuli.
Overall, this increased severity across a number of clinical char-
acteristics of is likely to reflect a more severe form of SAD, which
could be less likely to spontaneously remit. Consistent with this
interpretation, broader severity indicators, such as lower social
functioning and mental health scores and unemployment, were also
associated with lower probability of remission from SAD. Comor-
bidity with mood, personality, and other anxiety disorders were also
associated with persistence of SAD in the bivariate analyses. Comor-
bidity, particularly with avoidant personality disorder (APD), may be
an indicator of a more severe form of SAD (Brown et al., 1995;
Heimberg, 1996). Furthermore, comorbidity may indicate a broader
disruption of psychological functions or neurocircuits, which can
increase persistence and recurrence of SAD (Fyer et al., 1993;
Merikangas and Angst, 1995; Nelson et al., 2000; Kendler and
Prescott, 2006). In bivariate analysis, the present study also found
remission. However, after adjusting for other significant covariates,
that association was no longer significant. Increased use of alcohol
and other psychoactive substances, which has been previously
documented, may represent maladaptive attempts to alleviate SAD
symptoms, which has been previously documented (Schneier et al.,
After adjusting for other significant covariates, the association
between social interaction fears and higher number of avoided
social situations (probably proxies for generalized SAD), treatment-
seeking during past year, as well as comorbidity with mood disor-
ders remained significant. By contrast, none of the sociodemo-
graphic characteristics, psychosocial measures or other psychiatric
disorders remained significant, indicating that their effect on
persistence is fully explained by their association with the clinical
characteristics and comorbidity patterns of individuals with SAD.
The unique predictive value of social interaction fear, rather than
performance fear, topersistence of SAD is consistent with data from
the National Comorbidity Survey, which suggested that the
endorsement of only public speaking fear was the most important
predictorof remission of SAD (Kessler et al.,1998). The independent
predictive value of comorbidity indicates that severity may not be
the only consideration regarding the course of SAD or its treatment.
The strong association between SAD and mood disorders has been
frequently reported. Shared underlying etiological factors between
SAD and mood disorders have been documented in family and twin
studies (Fyer et al., 1993; Merikangas et al., 1994; Nelson et al.,
2000; Kendler and Prescott, 2006). The presence of comorbid
mood disorders among individuals with SAD may reflect broader
abnormalities in the internalizing domain of psychiatric disorders
(Krueger et al., 1998; Kendler et al., 2003; Krueger and Markon,
2006), which may require interventions not exclusively focused
on SAD. Pilot data (Schneier et al., 2003) suggest that selective
serotonin reuptake inhibitors may be effective in treating both
comorbid disorders, although randomized clinical trials are needed
to confirm this finding. Conflicting results have been reported
regarding the efficacy of cognitive-behavioral therapy in individ-
uals with depression. Some studies have found that higher self-
reported levels of depression were associated with poorer treat-
ment response (Chambless et al., 1997), whereas others have that
found that cognitive behavioral therapy for SAD results in equiva-
lent rates of improvement in SAD symptoms for individuals with
Childhood and Adult risk factors of individuals with persistent and remitted SAD.
n ¼ 221
n ¼ 768
Vulnerable family environment
Parental loss before age 18
Parental history of substance use disorder
Parental history of depression
Physical component summary
Mental component summary
Social functioning scale
Role emotional functioning scale
Mental health scale
Number of stressful events during past 12 months
Hierarchical stepwise regression.
Fear of interaction situations
Number of avoided social situations
Any past-year treatment-seeking
Any mood disorder
C. Blanco et al. / Journal of Psychiatric Research 45 (2011) 1557e1563
and without comorbid depression (Erwin et al., 2002). Future
research using randomized clinical trial designs is needed to
reconcile these conflicting findings.
Loss of significance of most clinical characteristics after hierar-
chical stepwise regression analyses, due to strong associations
among them, is consistent with our interpretation of them as
indicators of the severity of SAD. Social anxiety can be conceptu-
alized as a continuum with normal anxiety at one extreme and the
most severe cases of SAD at the other (Rettew, 2000; Tillfors et al.,
2001; Ralevski et al., 2005). If remission is understood as move-
ment from above the diagnostic threshold towards the normal end
of that continuum, higher severity cases (i.e., those further above
the diagnostic threshold) would be expected to be less likely to
spontaneouslycross that threshold, i.e., toremit. Our findings stress
the importance of interventions that improve treatment response
and increase remission rates for SAD (Gould et al., 1997; Blanco
et al., 2003; Hofmann and Smits, 2008).
Our study has limitations common to large scale surveys. First,
although the NESARC survey design included civilian households
and group living populations 18 years and older, information was
unavailable on adolescents, who may have a different course of
SAD. Second, characteristics such as genetic factors, self-efficacy,
and self-criticism (Watson and Friend, 1969; Cox et al., 2004),
which may affect the course of the disorder, were not assessed in
the NESARC. Third, all information was based on respondent report
and not verified by independent clinical evaluators. Fourth, it is
possible that some individuals may have remitted for a period of
time and then had a recurrence of their SAD, which would not truly
reflect persistence of SAD. Fifth, some individuals with SAD in Wave
1 did not participate in Wave 2. However, a comparison of the
demographic and clinical characteristics of individuals who
participated in both Waves (n ¼ 989) versus those who only
participated in Wave 1 (n ¼ 151), indicated that the only differences
between the two groups were that those who only participated in
Wave 1 were significantly more likely to be Hispanic and unem-
ployed than those who participated in both Waves. Since neither
characteristic uniquely predicted remission, these data suggest that
loss to follow-up is unlikely to have substantially influenced the
results of this study.
In summary, although persistence of SAD in the community is
less common than in clinical samples, prospective data indicate
that almost a quarter of individuals continue to have SAD three
years after their baseline assessment. Severity of SAD and psychi-
atric comorbidity increase the likelihood of SAD persistence. This
information may help inform treatment approaches for SAD.
The views and opinions expressed in this report are those of the
authors and should not be construed to represent the views of any
of the sponsoring organizations, agencies, or the U.S. government.
All procedures, including informed consent, received full ethical
review and approval from the U.S. Census Bureau and U.S. Office of
Management and Budget.
1. Conception and design, or acquisition of data, or analysis and
interpretation of data (Carlos Blanco, Yang Xu, Shang-Min Liu).
2. Drafting the article or revising it critically for important
intellectual content (Carlos Blanco, Yang Xu, Franklin Schneier,
Mayumi Okuda, Richard G. Heimberg).
3. Final approval of the version to be published (Carlos Blanco,
Yang Xu, Franklin Schneier, Mayumi Okuda, Shang-Min Liu, Richard
Role of funding source
DA020783DA020783 and DA023200 (to Dr. Blanco) and by the New
York State Psychiatric Institute (to Drs. Blanco and Schneier). The
NESARC was funded by the National Institute on Alcoholism and
Alcohol Abuse, with supplemental support from the National
Institute on Drug Abuse.
by NIHgrantsDA019606 DA019606,
Conflict of interest
All authors declare that they have no conflict of interest.
Alegria A, Hasin D, Nunes E, Liu S, Davies C, Grant B, et al. Comorbidity generalized
anxiety disorder and substance use disorders: results from the National
Epidemiologic Survey on alcohol and related conditions. Journal of Clinical
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. Washington: American Psychiatric Association; 1994.
Beard C, Moitra E, Weisberg RB, Keller MB. Characteristics and predictors of social
phobia course in a longitudinal study of primary-care patients. Depression and
Blanco C, Schneier FR, Schmidt A, Blanco-Jerez CR, Marshall RD, Sánchez-Lacay A,
et al. Pharmacological treatment of social anxiety disorder: a meta-analysis.
Depression and Anxiety 2003;18:29e40.
Bronisch T, Hecht H. Major depression with and without a coexisting anxiety
disorder: social dysfunction, social integration, and personality features. Journal
of Affective Disorders 1990;20:151e7.
Brown EJ, Heimberg RG, Juster HR. Social phobia subtype and avoidant personality
disorder: effect on severity of social phobia, impairment, and outcome of
cognitive behavioral treatment. Behavior Therapy 1995;26:467e86.
Cameron OG, Thyer BA, Feckner S, Nesse R, Curtis GC. Behavior therapy of phobias:
predictors of outcome. Psychiatry Research 1986;19:245e6.
Canino GJ, Bravo M, Ramírez R, Febo V, Fernández R, Hasin DS. The Spanish Alcohol
Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reli-
ability and concordance with clinical diagnoses in a Hispanic population.
Journal of Studies on Alcohol 1999;60:790e9.
Chambless DL, Tran GQ, Glass CR. Predictors of response to cognitive-behavioral
group therapy for social phobia. Journal of Anxiety Disorders 1997;11:221e40.
Chartier MJ, Hazen AL, Stein MB. Lifetime patterns of social phobia: a retrospective
study of the course of social phobia in a nonclinical population. Depress Anxiety
Chatterji S, Saunders JB, Vrasti R, Grant BF, Hasin D, Mager D. Reliability of the
alcohol and drug modules of the Alcohol Use Disorder and Associated
Disabilities Interview Schedule Alcohol/Drug-Revised (AUDADIS-ADR): an
international comparison. Drug and Alcohol Dependence 1997;47:171e85.
Cox BJ, Fleet C, Stein MB. Self-criticism and social phobia in the US National
Comorbidity Survey. Journal of Affective Disorders 2004;82:227e34.
Davidson JR, Hughes DL, George LK, Blazer DG. The epidemiology of social phobia:
findings from the Duke epidemiological catchment area study. Psychological
DeWit DJ, Ogborne A, Offord DR, MacDonald K. Antecedents of the risk of recovery
from DSM-III-R social phobia. Psychological Medicine 1999;29:569e82.
Erwin BA, Heimberg RG, Juster H, Mindlin M. Comorbid anxiety and mood disorders
among persons with social anxiety disorder. Behavior Research and Therapy
Fyer AJ, Mannuzza S, Chapman TF, Liebowitz MR, Klein DF. A direct interview family
study of social phobia. Achieves of General Psychiatry 1993;50:286e93.
Gould RA, Buckminster S, Pollack MH, Otto MW, Massachusetts LY. Cognitive-
behavioral and pharmacological treatment for social phobia: a meta-Analysis.
Clinical Psychology: Science and Practice 1997;4:291e306.
Grant BF, Dawson DA, Stinson FS, Chou PS, Kay W, Pickering R. The Alcohol Use
Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV):
reliability of alcohol consumption, tobacco use, family history of depression and
psychiatric diagnostic modules in a general population sample. Drug and
Alcohol Dependence 2003b;71:7e16.
Grant BF, Goldstein RB, Chou SP, Huang B, Stinson FS, Dawson DA, et al. Socio-
demographic and psychopathologic predictors of first incidence of DSM-IV
substance use, mood and anxiety disorders: results from the Wave 2 National
Epidemiologic Survey on Alcohol and Related Conditions. Molecular Psychiatry
Grant BF, Harford TC, Dawson DA, Chou PS, Pickering RP. The Alcohol Use Disorder
and Associated Disabilities Interview Schedule (AUDADIS): reliability of alcohol
C. Blanco et al. / Journal of Psychiatric Research 45 (2011) 1557e1563
and drug modules in a general population sample. Drug and Alcohol Depen-
Grant BF, Hasin DS, Blanco C, Stinson FS, Chou SP, Goldstein RB, et al. The epide-
miology of social anxiety disorder in the United States: results from the
National Epidemiologic Survey on alcohol and related conditions. Journal of
Clinical Psychiatry 2005;66:1351e61.
Grant BF, Kaplan K. Source and Accuracy Statement for the Wave 2 National
Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Rockville,
MD: National Institute on Alcohol on Alcohol Abuse and Alcoholism; 2005.
Grant BF, Moore TC, Shepard J, Kaplan K. Source and Accuracy Statement: Wave 1
National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).
Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; 2003a.
Grant BF, Stinson FS, Dawson DA, Chou SP, Dufour MC, Compton W, et al. Preva-
lence and co-occurrence of substance use disorders and independent mood
and anxiety disorders: results from the National Epidemiologic Survey on
alcohol and related conditions. Archives of General Psychiatry 2004;61:
Hasin DS, Van Rossem R, McCloud S, Endicott J. Differentiating DSM-IV alcohol
dependence and abuse by course: community heavy drinkers. Journal of
Substance Abuse 1997;9:127e35.
Hecht H, D Von Zerssen, Wittchen H-U. Anxiety and depression in a community
sample: the influence of comorbidity on social functioning. Journal of Affective
Heimberg R, Liebowitz M, Hope D, Schneier F. Social phobia: Diagnosis, assessment,
and treatment. New York: Guilford Press New York; 1995.
Hofmann S, Smits J. Cognitive-behavioral therapy for adult anxiety disorders:
a meta-analysis of randomized placebo-controlled trials. Journal of Clinical
JackMS,Heimberg RG, Mennin DS. Situational panic attacks: impacton social phobia
with and without panic disorder. Depression and Anxiety 1999;10:112e8.
Jenkinson C, Layte R, Jenkinson D, Lawrence K, Petersen S, Paice C, et al. A shorter
form health survey: can the SF-12 replicate results from the SF-36 in longitu-
dinal studies? Journal of Public Health 1997;19:179e86.
Karlsson B, Sigstrom R, Waern M, Ostling S, Gustafson D, Skoog I. The prognosis and
incidence of social phobia in an elderly population: a 5-year follow-up. Acta
Psychiatrica Scandinavica 2010;122:4e10.
Keller MB. The lifelong course of social anxiety disorder: a clinical perspective. Acta
Psychiatrica Scandinavica Supplements; 2003:85e94.
Kendler K, Prescott C. Genes, environment, and psychopathology. New York: Guil-
ford Press; 2006.
Kendler KS, Prescott CA, Myers J, Neale MC. The structure of genetic and environ-
mental risk factors for common psychiatric and substance use disorders in men
and women. Archives of General Psychiatry 2003;60:929e37.
Kessler RC. The impairments caused by social phobia in the general population:
implications for intervention. Acta Psychiatrica Scandinavica 2003;108:19e27.
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime
prevalence and age-of-onset distributions of DSM-IV disorders in the National
Comorbidity Survey replication. Archives of Generl Psychiatry 2005a;62:
Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of
12-Month DSM-IV disorders in the National Comorbidity Survey replication.
Archives of General Psychiatry 2005b;62:617e27.
Kessler RC, McGonagle KA, Zhao S, NelsonCB Hughes M, Eshleman S, Wittchen H-U,
et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in
the United States: results from the National Comorbidity Survey. Archives of
General Psychiatry 1994;51:8e19.
Kessler RC, Stein MB, Berglund P. Social phobia subtypes in the National Comor-
bidity Survey. American Journal of Psychiatry 1998;155:613e9.
Krueger RF, Caspi A, Moffitt TE, Silva PA. The structure and stability of common
mental disorders (DSM-III-R): a longitudinal-epidemiological study. Journal of
Abnormal Psychology 1998;107:216e27.
Krueger RF, Markon KE. Reinterpreting comorbidity: a model-based approach to
understanding and classifying psychopathology. Annual Review of Clinical
Magee WJ, Eaton WW, Wittchen HU, McGonagle KA, Kessler RC. Agoraphobia,
simple phobia, and social phobia in the National Comorbidity Survey. Archives
of General Psychiatry 1996;53:159e68.
Massion AO, Dyck IR, Shea MT, Phillips KA, Warshaw MG, Keller MB. Personality
disorders and time to remission in generalized anxiety disorder, social phobia,
and panic disorder. Archives of General Psychiatry 2002;59:434e40.
Merikangas K, Angst J. Comorbidity and social phobia: evidence from clinical,
epidemiologic, and genetic studies. European Archives of Psychiatry and Clin-
ical Neuroscience 1995;244:297e303.
Merikangas KR, Risch NJ, Weissman MM. Comorbidity and co-transmission of
alcoholism, anxiety and depression. Psychological Medicine 1994;24:69e80.
Mersch PP, Emmelkamp PM, Lips C. Social phobia: individual response patterns and
the long-term effects of behavioral and cognitive interventions. A follow-up
study. Behavior Research and Therapy 1991;29:357e62.
Müller N. Die soziale Angststörung bei Jugendlichen und jungen Erwachsenen,
Erscheinungsformen, Verlauf Und Konsequenzen (Social anxiety disorder in
adolescents and young adults, manifestations, course and consequences).
Münster, New York, München, Berlin: Waxma; 2002.
Nelson E, Grant J, Bucholz K, Glowinski A, Madden P, Reich W, et al. Social phobia in
a population-based female adolescent twin sample: co-morbidity and associ-
ated suicide-related symptoms. Psychological Medicine 2000;30:797e804.
Ralevski Sanislow CA, Grilo CM, Skodol AE, Gunderson JG, Shea MT, Yen S, et al.
Avoidant personality disorder and social phobia: distinct enough to be separate
disorders? Acta Psychiatrica Scandinavica 2005;112:208e14.
Rapee RM, Sanderson WC, Barlow DH. Social phobia features across the DSM-III-R
anxiety disorders. Journal of Psychopathology and Behavior Assessment 1988;
Reich J, Goldenberg I, Vasile R, Goisman R, Keller M. A prospective follow-along
study of the course of social phobia. Psychiatry Research 1994;54:249e58.
Research Triangle Institute. Software for Survey Data Analysis (SUDAAN), Version
9.0. Research Triangle Park, NC: Research Triangle Institute; 2004.
Rettew DC. Avoidant personality disorder, generalized social phobia, and shyness:
putting the personality back into personality disorders. Harvard Review of
Ruan WJ, Goldstein RB, Chou SP, Smith SM, Saha TD, Pickering RP, et al. The Alcohol
Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV):
reliability of new psychiatric diagnostic modules and risk factors in a general
population sample. Drug and Alcohol Dependence 2008;92:27e36.
Ruscio A, Brown T, Chiu W, Sareen J, Stein M, Kessler R. Social fears and social
phobia in the USA: results from the National Comorbidity Survey replication.
Psychological Medicine 2008;38:15e28.
Social phobia, avoidant personality disorder and the multiaxial conceptualization of
interpersonal anxiety (pp. 43e61). In: Heimberg R, Salkovskis PM, editors.
Trends in cognitive and behavioural therapies. New York: John Wiley & Sons;
1996. p. 43e61.
Schneier FR, Blanco C, Campeas R, Lewis-Fernandez R, Lin S-H, Marshall R, et al.
Citalopram treatment of social anxiety disorder with comorbid major depres-
sion. Depression and Anxiety 2003;17:191e6.
Schneier FR, Foose TE, Hasin DS, Heimberg RG, Liu S-M, Grant BF, et al. Social
anxiety disorder and alcohol use disorder co-morbidity in the National Epide-
miologic Survey on Alcohol and Related Conditions. Psychological Medicine
Schneier FR, Johnson J, Hornig CD, Liebowitz MR, Weissman MM. Social phobia.
comorbidity and morbidity in an epidemiologic sample. Archives of General
Stein MB, Walker JR, Forde DR. Setting diagnostic thresholds for social phobia:
considerations from a community survey of social anxiety. American Journal of
Stinson FS, Dawson DA, Chou SP, Smith S, Goldstein RB, Ruan WJ, et al. The
epidemiology of DSM-IV specific phobia in the USA: results from the National
Epidemiologic Survey on alcohol and related conditions. Psychological Medi-
The WHO World Mental Health Survey Consortium. Prevalence, severity, and
unmet need for treatment of mental disorders in the World Health Organiza-
tion World Mental Health Surveys. JAMA 2004;291:2581e90.
Tillfors M, Furmark T, Ekselius L, Fredrikson M. Social phobia and avoidant
personality disorder as related to parental history of social anxiety: a general
population study. Behavior Research and Therapy 2001;39:289e98.
Versiani M, Mundim FD, Nardi AE, Liebowitz MR. Tranylcypromine in social phobia.
Journal of Clinical Psychopharmacology 1988;8:279e83.
Vesga-López O, Schneier F, Wang S, Heimberg R, Liu S, Hasin D, et al. Gender
differences in generalized anxiety disorder: results from the National Epide-
miologic Survey on Alcohol and Related Conditions (NESARC). Journal of Clinical
Vriends N, Becker ES, Meyer A, Williams SL, Lutz R, Margraf J. Recovery from social
phobia in the community and its predictors: data from a longitudinal epide-
miological study. Journal of Anxiety Disorders 2007;21:320e37.
Wang PS, Berglund P, Olfson M, Pincus HA, Wells KB, Kessler RC. Failure and delay in
initial treatment contact after first onset of mental disorders in the National
Watson D, Friend R. Measurement of social-evaluative anxiety. Journal of Consul-
ting and Clinical Psychology 1969;33:448e57.
Widiger TA, Shea T. Differentiation of axis I and axis II disorders. Journal of
Abnormal Psychology 1991;100:399e406.
Wittchen H-U, Beloch E. The impact of social phobia on quality of life. International
Clinical Psychopharmacology 1996;11:15e23.
Yonkers KA, Bruce SE, Dyck IR, Keller MB. Chronicity, relapse, and illnessecourse of
panic disorder, social phobia, and generalized anxiety disorder: findings in men
and women from 8 years of follow-up. Depression and Anxiety 2003;17:173e9.
Yonkers KA, Dyck IR, Keller MB. An eight-year longitudinal comparison of clinical
course and characteristics of social phobia among men and women. Psychiatric
C. Blanco et al. / Journal of Psychiatric Research 45 (2011) 1557e1563