Article

Social anxiety disorder in veterans affairs primary care clinics

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Abstract

To examine the prevalence and correlates of social anxiety disorder (SAD) in veterans, 733 veterans from four VA primary care clinics were evaluated using self-report questionnaires, telephone interviews, and a 12-month retrospective review of primary care charts. We also tested the concordance between primary care providers' detection of anxiety problems and diagnoses of SAD from psychiatric interviews. For the multi-site sample, 3.6% met criteria for SAD. A greater rate of SAD was found in veterans with than without post-traumatic stress disorder (PTSD) (22.0% vs. 1.1%), and primary care providers detected anxiety problems in only 58% of veterans with SAD. The elevated rate of comorbid psychiatric diagnoses and suicidal risk associated with SAD was not attributable to PTSD symptom severity. Moreover, even after controlling for the presence of major depressive disorder, SAD retained unique, adverse effects on PTSD diagnoses and severity, the presence of other psychiatric conditions, and suicidal risk. These results attest to strong relations between SAD and PTSD, the inadequate recognition of SAD in primary care settings, and the significant distress and impairment associated with SAD in veterans.

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... Past year prevalence rates of SAD in both civilian and military populations are somewhat comparable, with 2.8% of the general and 3.6% of military populations meeting diagnostic criteria (Grant et al., 2005;Kashdan, Frueh, Knapp, Hebert, & Magruder, 2006). However, veterans suffering from PTSD are significantly more likely to have SAD than those without PTSD (22% vs. 1.1%). ...
... Likewise, veterans are more likely to have PTSD than the general population (11%-22% vs. 8%) (Ainspan, Penk, & Kearney, 2018;National Center on PTSD, 2018). Increasing the concern for veterans is that comorbid PTSD and SAD has been shown to increase risk of suicide (Kashdan et al., 2006) and aggression (Van Voorhees et al., 2018). ...
... They also may use drugs or alcohol to control feelings of discomfort and anxiety, resulting in potentially risktaking behavior and deleterious personal relationships (Gros et al., 2016). Thus, SAD diminishes potential for building a social support network, increasing risk for other mental health issues and suicidality (Kashdan et al., 2006;McMillan, Asmundson, & Sareen, 2017). ...
Article
Virtual environments have been increasingly used in conjunction with traditional cognitive behavioral treatments for disorders, such as posttraumatic stress disorder and social anxiety disorder. Research has found that virtual environments can be effectively used as an alternative to in vivo or imaginal exposure. However, research has yet to compare the costs and benefits of different platforms, such as virtual reality and 360° video, for creating virtual environments. The current qualitative study compares the experiences of veterans with symptoms of posttraumatic stress disorder and social anxiety disorder as they interact with a virtual grocery store environment. Participants were randomly assigned to experience the virtual reality (n = 7) or 360° video (n = 5) environments. After experiencing the virtual environments, the participants were interviewed about their perceptions of immersion, feasibility, and acceptability of the modality. Portions of the interviews are presented along with recommendations for clinical researchers seeking to use virtual technology with clinical treatments.
... In a sample of 86 veterans diagnosed with PTSD, 73.3% had another anxiety disorder diagnosis (Magruder et al., 2005). Within this sample, 39.3% of these veterans had a comorbid generalized anxiety disorder diagnosis, 37.4% had a comorbid panic disorder diagnosis, 22.1% had a comorbid social anxiety disorder diagnosis, and 12.8% had a comorbid obsessive-compulsive diagnosis (Gros, Frueh, & Magruder, 2011;Kashdan, Frueh, Knapp, Hebert, & Magruder, 2006;Milanak, Gros, Magruder, Brawman-Mintzer, & Frueh, 2013). Veterans with PTSD and comorbid panic disorder or comorbid social anxiety disorder had more severe PTSD symptoms than veterans with PTSD alone (Gros et al., 2011;Kashdan et al., 2006). ...
... Within this sample, 39.3% of these veterans had a comorbid generalized anxiety disorder diagnosis, 37.4% had a comorbid panic disorder diagnosis, 22.1% had a comorbid social anxiety disorder diagnosis, and 12.8% had a comorbid obsessive-compulsive diagnosis (Gros, Frueh, & Magruder, 2011;Kashdan, Frueh, Knapp, Hebert, & Magruder, 2006;Milanak, Gros, Magruder, Brawman-Mintzer, & Frueh, 2013). Veterans with PTSD and comorbid panic disorder or comorbid social anxiety disorder had more severe PTSD symptoms than veterans with PTSD alone (Gros et al., 2011;Kashdan et al., 2006). Notably, veterans in these studies were recruited from a master list of veterans who had been seen in VA primary care, and were not specifically seeking treatment for PTSD or other mental health diagnoses. ...
... PCL data from veterans without PTSD were included in the analyses as an indication of whether differences in self-reported PTSD symptom severity reflected genuine differences in PTSD severity or served as a marker of overall distress. The PCL has been commonly used in studies of veteran comorbidity to examine symptom severity (Gros et al., 2011;Gros et al., 2012;Ikin, Creamer, Sim, & McKenzie, 2010;Kashdan et al., 2006;Magruder et al., 2004;Magruder et al., 2005;Milanak et al. 2013;Walter, Barnes, & Chard, 2012). ...
Article
Objective: Comorbidity is the rule and not the exception among veterans with posttraumatic stress disorder (PTSD). Examining comorbidities in a veteran population allows us to better understand veterans' symptoms and recognize when mental health treatment may need to be tailored to other co-occurring issues. This article evaluates comorbid mood and anxiety disorders and PTSD symptom severity in a large sample of veterans from multiple eras of service, including the recent wars in Iraq and Afghanistan. Method: The current study used data from veterans who sought treatment for PTSD at a VA PTSD Clinical Team from 2005 to 2013. Veterans were assessed for PTSD, mood, and anxiety disorders using a structured clinical interview and completed self-report symptom measures as part of the PTSD clinic intake procedure. A total of 2,460 veterans were evaluated, and 867 met diagnostic criteria for PTSD. Results: Veterans with PTSD were significantly more likely than those without PTSD to be diagnosed with social anxiety disorder and obsessive-compulsive disorder, but significantly less likely to be diagnosed with depression. In addition, veterans who had at least one comorbid diagnosis in addition to PTSD reported significantly higher PTSD symptom severity than veterans with PTSD alone. PTSD symptom severity also varied by era of service. Conclusion: These results suggest that among veterans seeking treatment for PTSD, comorbid mood and anxiety disorders may be associated with greater severity of PTSD symptoms. Future work is needed to determine the impact of specific comorbidities on trauma-focused treatment outcomes. (PsycINFO Database Record
... Persons with both disorders report greater suicidal risk, poorer scores on quality of life dimensions, and greater distress and impairment in physical, mental, and social functioning relative to those with either disor- der. [8,11,12] Below, we review the available data on the epidemiology of co-occurring trauma, PTSD, SA, and SAD in both veteran and community samples. ...
... [16] We recently found no significant differences in socially related fears between persons reporting assaultive and nonassaultive trauma; however, it is noteworthy that our assessment of socially related fears was limited (i.e. the social concerns subscale of the Anxiety Sensitivity Index [18] and the Brief Fear of Negative Evaluation Scale [19] ) and may not generalize to all forms of SA or SAD.Table 1 shows the prevalence of SAD in individuals with a diagnosis of PTSD in veteran and civilian samples. Consistently higher rates of SAD have been observed in veterans with PTSD relative to those without PTSD (ranging from 12.5 to 72% [10,12,20,21] ); however, it is important to note that veterans have shown a consistent tendency to overreport pathol- ogy, [22] which may impact our understanding of cooccurring symptoms. Orsillo et al. [20] found that among 41 male Vietnam veterans, those meeting criteria for a diagnosis of PTSD were more likely (72%) to also warrant a diagnosis of SAD relative to those without PTSD (22%). ...
... panic disorder, obsessive–compulsive disorder, generalized anxiety disorder) were more commonly associated with SAD than was PTSD. [25] Much higher rates of PTSD have been reported in veterans with a diagnosis of SAD (73.1%) relative to those without a diagnosis of SAD (26.9% [12] ). Recent research also suggests that patients with SAD are more likely to interpret extremely stressful social events as traumatic and evidence PTSD-like symptoms in response to this event, relative to nonanxious controls. ...
Article
Posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD) are frequently comorbid among veteran and community samples. Several studies have demonstrated significant comorbidity between trauma, PTSD, and social anxiety (SA), and a growing number of studies have explored the nature of this association. Although a diagnosis of either PTSD or SAD alone can result in significant impairment in social and occupational functioning, these difficulties are often magnified in persons suffering from both disorders. This review describes the current state-of-the-art regarding the co-occurrence of trauma, PTSD, and SA. First, we provide an overview of empirical data on the prevalence of co-occurring trauma, PTSD, and SAD. Second, we describe possible explanatory models of the co-occurrence, with a specific focus on the shared vulnerability model. Third, we review the available empirical data addressing the postulates of this model, including both genetic and psychological vulnerabilities. Fourth, we describe additional factors-guilt, shame, and depressive symptoms-that may help to explain the co-occurrence of PTSD and SA. A better understanding of this complex relationship will improve the efficacy of treatment for individuals suffering from both disorders. We conclude with key areas for future research.
... In addition, those with comorbid PTSD and SAD demonstrated higher levels of guilt than those with a principal diagnosis of PTSD, lower levels of physical functioning than those with a principal diagnosis of SAD (but with a score equivalent to the principal PTSD group), as well as lower levels of mental functioning compared to either of the other two groups even after adjusting for other comorbid conditions. In addition, a recent study conducted using data from four Veterans Affairs medical centers demonstrated that after adjusting for PTSD severity, veterans diagnosed with SAD (73.1% of whom met criteria for PTSD) remained at an increased risk for suicide and comorbid psychiatric conditions (particularly major depression, dysthymia, and generalized anxiety disorder compared to veterans without SAD (of whom 26.9% met criteria for PTSD; Kashdan, Frueh, Knapp, Hebert, & Magruder, 2006). The high degree of comorbidity and risk for negative psychosocial outcomes documented within the extant literature demonstrates the need for a better understanding of the manner in which these disorders influence one another. ...
... To the best of our knowledge, there is only one study to date that has examined the impact of SAD on PTSD severity and symptom profile. Using a sample of 733 veterans from four Veterans Affairs primary care clinics, Kashdan et al. (2006) observed that the presence of SAD was associated with higher scores on overall measures of PTSD symptom severity and higher scores for each PTSD symptom cluster (assessed using the PTSD Checklist-Military version; Weathers, Litz, Herman, Huska, & Keane, 1993), with the largest differences observed within the Criterion C avoidance symptom domain. After adjusting for the presence of depression, veterans with SAD still demonstrated higher rates of PTSD and greater PTSD symptom severity. ...
... Although Kashdan et al. (2006) appears to represent the first examination of the relationship between SAD and PTSD symptom presentation, it was limited in both scope and sample, restricting the generalizability of the results. Specifically, the authors did not examine within criterion variability and utilized a highly circumscribed sample that was almost exclusively male (93.3%) with nearly half (43%) above 65 years of age (average age 61.2 years, SD = 11.9 years). ...
Article
Posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD) demonstrate a high degree of comorbidity (ranging from 14.8% to 46.0%); however, little is known about the nature of this association. Contemporary research has largely focused on treatment-seeking or veteran samples, and may not generalize to the population as a whole. Large-scale epidemiological studies are needed to fill existing gaps in the literature and to clarify this association for the general population. The current study examined whether the presence of comorbid SAD influenced PTSD symptom presentation. The rate of individual PTSD symptoms was investigated among individuals with PTSD and SAD in comparison to those with PTSD alone. Data were obtained from Wave 2 of the National Epidemiological Survey of Alcohol and Related Conditions, a large, nationally representative survey of American adults (n = 34,653). Analyses revealed elevated rates of PTSD symptoms among those with comorbid PTSD and SAD across all symptom clusters, with significant odds ratios ranging from 1.5 to 4.87. Adjusting for depression and other Axis I disorders did not substantially alter study findings. Results suggest that the presence of SAD is associated with differences in the expression of PTSD symptoms.
... Trait behavioral inhibition (BI), typified by reserved response or inactivity in the face of novel social and nonsocial situations [44,45], is a risk factor for anxiety disorders in children and adults [8,9,41,83,84,89,52,65,39]. The extreme behavioral withdrawal in BI is associated with enhanced stress reactivity, polymorphism of the corticotropin releasing hormone (CRH) gene [91,90] and increased reactivity within the hypothalamic pituitary adrenal axis [100]. ...
... One vulnerability factor for anxiety disorders is behavioral inhibition [8,9,41,83,84,89,52,65,39]. In addition to behavioral withdrawal, BI is associated with enhanced stress reactivity and increased reactivity within the hypothalamic pituitary adrenal axis [100]. ...
Article
Full-text available
The relationship between trait stress-sensitivity, avoidance acquisition and perseveration of avoidance was examined using male Wistar-Kyoto (WKY) and Sprague-Dawley (SD) rats. Behavior in an open field was measured prior to escape/avoidance (E/A) acquisition and extinction. E/A was assessed in a discrete trial lever-press protocol. The signal-shock interval was 60s with subsequent shocks delivered every 3s until a lever-press occurred. A 3-min flashing light safety signal was delivered contingent upon a lever-press (or failure to respond in 5 min). WKY rats displayed phenotypic low open field activity, but were clearly superior to SD rats in E/A performance. As avoidance responses were acquired and reached asymptotic performance, SD rats exhibited "warm up", that is, SD rats rarely made avoidance responses on the initial trial of a session, even though later trials were consistently accompanied with avoidance responses. In contrast, WKY rats did not show the "warm up" pattern and avoided on nearly all trials of a session including the initial trial. In addition to the superior acquisition of E/A, WKY rats demonstrated several other avoidance features that were different from SD rats. Although the rates of nonreinforced intertrial responses (ITRs) were relatively low and selective to the early safety period, WKY displayed more ITRs than SD rats. With removal of the shocks extinction was delayed in WKY rats, likely reflecting their nearly perfect avoidance performance. Even after extensive extinction, first trial avoidance and ITRs were evident in WKY rats. Thus, WKY rats have a unique combination of trait behavioral inhibition (low open field activity and stress sensitivity) and superior avoidance acquisition and response perseveration making this strain a good model to understand anxiety disorders.
... Psychiatric disorders widely studied in relation to trauma exposure include PTSD (by definition; American Psychiatric Association, 1994), social anxiety disorder (e.g., Kashdan, Frueh, Knapp, Hebert, & Magruder, 2006;Green, Lindy, Grace, & Leonard, 1992;Orsillo, Heimberg, Juster, & Garrett, 1996), and depression (e.g., O'Donnell, Creamer, & Pattison, 2004;Shalev et al., 1998). Despite high rates of comorbidity among these conditions, there is evidence for some degree of independent onset and consequences in trauma survivors (Yehuda, McFarlane, & Shalev, 1998). ...
... As a complementary model, experiential avoidance also moderated the effects of SAD on quality of life such that the only trauma survivors at high functioning were those without disorder and low in experiential avoidance; this is the third empirical study to support this model, each with different outcome variables and methodologies (Kashdan & Breen, 2008;. Dovetailing with prior work, the interpersonal problems, diminished positive experiences, and self-regulatory resource drain linked to SAD appears to be a neglected consideration in the study and treatment of trauma survivors (e.g., Frueh et al., 2006;Green et al., 1992;Julian et al., 2006;Orsillo et al., 1996). The current study represents an important, albeit preliminary step toward identifying more complete models of vulnerability and resilience in trauma survivors of war. ...
Article
Few studies have been conducted on psychological disorders other than post-traumatic stress disorder (PTSD) in war survivors. The aim of this study was to examine PTSD, social anxiety disorder (SAD), and major depressive disorder (MDD) and their associations with distress and quality of life in 174 Albanian civilian survivors of the Kosovo War. This included testing of conceptual models suggesting that experiential avoidance might influence associations between anxiety and mood disorders with psychological functioning. Each of the three psychiatric disorders was associated with greater experiential avoidance and psychological distress, and lower quality of life. Being a refugee was associated with a higher likelihood of having SAD and MDD. We found evidence for experiential avoidance as a partial mediator of the respective effects of SAD and PTSD on quality of life; experiential avoidance did not mediate the effects of disorders on global distress. We also found support for a moderation model showing that only war survivors without SAD and low experiential avoidance reported elevated quality of life; people with either SAD or excessive reliance on experiential avoidance reported compromised, low quality of life. This is the third independent study, each using a different methodology, to find empirical support for this moderation model [Kashdan, T. B., & Breen, W. E. (2008). Social anxiety and positive emotions: a prospective examination of a self-regulatory model with tendencies to suppress or express emotions as a moderating variable. Behavior Therapy, 39, 1-12; Kashdan, T. B., & Steger, M. F. (2006). Expanding the topography of social anxiety: an experience sampling assessment of positive emotions and events, and emotion suppression. Psychological Science, 17, 120-128]. Overall, we provided initial evidence for the importance of addressing PTSD, SAD, MDD, and experiential avoidance in primarily civilian war survivors.
... There has been a growing interest in the co-occurrence of socially related fears and posttraumatic stress symptoms (PTSS) (Asmundson & Carleton, 2005;Hofmann, Litz, & Weathers, 2003;Kashdan, Frueh, Knapp, Hebert, & Magruder, 2006;Zayfert, DeViva, & Hofmann, 2005). Although PTSS may co-occur with a variety of symptoms (e.g., mood and substance-use), examining socially related fears in persons who have experienced trauma is particularly important because social activity has a substantial impact on quality of life (Ryff & Singer, 2000). ...
... Comparisons made between the probable PTSD and no PTSD groups showed significant differences on the BFNE with moderate to large effect sizes (Cohen, 1988). These results are in line with previous research where higher levels of other socially related fears were found among individuals with PTSD relative to those without PTSD (e.g., Kashdan et al., 2006;Orsillo, Heimberg, Juster, & Garrett, 1996;Orsillo, Weathers, et al., 1996). Further investigation is needed to examine FNE among traumatized individuals. ...
Article
Few studies have examined why socially related fears and posttraumatic stress commonly, but not invariably, co-occur. It may be that only traumata of human agency (e.g., sexual assault), for which there is an interpersonal component, give rise to co-occurring socially related fears. These symptoms might also co-occur because of shared genetic factors. We investigated these issues using a sample of 882 monozygotic and dizygotic twins. No significant differences in socially related fear (i.e., fear of negative evaluation, fear of socially observable arousal symptoms) were found between participants reporting assaultive or nonassaultive trauma. However, significant differences in socially related fear were found when participants were grouped into probable PTSD and no PTSD groups. Participants with probable PTSD exhibited greater socially related fear (i.e., fear of negative evaluation) than those without PTSD. Using biometric structural equation modeling, trauma exposure was best explained by shared and nonshared environmental influences. The fear of socially observable arousal symptoms was influenced by genetic and nonshared environmental influences. Implications and directions for future research are discussed.
... They further concluded that measurement tools to evaluate the complexities of social support for combat-exposed Veterans are under developed. Kashdan, Frueh, Knapp, Herbert and Magruder's [21] evaluation of 733 Veterans, found a strong relationship between PTSD and Social Anxiety Disorder (SAD), which was characterized as distress in social interactions, social avoidance patterns and impaired social relationships. Combat Veterans with PTSD had a concurrent diagnosis of SAD at a rate of 22% as compared to veterans without PTSD at 1.1%. ...
... In evaluating the National Sample of Female and Male Vietnam Veterans, King, King, Foy, Keane, and Fairbank [22], reported that functional social support was quite potent in offsetting the deleterious consequences of PTSD. Additionally, Kashdan et al. [21] found that alcohol dependency, but not abuse, was related to Veterans with PTSD-SAD co-morbidity. They propose that Veterans with SAD cope by one of two extremes-binge drinking or alcohol avoidance. ...
Article
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Now that the financial needs of post 9/11 student service members/veterans have begun to be addressed, the attention has shifted to disabilities and recovery strategies of student service members/veterans. Therefore, in a cross sectional design, this study electronically surveyed 189 enrolled student service members/veterans attending a large urban state university about their experiences of returning to school. Specifically, this study described the students’ rates of Post-Traumatic Stress Disorder (PTSD) and alcohol abuse, perceived stress, adaptive and non-adaptive coping strategies, social support, participation in campus activities, and perceived campus climate. Moreover, correlates of recovery were examined. Although the majority of the returning students were doing well, 36.1% reported a high level of stress, 15.1% reported a high level of anger, 17.3% reported active symptoms of PTSD, and 27.1% screened positive for alcohol problems. Social networks were found to be the most salient factor in recovery. The study’s limitations are discussed and specific support strategies are presented that can be employed by disability services, counseling services and college administrators.
... Adverse life events and traumatic experiences are associated with higher levels of emotional disorders [2,34], including social anxiety disorder [29]. In our analyses, however, experienced pre-migration traumatic events did not have a unique effect on social anxiety. ...
Article
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Objective Unaccompanied refugee minors (URMs), are at high risk for mental health problems, yet there is a lack of knowledge about social anxiety among these youths. The aim of this study was to investigate symptoms of social anxiety among URMs resettled in Norway, and the combined effects of pre-migration traumatic events, post-migration acculturation related factors (perceived discrimination and culture competence in relation both to the heritage and majority cultures) and demographic background variables, over and above the effect of concurrent depressive symptoms. Methods Cross-sectional self-report questionnaire data were collected from 557 URMs from 31 different countries, mainly from Afghanistan (49,6%), Somalia (11,1%), and Iraq (7,0%). Results: The findings from structural equation model (SEM) showed that the effect of pre-migration traumatic events on social anxiety was non-significant (β = 0.001, p = .09), while perceived discrimination and majority culture competence had unique effects on social anxiety (β = 0.39, p < .001 and β = −0.12, p = .008, respectively) over and above depressive symptoms (β = 0.30, p < .001). Conclusions The findings show that factors of the current socio-cultural developmental context rather than pre-migration war-related traumatic events the youths experienced before migration accounts for variation in social anxiety. Potential practical implications of the findings for social workers, educational staff and clinicians are discussed.
... The potential implications of our findings are far-ranging. Primary care physicians, often the first and only professionals with an opportunity to evaluate and recommend treatment for mental health problems, routinely fail to detect the presence of anxiety disorders (e.g., Fifer, Mathias, Patrick, & Mazonson, 1994;Kashdan, Frueh, Knapp, Hebert, & Magruder, 2006). The inherent difficulties of detecting SAD can be amplified when clients present with atypical patterns of aggression, sexual impulsivity, and substance abuse. ...
Article
Little is known about people with social anxiety disorder (SAD) who are not behaviorally inhibited. To advance knowledge on phenomenology, functional impairment, and treatment seeking, we investigated whether engaging in risk-prone behaviors accounts for heterogeneous outcomes in people with SAD. Using the National Comorbidity Survey-Replication (NCS-R) dataset, our analyses focused on people with current (N = 679) or lifetime (N = 1143) SAD diagnoses. Using latent class analysis on NCS-R risk-prone behavior items, results supported two SAD classes: (1) a pattern of behavioral inhibition and risk aversion and (2) an atypical pattern of high anger and aggression, and moderate/high sexual impulsivity and substance use problems. An atypical pattern of risk-prone behaviors was associated with greater functional impairment, less education and income, younger age, and particular psychiatric comorbidities. Results could not be subsumed by the severity, type, or number of social fears, or comorbid anxiety or mood disorders. Conclusions about the nature, course, and treatment of SAD may be compromised by not attending to heterogeneity in behavior patterns.
... The use of a random two-week interval might account for why veterans with PTSD, rumination failed to predict changes in negative affect in daily life. A more focused sampling plan before, during and after stress periods might help us better understand and detect the relationships among rumination, affect, and symptoms of PTSD (and other psychological disorders in VA hospital patients; e.g., Kashdan, Frueh, Knapp, Hebert, & Magruder, 2006). Fifth, beyond the presence of PTSD, our two samples also differed on the presence of combat exposure and psychological treatment within the VA system. ...
Article
Prior research suggests that rumination and chronic negative emotions serve to maintain emotional disorders. However, some evidence suggests that pondering the nature and meaning of negative experiences can be adaptive. To better understand the function of this dimension of rumination, we studied the use of this strategy in response to negative emotions as they unfold from day to day in veterans with (n=27) and without (n=27) post traumatic stress disorder (PTSD). For two weeks, veterans completed daily questions about when they experienced a bad mood and how often they used rumination to feel differently. It was hypothesized that rumination would attenuate negative emotional reactions in veterans without PTSD, but that rigid, intense negative emotions would persist in veterans with PTSD. Using multilevel modeling, we found that on the same day, rumination was positively associated with negative affect. Because covariation fails to address directionality, we also examined lagged effects from one occasion to the next. For veterans without PTSD, more frequent use of rumination predicted less intense negative affect the next day; there was no support for a model with negative affect predicting rumination the next day. For veterans with PTSD, the prior day's intensity of negative affect was the only predictor of intensity of negative affect the next day. Results support the value of distinguishing within-day and across day effects, and the presence of PTSD, to clarify contexts when rumination is adaptive.
... Posttraumatic stress disorder (PTSD) is mainly thought of as an effect of victimization on mental health [11]. SAD co-occurs with PTSD [12] as reported mainly in adult combat veterans [13–15]. The association between SAD and PTSD is less well studied in children and adolescents [16]. ...
Article
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Recent findings from studies on adults show similarities between social anxiety disorder (SAD) and posttraumatic stress in the form of recurrent memories and intrusive and distressing images of earlier aversive events. Further, treatment models for SAD in adults have been successfully developed by using transdiagnostic knowledge on posttraumatic stress symptoms (PTSS). Studies on adolescents are though missing. The present study aimed at exploring the association between PTSS and SAD in Swedish adolescents. A second aim was to study mental health services utilization in relation to these conditions. A total of 5,960 high-school students participated and reported on SAD, life time victimization, PTSS and mental health service utilization. Socially anxious adolescents reported significantly higher levels of PTSS than adolescents not reporting SAD and this difference was seen in victimized as well as non-victimized subjects. Contact with a school counselor was the most common mental health service utilization in subjects with SAD and those with elevated PTSS. In the prediction of contact with a CAP-clinic, significant odds ratios were found for a condition of SAD and elevated PTSS (OR = 4.88, 95 % CI = 3.53-6.73) but not for SAD only. Screening of PTSS in adolescents with SAD is recommended. The service of school counselors is important in detecting and helping young people with SAD and elevated PTSS. Clinical studies on SAD and PTSS in adolescents could aid in modifying treatment models for SAD.
... High rates of anxiety disorders, in particular GAD (15.5 %), were also notable, with the third highest prevalence, ranking only below Santiago (18.7 %) and Rio de Janeiro (22.6 %) and more than double the average in this study (7.9 %). The prevalence of SP (3 %) was slightly higher than that reported in a primary care study in Spain (1.9 %) [23], but lower than that reported in a few other primary care studies, in which it ranged from 3.6 % in a veteran administration primary care clinic in the USA [24,35] to around 7 % in two other USA studies [25,26]. The rate of PTSD in primary clinics (2.4 %) was also lower than in the USA where prevalence rates range from 9 to 12 % [27,28]. ...
Article
Objective: Psychiatric morbidity is common among patients in primary care services and leads to disability and increased use of medical services. Comparison of primary care and community prevalence data is of interest in relation to the health services planning for mental disorders. The aim of the present study was to measure prevalence of mental disorders in six primary care clinics in Israel and to assess risk factors for these disorders. Method: Prevalence of mental disorders was measured in a sample of 2,948 primary care consecutive attendees, using two-stage stratified sampling with the General Health Questionnaire 12 (GHQ-12) and the Composite International Diagnostic Interview (CIDI). Results: A high rate (46.3%) of current mental disorders was found, with rates of current depressive episode, generalized anxiety disorder, somatization disorder, and neurasthenia being relatively high in comparison with rates in other countries. Low education was a risk factor for all categories of disorders, unemployment a risk factor for depressive disorders, and parenthood was protective for most categories of disorders. Conclusions: High rates of mental disorders were found in this Israeli primary care sample as compared to other countries, while in the community the rates were midrange as compared to other countries, pointing to a relatively higher use of primary care services by patients with mental disorders in Israel than in other countries.
... In fact, nearly one half of combat veterans endorse three or more comorbid affective disorders and significantly more impaired functioning as a result (Ginzburg et al., 2010). And finally, the prevalence, severity, and overlap of different specific affective disorders varies between civilians and veterans, with some disorders more prevalent/severe in civilian populations (e.g., SOC; Kashdan et al., 2006), and other disorders more prevalent/severe in Veterans populations (e.g., PTSD and PD; Gros et al., 2011). In fact, among the three most investigated transdiagnostic protocols, PTSD, arguably one of the most problematic psychiatric disorders within the DVA (Magruder et al., 2005), was found in less than 5% of the investigated samples (Farchione et al., 2012 Similarly, the majority of existing protocols also did not investigate efficacy in patients with principal diagnoses of MDD, another highly prevalent psychiatric disorder in veterans (Gros et al., 2012). ...
Article
Considerable attention has focused on the growing need for evidence-based psychotherapy for veterans with affective disorders within the Department of Veteran Affairs. Despite, and possibly due to, the large number of evidence-based protocols available, several obstacles remain in their widespread delivery within Veterans Affairs Medical Centers. In part as an effort to address these concerns, newer transdiagnostic approaches to psychotherapy have been developed to provide a single treatment that is capable of addressing several, related disorders. The goal of the present investigation was to develop and evaluate a transdiagnostic psychotherapy, Transdiagnostic Behavior Therapy (TBT), in veterans with affective disorders. Study 1 provided initial support for transdiagnostic presentation of evidence-based psychotherapy components in veterans with principal diagnoses of affective disorders (n=15). These findings were used to inform the development of the TBT protocol. In Study 2, an initial evaluation of TBT was completed in a second sample of veterans with principal diagnoses of affective disorders (n=29). The findings of Study 2 demonstrated significant improvements in symptoms of depression, anxiety, stress, posttraumatic stress, and related impairment across participants with various principal diagnoses. Together, the investigation provided preliminary support for effectiveness of TBT in veterans with affective disorders.
... This finding is also true of social anxiety in the children of such veterans [23]. In this study, there was no significant cor relation between the demographic variables and social anxiety, which agrees with the findings of Kashdan [31], while Mokhtaripoor et al. show that there is a significant correlation between these two sets of variables in the students of medical sciences universities (F=2.584, P=0.0086), with the highest negative correlation between the subjects' socioeconomic status and their anxiety [34]. ...
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Aims: Spiritual health is the only force that makes up the physical, mental and social dimensions of man. Social anxiety can cause this negative reaction to react. The aim of this study was to investigate the relationship between spiritual health and social anxiety in chemical veterans. Methods: This descriptive correlation study used a questionnaire that included demographic, health spiritual and Liebowitz social anxiety. 109 veterans were selected by available sampling in Kermanshah. Data analysis was performed by descriptive statistics and Spearman and Mann-Whitney test. Results: In this study, there was an inverse relationship between spiritual health and social anxiety (P = 0.01, r = -0/363), but there was not statistically significant relationship between spiritual health and social anxiety associated with demographic characteristics. Conclusion: Several studies have confirmed the existence of anxiety in veterans. Strengthening of spiritual health as a strong force on the physical, mental and social health, can control social anxiety. Because the veterans need to promote physical and psychological conditions in their activities. So reinforcing the spiritual health programs is obvious in accordance with the new social conditions.
... In the case of persons who have experienced MST, comorbidities are the rule rather than the exception. The most common comorbidities identified among women who have experienced MST include posttraumatic stress disorder or PTSD, depression and other anxiety disorders (Bean-Mayberry et al, 2011;Hoge, 2013;Kashdan et al., 2006;Kelly, Skelton & Bradley, 2011). Two WWII psychiatrists eloquently described the unequivocal result of trauma on any military member in a war zone. ...
Article
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Research suggests that there may be unique barriers to accessing care among women who have experienced military sexual trauma. The intent of the current research was to elucidate potential barriers to successful reintegration following deployment and to identify options for mental health care for women who have experienced military sexual trauma (MST). A secondary goal was to explore the feasibility of internet-based technology as a means of expanding options for counselor outreach, service delivery and social support for this population. A comprehensive literature review was conducted which revealed several important points. A strong correlation exists between successful reintegration for women who have experienced MST and a) the availability of social support networks and b) the ability of the individual to utilize these supports. Women who have experienced MST were found to experience high levels of organizational distrust, social isolation, and self-perceived stigma, which create significant barriers for participation in treatment services, and for community reintegration. A comprehensive literature review revealed that the use of social media and other internet technologies show promise, not only as effective therapeutic tools, but also as an effective outreach method to identify and connect with those who are difficult to reach. A summary of this research is provided, ethical implications are discussed, and recommendations are made for the use of these technologies within professional counseling practice. Keywords: Counseling, military sexual trauma, online, social support, women, veterans
... Additionally, if COSR becomes severe and goes untreated it can become Posttraumatic Stress Disorder (PTSD) which can result in secondary PTSD symptoms developing among service member families (Dirkzwager, Bramsen, Ader and Van de Ploeg, 2005;Figley, 2005). This can also have other undesired effects on spouses and family members (Jordan et al., 1992;Kashdan, Frueh, Knapp, Hebert and Magruder, 2006) which may increase the financial burden (Solomon, 2003) and decrease quality of life for military families. Ultimately this can impact the retention and recruitment of service members (Cobbold, 2005). ...
Thesis
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Full access to this thesis is available at http://diginole.lib.fsu.edu/etd/185/ Encouraging help-seeking behavior for Combat Operational Stress Reaction (COSR) among military service members is an important factor in maintaining military readiness and military family quality of life. This research explores the role that military spouses play in encouraging help-seeking behavior among service members using a hybrid model that merged the Theory of Planned Behavior (TPB) with elements of Protection Motivation Theory (PMT) to understand spouses’ behavior intention. Six predictor variables were explored during focus group meetings and ultimately incorporated into questions in an online survey completed by 306 military spouses of service members from all branches of service. The six predictor variables were analyzed using multiple regression and simple regression to determine their significance in predicting spouse behavior intention for service members to seek help at military and NON-military treatment facilities. The research focused on five hypotheses and seven research questions. The hypotheses focused on information sources and usefulness about COSR, the amount of direct experience with COSR, the degree of favorable outcomes of COSR medical treatment, the perceived stigma associated with combat stress, the perceived vulnerabilities which included risk and severity, normative beliefs about help-seeking and the perceived military spouse efficacy to encourage help-seeking behavior at both military and NON-military treatment faculties. The research questions provided a range of generalized information about the variables. Statistical analyses indicated that spouses who report that they have more military sources that provide useful information, about combat stress, are also more likely to (1) report more favorable beliefs about military care outcomes, (2) recognize the risks and severity of combat stress, and (3) feel that they are capable of effectively making recommendations that service members seek care at a military facility. Spouses with more direct experience with combat stress also are more likely to report favorable beliefs about outcomes resulting from military health care. Spouses who have more favorable outcome beliefs, higher perceptions of risk and severity (vulnerability), plus greater general and personal efficacy are more likely to encourage their service members to seek help at a military care facility. ix A positive relationship was found between useful NON-military information sources about combat stress and behavioral intentions to recommend care at a NONmilitary care facility. In addition, spouses who have more useful NON-military information report higher levels of perceived stigma associated with combat stress. Direct behavioral NON-military care experiences are positively related to beliefs about favorable outcomes resulting from care at NON-military facilities. Three variables were found to be predictors of behavior intentions. The spouses who have (1) favorable outcome beliefs, (2) who experience normative expectations and are motivated to comply with these norms, and (3) who feel greater efficacy are more likely to encourage service members to seek help at a NON-military care facility.
... Preliminary evidence from treatment-seeking populations suggests that comorbid PTSD and SAD is associated with higher levels of depression and anxiety, and lower levels of mental and social functioning, compared to those with either disorder alone (Zayfert et al., 2005). Similarly, a study of veterans documented an increased suicide risk when comorbid PTSD and SAD was present compared to PTSD alone, even after adjusting for PTSD symptom severity (Kashdan et al., 2006). The high rates of comorbidity in conjunction with deleterious mental health outcomes underscores the need for a greater understanding of comorbid presentations of PTSD and SAD. ...
... Despite these recommendations, identification of depression and anxiety in patients with COPD and CHF remains remarkably low [18]. Across a variety of samples, only one-third to one-half of patients who meet diagnostic criteria for an anxiety or depressive disorder have a diagnosis of depression or anxiety documented in their electronic medical record (EMR) [9,[19][20][21][22][23]; and in one study < 2% of patients who met criteria for generalized anxiety disorder (GAD) were diag-nosed with GAD by their primary care provider [24]. EMR documentation of anxiety and depression is critical to facilitating access to MH treatment. ...
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... This 4-item form assesses the treatment techniques providers used The M.I.N.I. [22] is a structured diagnostic interview for 17 Axis I psychiatric disorders found in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), including mood disorders, anxiety disorders, and substance use disorders. This instrument has been used in numerous studies of veteran samples [26]. The M.I.N.I. will be administered by the behavioral outcomes assessors during the first and second patient assessments. ...
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This randomized trial examines the dissemination and implementation of prolonged exposure (PE) therapy for posttraumatic stress symptoms in U.S. Army medical treatment facilities. The study compares two PE training models: Standard PE training, comprised of a 4-day workshop only, and Extended PE training, comprised of a 4-day workshop plus expert case consultation. Behavioral health providers (N = 180) across three medium-to-large Army installations will be randomly assigned to either Standard PE training or Extended PE training. Changes in provider attitudes will be examined across groups. After completing PE training, the use of PE components with patients reporting posttraumatic stress symptoms and clinical outcomes of these participating patients (N = 500) will be examined. This article describes the rationale and methods of the study. In addition, a number of methodological issues in conducting a multisite naturalistic study in the U.S. Army are discussed.
... In the United States, there are approximately 25% of veterans suffering from some form of mental health diagnosis (Trivedi et al., 2015), with potentially 3.6% of military populations meeting diagnostic criteria for social anxiety disorder (SAD; Grant et al., 2005;Kashdan, Frueh, Knapp, Hebert, & Magruder, 2006;Watson & Friend, 1969). SAD is a persistent fear of social or performance situations in which a person is exposed to unfamiliar people and/or potential scrutiny from others (American Psychiatric Association & others, 2013). ...
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Virtual reality (VR) has emerged as a promising technological intervention for anxiety disorders. However, there are no existing standards and best practices to evaluate the effectiveness of environments to achieve their intervention goals. The purpose of this study was to develop a VR intervention for student veterans with social anxiety disorder and test feasibility utilizing a three-stage development model. The development of a therapeutic VR environment may benefit from an interdisciplinary collaboration of researchers from various fields of study. Utilizing three stages of prototyping with two virtual reality platforms, fully immersive video (n = 6) and three-dimensional (3-D) immersive virtual reality (n = 8), the research team designed an intervention for student veterans with social anxiety disorder, testing bio-reactivity of participants. Results of prototyping include user feedback validating increased stress levels and increased bio-reactivity specifically in galvanic skin response and heart rate elevation. Implications include the use of 360° video for prototyping 3-D virtual reality interventions.
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Dissemination and implementation of evidence-based psychotherapies is challenging in real world clinical settings. Transdiagnostic Behavior Therapy (TBT) for affective disorders was developed with dissemination and implementation in clinical settings in mind. The present study investigated a voluntary local dissemination and implementation effort, involving 28 providers participating in a four-hour training on TBT. Providers completed immediate (n=22) and six-month follow-up (n=12) training assessments and were encouraged to collect data on their TBT patients (delivery fidelity was not investigated). Findings demonstrated that providers endorsed learning of and interest in using TBT after the training. At six-months, 50% of providers reported using TBT with their patients and their perceived effectiveness of TBT to be very good to excellent. Submitted patient outcome data evidenced medium to large effect sizes. Together, these findings provide preliminary support for the effectiveness of a real world dissemination and implementation of TBT.
Technical Report
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Suicide is a major public health concern in the United States (US), claiming over 36,000 lives each year and nearly 100 lives each day, and suicide among military and Veteran populations is of particular concern. Veterans returning from the Iraq and Afghanistan conflicts, referred to as Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans, may be particularly at risk, although the limited available data has shown mixed results. Several aspects of military experience may increase the risk of suicide, including mental health and substance abuse. Many risk factors specific to the OEF/OIF population have yet to be thoroughly evaluated and incorporated into clinical management. Ideally, suicide risk assessment tools need to account for the relationship among different risk factors and identify risk factors or combinations of risk factors that are particularly associated with suicidal self-directed violence. To be practically useful, such tools will be brief enough to be conducted in a primary care setting and will identify a threshold beyond which preventive action should be taken. Risk assessment tools should be able to discriminate those at high- and low-risk for suicidal self-directed violence. Likewise, studies of emerging risk factors need to evaluate the contribution of a new potential predictor of suicide and self-directed violence in the context of known risk factors in order to weigh the contribution of the new risk factor against those that are currently known. The objective of this report is to review recent evidence about risk factors and risk assessment tools within Veteran and military populations to provide evidence for clinical practice guideline development specific to these populations. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0042005.
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Purpose: Social anxiety disorder (SAD) is a disabling condition that affects almost 5% of the general population. Many types of drugs have shown their efficacy in the treatment of SAD. There are also some data regarding psychotherapies, but no data are available today about the efficacy of brain stimulation techniques. The aim of the study is to compare the efficacy of noninvasive brain stimulation neuro psycho physical optimization (NPPO) protocol performed by radio electric asymmetric conveyor (REAC) with that of sertraline in adults with SAD. Patients and methods: Twenty SAD patients on sertraline were compared with 23 SAD patients who refused any drug treatment and who chose to be treated with NPPO-REAC brain stimulation. This was a 6-month, open-label, naturalistic study. Patients on sertraline received flexible doses, whereas NPPO-REAC patients received two 18-session cycles of treatment. Clinical Global Improvement scale items "much improved" or "very much improved" and Liebowitz Social Anxiety Scale total score variation on fear and avoidance components were used to detect the results. The statistical analysis was performed with t-test. All measures <0.05 have been considered statistically significant. Results: Ten of 23 subjects on NPPO-REAC and six of the 20 taking sertraline were much improved or very much improved 1 month after the first NPPO-REAC cycle (t1). Sixteen of the subjects on NPPO-REAC and ten of the subjects taking sertraline were much improved or very much improved 1 month after the second NPPO-REAC cycle (t2). In respect of the Liebowitz Social Anxiety Scale, at t1 NPPO-REAC resulted in statistically more efficacy for sertraline on both fear and avoidance total scores. At t2, NPPO-REAC resulted in statistically more efficacy for sertraline on fear but not on avoidance. Conclusion: NPPO-REAC is an effective treatment for SAD, allowing substantial and clinically meaningful reductions in symptoms and disability in comparison with sertraline.
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Behavioral-genetic (twin) methods are important tools for understanding the etiology of trauma exposure and posttraumatic stress disorder (PTSD). The purpose of the present article is to synthesize the results obtained from twin studies and outline important avenues for further investigation. Twin research to date suggests that: (1) exposure to assaultive trauma is moderately heritable whereas exposure to non-assaultive trauma is not, (2) PTSD symptoms are moderately heritable, and (3) comorbidity of PTSD with other disorders may be partly due to shared genetic and environmental influences. Remarkably little is known about whether the observed comorbidity of PTSD with particular personality traits and poor physical health is due to shared genetic or environmental factors. Similarly, little is known about whether gene-environment interactions play an important role in trauma exposure and PTSD. Further research is required to clarify these issues and to determine whether findings to date, obtained mostly from male combat veterans, generalize to other populations. Research programs that integrate behavioral-genetics with molecular genetics and with cognitive-behavioral conceptualizations and research methods may deepen our understanding of the complex links among genes, brain, cognition, emotion, and the environment.
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The comorbidity of current and lifetime DSM-IV anxiety and mood disorders was examined in 1,127 outpatients who were assessed with the Anxiety Disorders Interview Schedule for DSM-IV :Lifetime version (ADIS-IV-L). The current and lifetime prevalence of additional Axis I disorders in principal anxiety and mood disorders was found to be 57% and 81%, respectively. The principal diagnostic categories associated with the highest comorbidity rates were mood disorders, posttraumatic stress disorder (PTSD), and generalized anxiety disorder (GAD). A high rate of lifetime comorbidity was found between the anxiety and mood disorders; the lifetime association with mood disorders was particularly strong for PTSD, GAD, obsessive-compulsive disorder, and social phobia. The findings are discussed in regard to their implications for the classification of emotional disorders.
Article
Social phobia is increasingly recognized as a prevalent and socially impairing mental disorder. However, little data is available regarding the general and disease-specific impairments and disabilities associated with social phobia. Furthermore, most studies have not controlled for the confounding effects of comorbid conditions. This study investigates: (a) the generic quality of life; (b) work productivity; and, (c) various other disorder-specific social impairments in current cases with pure (n = 65), comorbid (n = 51) and subthreshold (n = 34) DSM-IV social phobia as compared to controls with no social phobia (subjects with a history of herpes infections). Social phobia cases reported a mean illness duration of 22.9 years with onset in childhood or adolescence. Current quality of life, as assessed by the SF-36, was significantly reduced in all social phobia groups, particularly in the scales measuring vitality, general health, mental health, role limitations due to emotional health, and social functioning. Comorbid cases revealed more severe reductions than pure and subthreshold social phobics. Findings from the Liebowitz self-rated disability scale indicated that: (a) social phobia affects most areas of life, but in particular education, career, and romantic relationship; (b) the presence of past and current comorbid conditions increases the frequency of disease-specific impairments; and, (c) subthreshold social phobia revealed slightly lower overall impairments than comorbid social phobics. Past week work productivity of social phobics was significantly diminished as indicated by: (a) a three-fold higher rate of unemployed cases; (b) elevated rates of work hours missed due to social phobia problems; and, (c) a reduced work performance. Overall, these findings underline that social phobia in our sample of adults, whether comorbid, subthreshold, or pure was a persisting and impairing condition, resulting in considerable subjective suffering and negative impact on work performance and social relationships. The current disabilities and impairments were usually less pronounced than in the past, presumably due to adaptive behaviors in life style of the respondents. Data also confirmed that social phobia is poorly recognized and rarely treated by the mental health system.
Article
• Selected sociodemographic and clinical features of social phobia were assessed in four US communities among more than 13 000 adults from the Epidemiologic Catchment Area study. Rates of social phobia were highest among women and persons who were younger (age, 18 to 29 years), less educated, single, and of lower socioeconomic class. Mean age at onset was 15.5 years, and first onsets after the age of 25 years were uncommon. Lifetime major comorbid disorders were present in 69% of subjects with social phobia and usually had onset after social phobia. When compared with persons with no psychiatric disorder, uncomplicated social phobia was associated with increased rates of suicidal ideation, financial dependency, and having sought medical treatment, but was not associated with higher rates of having made a suicide attempt or having sought treatment from a mental health professional. An increase in suicide attempts was found among subjects with social phobia overall, but this increase was mainly attributable to comorbid cases. Social phobia, in the absence of comorbidity, was associated with distress and impairment, yet was rarely treated by mental health professionals. The findings are compared and contrasted with prior reports from clinical samples.
Article
Using outpatients with anxiety and mood disorders (N = 350), the authors tested several models of the structural relationships of dimensions of key features of selected emotional disorders and dimensions of the tripartite model of anxiety and depression. Results supported the discriminant validity of the 5 symptom domains examined (mood disorders; generalized anxiety disorder, GAD; panic disorder; obsessive-compulsive disorder; social phobia). Of various structural models evaluated, the best fitting involved a structure consistent with the tripartite model (e.g., the higher order factors, negative affect and positive affect, influenced emotional disorder factors in the expected manner). The latent factor, GAD, influenced the latent factor, autonomic arousal, in a direction consistent with recent laboratory findings (autonomic suppression); Findings are discussed in the context of the growing literature on higher order trait dimensions (e.g., negative affect) that may be of considerable importance to the understanding of the pathogenesis, course, and co-occurrence of emotional disorders.
Article
• This article addresses the issues of recognition of psychiatric disorders by general physicians (GPs) and the effects of recognition on management and course. Among 1994 patients who were screened with the General Health Questionnaire and who were rated by their GP, 1450 (72.7%) had not been identified by the GP as having a psychiatric disorder in the year before the index visit. Among these "new" patients, 557 (38.4%) had positive General Health Questionnaire scores. Only 47% of the new patients who met Bedford College diagnostic criteria for anxiety, depression, or illdefined disorder had their psychiatric disorder recognized by their GP. Among patients who met Bedford College criteria, mean episode durations were longer for anxiety disorders (20 to 22 months) than for depressive disorders (9 to 10 months). Among the new patients, those with psychiatric disorders recognized by the GP were more likely to receive mental health interventions. Recognition was associated with shorter episode duration among patients with an anxiety disorder, but not among patients with depressive or illdefined disorders.
Article
Background: Untreated anxiety may be particularly difficult for primary care physicians to recognize and diagnose because there are no reliable demographic or medical profiles for patients with this condition and because these patients present with a high rate of comorbid psychological conditions that complicate selection of treatment.Method: A prospective assessment of untreated anxiety symptoms and disorders among primary care patients.Results: Approximately 10% of eligible patients screened in clinic waiting rooms of a mixed-model health maintenance organization reported elevated symptoms and/or disorders of anxiety that were unrecognized and untreated. These patients with untreated anxiety reported significantly worse functioning on both physical and emotional measures than "not anxious" comparison patients; in fact these patients reported reduced functioning levels within ranges that would be expected for patients with chronic physical diseases, such as diabetes and congestive heart failure. The most severe reductions in functioning were reported by untreated patients whose anxiety was mixed with depression symptoms or disorders.Conclusion: Primary care physicians may benefit from screening tools and consultations by mental health specialists to assist in recognition and diagnosis of anxiety symptoms and disorders alone and mixed with depression.
Article
The Mini International Neuropsychiatric Interview (MINI) is a short diagnostic structured interview (DSI) developed in France and the United States to explore 17 disorders according to Diagnostic and Statistical Manual (DSM)-III-R diagnostic criteria. It is fully structured to allow administration by non-specialized interviewers. In order to keep it short it focuses on the existence of current disorders. For each disorder, one or two screening questions rule out the diagnosis when answered negatively. Probes for severity, disability or medically explained symptoms are not explored symptom-by-symptom. Two joint papers present the inter-rater and test-retest reliability of the Mini the validity versus the Composite International Diagnostic Interview (CIDI) (this paper) and the Structured Clinical Interview for DSM-IH-R patients (SCID) (joint paper). Three-hundred and forty-six patients (296 psychiatric and 50 non-psychiatric) were administered the MINI and the CIDI ‘gold standard’. Forty two were interviewed by two investigators and 42 interviewed subsequently within two days. Interviewers were trained to use both instruments. The mean duration of the interview was 21 min with the MINI and 92 for corresponding sections of the CIDI. Kappa coefficient, sensitivity and specificity were good or very good for all diagnoses with the exception of generalized anxietydisorder (GAD) (kappa = 0.36), agoraphobia (sensitivity = 0.59) and bulimia (kappa = 0.53). Inter-rater and test-retest reliability were good. The main reasons for discrepancies were identified. The MINI provided reliable DSM-HI-R diagnoses within a short time frame, The study permitted improvements in the formulations for GAD and agoraphobia in the current DSM-IV version of the MINI.
Article
Although decades of research have examined relationships between social anxiety and negative outcomes, this study examined relations with indices of positive psychological functioning. In college students (n = 204), a factor analysis on self-report measures of positive psychological functioning derived 3 conceptually meaningful broad domains: Positive Subjective Experiences, Curiosity, and Appetitive Motivations. Analyses were conducted to test whether social interaction anxiety demonstrated unique relationships with positive psychological domains after controlling for shared variance with social observation anxiety (e.g., eating in public, public speaking) and neuroticism. Social interaction anxiety explained unique variance in all 3 domains after separately controlling for social observation anxiety and neuroticism. In contrast, social observation anxiety demonstrated near-zero relationships with all 3 domains, and neuroticism predicted Positive Subjective Experiences, and to a lesser degree, Curiosity. These data provide evidence for the unique association between social interaction anxiety and positive psychological functioning, with implications for future basic and applied research.
Article
Maladaptive patterns of social functioning have been widely noted as core features associated with the clinical syndrome of combat-related posttraumatic stress disorder (PTSD), including interpersonal violence, social anxiety and avoidance, marital/family discord, and occupational impairment. Unfortunately, clinical instruments for evaluating the complex domains of social functioning are lacking, and no measures have been developed specifically for combat-related PTSD. Therefore, the development of reliable and valid procedures for assessing the social functioning of this group is sorely needed. A number of strategies currently exist, including symptom severity, symptom chronicity, and monetary gain incentive; however, assessment of this population represents several unique challenges. Until measures of social functioning are developed and validated specifically for combat-related PTSD, comprehensive assessment should consist of a multimethod approach, including (a) self-report measures; (b) structured interviews and clinician ratings; (c) patient ratings (e.g., daily diaries); (d) behavioral performance assessments of social skill strengths and deficits; and (e) other behavioral assessments, including functional analysis, psychophysiological measurements, and objective indicators of functioning. The development of an endstate functioning index, anchored to a normal population, would advance our ability to gage the social functioning of veterans following treatment.
Article
The Mini International Neuropsychiatric Interview (MINI) is a short diagnostic structured interview, developed in clinician (MINI-CR) and patient-rated (MINI-PR) formats, for 17 Diagnostic and Statistical Manual (DSM)-III-R Axis I psychiatric disorders. This study, which investigates the validity of the MINI in relation to the Structured Clinical Interview for DSM-III-R Patients (SCID-P), was conducted in conjunction with a similar study, investigating the validity of the MINI in relation to the Composite International Diagnostic Interview (CIDI) for International Statistical Classification of Disease (ICD)-10. Both studies also examined the inter-rater and test-retest reliability of the MINI. Three hundred and seventy subjects (330 in Florida and 40 in Paris) participated in the validation of the MINI versus the SCID-P. Of these, 308 had at least one psychiatric disorder and 62 were non-patient adult controls. Eighty of the subjects (40 in Florida and 40 in Paris) also participated in the parallel study of the validity of the MINI versus the CIDI. The 330 Florida subjects first completed the patient-rated version of the MINI. All subjects were administered the MINI-CR (after the MINI-PR in the case of the Florida subjects), followed by the SCID-P. The MINI-CR was rated by two interviewers for 42 subjects in Florida and 42 in Paris (inter-rater reliability test) and readministered by a third blind interviewer one to two days after the initial rating (test-retest reliability test). Overall, the results supported the validity and reliability of the MINI. In addition, administration of the MINI-CR took half as long as administration of corresponding sections of the SCID-P. The application of short structured interviews in clinical and research settings is discussed.
Article
Selected sociodemographic and clinical features of social phobia were assessed in four US communities among more than 13,000 adults from the Epidemiologic Catchment Area study. Rates of social phobia were highest among women and persons who were younger (age, 18 to 29 years), less educated, single, and of lower socioeconomic class. Mean age at onset was 15.5 years, and first onsets after the age of 25 years were uncommon. Lifetime major comorbid disorders were present in 69% of subjects with social phobia and usually had onset after social phobia. When compared with persons with no psychiatric disorder, uncomplicated social phobia was associated with increased rates of suicidal ideation, financial dependency, and having sought medical treatment, but was not associated with higher rates of having made a suicide attempt or having sought treatment from a mental health professional. An increase in suicide attempts was found among subjects with social phobia overall, but this increase was mainly attributable to comorbid cases. Social phobia, in the absence of comorbidity, was associated with distress and impairment, yet was rarely treated by mental health professionals. The findings are compared and contrasted with prior reports from clinical samples.
Article
Individuals with subthreshold social phobia (SSP) in the community are characterized relative to nonphobic, healthy controls (C), and diagnosed social phobics (SP). Data from 1488 subjects from the Duke University Epidemiological Catchment Area Study were examined. Bivariate and multivariate methods were used to compare the SSP, SP, and C groups on 10 sets of variables. Compared with C respondents, SSP respondents were more likely to be female and unmarried and to report less income and education. The SSP respondents were also more likely to report work attendance problems, poor grades in school, symptoms of conduct disturbance, impaired subjective social support, lack of self-confidence, lack of a close friend, use of psychotropic drugs in past year, and a greater number of life changes, chronic medical problems, and mental health visits within the past 6 months. In a multivariate logistic regression model with group membership as the dependent variable, compared with C respondents, SSP respondents were more likely to be female, to have less education, and to report more indicators of poor school performance and symptoms of adolescent conduct disturbance. In contrast, in a similar but separate multivariate model, compared with SP respondents, SSP respondents met the criteria for fewer DSM-III psychiatric disorders and were less likely to report impaired instrumental support. Social phobia adversely affects over 10% of the population. Previous epidemiologic catchment area-based prevalence estimates have probably been unrealistically low.
Article
This study examined the nature of impairment of functioning in persons with social phobia and assessed the validity of two new rating scales for describing impairment in social phobia. In 32 patients with social phobia and 14 normal control subjects, impairment was assessed using the Disability Profile and the Liebowitz Self-Rated Disability Scale, new instruments designed to provide clinician- and patient-rated descriptive measures of current and lifetime functional impairment related to emotional problems. Validity of the new scales was assessed by measuring internal consistency, comparing scores for patients and controls, and comparing scores with those on standard measures of disability, social phobia symptoms, and social support. More than half of all social phobic patients reported at least moderate impairment at some time in their lives, due to social anxiety and avoidance, in areas of education, employment, family relationships, marriage/romantic relationships, friendships/social network, and other interests. Social phobic patients were rated more impaired than normal controls on nearly all items on both measures. Both scales were internally consistent, with Cronbach's alpha coefficients for lifetime and current disability subscales in the range of .87 to .92. Significant positive correlations of scores on the new scales with scores on coadministered standard scales of social phobia symptoms and disability demonstrated concurrent validity. Disability was not significantly correlated with measures of social support. Social phobia is associated with impairment in most areas of functioning, and the new scales appear useful in assessing functional impairment related to social phobia.
Article
Untreated anxiety may be particularly difficult for primary care physicians to recognize and diagnose because there are no reliable demographic or medical profiles for patients with this condition and because these patients present with a high rate of comorbid psychological conditions that complicate selection of treatment. A prospective assessment of untreated anxiety symptoms and disorders among primary care patients. Approximately 10% of eligible patients screened in clinic waiting rooms of a mixed-model health maintenance organization reported elevated symptoms and/or disorders of anxiety that were unrecognized and untreated. These patients with untreated anxiety reported significantly worse functioning on both physical and emotional measures than "not anxious" comparison patients; in fact these patients reported reduced functioning levels within ranges that would be expected for patients with chronic physical diseases, such as diabetes and congestive heart failure. The most severe reductions in functioning were reported by untreated patients whose anxiety was mixed with depression symptoms or disorders. Primary care physicians may benefit from screening tools and consultations by mental health specialists to assist in recognition and diagnosis of anxiety symptoms and disorders alone and mixed with depression.
Article
Prevalence of crime and noncrime civilian traumatic events, lifetime posttraumatic stress disorder (PTSD), and PTSD in the past 6 months were assessed in a sample of U.S. adult women (N = 4,008). Random digit-dial telephone methods were used to identify study participants. Structured telephone interviews for assessment of specific crime or other traumatic event history and PTSD were conducted by trained female interviewers. Lifetime exposure to any type of traumatic event was 69%, whereas exposure to crimes that included sexual or aggravated assault or homicide of a close relative or friend occurred among 36%. Overall sample prevalence of PTSD was 12.3% lifetime and 4.6% within the past 6 months. The rate of PTSD was significantly higher among crime versus noncrime victims (25.8% vs. 9.4%). History of incidents that included direct threat to life or receipt of injury was a risk factor for PTSD. Findings are compared with data from other epidemiological studies. Results are discussed as they relate to PTSD etiology.
Article
The authors examined the effect of patients' style of clinical presentation on primary care physicians' recognition of depression and anxiety. The subjects were 685 patients attending family medicine clinics on self-initiated visits. They completed structured interviews assessing presenting complaints, self-report measures of symptoms and hypochondriacal worry, the Diagnostic Interview Schedule (DIS), and the Center for Epidemiologic Studies Depression Scale (CES-D). Physician recognition was determined by notation of any psychiatric condition in the medical chart over the ensuing 12 months. The authors identified three progressively more persistent forms of somatic presentations, labeled "initial," "facultative," and "true" somatization. Of 215 patients with CES-D scores of 16 or higher, 80% made somatized presentations; of 75 patients with DIS-diagnosed major depression or anxiety disorder, 76% made somatic presentations. Among patients with DIS major depression or anxiety disorder, somatization reduced physician recognition from 77%, for psychosocial presenters, to 22%, for true somatizers. The same pattern was found for patients with high CES-D scores. In logistic regression models education, seriousness of concurrent medical illness, hypochondriacal worry, and number of lifetime medically unexplained symptoms each increased the likelihood of recognition, while somatized presentations decreased the rate of recognition. While physician recognition of psychiatric distress in primary care varied widely with different criteria for recognition, the same pattern of reduction of recognition with increasing level of somatization was found for all criteria. In contrast, hypochondriacal worry and medically unexplained somatic symptoms increased the rate of recognition.
Article
Data are presented on the general population prevalences, correlates, comorbidities, and impairments associated with DSM-III-R phobias. Analysis is based on the National Comorbidity Survey. Phobias were assessed with a revised version of the Composite International Diagnostic Interview. Lifetime (and 30-day) prevalence estimates are 6.7% (and 2.3%) for agoraphobia, 11.3% (and 5.5%) for simple phobia, and 13.3% (and 4.5%) for social phobia. Increasing lifetime prevalences are found in recent cohorts. Earlier median ages at illness onset are found for simple (15 years of age) and social (16 years of age) phobias than for agoraphobia (29 years of age). Phobias are highly comorbid. Most comorbid simple and social phobias are temporally primary, while most comorbid agoraphobia is temporally secondary. Comorbid phobias are generally more severe than pure phobias. Despite evidence of role impairment in phobia, only a minority of individuals with phobia ever seek professional treatment. Phobias are common, increasingly prevalent, often associated with serious role impairment, and usually go untreated. Focused research is needed to investigate barriers to help seeking.
Article
Posttraumatic stress disorder (PTSD) is the most prevalent psychological disorder experienced by Vietnam veterans. However, there are many other disorders and problems of adjustment, like social anxiety and social phobia, that have not been fully investigated in this population. This study examined the prevalence of social phobia and the comorbidity of social phobia and PTSD, and tested out a theory of the etiology of social anxiety in trauma victims. Forty one Vietnam combat veterans were interviewed and completed self-report measures assessing PTSD and social phobia. Adversity of homecoming was also assessed. Using a conservative multi-method assessment approach, 32% of the sample were found to be positive for both social phobia and PTSD. Veterans with PTSD were significantly more likely to carry an additional diagnosis of social phobia as compared to veterans without PTSD. Adversity of homecoming and shame about one's experience in Vietnam were significant predictors of current level of social anxiety over and above the effects of pre-military anxiety and severity of combat exposure. These observations suggest that social anxiety and social phobia may be significant problems among individuals with PTSD. Further, these findings offer preliminary support for the theory that posttrauma environment may impact upon the later development of social anxiety.
Article
The development and initial evaluation of a new, comprehensive and multicomponent behavioral treatment (Trauma Management Therapy, or TMT) for chronic combat-related Post-Traumatic Stress Disorder (PTSD) is described. The program utilizes elements of intensive exposure therapy, programmed practice, and structured social and emotional skills training to target the multiple aspects of chronic combat-related PTSD. The treatment was found to be effective in alleviating a broad spectrum of difficulties in combat veterans with chronic PTSD, most of whom had co-occurring Axis I and/or Axis II disorders. The results are discussed with respect to the implementation of the new treatment and the general need for a comprehensive approach to treating combat-related PTSD. Implications for the potential cost-effectiveness of the treatment program also are discussed.
Article
The psychometric properties of the PTSD Checklist (PCL), a new, brief, self-report instrument, were determined on a population of 40 motor vehicle accident victims and sexual assault victims using diagnoses and scores from the CAPS (Clinician Administered PTSD Scale) as the criteria. For the PCL as a whole, the correlation with the CAPS was 0.929 and diagnostic efficiency was 0.900 versus CAPS. Examination of the individual items showed wide ranging values of individual item correlations ranging from 0.386 to 0.788, and with diagnostic efficiencies of 0.700 or better for symptoms. We support the value of the PCL as a brief screening instrument for PTSD.
Article
The current paper presents a model of the experience of anxiety in social/evaluative situations in people with social phobia. The model describes the manner in which people with social phobia perceive and process information related to potential evaluation and the way in which these processes differ between people high and low in social anxiety. It is argued that distortions and biases in the processing of social/evaluative information lead to heightened anxiety in social situations and, in turn, help to maintain social phobia. Potential etiological factors as well as treatment implications are also discussed.
Article
This study examined the quality of the intimate relationships of male Vietnam veterans. Heterosexual couples in which the veteran had posttraumatic stress disorder (PTSD; n = 26) were compared to couples in which the veteran did not have PTSD (n = 24). Over 70% of the PTSD veterans and their partners reported clinically significant levels of relationship distress compared to only about 30% of the non-PTSD couples. Relationship difficulties appeared to encompass a wide range of areas, with PTSD veterans and their partners reporting that they had more problems in their relationships, more difficulties with intimacy, and had taken more steps toward separation and divorce than the non-PTSD veterans and their partners. The degree of relationship distress was correlated with the severity of veterans' PTSD symptoms, particularly symptoms of emotional numbing. Research and clinical implications of the results are discussed.
Article
The relationship between posttraumatic stress disorder (PTSD) and self-reported levels of social anxiety among combat veterans was assessed using the Social Phobia and Anxiety inventory (SPAI). Participants were 45 veterans with combat-related PTSD assessed using a multimeasure assessment package. The veterans reported a high level of social anxiety and agoraphobia-like symptoms. Agoraphobia scores were predicted by PTSD severity and elevated by Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales of acute distress and psychopathology. Social phobia scores were predicted by severity of depression. The relationship between social anxiety, depression, and PTSD is discussed. Implications for the assessment and treatment of PTSD are also discussed.
Article
Social phobia is increasingly recognized as a prevalent and socially impairing mental disorder. However, little data is available regarding the general and disease-specific impairments and disabilities associated with social phobia. Furthermore, most studies have not controlled for the confounding effects of comorbid conditions. This study investigates: (a) the generic quality of life; (b) work productivity; and, (c) various other disorder-specific social impairments in current cases with pure ( n = 65), comorbid ( n = 51) and subthreshold ( n = 34) DSM-IV social phobia as compared to controls with no social phobia (subjects with a history of herpes infections). Social phobia cases reported a mean illness duration of 22.9 years with onset in childhood or adolescence. Current quality of life, as assessed by the SF-36, was significantly reduced in all social phobia groups, particularly in the scales measuring vitality, general health, mental health, role limitations due to emotional health, and social functioning. Comorbid cases revealed more severe reductions than pure and subthreshold social phobics. Findings from the Liebowitz self-rated disability scale indicated that: (a) social phobia affects most areas of life, but in particular education, career, and romantic relationship; (b) the presence of past and current comorbid conditions increases the frequency and severity of disease-specific impairments; and, (c) subthreshold social phobia revealed slightly lower overall impairments than comorbid social phobics. Past-week work productivity of social phobics was significantly diminished as indicated by: (a) a three-fold higher rate of unemployed cases; (b) elevated rates of work hours missed due to social phobia problems; and (c) a reduced work performance. Overall, these findings underline that social phobia in our sample of adults, whether comorbid, subthreshold, or pure was a persisting and impairing condition, resulting in considerable subjective suffering and negative impact on work performance and social relationships. The current disabilities and impairments were usually less pronounced than in the past, presumably due to adaptive behaviors in life style of the respondents. Data also confirmed that social phobia is poorly recognized and rarely treated by the mental health system.
Article
Previous analysis of data from the U.S. National Comorbidity Survey (NCS) [24] suggested that the lifetime prevalence of social phobia in the community has increased significantly in recent cohorts. Furthermore, a latent class analysis of NCS data [21] revealed two primary classes of persons with social phobia: those with exclusive speaking fears and those with one or more other social-evaluative fears. Social phobia in the other social fear group is more persistent, more impairing, and more highly co-morbid with other DSM-III-R disorders. The current report presents data on whether the cohort effect is a general aspect of social phobia or is specific to one of the NCS social phobia subtypes, and whether the cohort effect varies as a function of socio-demographic characteristics. Data were drawn from the NCS. Social phobia was assessed with a revised version of the Composite International Diagnostic Interview. Retrospective age of onset reports were used to estimate Kaplan-Meier survival curves for first onset of social phobia in each cohort represented in the survey. Comparison of these curves allowed us to make synthetic estimates based on retrospective reports of intercohort trends in lifetime prevalence. The lifetime prevalence of social phobia appears to have increased in recent cohorts. However, this increase does not exist among social phobics with exclusive fears of speaking. The increase is most pronounced among white, educated, and married persons, and it is not explained by increased co-morbidity with other mental disorders. The fact that the cohort effect is more pronounced for social phobia with one or more non-speaking fears is important in that this is generally a more severe form of the disorder with an earlier age of onset than social phobia with pure speaking fears. The fact that the cohort effect is most pronounced among people with social and economic advantage (i.e., white, married, well-educated) is intriguing and raises questions about the etiologic process that warrant further study in future research.
Article
The Clinician-Administered PTSD Scale (CAPS) is a structured interview for assessing posttraumatic stress disorder (PTSD) diagnostic status and symptom severity. In the 10 years since it was developed, the CAPS has become a standard criterion measure in the field of traumatic stress and has now been used in more than 200 studies. In this paper, we first trace the history of the CAPS and provide an update on recent developments. Then we review the empirical literature, summarizing and evaluating the findings regarding the psychometric properties of the CAPS. The research evidence indicates that the CAPS has excellent reliability, yielding consistent scores across items, raters, and testing occasions. There is also strong evidence of validity: The CAPS has excellent convergent and discriminant validity, diagnostic utility, and sensitivity to clinical change. Finally, we address several concerns about the CAPS and offer recommendations for optimizing the CAPS for various clinical research applications.
Article
Research on depression is often conducted with analogue samples that have been divided into depressed and nondepressed groups using a cutoff score on the Beck Depression Inventory (BDI). Although the relative merits of different cut scores are frequently debated, no study has yet determined whether the use of any cut score is valid, that is, whether the latent structure of BDI depression is categorical or dimensional in analogue samples. The BDI responses of 2,260 college students were submitted to 3 taxometric procedures whose results were compared with those of simulated data sets with equivalent parameters. Analyses provided converging evidence for the dimensionality of analogue depression, arguing against the use of the BDI to classify analogue participants into groups. Analyses also illustrated the notable impact of pronounced skew on taxometric results and the value of using simulated comparison data as an interpretive aid.
Article
This study compared Gulf War veterans seeking VA primary care with Gulf War veterans seeking treatment from a Department of Defense primary care clinic on measures of physical symptoms, psychiatric complaints, and functional status. Additionally, the association between employment status and health was examined. Analysis was based on the responses of consecutive patients attending the Gulf War Primary Care clinics at either the VA Puget Sound Health Care System in Seattle, WA (N= 223), or the Walter Reed Army Medical Center in Washington, DC (N= 153), between March 1998 and September 1999. After controlling for demographic variables, Gulf War veterans who sought VA care reported significantly more anxiety and PTSD symptoms than active duty military personnel. The groups did not differ on somatic complaints or summary scores from the SF-36. Employment status was significantly, independently, and consistently associated with greater psychiatric symptoms, physical symptoms, and decreased functional status. Our findings reveal important differences in health status between veterans seeking primary care at a VA and a Department of Defense facility, differences that are in part related to employment status. Both groups report symptoms of psychiatric distress and decreased functional status, though VA patients are more impaired. Research findings based on clinical samples of veterans at VA sites may not generalize to Gulf War veterans still on active duty (and vice versa).
Article
Many Vietnam veterans with PTSD report a high level of social anxiety and avoidance. Many traumatized individuals also suffer from symptoms of depression, which is often associated with significant problems in social functioning. In order to explore the relationship between social anxiety, depression, and PTSD, we recruited a group of Vietnam veterans with PTSD (n = 27), veterans with other mental disorders (n = 20), and veterans with no mental disorders (n = 35). Participants were administered diagnostic interviews and some of the most commonly used social anxiety instruments. Although the groups did not differ in their rates of social phobia, veterans with PTSD scored highest in most social anxiety measures. Veterans with PTSD were also more likely to be clinically depressed than veterans without PTSD at the time of the assessment. When controlling for the level of depression, the three groups no longer differed in any of the social anxiety measures. Furthermore, level of depression was the best predictor for group membership. These findings suggest that social anxiety in Vietnam combat veterans with PTSD is closely associated with mood disturbance, social withdrawal, and isolation associated with depression.
Article
Depressive symptoms are associated with both the presence of negative subjective experiences and relative absence of positive subjective experiences. A similar affective profile of high negative affect and low positive affect (PA) has been associated with excessive social anxiety (SA). This initial cross-sectional study evaluated the incremental effects of social interaction anxiety on hedonic deficits beyond the effects of depressive and anxiety (i.e., physiological arousal, worry) symptoms. From a sample of 97 college students, a factor analysis on self-report measures of hedonic functioning derived two domains: Positive Subjective Experiences and Curiosity. Social interaction anxiety was uniquely, negatively related to Positive Subjective Experiences and Curiosity after removing variance attributable to various depressive and anxiety symptoms. In contrast, anxious arousal and nonspecific anxiety had near-zero relationships with both domains, and depressive symptoms were negatively related to Positive Subjective Experiences. These data provide some evidence for an association between social interaction anxiety and hedonic deficits that is not attributable to covariance with other internalizing conditions.
Article
We hypothesized that PTSD symptomatology would have an inverse relationship with functional status and would vary as a function of sociodemographic variables. Primary care patients (N = 513) at two VA Medical Centers were randomly selected and recruited to participate. After adjustment for other demographic variables, PTSD symptom levels were significantly related to age (younger patients had more severe symptoms), employment status (disabled persons had higher symptom levels), war zone experience, and clinic location. PTSD symptomatology was inversely related to mental and physical functioning, even after control for potential confounding. These findings have implications for screening and service delivery in VA primary care clinics, and support the more general finding in the literature that PTSD is associated with impaired functioning.
Risk factors for adolescent substance abuse and dependence: Data from a national sample ARTICLE Resilience-recovery factors in post-traumatic stress disorder among female and male Vietnam veterans: Hardiness, postwar social support, and additional stressful life events
  • D G Kilpatrick
  • R Acierno
  • B Saunders
  • H S Resnick
  • C L Best
  • P P Schnurr
  • T B In
  • Kashdan
Kilpatrick, D. G., Acierno, R., Saunders, B., Resnick, H. S., Best, C. L., & Schnurr, P. P. (2000). Risk factors for adolescent substance abuse and dependence: Data from a national sample. Journal of Consulting and Clinical Psychology, 68, 19–30. ARTICLE IN PRESS T.B. Kashdan et al. / Behaviour Research and Therapy 44 (2006) 233–247 245 rKing, L. A., King, D. W., Fairbank, J. A., Keane, T. M., & Adams, G. A. (1998). Resilience-recovery factors in post-traumatic stress disorder among female and male Vietnam veterans: Hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology, 74, 420–434