When social anxiety disorder co-exists with risk-prone, approach behavior: Investigating a neglected, meaningful subset of people in the National Comorbidity Survey-Replication

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Abstract

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.

Section snippets

Self-regulatory patterns and social anxiety disorder

The notion of multifinality (Cicchetti and Rogosch, 1996, Rutter, 2005) can be applied to the various ways that people with SAD avoid being rejected and improve their ability to gain acceptance by others. Basically, subgroups of people with similar problems (i.e., SAD) generate different (i.e., risk averse versus prone) behaviors and strategies that in turn, lead to different outcomes. The fundamental issue is how to best capture this heterogeneity in people with social anxiety problems.

The

Modeling the heterogeneity of social anxiety disorder

The current study is part of a program of research focused on uncovering meaningful but omitted variables in describing and understanding SAD. Preliminary empirical evidence for the utility of these variables has been found with three independent clinical (Kachin et al., 2001, Kashdan and Hofmann, 2008) and non-clinical (Kashdan et al., 2008) samples. These studies, however, were limited by small samples, unstable data analytic procedures (relying on cluster analyses), self-report

Participants

The data come from the National Comorbidity Survey-Replication NCS-R (Kessler et al., 2004) – a nationally representative, face-to-face household survey conducted in the United States. The survey used a multistage clustered-area design whereby participants were randomly recruited (response rate 70.9%) from geographic regions. Survey respondents were first recruited via a letter and then provided detailed instructions and verbal informed consent. All respondents completed the first part of the

Risk-prone behavior

The latent class models from both the current and lifetime SAD subsamples indicated that a 2-class solution fit best (see Table 3) for the risk-prone behavior items. There were no differences between the two samples for either solution so the remainder of the results focused exclusively on the current SAD sample due to more complete data and the better reliability associated with recent reporting. The two classes generated by the risk-prone behavior model were theoretically meaningful. Class 1

Discussion

With new epidemiological data from the NCS-R, we used a latent class model to describe and classify people with SAD using risk-prone behavior items. Our latent class analysis provided evidence for critical heterogeneity in SAD based on aggression, anger, sexuality, and substance use behavior patterns. The majority of people with SAD reported a prototypical pattern of behavioral inhibition and risk aversion. A smaller subset of people reported elevated aggression and moderate levels of sexual

Summary

With over 25 years of research on the nature of SAD, clinicians and researchers should be skeptical of any new model of splitting clients into subgroups. The sine qua non of any data reduction technique is obtaining a theoretically meaningful solution that can be replicated in multiple samples using various methods. Our latent class solution is theoretically meaningful, converging with recent work on social anxiety and self-regulation (Maner et al., 2007, Nezlek and Leary, 2002, Rodebaugh, 2007

Acknowledgements

The contributions of the first two authors are equal. This work was supported by National Institute of Mental Health grant MH-73937 to Todd B. Kashdan. Stefan G. Hofmann is a paid consultant of Organon and supported by NIMH grants MH-078308 and MH-081116.

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