Evidence based assessment/Social anxiety disorder (disorder portfolio)

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Medical disclaimer: This page is for educational and informational purposes only and may not be construed as medical advice. The information is not intended to replace medical advice offered by physicians. Please refer to the full text of the Wikiversity medical disclaimer.

What is a "portfolio"?[edit]

  • For background information on what assessment portfolios are, click the link in the heading above.

Preparation phase[edit]

Diagnostic criteria for phobic anxiety disorders[edit]

Click here for ICD-10 and DSM-5 Diagnostic Information

ICD-10 Diagnostic Criteria for Anxiety Disorders

  • A group of disorders in which anxiety is evoked only, or predominantly, in certain well-defined situations that are not currently dangerous. As a result these situations are characteristically avoided or endured with dread. The patient's concern may be focused on individual symptoms like palpitations or feeling faint and is often associated with secondary fears of dying, losing control, or going mad. Contemplating entry to the phobic situation usually generates anticipatory anxiety. Phobic anxiety and depression often coexist. Whether two diagnoses, phobic anxiety and depressive episode, are needed, or only one, is determined by the time course of the two conditions and by therapeutic considerations at the time of consultation.

Social phobia

  • Fear of scrutiny by other people leading to avoidance of social situations. More pervasive social phobias are usually associated with low self-esteem and fear of criticism. They may present as a complaint of blushing, hand tremor, nausea, or urgency of micturition, the patient sometimes being convinced that one of these secondary manifestations of their anxiety is the primary problem. Symptoms may progress to panic attacks. Specific criteria for social phobia includes:
  • A. Either of the following must be present:
    • 1. marked fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating;
    • 2. marked avoidance of being the focus of attention or of situations in which there is fear of behaving in an embarrassing or humiliating way.

These fears are manifested in social situations, such as eating or speaking in public, encountering known individuals in public or entering or enduring small group situations (e.g. parties, meetings, classrooms).

  • B. At least 2 symptoms of anxiety in the feared situation as defined in F40.0, Criterion B, must have been manifest at some time since the onset of the disorder, together with at least one of the following symptoms:
    • 1. blushing or shaking;
    • 2. fear of vomiting;
    • 3. urgency or fear of micturition or defecation.
  • C. Significant emotional distress is caused by the symptoms or the avoidance, and the individual recognizes that these are excessive or unreasonable.
  • D. Symptoms are restricted to, or predominate in, the feared situations or contemplation of the feared situations.
  • E. Most commonly used exclusion clause. The symptoms listed in criteria A and B are not the result of delusions, hallucinations, or other disorders such as organic mental disorders, schizophrenia and related disorders, mood [affective] disorders, or obsessive-compulsive disorder, and are not secondary to cultural beliefs.

Changes in DSM-5

  • The diagnostic criteria for simple phobia changed slightly from DSM-IV to DSM-5. Summaries are available here and here.

Base rates of social phobia in different clinical settings[edit]

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of social anxiety disorder they are likely to see in their clinical practice.

  • To see prevalence rates across multiple disorders, click here.
Setting Base Rate Demography Diagnostic Method Best Recommended For
The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project. Psychiatric outpatient practice sample (n=859)[1] 27.8% Rhode Island SIDP-IV
Representative probability within primary care group sample ages 18-70 (n=1001)[2] 3% Oakland, California SCID
National Comorbidity Survey Replication (NCS-R). Nationally representative household survey, community sample of adults ages 18+ (n=9282).[3] 12.1% (lifetime)

7.1% (12-month)

All of U.S.A. WHO-CIDI Clinical Interview
NCS Adolescent Supplement (NCS-A) for ages 13 to 17. Community sample, (n=6243).[4] Females 11.2%

Males 6.2% Total 8.6%

All of U.S.A. WHO-CIDI Clinical Interview, modified to simplify language and use examples relevant to adolescents.
The Great Smoky Mountains Study (GSMS). Longitudinal, community sample of children ages 9 to 16 (n=6674)[5] Females 0.8%

Males 0.3% Total 0.5%

Western North Carolina. CAPA
Teen Health 2000 (TH2K). Community sample in large, metropolitan area, ages 11 to 17 (n=4,175).[6] 1.6% Houston, Texas metropolitan area. DISC-IV
Representative household probability community sample, ages 4 to 17 (n=1886)[7] 2.8% Puerto Rico DISC-IV
Child and Adolescent Anxiety Disorders outpatient research clinic, ages 8 to 13 with anxiety disorder diagnosis (n=199).[8] 20% Children referred to Anxiety Disorders clinic ADIS-C/P
Meta-analysis of data collected across multiple clinical settings, 1995-2006 (n=15,967)[9] 20% (SDI)

6% (unstructured interview)

All of U.S.A. – clinical settings Structured or Semi-Structure Diagnostic Interviews and unstructured clinical interviews.
Outpatient clinic 6% (DAU)[10] Metanalysis of outpatient clinics
Outpatient clinic 20% (SDI)[11] Metanalysis of outpatient clinics
General Population 9% [12] Intended to apply to the entire United States

Note: WHO-CIDI = World Health Organization Composite International Diagnostic Interview; NCS-A (lifetime prevalence); CAPA= Children and Adolescent Psychiatric Assessment (3-month prevalence); DISC-IV = Diagnostic Interview Schedule for Children, Version 4 (12-month prevalence); ADIS-C/P=Anxiety Disorders Interview Schedule for Children/Parents; SIDP-IV = Structured Interview for DSM-IV Personality; SCID=Structured Clinical Interview for DSM-IV; SDIs included in Rettew et al. (2009): CIDI, DAWBA, DICA, DISC, DIS, MINI, K-SADS-PL, SCAN-2, SCID, SCID-II.

  • Higher rates of social anxiety disorder are found in females than in males, with more pronounced differences in adolescence. Prevalence rates in children and adolescents are comparable to those in adults. Onset is typically in early adolescence (DSM-5, 2013).

Prediction phase[edit]

Psychometric properties of screening instruments for social anxiety disorder[edit]

The following section contains a list of screening and diagnostic instruments for social anxiety disorder. The section includes administration information, psychometric data, and PDFs or links to the screenings.

  • Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
  • For a list of more broadly reaching screening instruments, click here.
Measure Format (Reporter) Age Range Administration/

Completion Time

Inter-rater reliability Test-retest reliability Construct validity Content validity Highly recommended Free and Accessible Measures
Liebowitz Social Anxiety Scale (LSAS)[13] Questionnaire (clinician administered, self-report) 7 years-adult 15 minutes U U G E[14]
Overall Anxiety Severity And Impairment Scale (OASIS)[15] Questionnaire (clinician administered, self-report) 10-15 minutes
Social Phobia Inventory (SPIN)[16] Questionnaire (self-report) 12 years-adult 5-10 minutes NA A G G
Revised Children’s Anxiety and Depression Scale (RCADS) Questionnaire (Child) 6-18 12 minutes G[17] G[18] G[17]

PDFs for RCADS

  • RCADS Child Self-reported (8-18 years)
  • *RCADS Parent-reported Subscales Translations User Guide
    Social Phobia and Anxiety Inventory (SPAI)[19] Questionnaire (self-report) 14 years-adult 20-30 minutes NA A E E Not free
    Brief Social Phobia Scale Observer Checklist (clinician) Adults 5-10 minutes U A A A Not free
    Social Phobia and Anxiety Inventory for Children (SPAIC) Questionnaire 8-14 years 20-30 minutes NA E G E Not free

    Note: L= Less than adequate; A= Adequate; G= Good; E= Excellent; U= Unavailable; NA= Not applicable

    Likelihood ratios and AUCs of screening measures for social anxiety disorder[edit]

    • For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
    Screening Measure (Primary Reference) AUC (Sample Size) DiLR+ (Score) DiLR- (Score) Clinical Generalizability
    Liebowitz Social Anxiety Scale (LSAS)

    [20]

    [21] and [22]

    0.94 - differentiating from subclinical patients

    0.98 - differentiating from healthy controls

    Not reported Not reported
    Overall Anxiety Severity And Impairment Scale (OASIS)[23] .87[24] 3.07 (> or = cut score 8)
    Cut-score of ≥ 8 to be optimal given that it successfully classified 87% of the sample with the most favorable balance of sensitivity (89%) and specificity (71%)

    [24]

    Not reported Unknown[24]
    Spence Children’s Anxiety Scale - Parent Version (SCAS-P)

    (Nauta, 2005)

    0.59 (n=543) Not reported Not reported
    Multidimensional Anxiety Scale for Children (MASC)
    [25][26] and [27]
    .61 for Males
    .69 for Females
    .80 Total for SA Subscale
    (n=632)
    3.4(13.5+) .46
    Revised Children’s Manifest Anxiety Scale (RCMAS)
    [28][26] and (Hodges, 1990)
    .61 for Males
    .58 for Females
    (n=632)
    5.25 (t >60) .63
    Social Phobia and Anxiety Inventory for Children (SPAI-C)
    (Beidel, Turner, & Morris, 1995)

    [29] and [30]

    .65 (n=172) 3.55 (18+) .47
    Screen for Child Anxiety and Related Emotional Disorders (SCARED)
    [31][32]
    .72 (n=119) 1.9 (27+) .50
    Brief Fear of Negative Evaluation Scale Revised (BFNE-R)
    (Leary, 1983)

    [33]

    Not reported 3.3 (+38) .45
    Click here for notes about the above table
    • Note: All studies used some version of ADIS-C, K-SADS or CAS administered by trained raters. “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation (Sackett et al., 2000). AUC guidelines according to Swets and Pickett (1982)[34]: .50 to .70 (low accuracy), .70 to .90 (moderate accuracy), and greater than .90 (high accuracy).
    • Note: Silverman & Ollendick (2005)[35] suggest that the SPAI-C is the better instrument for identifying those children and adolescents who most likely meet DSM-IV criteria for social phobia, but that this measure may miss some adolescents who would meet criteria for social phobia. Child and Adolescent Social Anxiety Disorder Jacqueline Nesi 7 Although the MASC has evidence to support it, the current evidence only applies to screening for GAD in girls and anxiety comorbidities (p.404). Thus, for both of these measures, another assessment method is to be used as well, such as an interview schedule (pp 401-5). The SCARED, MASC, and FSSC-R may be helpful to discriminate between youth with social phobia versus other anxiety disorders (p. 404).

    Interpreting social anxiety disorder screening measure scores[edit]

    Prescription phase[edit]

    Gold standard diagnostic interviews[edit]

    • For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

    Recommended diagnostic interviews for social anxiety disorder[edit]

    Diagnostic instruments for social anxiety disorder
    Measure Format (Reporter) Age Range Administration/

    Completion Time

    Interrater Reliability Test-Retest Reliability Construct Validity Content Validity Highly Recommended Free and Accessible Measures
    Anxiety Disorders Interview Schedule (ADIS) Interview (clinician) 7 years-adult 90 minutes E E E E
    Diagnostic Interview Schedule for Children (DISC-IV) Interview (clinician) 6-17 years 1-2 hours A G G G

    Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

    Severity interviews for social anxiety disorder[edit]

    Diagnostic instruments for social anxiety disorder
    Measure Format (Reporter) Age Range Administration/

    Completion Time

    Interrater Reliability Test-Retest Reliability Construct Validity Content Validity Highly Recommended Free and Accessible Measures

    Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

    Process phase[edit]

    The following section contains a brief overview of treatment options for social anxiety disorder and list of process and outcome measures for social anxiety disorder. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

    Process measures[edit]

    Outcome and severity measures[edit]

    This table includes clinically significant benchmarks for social anxiety disorder specific outcome measures

    • Information on how to interpret this table can be found here.
    • Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
    • For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
    Benchmarks Based on Non-Referred Sample of Adolescents (Anderson et al., 2009)
    Measure Subscale Cut-off scores Critical Change
    (unstandardized scores)
    A B C 95% 90% SEdifference
    MASC (2009) Total 15.9 63.8 38.9 11.9 10.0 6.1
    Social Anxiety Scale 3.5 19.9 11.8 7.8 6.6 4.0
    SPAI-C (2009) Total 3.3 26.6 15.9 7.5 6.3 3.8
    Benchmarks Based on Published Norms
    Measure Subscale Cut-off scores Critical Change
    (unstandardized scores)
    A B C 95% 90% SEdifference
    CBCL T-Scores (2001 Norms) Total 49 70 58 5 4 2.4
    Internalizing n/a 70 56 9 7 4.5
    TRF T-Scores (2001 Norms) Total n/a 70 57 5 4 2.3
    Internalizing n/a 70 55 9 7 4.4
    YSR T-Scores (2001 Norms) Total n/a 70 54 7 6 3.3
    Internalizing n/a 70 54 9 8 4.8

    Note: A = Away from the clinical range; B= Back into the nonclinical range; and C = Closer to the nonclinical than clinical mean.

    Treatment[edit]

    Click here for information of therapy for social anxiety

    According to Effective Child Therapy, no “Well-Established” treatments have been empirically validated for Social Phobia.

    • However, group Cognitive Behavioral Therapy, or Group CBT, for Anxiety has been identified as “Probably Efficacious” in treating Social Phobia.
    • According to Effective Child Therapy, the “Probably Efficacious” distinction marks a treatment as having “strong research support” but lacking the criteria that at least two large-scale randomized controlled trials have been conducted by “independent investigatory teams working at different research settings.” This prevents the treatment from moving into the “Well-Established” group.
    • Currently, however, CBT is identified as the most promising treatment for childhood and adolescent social phobia.

    Cognitive Behavioral Therapy

    • Effective Child Therapy identifies the following core components of CBT for anxious youth, including those with Social Phobia: Emotions Education and Relaxation.
    • Parents and child are taught about the interrelated physiological, cognitive, and behavioral components of anxiety.
    • Activities help demonstrate different emotions, body postures, and cognitive and physiological correlates. Progressive relaxation training helps anxious children develop awareness and control over their own physiological and muscular responses to anxiety.

    Cognitive restructuring

    • Cognitive restructuring helps children identify and replace distorted cognitions with more adaptive beliefs.
    • Basic cognitive strategies include identifying and reducing negative self-talk, generating positive self-statements, thought stopping, thought challenging (weighing evidence for and against), testing both dysfunctional and adaptive beliefs, and creating a coping plan for feared situations.

    Imaginal and in-vivo exposure

    • The goals of exposures are to encourage approach behavior by positioning the child in a previously feared or challenging situation.
    • The child attempts to complete tasks in a graded "fear hierarchy" such that the child experiences early success before attempting greater challenges.
    • During individual exposures, a child is encouraged to use any number of coping skills, including relaxation exercises, coping thoughts (challenging anxious thoughts with more positive, realistic thoughts), concrete problem-solving, or rehearsal of desirable skills.

    Parent Interventions

    • Parents may have their own preconceptions about the threatening nature of anxiety and they may not know how best to encourage a child to cope with anxiety.
    • CBT provides parents education about the risks of continued avoidance and guidance in managing their own anxiety
    • CBT may also impart basic parenting strategies (e.g., positive/negative reinforcement, planned ignoring, modeling, reward planning) to facilitate the practice of therapy skills in the home.

    Sources: Effective Child Therapy page on Fear, Worry & Anxiety

    Please refer to the Wikipedia page on Social Anxiety Disorder for more information on available treatment for social anxiety or go to Effective Child Therapy for a curated resource on effective treatments for anxiety disorders.

    External resources[edit]

    1. ICD-10 diagnostic criteria
    2. Find-a-Therapist
      • A curated list of find-a-therapist websites where you can find a provider
    3. NIMH
      • Go to this resource for more information on anxiety disorders
    4. OMIM (Online Mendelian Inheritance in Man)
    5. Effective Child Therapy page for Fear, Worry, & Anxiety
      • Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society for Clinical Child and Adolescent Psychology (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.
    6. Society of Clinical Child and Adolescent Psychology
    7. Behavioral Health Virtual Resource
      • This resource has free PDFs of anxiety screenings, as well as information on diagnosing and treating different anxiety disorders
    8. www.abctcentral.org 
      • This is a website sponsored by the Association for Behavioral and Cognitive Therapies.
      • Use the “Find a Therapist” option to search for local therapists using CBT, an effective treatment for Social Anxiety.
    9. www.BravePracticeForKids.com
      • This website, created by Dr. Emily Becker-Haimes at the University of Pennsylvania, has information on conducting Exposure Therapy for anxiety disordered youth.

    References[edit]

    Click here for references
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