David M. Fresco

The Liebowitz Social Anxiety Scale: a comparison of the psychometric properties of self-report and clinician-administered formats

BACKGROUND The clinician-administered version of the Liebowitz Social Anxiety Scale (LSAS-CA) is a commonly used assessment device for the evaluation of social anxiety disorder and has been shown to have strong psychometric characteristics. Because of its apparently straightforward rating format and potential savings in time and effort, interest in the use of the LSAS as a self-report (LSAS-SR) measure has increased, and the LSAS-SR has been used in a number of studies. However, the psychometric properties of the LSAS-SR have not been well established. METHODS This study examined the psychometric properties of the LSAS-SR in comparison to the LSAS-CA in a sample of 99 individuals with a primary diagnosis of social anxiety disorder and 53 individuals with no current psychiatric disorder. RESULTS There was little difference between the two versions of the LSAS on any scale or subscale score. Both forms were internally consistent and the subscale intercorrelations for the two forms were essentially identical. Correlations of each LSAS-SR index with its LSAS-CA counterpart were all highly significant. Finally, the convergent and discriminant validity of the two forms of the LSAS was shown to be strong. CONCLUSION Results of this study suggest that the self-report version of the LSAS compares well to the clinician-administered version and may be validly employed in the assessment of social anxiety disorder.

Distinct and Overlapping Features of Rumination and Worry: The Relationship of Cognitive Production to Negative Affective States

Worry and rumination are cognitive processes, often represented as verbal or linguistic activities. Despite similarities in definition and description, worry has been most closely examined in relation to anxiety whereas rumination has traditionally been related to depression. This distinction remains in spite of high rates of comorbidity between anxiety and depression. This study sought to better understand the distinct and overlapping features of worry and rumination as well as their relationship to anxiety and depression. Seven hundred eighty-four unselected college students completed self-report measures of worry, rumination, anxiety, and depression. Items from the respective worry and rumination scales were submitted to factor analysis, which revealed a four-factor solution comprised of 2 worry factors and 2 rumination factors. A Worry Engagement factor as well as a Dwelling on the Negative factor emerged as distilled measures of worry and rumination, respectively. Scores on these factors were highly correlated with each other and demonstrated equally strong relationships to both anxiety and depression. Findings from this study suggest that worry and rumination represent related but distinct cognitive processes that are similarly related to anxiety and depression.

Empirical validation and psychometric evaluation of the brief fear of negative evaluation scale in patients with social anxiety disorder

The Brief Fear of Negative Evaluation Scale (BFNE; M. R. Leary, 1983a) is often used to assess fear of negative evaluation, the core feature of social anxiety disorder. However, few studies have examined its psychometric properties in large samples of socially anxious patients. Although the BFNE yields a single total score, confirmatory factor analysis indicated a 2-factor solution to be more appropriate, with the 1st factor consisting of all straightforwardly worded items (BFNE-S) and the 2nd of all reverse-scored items (BFNE-R). Support was obtained for the convergent and discriminant validity of the BFNE and BFNE-S, but not the BFNE-R. These results suggest that standard scoring of the BFNE may not be optimal for patients with social anxiety disorder.

Emotion Dysregulation in Generalized Anxiety Disorder: A Comparison with Social Anxiety Disorder

From an emotion regulation framework, generalized anxiety disorder (GAD) can be conceptualized as a syndrome involving heightened intensity of subjective emotional experience, poor understanding of emotion, negative reactivity to emotional experience, and the use of maladaptive emotion management strategies (including over-reliance on cognitive control strategies such as worry). The current study sought to replicate previous findings of emotion dysregulation among individuals with GAD and delineate which aspects of emotion dysregulation are specific to GAD or common to GAD and another mental disorder (social anxiety disorder). Individuals with GAD reported greater emotion intensity and fear of the experience of depression than persons with social anxiety disorder and nonanxious control participants. Individuals with social anxiety disorder indicated being less expressive of positive emotions, paying less attention to their emotions, and having more difficulty describing their emotions than either persons with GAD or controls. Measures of emotion differentiated GAD, social anxiety disorder, and normal control groups with good accuracy in a discriminant function analysis. Findings are discussed in light of theoretical and treatment implications for both disorders.

Screening for social anxiety disorder in the clinical setting: Using the Liebowitz Social Anxiety Scale.

OBJECTIVE We sought to determine optimal cutoff values for the Liebowitz Social Anxiety Scale (LSAS) total and subscale scores for the diagnosis of social anxiety disorder (SAD) and designation of the generalized subtype of SAD. METHOD Three hundred and sixty-four patients from a multi-site sample who met criteria for SAD according to structured diagnostic interview, 262 of whom met criteria for the generalized subtype, and 34 control participants free of current Axis I disorders participated in this study. All participants were given the Liebowitz Social Anxiety Scale by an independent assessor. RESULTS Receiver Operating Characteristics analysis revealed that the LSAS performed well in identifying individuals who met criteria for SAD and for the generalized subtype of SAD. Cutoffs of 30 for SAD and 60 for its generalized subtype on the LSAS total score represented the best balance of specificity and sensitivity. CONCLUSIONS These findings provide support for the use of the Liebowitz Social Anxiety Scale for the identification of individuals with SAD and its generalized subtype in clinical settings. Identification of patients with SAD should increase the percentage of these patients who receive appropriate treatment for this impairing disorder.

Screening for social anxiety disorder with the self-report version of the Liebowitz Social Anxiety Scale.

Objective: This study examined whether the self‐report version of the Liebowitz Social Anxiety Scale (LSAS‐SR) could accurately identify individuals with social anxiety disorder and individuals with the generalized subtype of social anxiety disorder. Furthermore, the study sought to determine the optimal cutoffs for the LSAS‐SR for identifying patients with social anxiety disorder and its generalized subtype. Methods: Two hundred and ninety‐one patients with clinician‐assessed social anxiety disorder (240 with generalized social anxiety disorder) and 53 control participants who were free from current Axis‐1 disorders completed the LSAS‐SR. Results: Receiver Operating Characteristic analyses revealed that the LSAS‐SR performed well in identifying participants with social anxiety disorder and generalized social anxiety disorder. Consistent with Mennin et al.s [2002: J Anxiety Disord 16:661–673] research on the clinician‐administered version of the LSAS, cutoffs of 30 and 60 on the LSAS‐SR provided the best balance of sensitivity and specificity for classifying participants with social anxiety and generalized social anxiety disorder, respectively. Conclusions: The LSAS‐SR may be an accurate and cost‐effective way to identify and subtype patients with social anxiety disorder, which could help increase the percentage of people who receive appropriate treatment for this debilitating disorder. Depression and Anxiety, 2009.

Relationship of Posttreatment Decentering and Cognitive Reactivity to Relapse in Major Depression

Z. V. Segal et al. (2006) demonstrated that depressed patients treated to remission through either antidepressant medication (ADM) or cognitive-behavioral therapy (CBT), but who evidenced mood-linked increases in dysfunctional thinking, showed elevated rates of relapse over 18 months. The current study sought to evaluate whether treatment response was associated with gains in decentering-the ability to observe ones thoughts and feelings as temporary, objective events in the mind-and whether these gains moderated the relationship between mood-linked cognitive reactivity and relapse of major depression. Findings revealed that CBT responders exhibited significantly greater gains in decentering compared with ADM responders. In addition, high post acute treatment levels of decentering and low cognitive reactivity were associated with the lowest rates of relapse in the 18-month follow-up period.

Cognitive Styles and Life Events in Subsyndromal Unipolar and Bipolar Disorders: Stability and Prospective Prediction of Depressive and Hypomanic Mood Swings

We examined the interaction of cognitive styles and life events in predicting the depressive and hypomanic mood swings of 43 undergraduates meeting criteria for a subsyndromal mood disorder (i.e., cyclothymia, dysthymia, or hypomania) or no lifetime diagnosis. Participants completed symptom, cognitive style, and life events measures on three separate occasions as the different mood states characteristic of their subsyndromal disorder naturally occurred. Normal controls were assessed in three separate normal mood states at times yoked to participants in the three disorder groups. All groups’ attributional styles and dysfunctional attitudes remained stable across large changes in mood and symptomatology and cyclothymics’ cognitive styles were as negative as those of dysthymics. Moreover, hierarchical regression analyses indicated that participants’ attributional styles, as measured in a normal mood state (Time 1), in interaction with intervening life events predicted prospectively their depressive symptom changes at Times 2 and 3 and their hypomanic symptom changes at Time 2. These findings provide support for the cognitive vulnerability-stress hypothesis of the Hopelessness theory of depression (Abramson, Metalsky, & Alloy, 1989) and suggest that the logic of the Hopelessness theory’s vulnerability-stress hypothesis extends to the prediction of manic/hypomanic symptoms.

Confirmatory factor analysis of the Penn State Worry Questionnaire

Worry is often assessed with the 16-item Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990. Behaviour Research and Therapy, 28, 487-495), but the factor structure of the PSWQ is not well articulated. Three factor analyses of the PSWQ have been conducted, with two (Brown, Antony, & Barlow, 1992. Behaviour Research and Therapy, 30, 33-37; van Rijsoort, Emmelkamp, & Vervaeke, 1999) retaining a unifactorial solution and one (Stöber, 1995) retaining a two-factor solution. We sought to determine the relative strengths of these solutions. Seven hundred eighty-eight undergraduates completed the PSWQ and measures of depression and anxiety. Confirmatory factor analyses indicated that the two-factor solution provided a better fit to the data. There was also evidence for a higher order worry factor. Multiple regression analyses revealed that factor 1 (Worry Engagement) explained the majority of the variance in the symptom measures. The higher order worry factor also accounted for variance in some measures. Compared to the PSWQ total score, Worry Engagement demonstrated slightly higher internal consistency and significantly stronger correlations with most measures of depression and anxiety. Factor 2 (Absence of Worry) demonstrated moderate negative correlations with Worry Engagement and the PSWQ Total Score but only modest correlations with depression and anxiety.

A Placebo-Controlled Trial of Phenelzine, Cognitive Behavioral Group Therapy, and Their Combination for Social Anxiety Disorder

CONTEXT Medication and cognitive behavioral treatment are the best-established treatments for social anxiety disorder, yet many individuals remain symptomatic after treatment. OBJECTIVE To determine whether combined medication and cognitive behavioral treatment is superior to either monotherapy or pill placebo. DESIGN Randomized, double-blind, placebo-controlled trial. SETTING Research clinics at Columbia University and Temple University. PARTICIPANTS One hundred twenty-eight individuals with a primary DSM-IV diagnosis of social anxiety disorder. INTERVENTIONS Cognitive behavioral group therapy (CBGT), phenelzine sulfate, pill placebo, and combined CBGT plus phenelzine. MAIN OUTCOME MEASURES Liebowitz Social Anxiety Scale and Clinical Global Impression (CGI) scale scores at weeks 12 and 24. RESULTS Linear mixed-effects models showed a specific order of effects, with steepest reductions in Liebowitz Social Anxiety Scale scores for the combined group, followed by the monotherapies, and the least reduction in the placebo group (Williams test = 4.97, P < .01). The CGI response rates in the intention-to-treat sample at week 12 were 9 of 27 (33.3%) (placebo), 16 of 34 (47.1%) (CBGT), 19 of 35 (54.3%) (phenelzine), and 23 of 32 (71.9%) (combined treatment) (chi(2)(1) = 8.76, P < .01). Corresponding remission rates (CGI = 1) were 2 of 27 (7.4%), 3 of 34 (8.8%), 8 of 35 (22.9%), and 15 of 32 (46.9%) (chi(2)(1) = 15.92, P < .01). At week 24, response rates were 9 of 27 (33.3%), 18 of 34 (52.9%), 17 of 35 (48.6%), and 25 of 32 (78.1%) (chi(2)(1) = 12.02, P = .001). Remission rates were 4 of 27 (14.8%), 8 of 34 (23.5%), 9 of 35 (25.7%), and 17 of 32 (53.1%) (chi(2)(1) = 10.72, P = .001). CONCLUSION Combined phenelzine and CBGT treatment is superior to either treatment alone and to placebo on dimensional measures and on rates of response and remission.