Michael R. Liebowitz

Assessment of anxiety in social interaction and being observed by others : The social interaction anxiety scale and the social phobia scale

Social phobia has become a focus of increased research since its inclusion in DSM-III. However, assessment of social phobia has remained an underdeveloped area, especially self-report assessment. Clinical researchers have relied on measures that were developed on college populations, and these measures may not provide sufficient coverage of the range of situations feared by social phobic individuals. There is a need for additional instruments that consider differences in the types of situations (social interaction vs. situations involving observation by others) that may be feared by social phobics and between subgroups of social phobic patients. This study provides validational data on two instruments developed by Mattick and Clarke (1989): the Social Interaction Anxiety Scale (SIAS), a measure of anxiety in social interactional situations, and the Social Phobia Scale (SPS), a measure of anxiety in situations involving observation by others. These data support the use of the SIAS and SPS in the assessment of individuals with social phobia.

Psychometric properties of the Liebowitz Social Anxiety Scale

BACKGROUND The present study provides data on the reliability, validity and treatment sensitivity of the Liebowitz Social Anxiety Scale (LSAS), one of the most commonly used clinician-administered scales for the assessment of social phobia. METHOD Three hundred and eighty-two patients from several studies of the treatment of social phobia were evaluated. An independent assessor administered the LSAS to each patient prior to the initiation of treatment. Patients also completed other measures of social anxiety and avoidance, although the specific measures varied across samples. RESULTS The LSAS and its subscales were normally distributed and demonstrated excellent internal consistency. The convergent validity of the LSAS was demonstrated via significant correlations with other commonly-used measures of social anxiety and avoidance. These correlations also tended to be larger than correlations with measures of depression, especially after treatment. However, the pattern of correlations of LSAS subscales with one another and with the other measures suggest that the fear subscales and the avoidance subscales may not be sufficiently distinct in clinical samples. The LSAS was also demonstrated to be sensitive to the effects of pharmacological treatments of social phobia over time and in comparison to double-blind pill placebo. CONCLUSION The LSAS appears to be a reliable, valid and treatment sensitive measure of social phobia. Further study of the LSAS, both in samples with severe social phobia and in community samples, is needed.

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.

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.

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.

The issue of subtypes in the diagnosis of social phobia

Abstract A number of changes will occur in the criteria for diagnosis of anxiety disorders with the publication of DSM-IV. For social phobia, a central issue has been the specification and definition of subtypes. DSM-III-R specified a generalized subtype, but the DSM-IV subworkgroup on social phobia considered additional subtyping strategies, and struggled with issues of number and definition. This paper reviews the literature on subtyping in clinical samples of individuals with social phobia, and considers issues such as demographic differences, clinical features, and treatment response. The issue of overlap between generalized social phobia and avoidant personality disorder is considered. An analysis of the subtype issue from a situationist perspective is also presented. Options for subtyping that were considered for DSM-IV are presented, and issues that require further research on subtypes of social phobia are discussed.

An open trial of fluoxetine in the treatment of panic attacks

Fluoxetine is a new antidepressant with pharmacologic effects apparently limited to blockade of neuronal serotonin reuptake. We entered 20 patients who met DSM-III criteria for either panic disorder or agoraphobia with panic attacks into an open, uncontrolled pilot study of fluoxetine. Four responded to placebo in the week before fluoxetine administration and were dropped from the study. Of the remaining 16 patients, nine were nonresponders and seven were responders, with complete cessation of their panic attacks. Eight of the nine nonresponders were unable to tolerate the side effects of fluoxetine. In contrast, all of the responders (and one nonresponder) experienced minimal side effects. Fluoxetine may be effective in the treatment of panic attacks, perhaps implicating the serotonergic system in the pathophysiology of panic disorder. Future studies should use very low doses of fluoxetine to initiate treatment. (J Clin Psychopharmacol 1987;7:329–332)

Cognitive‐behavioral group therapy versus phenelzine in social phobia: Long term outcome

To evaluate the effects of maintenance treatment and durability of gains after treatment discontinuation, responders to either phenelzine (PZ) or cognitive‐behavioral group therapy (CBGT) from an acute trial comparing these two treatments as well as pill placebo and a psychotherapy control (educational supportive group therapy) were enrolled into maintenance and treatment‐free follow‐up phases. Experimental design: Responders to an acute trial contrasting PZ and CBGT entered a six‐month maintenance phase. Patients who continued to respond through the maintenance phase entered a six‐month treatment free phase. Patients receiving pill placebo or educational supportive group therapy in the acute trial did not enter the long term study. Principal observations: PZ patients entered maintenance more improved than CBGT patients, and nonrelapsing PZ patients maintained their superior gains throughout the study. Relapse during maintenance did not differ between treatments. However, PZ patients showed a trend toward greater relapse during treatment‐free follow‐up. There was a greater relapse among patients with generalized social phobia with phenelzine. Conclusions: PZ and cognitive‐behavioral group therapy may differ in their long term effects. The superiority seen with PZ on some measures in the acute study persisted in patients who maintained their gains over the course of maintenance and treatment‐free follow‐up. However, CBGT may lead to a greater likelihood of maintaining response after treatment has terminated. Replication with larger samples is needed, as is a study of the acute and long‐term efficacy of combined PZ and CBGT. Depression and Anxiety 10:89–98, 1999.

A Randomized, Controlled Trial of Cognitive-Behavioral Therapy for Augmenting Pharmacotherapy in Obsessive-Compulsive Disorder

OBJECTIVE Although serotonin reuptake inhibitors (SRIs) are approved for the treatment of obsessive-compulsive disorder (OCD), most OCD patients who have received an adequate SRI trial continue to have clinically significant OCD symptoms. The purpose of this study was to examine the effects of augmenting SRIs with exposure and ritual prevention, an established cognitive-behavioral therapy (CBT) for OCD. METHOD A randomized, controlled trial was conducted at two academic outpatient clinics to compare the effects of augmenting SRIs with exposure and ritual prevention versus stress management training, another form of CBT. Participants were adult outpatients (N=108) with primary OCD and a Yale-Brown Obsessive Compulsive Scale total score > or = 16 despite a therapeutic SRI dose for at least 12 weeks prior to entry. Participants received 17 sessions of CBT (either exposure and ritual prevention or stress management training) twice a week while continuing SRI pharmacotherapy. RESULTS Exposure and ritual prevention was superior to stress management training in reducing OCD symptoms. At week 8, significantly more patients receiving exposure and ritual prevention than patients receiving stress management training had a decrease in symptom severity of at least 25% (based on Yale-Brown Obsessive Compulsive Scale scores) and achieved minimal symptoms (defined as a Yale-Brown Obsessive Compulsive Scale score < or = 12). CONCLUSIONS Augmentation of SRI pharmacotherapy with exposure and ritual prevention is an effective strategy for reducing OCD symptoms. However, 17 sessions were not sufficient to help most of these patients achieve minimal symptoms.

Attachment in individuals with social anxiety disorder : The relationship among adult attachment styles, social anxiety, and depression

Despite their apparent implications for social functioning, adult attachment styles have never been specifically explored among persons with social anxiety disorder. In the current study, a cluster analysis of the Revised Adult Attachment Scale (N. L. Collins, 1996) revealed that 118 patients with social anxiety were best represented by anxious and secure attachment style clusters. Members of the anxious attachment cluster exhibited more severe social anxiety and avoidance, greater depression, greater impairment, and lower life satisfaction than members of the secure attachment cluster. This pattern was replicated in a separate sample of 56 patients and compared with the pattern found in 36 control participants. Social anxiety mediated the association between attachment insecurity and depression. Findings are discussed in the context of their relevance to the etiology, maintenance, and cognitive-behavioral treatment of social anxiety disorder.