- Email: [email protected]
Some further comments on the measurement of social phobia
Behm.
Res.
Thu.
Vol.
26, No.
5, pp.
411-413.
1988
0005-7967/‘88
Printed in Great Britain. All rights reserved
SOME FURTHER
$3.00
+ 0.00
Copyright c 1988Pergamon Press plc
COMMENTS ON THE MEASUREMENT OF SOCIAL PHOBIA
SAMUEL M. TURNER and DEBORAH C. BEIDEL Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, CA 15213-2593, U.S.A. Summary-After consideration of Heimberg er ~1,‘scritique of our 1987 (Turner et al.) study examining the discriminative ability of the SAD and FNE, we still must conclude that their use as distinct measures of social phobia is questionable.
The Social Avoidance and Distress Scale (SAD) and the Fear of Negative Evaluation Scale (FNE; Watson and Friend, 1969) are used frequently to assess social distress, social avoidance, and fear of negative evaluation. More recently, these instruments have been used in studies of social phobia. In a recent article (Turner, McCanna and Beidel, 1987), we noted that performance on these instruments did not differ across the major anxiety diagnostic groups, and the scores were significantly correlated with more general measures of anxiety, depression, and general emotional distress. Based on these findings, we questioned the utility of these scales as distinctive measures of social phobia. The paper by Heimberg, Hope, Rapee and Bruch (1987) raises some interesting points with regard to alternative interpretations of our data. Basically, these authors assert that: (a) the finding of no differences among the various anxiety disorders groups may have been due to the presence of clinically meaningful social anxiety in all of the groups, (b) significant differences among the anxiety disorders groups may have been hidden by the heterogeneity among patients who receive the diagnosis of social phobia, and (c) the distribution of FNE scores in our sample may have been unusually restricted. In essence, then, the discussion by Heimberg et al. (1987), as well as our empirical data, can be reduced to two issues: (a) are social phobia and social anxiety one and the same condition? and (b) do the SAD and FNE measure social phobia, social anxiety, or just general distress? One impetus for conducting the original study (Turner et al., 1987) was our concern about the wholesale adoption of the SAD and FNE as measures of social phobia despite the fact that these instruments preceded the publication of the diagnostic criteria by over 10 years. Obviously, social fears existed prior to 1980, but the criteria for the condition of social phobia as currently conceptualized had not been adopted. The use of these scales in studies of social phobia prior to an assessment of their discriminative validity is premature. As evident from our earlier paper, we are in total agreement with Heimberg and his colleagues that inventories of this type should not be used for deriving diagnoses. However, we believe it is possible that the continued use of these scales without an assessment of their discriminative validity could lead eventually to their adoption as diagnostic instruments, in much the same way that many research protocols use the Beck Depression Inventoryas a selection device for studies of depression. Particularly where resources may mitigate against conducting individual diagnostic interviews, selection of subjects by scale scores is a tempting possibility. Heimberg, Hope, Rapee and Bruch (1987) suggested that one reason for the lack of discriminative validity of the SAD and FNE in our study may have been due to the existence of clinically meaningful social anxiety in several of the anxiety disorders. However, our conclusion regarding the utility of these scales was based on both the lack of significant discrimination among these groups and the high correlation with more general measures of distress. It is true that social anxiety can be found in numerous diagnostic categories, including disorders other than the anxiety disorders. This observation strengthens our argument regarding the lack of discriminative ability of these instruments. The inventories may well measure social anxiety but the question is whether or not they are suitable instruments to detect social phobia. The Turner et al. (1987) study suggested that they cannot. It is critical to differentiate the construct of social anxiety from that of social phobia, as they are not the same (Turner and Beidel, in press). Just as a fever may signal the 411
412
SAMIXL M. TLJR~R
and DEBORAH C. BEIDEL
presence of many different medical abnormalities, anxiety when in the presence of others can occur in a variety of Axis I and Axis II disorders. However, the basis of the distress is often categorically different. For example, the paranoid person mistrusts others and fears they will try to harm him, while the agoraphobic fears a crowd will prevent escape or getting help should a panic attack occur (for a full discussion of the relationship of social anxiety, shyness and social phobia, see Turner and Beidel, in press). Therefore, the reason for the social distress must be carefully evaluated. Simply recording affirmative responses to questions such as those in the ADIS-R (“are you overly concerned that you may say and/or do something that might embarrass or humiliate yourself in front of others. . .“) cannot untangle this issue. For example, in the case of panic patients, the line of questioning must be pursued further to determine that indeed the social concern is unrelated to a fear of embarrassment caused by panicking in public. This relationship is particularly problematic inasmuch as it is unclear from the DSM-III-R what the correct diagnosis is when the basis of the humiliation and concern is the occurrence of the panic attack (e.g. “everyone will see me faint and that would be extremely embarrassing”). To conclude, as Heimberg, Hope, Rapee and Bruch (1987) do that the social anxiety experienced by social phobics may be discriminated from other anxious patients by the degree of social fear that they experience and the amount of disruption it causes is contrary to an entire body of data which suggests that social phobics have a different personality style, a characteristic pattern of somatic sensations, and a different basis for their fear (Amies, Gelder and Shaw, 1983). Furthermore, even if Heimberg et al.‘s conclusion is correct (i.e. social anxiety is merely a symptom of many disorders just as a fever is symptomatic of many medical maladies), the difference in severity and impairment should still be a discriminating factor, just as the difference between body temperatures of 99 and 104°F suggest radically different conditions. While we cannot disagree totally that the lack of differentiation of the SAD and the FNE may be due to some degree of social anxiety among the other diagnostic groups, we feel that the issue of co-morbidity deserves more extensive investigation before concluding that the social distress of social phobics is only quantitatively different. Heimberg, Hope, Rapee and Bruch (1987) question our unidirectional interpretation of the correlations between the SAD and the FNE and other instruments such as the State-Trait Anxiety Inventory (Spielberger, Gorsuch and Lushene, 1970), The Beck Depression Inventory (Beck, Ward, Mendelson, Mock and Erbaugh, 1961), and the Symptom Checklist 90-Revised (Derogatis, 1983). As correctly acknowledged by Heimberg, Hope, Rapee and Bruch (1987), correlational analyses are not unidirectional. One suggested alternative explanation for our findings was that the STAI, BDI, and SCL 90-R may have items that are sensitive to social anxiety and that the correlations may be the result of shared social anxiety item content. It was further suggested that a review of the items on these scales indicated a reasonable degree of face validity for this alternative. Our review of these items does not reveal a single question on the STAI and only one question on the BDI where another individual is mentioned. The SCL 90-R does contain an interpersonal sensitivity subscale, but this subscale only contributes 10% of the total score. Therefore, on even a face validity basis, we find that the suggestion that the other inventories contain a meaningful component of social anxiety very untenable. The second alternative explanation, that social anxiety may be a meaningful component of trait anxiety, depression or distress, is more compelling and does deserve further empirical consideration. It is likely that those who are fearful around others also feel clinically significant levels of general anxiety, depression, and general distress. However, it is possible for a scale to correlate highly with another measure, yet still sufficiently discriminate among various groups, and we suspect that if the SAD and FNE are measuring something distinctly different from the other scales, the significant correlations should not preclude some differentiation among the groups. An additional concern raised by Heimberg and his colleagues was that a heterogeneous category of social phobics may have an effect on the group score, in that those with more specific and circumscribed fears appear to score lower on the SAD than those with generalized fears. The category of generalized social phobia was introduced in the DSM-III-R, and we believe this subtype is in need of empirical validation. Generalized social phobics are those who are fearful of most social situations, and it is unclear if this group is a subtype of social phobia or should be considered Avoidant Personality Disorders. Our sample of social phobics was composed of those with DSM-III social phobia, although only in rare instances will a social phobic have only one phobic
Social phobia
413
situation (Turner, Beidel, Dancu and Keys, 1986). As reported by Heimberg, Hope, Dodge and Becker (1987), as well as an earlier investigation of our own (Turner et al., 1986), individuals with generalized social phobia or Avoidant Personality Disorder do significantly differ from those with more specific social concerns on several relevant variables including the SAD (Turner et al., 1986). However, the SAD score for the “specific” sample of social phobics in the discriminant validity study under discussion here was quite high (M = 22.7, SD = 7.1), raising doubt about Heimberg, Hope, Rapee and Bruch’s contention that the lack of differentiation by the SAD was influenced by a sample of “specific” social phobics. The FNE scores in our sample were lower than those Heimberg, Hope, Rapee and Bruch (1987) presented from their clinic. It is not unusual that different samples, drawn from different geographic areas, and at different times will have different scores on a particular instrument. However, inasmuch as our conclusion was based on the concurrent results of the SAD and FNE analyses, it does not appear that the lower FNE scores necessarily negate our conclusion. Contrary to the Heimberg, Hope, Rapee and Bruch (1987) assertion, there are also data to question the utility of these instruments for assessing treatment outcome with social phobics. An examination of treatment outcome data using these instruments, while indicating statistically significant changes from pre- to post-treatment, were based on absolute changes of only four or five points (Butler, Cullington, Munby, Amies and Gelder, 1984; Heimberg, Dodge, Hope, Kennedy, Zollo and Becker, 1987), although an earlier paper with a smaller subject sample did report a decrease of eight points (Heimberg, Becker, Goldfinger and Vermilyea, 1985). The findings for clinical changes on the FNE are similar. Inasmuch as Heimberg, Dodge et al.‘s (1987) subjects made marked improvement on other measures of social phobia, the clinical significance of the changes and the sensitivity of the SAD and FNE to assess the treatment outcome of social phobics must be questioned. In conclusion, then, Heimberg, Hope, Rapee and Bruch (1987) suggested that the SAD and FNE have a useful role in the assessment of social anxiety and as outcome measures of social phobia. Based on our earlier empirical findings, and the above discussion, we are still forced to conclude that the utility of these instruments for the assessment of social phobia remains suspect. REFERENCES Amies P. L., Gelder M. G. and Shaw P. M. (1983) Social phobia: A comparative clinical study. Br. J. Psychiat. 142, 174-179. Beck A. T., Ward C. H., Medeisohn M., Mock I. and Erbaugh J. (1961) An inventory for measuring depression. A&s. Gen. Psychiat. 4, 561-571. Butler G., Cullington A., Munby M., Amies P. and Gelder M. (1984) Exposure and anxiety management in the treatment of social phobia. J. consult. clin. Psychol. 52, 642-650. Heimberg R. G., Becker R. E., Goldfinger K. and Vermilyea J. H. (1985) Treatment of social phobia by exposure, cognitive restructuring and homework assignments. J. New. menr. Dis. 173, 236245. Derogatis L. R. (1983) XL-90-R: Ad ministration. Scoring and Procedures Manual. Clinical Psychometric Research, Baltimore. Heimberg R. G., Dodge C. S., Hope D. A., Kennedy C. R., Zollo L. J. and Becker R. E. (1987) Treatment of social phobia: A controlled evaluation of cognitive-behavioral group therapy. Paper presented at the annual meeting of the Association for Advancement of Behavior Therapy, Boston, MA. Heimberg R. G., Hope D. A., Dodge C. S. and Becker R. E. (1987) An examination of DSM-III-R subtypes of social phobia. Paper presented at the annual meeting of the Association for Advancement of Behavior Therapy, Boston, MA. Heimberg R. G., Hope D. A., Rapee R. M. and Bruch M. A. (1987) The validity of the Social Avoidance and Distress Scale and the Fear of Negative Evaluation Scale with social phobic patients: Additional considerations. Manuscript submitted for publication. Spielberger C. D., Gorsuch R. L. and Lushene R. E. (1970) The State-trait Anxiery Inventory: Test Manual for Form X. Consulting Psychologists Press, Palo Alto. Turner S. M. and Beidel D. C. (1988) Social phobia: Clinical syndrome, diagnosis and co-morbidity. Clin. Psychol. Rev. Turner S. M., Beidel D. C., Dancu C. V. and Keys D. J. (1986) Psychopathology of social phobia and comparison to avoidant personality disorder. J. abnorm. Psychol. 95, 389-394. Turner S. M., McCanna M. and Beidel D. C. (1987) Validity of the social avoidance and distress and fear of negative evaluation scales. Behau. Res. Ther. 25, 113-l 15. Watson D. and Friend R. (1969) Measurement of social-evaluative anxiety. J. con&r. clin. Psychol. 33, 448-457.
Res.
Thu.
Vol.
26, No.
5, pp.
411-413.
1988
0005-7967/‘88
Printed in Great Britain. All rights reserved
SOME FURTHER
$3.00
+ 0.00
Copyright c 1988Pergamon Press plc
COMMENTS ON THE MEASUREMENT OF SOCIAL PHOBIA
SAMUEL M. TURNER and DEBORAH C. BEIDEL Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, CA 15213-2593, U.S.A. Summary-After consideration of Heimberg er ~1,‘scritique of our 1987 (Turner et al.) study examining the discriminative ability of the SAD and FNE, we still must conclude that their use as distinct measures of social phobia is questionable.
The Social Avoidance and Distress Scale (SAD) and the Fear of Negative Evaluation Scale (FNE; Watson and Friend, 1969) are used frequently to assess social distress, social avoidance, and fear of negative evaluation. More recently, these instruments have been used in studies of social phobia. In a recent article (Turner, McCanna and Beidel, 1987), we noted that performance on these instruments did not differ across the major anxiety diagnostic groups, and the scores were significantly correlated with more general measures of anxiety, depression, and general emotional distress. Based on these findings, we questioned the utility of these scales as distinctive measures of social phobia. The paper by Heimberg, Hope, Rapee and Bruch (1987) raises some interesting points with regard to alternative interpretations of our data. Basically, these authors assert that: (a) the finding of no differences among the various anxiety disorders groups may have been due to the presence of clinically meaningful social anxiety in all of the groups, (b) significant differences among the anxiety disorders groups may have been hidden by the heterogeneity among patients who receive the diagnosis of social phobia, and (c) the distribution of FNE scores in our sample may have been unusually restricted. In essence, then, the discussion by Heimberg et al. (1987), as well as our empirical data, can be reduced to two issues: (a) are social phobia and social anxiety one and the same condition? and (b) do the SAD and FNE measure social phobia, social anxiety, or just general distress? One impetus for conducting the original study (Turner et al., 1987) was our concern about the wholesale adoption of the SAD and FNE as measures of social phobia despite the fact that these instruments preceded the publication of the diagnostic criteria by over 10 years. Obviously, social fears existed prior to 1980, but the criteria for the condition of social phobia as currently conceptualized had not been adopted. The use of these scales in studies of social phobia prior to an assessment of their discriminative validity is premature. As evident from our earlier paper, we are in total agreement with Heimberg and his colleagues that inventories of this type should not be used for deriving diagnoses. However, we believe it is possible that the continued use of these scales without an assessment of their discriminative validity could lead eventually to their adoption as diagnostic instruments, in much the same way that many research protocols use the Beck Depression Inventoryas a selection device for studies of depression. Particularly where resources may mitigate against conducting individual diagnostic interviews, selection of subjects by scale scores is a tempting possibility. Heimberg, Hope, Rapee and Bruch (1987) suggested that one reason for the lack of discriminative validity of the SAD and FNE in our study may have been due to the existence of clinically meaningful social anxiety in several of the anxiety disorders. However, our conclusion regarding the utility of these scales was based on both the lack of significant discrimination among these groups and the high correlation with more general measures of distress. It is true that social anxiety can be found in numerous diagnostic categories, including disorders other than the anxiety disorders. This observation strengthens our argument regarding the lack of discriminative ability of these instruments. The inventories may well measure social anxiety but the question is whether or not they are suitable instruments to detect social phobia. The Turner et al. (1987) study suggested that they cannot. It is critical to differentiate the construct of social anxiety from that of social phobia, as they are not the same (Turner and Beidel, in press). Just as a fever may signal the 411
412
SAMIXL M. TLJR~R
and DEBORAH C. BEIDEL
presence of many different medical abnormalities, anxiety when in the presence of others can occur in a variety of Axis I and Axis II disorders. However, the basis of the distress is often categorically different. For example, the paranoid person mistrusts others and fears they will try to harm him, while the agoraphobic fears a crowd will prevent escape or getting help should a panic attack occur (for a full discussion of the relationship of social anxiety, shyness and social phobia, see Turner and Beidel, in press). Therefore, the reason for the social distress must be carefully evaluated. Simply recording affirmative responses to questions such as those in the ADIS-R (“are you overly concerned that you may say and/or do something that might embarrass or humiliate yourself in front of others. . .“) cannot untangle this issue. For example, in the case of panic patients, the line of questioning must be pursued further to determine that indeed the social concern is unrelated to a fear of embarrassment caused by panicking in public. This relationship is particularly problematic inasmuch as it is unclear from the DSM-III-R what the correct diagnosis is when the basis of the humiliation and concern is the occurrence of the panic attack (e.g. “everyone will see me faint and that would be extremely embarrassing”). To conclude, as Heimberg, Hope, Rapee and Bruch (1987) do that the social anxiety experienced by social phobics may be discriminated from other anxious patients by the degree of social fear that they experience and the amount of disruption it causes is contrary to an entire body of data which suggests that social phobics have a different personality style, a characteristic pattern of somatic sensations, and a different basis for their fear (Amies, Gelder and Shaw, 1983). Furthermore, even if Heimberg et al.‘s conclusion is correct (i.e. social anxiety is merely a symptom of many disorders just as a fever is symptomatic of many medical maladies), the difference in severity and impairment should still be a discriminating factor, just as the difference between body temperatures of 99 and 104°F suggest radically different conditions. While we cannot disagree totally that the lack of differentiation of the SAD and the FNE may be due to some degree of social anxiety among the other diagnostic groups, we feel that the issue of co-morbidity deserves more extensive investigation before concluding that the social distress of social phobics is only quantitatively different. Heimberg, Hope, Rapee and Bruch (1987) question our unidirectional interpretation of the correlations between the SAD and the FNE and other instruments such as the State-Trait Anxiety Inventory (Spielberger, Gorsuch and Lushene, 1970), The Beck Depression Inventory (Beck, Ward, Mendelson, Mock and Erbaugh, 1961), and the Symptom Checklist 90-Revised (Derogatis, 1983). As correctly acknowledged by Heimberg, Hope, Rapee and Bruch (1987), correlational analyses are not unidirectional. One suggested alternative explanation for our findings was that the STAI, BDI, and SCL 90-R may have items that are sensitive to social anxiety and that the correlations may be the result of shared social anxiety item content. It was further suggested that a review of the items on these scales indicated a reasonable degree of face validity for this alternative. Our review of these items does not reveal a single question on the STAI and only one question on the BDI where another individual is mentioned. The SCL 90-R does contain an interpersonal sensitivity subscale, but this subscale only contributes 10% of the total score. Therefore, on even a face validity basis, we find that the suggestion that the other inventories contain a meaningful component of social anxiety very untenable. The second alternative explanation, that social anxiety may be a meaningful component of trait anxiety, depression or distress, is more compelling and does deserve further empirical consideration. It is likely that those who are fearful around others also feel clinically significant levels of general anxiety, depression, and general distress. However, it is possible for a scale to correlate highly with another measure, yet still sufficiently discriminate among various groups, and we suspect that if the SAD and FNE are measuring something distinctly different from the other scales, the significant correlations should not preclude some differentiation among the groups. An additional concern raised by Heimberg and his colleagues was that a heterogeneous category of social phobics may have an effect on the group score, in that those with more specific and circumscribed fears appear to score lower on the SAD than those with generalized fears. The category of generalized social phobia was introduced in the DSM-III-R, and we believe this subtype is in need of empirical validation. Generalized social phobics are those who are fearful of most social situations, and it is unclear if this group is a subtype of social phobia or should be considered Avoidant Personality Disorders. Our sample of social phobics was composed of those with DSM-III social phobia, although only in rare instances will a social phobic have only one phobic
Social phobia
413
situation (Turner, Beidel, Dancu and Keys, 1986). As reported by Heimberg, Hope, Dodge and Becker (1987), as well as an earlier investigation of our own (Turner et al., 1986), individuals with generalized social phobia or Avoidant Personality Disorder do significantly differ from those with more specific social concerns on several relevant variables including the SAD (Turner et al., 1986). However, the SAD score for the “specific” sample of social phobics in the discriminant validity study under discussion here was quite high (M = 22.7, SD = 7.1), raising doubt about Heimberg, Hope, Rapee and Bruch’s contention that the lack of differentiation by the SAD was influenced by a sample of “specific” social phobics. The FNE scores in our sample were lower than those Heimberg, Hope, Rapee and Bruch (1987) presented from their clinic. It is not unusual that different samples, drawn from different geographic areas, and at different times will have different scores on a particular instrument. However, inasmuch as our conclusion was based on the concurrent results of the SAD and FNE analyses, it does not appear that the lower FNE scores necessarily negate our conclusion. Contrary to the Heimberg, Hope, Rapee and Bruch (1987) assertion, there are also data to question the utility of these instruments for assessing treatment outcome with social phobics. An examination of treatment outcome data using these instruments, while indicating statistically significant changes from pre- to post-treatment, were based on absolute changes of only four or five points (Butler, Cullington, Munby, Amies and Gelder, 1984; Heimberg, Dodge, Hope, Kennedy, Zollo and Becker, 1987), although an earlier paper with a smaller subject sample did report a decrease of eight points (Heimberg, Becker, Goldfinger and Vermilyea, 1985). The findings for clinical changes on the FNE are similar. Inasmuch as Heimberg, Dodge et al.‘s (1987) subjects made marked improvement on other measures of social phobia, the clinical significance of the changes and the sensitivity of the SAD and FNE to assess the treatment outcome of social phobics must be questioned. In conclusion, then, Heimberg, Hope, Rapee and Bruch (1987) suggested that the SAD and FNE have a useful role in the assessment of social anxiety and as outcome measures of social phobia. Based on our earlier empirical findings, and the above discussion, we are still forced to conclude that the utility of these instruments for the assessment of social phobia remains suspect. REFERENCES Amies P. L., Gelder M. G. and Shaw P. M. (1983) Social phobia: A comparative clinical study. Br. J. Psychiat. 142, 174-179. Beck A. T., Ward C. H., Medeisohn M., Mock I. and Erbaugh J. (1961) An inventory for measuring depression. A&s. Gen. Psychiat. 4, 561-571. Butler G., Cullington A., Munby M., Amies P. and Gelder M. (1984) Exposure and anxiety management in the treatment of social phobia. J. consult. clin. Psychol. 52, 642-650. Heimberg R. G., Becker R. E., Goldfinger K. and Vermilyea J. H. (1985) Treatment of social phobia by exposure, cognitive restructuring and homework assignments. J. New. menr. Dis. 173, 236245. Derogatis L. R. (1983) XL-90-R: Ad ministration. Scoring and Procedures Manual. Clinical Psychometric Research, Baltimore. Heimberg R. G., Dodge C. S., Hope D. A., Kennedy C. R., Zollo L. J. and Becker R. E. (1987) Treatment of social phobia: A controlled evaluation of cognitive-behavioral group therapy. Paper presented at the annual meeting of the Association for Advancement of Behavior Therapy, Boston, MA. Heimberg R. G., Hope D. A., Dodge C. S. and Becker R. E. (1987) An examination of DSM-III-R subtypes of social phobia. Paper presented at the annual meeting of the Association for Advancement of Behavior Therapy, Boston, MA. Heimberg R. G., Hope D. A., Rapee R. M. and Bruch M. A. (1987) The validity of the Social Avoidance and Distress Scale and the Fear of Negative Evaluation Scale with social phobic patients: Additional considerations. Manuscript submitted for publication. Spielberger C. D., Gorsuch R. L. and Lushene R. E. (1970) The State-trait Anxiery Inventory: Test Manual for Form X. Consulting Psychologists Press, Palo Alto. Turner S. M. and Beidel D. C. (1988) Social phobia: Clinical syndrome, diagnosis and co-morbidity. Clin. Psychol. Rev. Turner S. M., Beidel D. C., Dancu C. V. and Keys D. J. (1986) Psychopathology of social phobia and comparison to avoidant personality disorder. J. abnorm. Psychol. 95, 389-394. Turner S. M., McCanna M. and Beidel D. C. (1987) Validity of the social avoidance and distress and fear of negative evaluation scales. Behau. Res. Ther. 25, 113-l 15. Watson D. and Friend R. (1969) Measurement of social-evaluative anxiety. J. con&r. clin. Psychol. 33, 448-457.