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Background: The Bivalent Fear of Evaluation Model proposes that the fears of positive and negative evaluation each uniquely contribute to social anxiety severity. However, the debate continues as to whether these are distinct constructs, and, if so, the degree of influence each has on social anxiety severity. This study used a longitudinal evaluation of these relationships in a clinical sample to identify whether the two fears differentially change over time and differentially relate to social anxiety severity., Methods: Individuals with a social anxiety disorder (N = 105) completed measures of fears of negative and positive evaluation weekly, and social interaction anxiety monthly, for 12 weeks. Temporal relationships were assessed using residual dynamic structural equation modeling., Results: Fears of positive and negative evaluation both predicted the future status of the other (ϕ = 0.18, 95% credibility interval [0.10-0.28] and ϕ = 0.22 [0.12-0.35], respectively). Fear of negative evaluation (ϕ = 0.16 [0.05-0.28]) but not positive evaluation (ϕ < 0.01 [-0.09 to 0.10]) directly predicted future social anxiety severity. Fear of positive evaluation only indirectly predicted anxiety severity via fear of negative evaluation., Conclusions: Previous fears of negative evaluation could not fully explain future fears of positive evaluation (or vice-versa), which is consistent with the two constructs being likely distinct in social anxiety disorder. Given its more direct relationship with social anxiety severity, fear of negative evaluation should be targeted in treatment, as this could both directly reduce social anxiety severity and minimize the indirect impact of fear of positive evaluation., (© 2020 Wiley Periodicals LLC.)

Major depressive disorder is among the most frequently diagnosed mental disorders and is often accompanied by other disorders such as anxiety or substance abuse. As a result of a complicated tangle of comorbidities, psychotherapy in such cases can become quite demanding. The present case study presents and discusses the challenges represented by a complex case of psychotherapy, focusing on ongoing modifications of the clinical hypotheses and therapeutic approach. This process is illustrated through the case of Andy, a 44-year-old man suffering from depressive disorder, social phobia, substance dependency, and an avoidant personality disorder. This case draws attention to the quality of the relationship and the flexibility and adaptation required from the therapist while depicting an integrative way of working therapeutically with complex cases., (© 2019 Wiley Periodicals, Inc.)

Introduction: Possibility of a causal influence of emotional stress, on the course of various skin diseases, has been postulated. However, it is still inconclusive about the role of stressful life events in acne. In this background, the present study was carried out to know its role in acne., Methods: Consecutive one hundred patients who were diagnosed with acne vulgaris in the age group of 12 to 45 years were included. Age and sex matched controls were taken. A semistructured proforma was used to collect sociodemographic details. Stressful life events were assessed using presumptive stressful life event scale. Anxiety was evaluated using Hamilton Anxiety Rating scale and Depression by Hamilton Depression Rating Scale., Results: There was no difference in total stressful life events in past one year between patients and controls. The undesirable life event was present in 65 patients and 50 controls, this difference was statistically significant. Getting married or appearing for exams were the most common stressful life event in patients. Forty patients had comorbid psychiatric illness whereas in controls comorbidity was in 24 and this difference was statistically significant., Discussion: The undesirable stressful life events and psychiatric comorbidity were more in acne patients than in controls., (© 2018 John Wiley & Sons Australia, Ltd.)

Objective: Despite the ample literature on gender differences in anxiety and mood disorders, gender differences in social anxiety disorder (SAD) have received little empirical attention. The aim of the present study is to examine gender differences in 12-months prevalence, patterns of comorbidity, clinical presentation, subjective distress and functional impairment, age of onset, and treatment seeking, and discuss their clinical implications., Method: We used data from the National Comorbidity Survey-Replication (NCS-R; n = 652, 63.3% women) to examine gender differences., Results: Main findings highlighted that compared with men, women are more likely to have SAD, to have a more severe clinical presentation of the disorder and to have greater subjective distress. Women are more likely than men to have comorbid specific phobia, generalized anxiety disorder and posttraumatic stress disorder, whereas men are more likely to have comorbid substance abuse disorders and conduct disorder., Conclusions: Greater SAD prevalence and severity among women can have implications for assessment (e.g., potentially setting gender-specific cutoffs) and treatment (e.g., guiding exposures) of SAD., (© 2018 Wiley Periodicals, Inc.)

Background: Comorbid anxiety is common in bipolar disorder (BD) and associated with worse clinical outcomes including increased suicidality. Despite effective psychological treatments for anxiety, research into treating anxiety in BD is underdeveloped. This paper describes a novel psychological intervention to address anxiety in context of bipolar disorder (AIBD)., Methods: Adults with BD and clinically significant anxiety symptoms were randomized to AIBD plus treatment as usual (TAU) or TAU alone. AIBD offered 10 sessions of psychological therapy using a formulation-based approach. Feasibility and acceptability were evaluated through recruitment, retention, therapy attendance, alliance, fidelity, and qualitative feedback. Clinical outcomes were assessed at baseline, 16, 48, and 80 weeks: interim assessments of relapse at 32 and 64 weeks., Results: Seventy-two participants were recruited with 88% retention to 16 weeks and 74% to 80 weeks (similar between arms). Therapy participants attended x ¯ 7.7 (SD 2.8) sessions. Therapeutic alliance and therapy fidelity were acceptable. Qualitative interviews indicated that participants valued integrated support for anxiety with BD and coping strategies. Some suggested a longer intervention period. Clinical outcomes were not significantly different between arms up to 80 weeks follow-up., Conclusions: AIBD is feasible and acceptable but lack of impact on clinical outcomes indicates that adaptations are required. These are discussed in relation to qualitative feedback and recent literature published since the trial completed., (© 2018 Wiley Periodicals, Inc.)

Background: Major Depressive Disorder (MDD) and Social Anxiety Disorder (SAD) are highly comorbid, yet the combined condition has not been subject to any placebo-controlled treatment trials. This study reports a trial of vortioxetine, an antidepressant that has also shown benefit in Generalized Anxiety Disorder (GAD), in patients meeting DSM-5 criteria for both MDD and SAD., Methods: The study was a 12-week double-blind, placebo-controlled comparison of vortioxetine 10-20 mg/day or placebo administered on a 1:1 ratio. The study was designed to include 40 male or female outpatients aged 18-70 years. The primary endpoint was the "composite" Clinical Global Impression of Improvement (CGI-I) responder rate, factoring in improvement in both MDD and SAD features. Major secondary outcome measures were changes on the Montgomery Asberg Depression Rating Scale (MADRS) and Liebowitz Social Anxiety Scale (LSAS)., Results: On the composite CGI-I, 10 of 20 (50%) vortioxetine and six of 20 (30%) placebo-treated patients were rated as responders, a non-significant difference. However, vortioxetine-treated patients did show significantly greater improvement than those on placebo on both the MADRS (effect size 0.672) and LSAS (effect size 0.714). Efficacy in depression was seen before improvement in SAD. Adverse effects were similar to those previously reported., Conclusions: In this preliminary trial vortioxetine appears safe and effective for patients with MDD comorbid with SAD, with robust effect sizes on dimensional measures of both depression and social anxiety, but failure to separate from placebo on the primary outcome measure of composite responder rate. More studies of patients with comorbid conditions are needed, as this mirrors what is often seen in clinical practice., (© 2017 Wiley Periodicals, Inc.)

Background: Little is known about differences in mental health comorbidity and quality of life in individuals with social anxiety disorder (SAD) according to the number and the types of feared situations., Methods: Using a US nationally representative sample, the National Epidemiologic Survey on Alcohol and Related Conditions, we performed latent class analysis to compare the prevalence rates of mental disorders and quality of life measures across classes defined by the number and the types of feared social situations among individuals with SAD., Results: Among the 2,448 participants with a lifetime diagnosis of SAD, we identified three classes of individuals who feared most social situations but differed in the number of feared social situations (generalized severe [N = 378], generalized moderate [N = 1,049] and generalized low [N = 443]) and a class of subjects who feared only performance situations [N = 578]. The magnitude of associations between each class and a wide range of mental disorders and quality of life measures were consistent with a continuum model, supporting that the deleterious effects of SAD on mental health may increase with the number of social situations feared. However, we found that individuals with the "performance only" specifier may constitute an exception to this model because these participants had significantly better mental health than other participants with SAD., Conclusions: Our findings give additional support to the recent changes made in the DSM-5, including the introduction of the "performance only" specifier and the removal of the "generalized" specifier to promote the dimensional approach of the number of social fears., (© 2016 Wiley Periodicals, Inc.)

Background: Anxiety disorders are a potentially disabling group of disorders that frequently co-occur with alcohol use disorders. Comorbid anxiety and alcohol use disorders are associated with poorer outcomes, and are difficult to treat with standard psychosocial interventions. In addition, improved understanding of the biological basis of the conditions has contributed to a growing interest in the use of medications for the treatment of people with both diagnoses., Objectives: To assess the effects of pharmacotherapy for treating anxiety in people with comorbid alcohol use disorders, specifically: to provide an estimate of the overall effects of medication in improving treatment response and reducing symptom severity in the treatment of anxiety disorders in people with comorbid alcohol use disorders; to determine whether specific medications are more effective and tolerable than other medications in the treatment of particular anxiety disorders; and to identify which factors (clinical, methodological) predict response to pharmacotherapy for anxiety disorders., Search Methods: Review authors searched the specialized registers of The Cochrane Collaboration Depression, Anxiety and Neurosis Review Group (CCDANCTR, to January 2014) and the Cochrane Drugs and Alcohol Group (CDAG, to March 2013) for eligible trials. These registers contain reports of relevant randomized controlled trials (RCT) from: the Cochrane Central Register of Controlled Trials (CENTRAL, all years), MEDLINE (1950 to date), EMBASE (1974 to date) and PsycINFO (1967 to date). Review authors ran complementary searches on EMBASE, PubMed, PsycINFO and the Alcohol and Alcohol Problems Science Database (ETOH) (to August 2013). We located unpublished trials through the National Institutes of Health (NIH) RePORTER service and the World Health Organization (WHO) International Clinical Trials Registry Platform (to August 2013). We screened reference lists of retrieved articles for additional studies., Selection Criteria: All true RCTs of pharmacotherapy for treating anxiety disorders with comorbid alcohol use disorders. Trials assessing drugs administered for the treatment of drinking behaviour, such as naltrexone, disulfiram and acomprosate were not eligible for inclusion in this systematic review., Data Collection and Analysis: A systematic review is a standardised evaluation of all research studies that address a particular clinical issue.Two review authors independently assessed RCTs for inclusion in the review, collated trial data and assessed trial quality. We contacted investigators to obtain missing data. We calculated categorical and continuous treatment effect estimates and their 95% confidence intervals (CI) for treatment using a random-effects model with effect-size variability expressed using Chi(2) and I(2) heterogeneity statistics., Main Results: We included five placebo-controlled pharmacotherapy RCTs (with 290 participants) in the review. Most of the trials provided little information on how randomization was performed or on whether both participants and study personnel were blinded to the intervention. Two of the three trials reporting superiority of medication compared with placebo on anxiety symptom outcomes were industry funded. We regarded one trial as being at high risk of bias due to selective reporting.Study participants had Diagnostic and Statistical Manual (DSM) III- and DSM IV-diagnosed alcohol use disorders and post-traumatic stress disorder (two studies), social anxiety disorder (SAD; two studies) or generalized anxiety disorder (GAD; one study). Four trials assessed the efficacy of the selective serotonin re-uptake inhibitors (SSRIs: sertraline, paroxetine); one RCT investigated the efficacy of buspirone, a 5-hydroxytryptamine (5-HT) partial agonist. Treatment duration lasted between eight and 24 weeks. Overall, 70% of participants included in the review were male.There was very low quality evidence for an effect of paroxetine on global clinical response to treatment, as assessed by the Clinical Global Impressions - Improvement scale (CGI-I). Global clinical response was observed in more than twice as many participants with paroxetine than with placebo (57.7% with paroxetine versus 25.8% with placebo; risk ratio (RR) 2.23, 95% CI 1.13 to 4.41; 2 trials, 57 participants). However, there was substantial uncertainty regarding the size of the effect of paroxetine due to the small number of studies providing data on clinically diverse patient samples. The second primary outcome measure was reduction of anxiety symptom severity. Although study investigators reported that buspirone (one trial) was superior to placebo in reducing the severity of anxiety symptoms over 12 weeks, no evidence of efficacy was observed for paroxetine (mean difference (MD) -14.70, 95% CI -33.00 to 3.60, 2 trials, 44 participants) and sertraline (one trial). Paroxetine appeared to be equally effective in reducing the severity of post-traumatic stress disorder (PTSD) symptoms as the tricyclic antidepressant desipramine in one RCT. The maximal reduction in anxiety disorder symptom severity was achieved after six weeks with paroxetine (two RCTs) and 12 weeks with buspirone (one RCT), with maintenance of medication efficacy extending to 16 with paroxetine and 24 weeks with buspirone. There was no evidence of an effect for any of the medications tested on abstinence from alcohol use or depression symptoms. There was very low quality evidence that paroxetine was well tolerated, based on drop-out due to treatment-emergent adverse effects. Nevertheless, levels of treatment discontinuation were high, with 43.1% of the participants in the studies withdrawing from medication treatment. Certain adverse effects, such as sexual problems, were commonly reported after treatment with paroxetine and sertraline., Authors' Conclusions: The evidence-base for the effectiveness of medication in treating anxiety disorders and comorbid alcohol use disorders is currently inconclusive. There was a small amount of evidence for the efficacy of medication, but this was limited and of very low quality. The majority of the data for the efficacy and tolerability of medication were for SSRIs; there were insufficient data to establish differences in treatment efficacy between medication classes or patient subgroups. There was a small amount of very low quality evidence that medication was well tolerated. There was no evidence that alcohol use was responsive to medication.Large, rigorously conducted RCTs would help supplement the small evidence-base for the efficacy and tolerability of pharmacotherapy for anxiety and comorbid alcohol use disorders. Further research on patient subgroups who may benefit from pharmacological treatment, as well as novel pharmacological interventions, is warranted.