Childhood History of Behavioral Inhibition and Comorbidity Status in 256 Adults with Social Phobia

Journal of Affective Disorders 129 (2011) 338–341

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Journal of Affective Disorders

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Brief report Childhood history of behavioral inhibition and comorbidity status in 256 adults with social phobia

Jean-Yves Rotge a,b,⁎, Denis Grabot a, Bruno Aouizerate a, Antoine Pélissolo c,d, Jean-Pierre Lépine e, Jean Tignol a a Department of Psychiatry, Charles Perrens Hospital, Bordeaux, France b Movement Adaptation Cognition Laboratory, CNRS UMR 5227, Bordeaux 2 University, Bordeaux, France c Department of Psychiatry, Pitié-Salpêtrière Hospital, Paris, France d CNRS USR 3246, Pierre et Marie Curie University, Paris, France e Department of Psychiatry, Lariboisiere Fernand Widal Hospital, Assistance Publique Hôpitaux de Paris, INSERM U 705 CNRS UMR 8206, Paris Diderot University, Paris, France article info abstract

Article history: Background: Behavioral inhibition (BI), a heritable temperament, predisposes one to an Received 19 May 2010 increased risk of social phobia. Recent investigations have reported that BI may also be a Received in revised form 28 July 2010 precursor to anxiety as well as depressive and alcohol-related disorders, which are frequently Accepted 28 July 2010 Available online 24 August 2010 comorbid with social phobia. In the present study, we explored the relationship between BI and psychiatric disorders in 256 adults with a primary diagnosis of social phobia. Methods: BI severity was retrospectively assessed with the Retrospective Self-Report of Keywords: Inhibition (RSRI). The severity of social phobia and the presence of comorbid diagnoses were Anxiety disorder Avoidant personality disorder evaluated with the Liebowitz Social Anxiety Scale (LSAS) and the Mini-International Behavioral inhibition Neuropsychiatric Interview, respectively. Major depressive disorder Results: The RSRI score was signiﬁcantly and positively correlated with both the LSAS score and Social phobia the occurrence of a major depressive disorder. No signiﬁcant association was found with other anxiety and substance-related disorders. Limitation: The assessment of BI was retrospective and self-reported. Conclusion: A childhood history of BI was associated with an increased risk of depressive comorbidity in social phobia. © 2010 Elsevier B.V. All rights reserved.

1. Introduction novelty, has been proposed as a predictive factor of social phobia (Kagan et al., 1988; Hirshfeld et al., 1992; Biederman Social phobia is a common anxiety disorder that often et al., 2001). However, recent studies have reported that imposes persistent functional impairment (Lepine, 2001). Both children with BI may also be at risk of having depression, family-association and prospective studies suggest the exis- alcohol-related disorders, or other anxiety disorders that tence of a continuity of social anxiety symptomatology from frequently occur alongside social phobia (Rosenbaum et al., childhood to adulthood (Rosenbaum et al., 1991a; Fyer et al., 1991b; Hirshfeld et al., 1992; Caspi et al., 1996; Magee et al., 1995; Caspi et al., 1996). Indeed, behavioral inhibition to the 1996; Hill et al., 1999; Neal et al., 2002; Coles et al., 2006). unfamiliar and novelty (BI), a heritable childhood tempera- In the present study, we tested the hypothesis that a ment deﬁned by a tendency to restrict exploration and avoid childhood history of BI increases the severity of social phobia and the risk of suffering from other psychiatric disorders, especially depression, in social phobia. For this, we used data ⁎ Corresponding author. Laboratoire Mouvement Adaptation Cognition, from a French multisite investigation that included 256 adults CNRS UMR 5227, Université Bordeaux 2, 146 rue Léo-Saignat, 33076 Bordeaux, France. Tel.: +33 5 57 57 15 51; fax: +33 5 56 90 14 21. with social phobia, and we explored the links between the E-mail address: [email protected] (J.-Y. Rotge). severity of BI and i) the severity of social phobia and ii) the

0165-0327/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2010.07.031 J.-Y. Rotge et al. / Journal of Affective Disorders 129 (2011) 338–341 339 occurrence of lifetime comorbidity associations, especially on social phobia severity (LSAS score) was implemented with depression, alcohol-related disorders, and other anxiety the aim of limiting a possible confusion bias. Adjusted ORs disorders. were considered as statistically significant when 95% confidence intervals (95% CI) excluded 1. The Wald chi-square test 2. Methods was used to assess the statistical significance of each parameter. When a significant correlation was found between 2.1. Study population the RSRI global score and any variable, analyses were repeated with the two RSRI subscores, i.e. the Social/School Two hundred and seventy adult patients with a primary and Fear/Illness Factors, by using the same adjustments. ORs diagnosis of social phobia were recruited to participate in this were also adjusted for age, sex, and LSAS score. study through six French outpatient centers specialized in the management of social phobia. All of the patients fulfilled the 3. Results DSM-IV criteria for social anxiety disorder in accordance with the Munich-Composite International Diagnostic Interview Fourteen respondents (5.1%) were excluded due to (Wittchen, 1998). Exclusion criteria for the patients consisted missing data. The study population consisted of 256 patients of the presence of psychotic disorder, a history of neurological (113 men; mean age=34.0, SD=9.7) who suffered from affliction, or the presence of active medical problems. After social phobia for an average of 20.7 years (SD=11.4). the experimental procedure had been fully explained, all Generalized social phobia affects 199 of the included patients. participants provided written informed consent. With regard to treatment at the moment of the study, 183 patients received serotonin reuptake inhibitors (n=143), 2.2. Assessments benzodiazepines (n =112), and/or cognitive–behavioral therapy (n=25). At the moment of the inclusion, patients BI severity was assessed with the Retrospective Self-Report with social phobia suffered from one or more current of Inhibition (RSRI) based on 30 questions whose answers comorbid mental disorders: major depressive disorder ranged from 1 to 5, with 5 representing the most severe (n =63), panic disorder (n= 56), agoraphobia (n= 70), indicative of inhibition (Reznick et al., 1992). The subjects were generalized anxiety disorder (n=78), obsessive–compulsive instructed to think about themselves as they had been in disorder (n=20), alcohol abuse (n=13), alcohol depen- elementary school. The RSRI global score was calculated by dence (n=21), substance abuse (n=10), and substance averaging the scores of all of the items (mean score=2.8, dependence (n=8). SD=0.6). Two RSRI subscores, the Social/School and Fear/ The severity of social phobia, assessed with the LSAS score Illness Factors, were also determined by using two subsets of 12 (mean: 79.4, SD: 23.6), was positively associated with the items. The Social/School Factor consisted of questions about RSRI global score (F=18.6, pb0.001; r2 =0.28, pb0.001), the inhibition in school and social situations, whereas the Fear/ Social/School Factor (r2 =0.17, pb0.001) and, the Fear/Illness Illness Factor was related to fear and disease items (Reznick Factor (r2 =0.08, pb0.001). The age of social phobia onset et al., 1992). Patients were also administered the Liebowitz was also positively linked to all RSRI scores: the RSRI global Social Anxiety Scale (LSAS) in order to evaluate the severity of score (F=8.2, pb0.001; r2 =0.11, pb0.001), the Social/ social anxiety symptomatology (Liebowitz, 1987). School Factor (r2 =0.12, pb0.001), and the Fear/Illness Factor Lifetime comorbid diagnoses were examined by using the (r2 =0.04, pb0.01). Mini-International Neuropsychiatric Interview based on Relationships between childhood BI and lifetime comor- DSM-IV diagnostic criteria (Sheehan et al., 1998). Current bidities in social phobia are presented in Table 1.The comorbidity was reported only in order to properly describe presence of avoidant personality disorder was significantly the included population but was not included in the analyses. correlated with both the RSRI global score (OR=1.99, 95% The diagnosis of avoidant personality disorder was estab- CI=1.12–3.54) and the Social/School Factor (OR=1.59, 95% lished using the corresponding sections of the Schedule for CI=1.06–2.37; Waldχ2 =5.08, df=4, pb0.05) but not with Affective Disorders and Schizophrenia – Lifetime version — the Fear/Illness Factor (OR=1.02, 95% CI=0.38–2.72; Anxiety Disorders – Revised. Waldχ2 =0.01, df=4, p=0.97). With regard to depressive comorbidity, we found a significant correlation with both the 2.3. Analytic methods RSRI global score (OR=1.88, 95% CI=1.08–3.29) and the Fear/Illness Factor (OR=2.78, 95% CI=1.58–4.89; To explore the relationship between the RSRI global score Waldχ2 =12.66, df=4, pb0.001) but not with the Social/ and the severity of social phobia or the age of social phobia School Factor (OR=1.20, 95% CI=0.83–1.75; Waldχ2 =0.92, onset, linear regressions were computed. We used controls df=4, p = 0.34). No other significant relationship with for age, sex, and treatment (drugs and cognitive–behavioral lifetime comorbidity associations was established (Table 1). therapy). A one-tailed alpha level of 0.01 was regarded as statistically significant for linear regressions. One-tailed test was used according to our unidirectional hypothesis based on 4. Discussion the consistent results, suggesting that BI represents a risk factor for the development of anxiety disorders. Our findings show that the severity of childhood BI was Correlations between the RSRI global score and lifetime associated with the severity of social anxiety and the comorbidity associations were measured by calculating odds occurrence of lifetime avoidant personality disorder and ratios (OR) adjusted for age, sex, and LSAS score. The control major depressive disorder in adults with social phobia. No 340 J.-Y. Rotge et al. / Journal of Affective Disorders 129 (2011) 338–341

Table 1 Correlations between the RSRI global score and lifetime comorbidities in social phobia (n=256).

Lifetime comorbidity ORsa IC 95% Wald's Chi-square test

χ2 df p

Major Depressive Disorderb (n=196) 1.88 1.08–3.29 4.95 4 b0.05 Panic Disorder (n=86) 1.34 0.85–2.12 1.56 4 0.21 Agoraphobia (n=81) 1.51 0.94–2.41 2.93 4 0.09 Generalized Anxiety Disorder (n=78) 1.47 0.91–2.37 2.47 4 0.12 Obsessive–Compulsive Disorder (n=32) 1.01 0.99–1.01 0.87 4 0.35 Alcohol abuse (n=30) 1.39 0.70–2.77 0.89 4 0.35 Alcohol dependence (n=44) 1.69 0.94–3.05 3.10 4 0.08 Substance abuse (n=14) 0.46 0.01–73.29 0.09 4 0.77 Substance dependence (n=24) 0.79 0.37–1.69 0.35 4 0.55 Avoidant Personality Disorderb (n=183) 1.99 1.12–3.54 5.54 4 b0.05

OR: Odds Ratio, IC 95%: 95% confidence interval, df: degrees of freedom. aAdjustments were made for age, sex and LSAS score. bIC 95% excluded 1. significant association was found between BI and other helpful for defining the relationship between BI and depres- lifetime comorbidities. sive symptoms. Finally, our analyses could not exclude the First, we found a significant relationship between BI and possible mediation of the avoidant personality disorder in the avoidant personality disorder in social phobia. This result is relationship between BI and depression. concordant with the relationship between the severity of Our study shows that childhood history of BI may be childhood BI and the severity of social phobia, according to associated with an increased risk of depression and avoidant the view that “social phobia and avoidant personality personality disorder comorbidity in adulthood social phobia. disorder may represent different points on a severity The present findings give further support to the need for continuum” (Tillfors et al., 2004). Second, we also found a assessing childhood history of BI, as a risk factor of a more significant relationship between childhood BI and lifetime severe social phobia and lifetime depression. depressive comorbidity in social phobia. This finding is in accordance with previous studies that reported similar Role of the funding source relationship between BI and depressive symptoms (Schofield This investigation was carried out through a grant from the French et al., 2009; Gladstone and Parker, 2006). Our results further Ministry of Health (Programme Hospitalier de Recherche Clinique AOM 96- 242). The French Ministry of Health had no further role in study design; in support that BI could be a more general risk factor for the collection, analysis and interpretation of data; in the writing of the internalizing disorders, and not a specific predictor of social report; and in the decision to submit the paper for publication. phobia (Schofield et al., 2009). Furthermore, in their study Gladstone and Parker showed that social anxiety mediates Conflict of interest the relationship between BI and depression (Gladstone and The authors report no financial disclosure. Parker, 2006). The lack of association between childhood BI and other References lifetime anxiety or substance-related disorders in subjects with social phobia suggests that BI is not predictive of Biederman, J., Hirshfeld-Becker, D.R., Rosenbaum, J.F., Herot, C., Friedman, D., enhanced comorbidity when considering other anxiety Snidman, N., Kagan, J., Faraone, S.V., 2001. Further evidence of association between behavioral inhibition and social anxiety in children. disorders or substance-related disorders. However, this result Am. J. Psychiatry 158, 1673–1679. should be interpreted cautiously, since the clinical sample Caspi, A., Moffitt, T.E., Newman, D.L., Silva, P.A., 1996. Behavioral observations with such comorbidities was relatively small in comparison at age 3 years predict adult psychiatric disorders. Longitudinal evidence from a birth cohort. Arch. Gen. Psychiatry 53, 1033–1039. with subjects suffering from depression or avoidant person- Coles, M.E., Schofield, C.A., Pietrefesa, A.S., 2006. 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