Journal of Anxiety Disorders, Vol. 14, No. 4, pp. 395–411, 2000Copyright 2000 Elsevier Science LtdPrinted in the USA. All rights reserved0887-6185/00 $–see front matterPergamonPII S0887-6185(00)00030-XGeneralized Social Phobia VersusAvoidant Personality Disorder:Differences in Psychopathology,Personality Traits, and Social andOccupational FunctioningCarol J. M. van Velzen, M.A.Academical Hospital, Groningen, The NetherlandsPaul M. G. Emmelkamp, Ph.D., and Agnes Scholing, Ph.D.University of Amsterdam, Amsterdam, The NetherlandsAbstract—Four groups of patients with social phobia (SP) were compared with regardto psychopathologic characteristics, personality traits, and social and occupational func-tioning. Fifteen persons with discrete social phobia without any personality disorder(DSP), 28 persons with generalized social phobia (GSP) without any personality disor-der, 24 persons with GSP with a single diagnosis of avoidant personality disorder(APD), and 23 persons with GSP with more than one PD were included in the presentstudy. APD had higher levels of social phobic avoidance, depressive symptoms, neuroti-cism, introversion, and social and occupational impairment as compared with GSP. DSPwas found to be the least severe condition. OPD was the most impaired on nearly allvariables. Logistic regression analyses revealed that introversion and depressive symp-toms were able to predict correctly the presence or absence of an APD in 85% of thosewith social phobia. These findings are discussed in the light of the severity continuumhypothesis of social phobia and APD and recommendations for future research aregiven. 2000 Elsevier Science Ltd. All rights reserved.Keywords: Social phobia; Avoidant personality disorder; ComorbidityDuring the past decade, the relationship between social phobia (SP) andthe avoidant personality disorder (APD) has received a great deal of attentionRequests for reprints should be sent to Carol J. M. van Velzen, Department of Psychiatry, Aca-demical Hospital, P.O. Box 30.001, 9700 RB Groningen, The Netherlands. E-mail: acggn.azg.nl395396C. J. M. VAN VELZEN, P. M. G. EMMELKAMP, AND A. SCHOLINGbecause of the apparent similarity between both disorders. According to theDiagnostic and Statistical Manual of Mental Disorders (3rd ed., revised [DSM-III-R]; American Psychiatric Association, 1987), the main characteristic ofboth SP and APD is a fear of negative evaluation, resulting in avoidance of so-cial situations or feeling uncomfortable in social situations. In the DSM-III-R,a subtype of SP was introduced: the diagnosis of GSP should be assigned whenthe anxiety and avoidance is related to most social situations. The remainingpersons with SP could be typed as having a DSP, indicating that the patientdoes not report fear in most social situations, but that the fear is limited to asmall number of circumscribed situations (e.g., public speaking situations). In-troduction of the generalized subtype resulted in a large conceptual overlapbetween this disorder and the APD: six of the seven DSM-III-R diagnostic cri-teria for the APD are clearly related to the criteria of SP. In addition, the ageof onset is similar in both disorders: both begin in late childhood or early ado-lescence (Scholing & Emmelkamp, 1990), indicating that SP may be as chronicas the APD. In the course of the research on subtypes of SP, a three-categorysubtyping scheme has been proposed (Heimberg, Holt, Schneier, Spitzer, &Liebowitz, 1993). Besides the GSP and DSP (or circumscribed SP), a third cat-egory was added, the non-GSP, including those patients that fell in between‘most social situations’ and ‘a limited number of discrete situations.’In the Diagnostic and Statistical Manual of Mental Disorders (4th ed.[DSM-IV]; American Psychiatric Association, 1994), the overlap between SPand APD is acknowledged as possibly resulting from alternative conceptual-izations of the same or similar conditions. Stated in terms of the overlappingsymptomatology model: the comorbidity of GSP and APD is an artifact as aresult of overlapping criteria (van Velzen & Emmelkamp, 1999). This modelwould be supported when prevalence rates of APD in GSP will approach100%. However, studies reported varying prevalence rates, ranging from 18%(Jansen, Arntz, Merckelbach, & Mersch, 1994) to 90% (Alnaes & Torgerson,1988), indicating that there is a subsample of persons with SP in whom a com-orbid diagnosis of APD is not present. When this subsample would mainlyconsist of those with DSP, it would not reject the overlapping symptomatologymodel. However, Jansen, Arntz, Merckelbach, and Mersch (1994) reportedthat 94% of their SP sample was diagnosed as having GSP, whereas, as notedabove, only 18% of their sample was diagnosed with APD.In studies addressing the comorbidity issue of SP and APD, the severitycontinuum hypothesis has been the dominant hypothesis, stating that SP andAPD only differ in severity. This latter hypothesis can be viewed as a specifi-cation of the overlapping symptomatology hypothesis. Studies comparing SPand APD have led to the conclusion that both disorders are not qualitativelydifferent, but only differ in severity of dysfunction (e.g., Liebowitz, Gorman,Feyer, & Klein, 1985; Widiger, 1992). The differences found between those397GENERALIZED SOCIAL PHOBIA AND AVOIDANT PERSONALITY DISORDERwith GSP without APD and those with GSP with APD were related to sever-ity of the disorder (e.g., general distress, severity of the social anxiety or socialfunctioning, and depressive symptoms) or to additional diagnoses (Axis I andAxis II) in GSP with APD. Similar findings were reported between general-ized and DSP (Heimberg, Hope, Dodge, & Becker, 1990; Turner, Beidel, &Townsley, 1992; Herbert, Hope, & Bellack, 1992; Tran & Chambless, 1995;Boone et al., 1999). In addition, only a minority of those with DSP was diag-nosed with an APD as compared with most of those with GSP (Holt, Heim-berg, & Hope, 1992; Herbert, Hope, & Bellack, 1992; Turner, Beidel, &Townsley, 1992; Schneier, Spitzer, Gibbon, Fyer, & Liebowitz, 1991). Differ-entiating SP into three groups (discrete or non-GSP, GSP without APD, andGSP with APD) revealed that the differences in severity and additional disor-ders were more frequently found between the two subtypes of SP (discrete ornongeneralized versus generalized) than between GSP with APD and GSPwithout APD (Boone et al., 1999; Brown, Heimberg, & Juster, 1995; Tran &Chambless, 1995; Holt,
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