Review Open Access
Copyright ©2012 Baishideng. All rights reserved.
World J Psychiatr. Oct 22, 2012; 2(5): 83-85
Published online Oct 22, 2012. doi: 10.5498/wjp.v2.i5.83
Instruments for the assessment of social anxiety disorder: Validation studies
Sonia Regina Loureiro, José Alexandre de Souza Crippa, Flávia de Lima Osório
Flávia de Lima Osório, José Alexandre de Souza Crippa, Sonia Regina Loureiro, Department of Neuroscience and Behavior, Faculty of Medicine of Ribeirão Preto, University of São Paulo, INCT Translational Medicine, Hospital das Clínicas, FMRP-USP, Avenida dos Bandeirantes 3900, Ribeirão Preto SP, CEP 14049-900, Brazil
Author contributions: All authors contributed to this manuscript.
Correspondence to: Flávia de Lima Osório, PhD, Department of Neuroscience and Behavior, Faculty of Medicine of Ribeirão Preto, University of São Paulo, INCT Translational Medicine, Hospital das Clínicas, FMRP-USP, Avenida dos Bandeirantes 3900, Ribeirão Preto SP, CEP 14049-900, Brazil. flaliosorio@ig.com.br
Telephone: +55-16-6022703
Received: August 9, 2011
Revised: June 7, 2012
Accepted: September 26, 2012
Published online: October 22, 2012

Abstract

Great progress has been observed in the literature over the last decade regarding the validation of instruments for the assessment of Social Anxiety Disorder in the Brazilian context. Particularly outstanding in this respect is the production of a group of Brazilian investigators regarding the psychometric study of the following instruments: Liebowitz Social Anxiety Scale, Social Phobia Inventory, Brief Social Phobia Scale, Disability Profile, Liebowitz Self-Rated Disability Scale, Social Phobia Safety Behaviors Scale and Self-Statements During Public Speaking Scale, which have proved to be appropriate and valid for use in the adult Brazilian population, representing resources for the assessment of social anxiety in clinical and experimental situations.

Key Words: Social anxiety, Social phobia, Instruments, Validation, Scale



TEXT

Social anxiety disorder (SAD) is characterized by a marked and persistent fear of situations of social performance and interaction in which an individual may feel humiliated, embarrassed or negatively evaluated[1]. It is considered to be the third most prevalent psychiatric disorder, with a chronic course associated with the development of comorbidities[2,3]. Although it is treatable, this disorder is underdiagnosed, so that about 2/3 of affected individuals do not receive appropriate treatment, a fact that favors the onset of major clinical and psychosocial impairment[4,5].

Assessment instruments can be used as strategies for the large-scale screening of SAD and the characterization of the associated symptoms and damage. A literature review of the instrument for SAD evaluation[6] pointed out about 23 available instruments with varying objectives, forms of application and extension. The study also indicated that some of them, such as the Fear of Negative Evaluation and the Social Avoidance and Distress Scale, were already available before the official recognition of SAD as a psychiatric disorder[7], which occurred in 1994[1]. Most of the remaining instruments were proposed during the 1990s and some more recently, up to the mid 2000s. Conversely, in Brazil, up to the mid 2000s[6,8], there was no original instrument available in the national literature or validated for this sociocultural context.

On this basis, our research group conducted an ample thematic study involving different aspects of SAD, such as epidemiological aspects, neuroimaging diagnosis, therapeutic approaches and studies of the validation of a set of instruments applicable to adults. The objective was to validate instruments previously referenced in the literature, with their use recognized for the assessment of adults and for application in the clinical-experimental context. Among them, we may first cite the Liebowitz Social Anxiety Scale (LSAS)[9], the Social Phobia Inventory (SPIN)[10] and the Brief Social Phobia Scale (BSPS)[11], which were validated in samples of the general population and in a clinical SAD sample involving cases, non-cases and subclinical subjects. Information regarding these instruments is briefly described below.

The LSAS is the self-rating scale most extensively studied all over the world regarding its psychometric qualities, is most frequently used in clinical assays and has been validated for five languages, in addition to the English original[8]. The parameters of the validated Brazilian version agree with the international ones in terms of validity and reliability. The validated Brazilian scale can also discriminate between subjects diagnosed as SAD cases and those diagnosed as subclinical cases. Also, in the latter group, whose main characteristic is the absence of significant damages associated with the symptoms, the intensity of the frequency of fear and avoidance was also lower than that observed in the case group.

The SPIN is a self-rating instrument which, like the LSAS, intends to assess fear and avoidance symptoms, differing from the LSAS by evaluating physiological symptoms, such as palpitation, blushing, tremor and transpiration, also associated with the disorder, by means of four specific items. The SPIN has been validated for use in different languages[6]. The Portuguese version showed adequate psychometric indicators regarding internal consistency, concurrent validity and discriminant validity[12,13]. The reduced version of the SPIN, the Mini-SPIN (MS)[14], consisting of three items of the original scale, is an instrument of even shorter and more rapid application, with high discriminant power. In contrast to studies with other versions of the MS, the cut-off note of seven seems to be more adequate for use in Brazil, keeping a balance between sensitivity and specificity[15].

The BSPS is a hetero-applied instrument which, by involving evaluation by a clinician, is useful when we consider that individuals often have difficulty in recognizing symptoms and identifying them as part of a disorder. For the application of this scale, we proposed a question guide for the systematization and standardization of the instrument, which led to an increase of about 25% in inter-rater diagnostic agreement[16].

Our group also validated scales that assess the psychosocial damages associated with SAD, which represent important diagnostic criteria of the disorder, especially in order to differentiate clinical from subclinical signs and symptoms. Two scales, a hetero-assessment one (The Disability Profile)[9] and a self-rating one (Liebowitz Self-Rated Disability Scale)[17], were checked and the findings agreed with those of the original study. Comparison of the two scales revealed that the self-rating scale showed subtly superior parameters[18].

Studies with instruments that assess the specificities of SAD are also important, such as safety behaviors and fear of public speaking. The Social Phobia Safety Behaviors Scale[19] is a self-rating scale designed to evaluate safety behaviors that social phobics use in the feared situations. Safety behaviors have been defined as a wide range of behaviors that social phobics carry out when in social situations and through which they try to reduce the risk of negative evaluation, trying to prevent feared outcomes from occurring. The Brazilian study of the instrument pointed out a test-retest reliability of 0.1 to 0.90 (2 wk) and factorial analysis revealed the presence of a single factor explaining 54.1% of data variance[20].

Regarding the instrument that assesses the specific aspects of public speaking, we validated the Self-Statements During Public Speaking Scale[21], whose factorial analysis pointed out, as observed in the initial psychometric study, the presence of two factors: positive self-assessment and negative self-assessment, explaining 52% of data variance. An adapted version of this instrument[22] has been used in experimental studies that employ models of anxiety (Simulated Public Speaking Test)[23]. The subscale of negative self-assessment was the one that proved to be most sensitive in discriminating cases from non-cases and from subclinical subjects[24], supporting the hypothesis of the cognitive etiology of SAD associated with a negative self-perception since, in these experiments, SAD cases tend to obtain a higher score on this subscale.

We should also point out the importance of using specific scales for SAD evaluation, especially regarding screening. Even considering that the diagnosis of this disorder is clinical and based on the indication of a specialist, the specific scale of SAD signs and symptoms has a greater discriminative power compared to general anxiety scales, such as the Beck Anxiety Inventory (BAI)[25]. An example of this can be seen in the study conducted by us which detected a 20% higher discriminative power for SAD screening with the use of the SPIN compared to the BAI, which favored false-positive indices[26].

In addition to these studies, there are others conducted in parallel by other local research groups which have validated other scales for SAD evaluation, such as the Social Phobia and Anxiety Inventory[27,28], the Social Avoidance and Distress Scale[29] and the Social Interaction and Self-Statement[30], also detecting favorable indicators that recommend their use, expanding even more the instrumental arsenal for SAD evaluation within both a clinical and research context.

We conclude that the studies conducted by our group and others have made available a wide variety of instruments that can be used to assess adults within the SAD context, filling an important gap in the literature.

Footnotes

Peer reviewer: Gábor Gazdag, MD, PhD, Consultation-Liaison Psychiatric Service, Szent Istvan and Szent Laszlo Hospitals, Gyali ut 5-7, 1097 Budapest, Hungary

S- Editor Wang JL L- Editor Roemmele A E- Editor Zheng XM

References
1.  American Psychiatric Association Diagnostic and statistical manual of mental disorders. 4th ed. Washingtonn, DC: American Psychiatric Association 1994; .  [PubMed]  [DOI]  [Cited in This Article: ]
2.  Brunello N, den Boer JA, Judd LL, Kasper S, Kelsey JE, Lader M, Lecrubier Y, Lepine JP, Lydiard RB, Mendlewicz J. Social phobia: diagnosis and epidemiology, neurobiology and pharmacology, comorbidity and treatment. J Affect Disord. 2000;60:61-74.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  Filho AS, Hetem LA, Ferrari MC, Trzesniak C, Martín-Santos R, Borduqui T, de Lima Osório F, Loureiro SR, Busatto Filho G, Zuardi AW. Social anxiety disorder: what are we losing with the current diagnostic criteria. Acta Psychiatr Scand. 2010;121:216-226.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 45]  [Cited by in F6Publishing: 49]  [Article Influence: 3.8]  [Reference Citation Analysis (0)]
4.  Pollack MH. Comorbidity, neurobiology, and pharmacotherapy of social anxiety disorder. J Clin Psychiatry. 2001;62 Suppl 12:24-29.  [PubMed]  [DOI]  [Cited in This Article: ]
5.  Martín-Santos R, Crippa JAS. Transtornos de ansiedad en atención primaria. Abordaje de los problemas de salud mental en el ámbito extrahospitalario. Barcelona: Profármaco 2003; 17-31.  [PubMed]  [DOI]  [Cited in This Article: ]
6.  Osório FL, Crippa JAS, Loureiro SR. Instruments for the Evaluation of Social Phobia. Social Phobia: Etiology, Diagnoses and Treatment. Hauppauge: Nova Science Publishers 2009; 1-66.  [PubMed]  [DOI]  [Cited in This Article: ]
7.  Watson D, Friend R. Measurement of social-evaluative anxiety. J Consult Clin Psychol. 1969;33:448-457.  [PubMed]  [DOI]  [Cited in This Article: ]
8.  Osório FL, Crippa JAS, Loureiro SR. Instruments for the assessment of social anxiety disorder. Rev Psiquiatr Clin. 2005;32:73-83.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 15]  [Cited by in F6Publishing: 16]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
9.  Liebowitz MR. Social Phobia. Anxiety. Basel: Karger 1987; 141-173.  [PubMed]  [DOI]  [Cited in This Article: ]
10.  Connor KM, Davidson JR, Churchill LE, Sherwood A, Foa E, Weisler RH. Psychometric properties of the Social Phobia Inventory (SPIN). New self-rating scale. Br J Psychiatry. 2000;176:379-386.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 809]  [Cited by in F6Publishing: 851]  [Article Influence: 36.8]  [Reference Citation Analysis (0)]
11.  Davidson JR, Potts NL, Richichi EA, Ford SM, Krishnan KR, Smith RD, Wilson W. The Brief Social Phobia Scale. J Clin Psychiatry. 1991;52 Suppl:48-51.  [PubMed]  [DOI]  [Cited in This Article: ]
12.  Osório Fde L, Crippa JA, Loureiro SR. Cross- cultural validation of the Brazilian Portuguese version of the Social Phobia Inventory (SPIN): study of the items and internal consistency. Rev Bras Psiquiatr. 2009;31:25-29.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 28]  [Cited by in F6Publishing: 29]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
13.  Osório FL, Crippa JA, Loureiro SR. Evaluation of the psychometric properties of the Social Phobia Inventory in university students. Compr Psychiatry. 2010;51:630-640.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 23]  [Cited by in F6Publishing: 26]  [Article Influence: 1.9]  [Reference Citation Analysis (0)]
14.  Connor KM, Kobak KA, Churchill LE, Katzelnick D, Davidson JR. Mini-SPIN: A brief screening assessment for generalized social anxiety disorder. Depress Anxiety. 2001;14:137-140.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 268]  [Cited by in F6Publishing: 281]  [Article Influence: 12.8]  [Reference Citation Analysis (0)]
15.  de Lima Osório F, Crippa JA, Loureiro SR. A study of the discriminative validity of a screening tool (MINI-SPIN) for social anxiety disorder applied to Brazilian university students. Eur Psychiatry. 2007;22:239-243.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 47]  [Cited by in F6Publishing: 44]  [Article Influence: 3.1]  [Reference Citation Analysis (0)]
16.  Osório Fde L, Crippa JA, Loureiro SR. Cross-cultural validation of the Brief Social Phobia Scale for use in Portuguese and the development of a structured interview guide. Rev Bras Psiquiatr. 2006;28:212-217.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 13]  [Cited by in F6Publishing: 14]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
17.  Schneier FR, Heckelman LR, Garfinkel R, Campeas R, Fallon BA, Gitow A, Street L, Del Bene D, Liebowitz MR. Functional impairment in social phobia. J Clin Psychiatry. 1994;55:322-331.  [PubMed]  [DOI]  [Cited in This Article: ]
18.  Abumusse LVM, Osório FL, Crippa JAS, Loureiro SR. Disability profile/clinician-rated: reliability and validity for brazilian university students with and without social anxiety disorder. Span J Psychol. 2011;In press.  [PubMed]  [DOI]  [Cited in This Article: ]
19.  Pinto Gouveia J, Cunha MI, Do Ceu Salvador M. Assessment Of Social Phobia By Self-Report Questionnaires: The Social Interaction And Performance Anxiety And Avoidance Scale And The Social Phobia Safety Behaviours Scale. Behav Cogn Psychother. 2003;31:291-311.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 30]  [Cited by in F6Publishing: 30]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
20.  Burato KRSS, Crippa JAS, Loureiro SR. Validade e fidedignidade da escala de comportamento de segurança na ansiedade social. Rev Psiquiatr Clin. 2009;36:175-181.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3]  [Cited by in F6Publishing: 3]  [Article Influence: 0.2]  [Reference Citation Analysis (0)]
21.  Hofmann SG, Dibartolo PM. An instrument to assess self-statements during public speaking: scale development and preliminary psychometric properties. Behav Ther. 2000;31:499-515.  [PubMed]  [DOI]  [Cited in This Article: ]
22.  Os¨®rio FL Transtorno de Ansiedade Social: validação de instrumentos de avaliação. 2008. Tese de Doutorado - Faculdade de Medicina, Universidade de São Paulo, Ribeirão Preto, 2008. .  [PubMed]  [DOI]  [Cited in This Article: ]
23.  Guimarães FS, Zuardi AW, Graeff FG. Effect of chlorimipramine and maprotiline on experimental anxiety in humans. J Psychopharmacol. 1987;1:184-192.  [PubMed]  [DOI]  [Cited in This Article: ]
24.  Bergamaschi MM, Queiroz RH, Chagas MH, de Oliveira DC, De Martinis BS, Kapczinski F, Quevedo J, Roesler R, Schröder N, Nardi AE. Cannabidiol reduces the anxiety induced by simulated public speaking in treatment-naïve social phobia patients. Neuropsychopharmacology. 2011;36:1219-1226.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 416]  [Cited by in F6Publishing: 441]  [Article Influence: 37.8]  [Reference Citation Analysis (0)]
25.  Beck AT, Steer RA.  Manual for the Beck Anxiety Inventory. San Antonio: Psychological Corporation 1993; .  [PubMed]  [DOI]  [Cited in This Article: ]
26.  de Lima Osório F, Crippa JA, Loureiro SR. Further psychometric study of the Beck Anxiety Inventory including factorial analysis and social anxiety disorder screening. Int J Psychiatry Clin Pract. 2011;15:255-262.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 24]  [Cited by in F6Publishing: 24]  [Article Influence: 2.4]  [Reference Citation Analysis (0)]
27.  Picon P, Gauer GJC, Fachel JMG, Beidel DC, Seganfredo AC, Manfro GG. The portuguese linguage version of Social Phobia and Anxiety Inventory: analysis of itens and internal consistency in a brazilian sample of 1014 undergraduate students. J Bras Psiquiat. 2006;55:114-119.  [PubMed]  [DOI]  [Cited in This Article: ]
28.  Gauer GC, Picon P, Davoglio TR, Silva LM, Beidel DC. Psychometric characteristics of the Brazilian Portuguese version of Social Phobia and Anxiety Inventory for Children (SPAI-C). Psico. 2009;40:354-358.  [PubMed]  [DOI]  [Cited in This Article: ]
29.  Levitan MN, Nascimenot I, Freire RC, Mezzasalma MA, Nardi AG. Equivalência semÂntica da versão brasileira da Social Avoidance and Distress Scale (SADS). Rev Psiquiatr Rio Gd Sul. 2008;30:49-58.  [PubMed]  [DOI]  [Cited in This Article: ]
30.  Silva ACO, Nardi AE. Brazilian version of the Social Interaction Self-Statement Test (SISST): translation and cross-cultural adaptation. Rev Psiquiatr Clin. 2010;37:199-205.  [PubMed]  [DOI]  [Cited in This Article: ]