Depression and social anxiety disorder (SAD) are two of the most common mental health conditions, and often occur together. Depression is usually identified as the presenting problem, which may result in SAD being overshadowed and undertreated among those with this particular comorbidity. In this case study, diagnostic overshadowing results in successful treatment of depression but delayed identification of SAD, causing an attenuated anxiety treatment response. We present recommendations on how clinicians may more thoroughly assess for comorbid Axis I diagnoses, avoid diagnostic overshadowing, and better integrate treatment approaches for SAD–major depressive disorder (MDD) comorbidity. Mechanisms underlying cognitive-behavioral treatments such as behavioral activation and exposure hold particular promise for promoting improvement in SAD and major depression simultaneously.
AcarturkC.SmitF.do GraafR.van StratenA.ten HaveM.CuijpersP. (2009). Incidence of social phobia and identification of its risk indicators: A model for prevention. Acta Psychiatria Scandinavia, 119, 62-70. doi:10.1111/j/1600-447.2008.01275.x
2.
AlpertJ. E.UebelackerL. A.McLeanN. E.NierenbergA. A.PavaJ. A.WorthingtonJ. J.. . . FavaM. (1997). Social phobia, avoidant personality disorder and atypical depression: Co-occurrence and clinical implications. Psychological Medicine, 27, 627-633. doi:10.1017/s0033291797004765
3.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
4.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
5.
ArchJ. J.EifertG. H.DaviesC.VilardagaJ. C.PlumbR.RaphaelD.CraskeM. G. (2012). Randomized clinical trial of Cognitive Behavioral Therapy (CBT) versus Acceptance and Commitment Therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology. doi:10.1037/a0028310 ; 10.1037/a0028310.supp
6.
BarlowD. H.AllenL. B.ChoateM. L. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35, 205-230. doi:10.1016/s0005-7894(04)80036-4
7.
BeckA. T.SteerR. A.BrownG. K. (1996). Manual for the Beck Depression Inventory–II. San Antonio, TX: Psychological Corporation.
8.
BelzerK.SchneierF. R. (2004). Comorbidity of anxiety and depressive disorders: Issues in conceptualization, assessment, and treatment. Journal of Psychiatric Practice, 10, 296-306.
9.
BlascovichJ.TomakaJ. (1993). Measures of self-esteem. In RobinsonJ. P.ShaverP. R.WrightsmanL. S. (Eds.), Measures of personality and social psychological attitudes (3rd ed., pp. 115-160). Ann Arbor, MI: Institute for Social Research.
10.
BorgeatF.StankovicM.KhazaalY.RougetB.BaumannM.RiquierF.. . . BondolfiG. (2009). Does the form or the amount of exposure make a difference in the cognitive-behavioral therapy treatment of social phobia?Journal of Nervous and Mental Disease, 197, 507-513. doi:10.1097/NMD.0b013e3181aacc08
11.
BouvardM.GuerinJ.RionA. C.BouchardC.DucottetE.SechaudM.. . . CottrauxJ. (1999). Psychometric study of the social self-esteem inventory of Lawson et al. (1979). European Review of Applied Psychology, 49, 165-172.
12.
BurnsD. D. (1980). Feeling good: The new mood therapy. New York, NY: Morrow.
13.
ButlerA. C.ChapmanJ. E.FormanE. M.BeckA. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17-31.
14.
Campbell-SillsL.SherbourneC. D.Roy-ByrneP.CraskeM. G.SullivanG.BystritskyA.. . . SteinM. B. (2012). Effects of co-occurring depression on treatment for anxiety disorders: Analysis of outcomes from a large primary care effectiveness trial. The Journal of Clinical Psychiatry, 73, 1509-1516. doi:10.4088/JCP.12m07955
15.
ClarkD. M.WellsA. (1995). A cognitive model of social phobia. In HeimbergR.LiebowitM.HopeD. A.SchneierF. R. (Eds.), Social phobia: Diagnosis assessment and treatment (pp. 69-93). New York, NY: Guilford Press.
16.
ColesM. E.GibbB. E.HeimbergR. G. (2001). Psychometric evaluation of the Beck Depression Inventory in adults with social anxiety disorder. Depression and Anxiety, 14, 145-148.
17.
CraskeM. G. (2012). Transdiagnostic treatment for anxiety and depression. Depression and Anxiety, 29, 749-753. doi:10.1002/da.21992
18.
DalrympleK. L. (2012). Social anxiety disorder comorbid with depression: Current research and future directions for treatment. In ColumbusA. M. (Ed.), Advances in psychology research (Vol. 89, pp. 1-28). Hauppauge, NY: Nova Science Publishers.
19.
DalrympleK. L.ZimmermanM. (2007). Does comorbid social anxiety disorder impact the clinical presentation of principal major depressive order?Journal of Affective Disorders, 100, 241-247.
20.
DalrympleK. L.ZimmermanM. (2011). Treatment-seeking for social anxiety disorder in a general outpatient psychiatry setting. Psychiatry Research, 187, 375-381. doi:10.1016/j.psychres.2011.01.004
21.
DavidsonJ. R. T.HughesD. C.GeorgeL. K.BlazerD. G. (1994). The boundary of social phobia: Exploring the threshold. Archives of General Psychiatry, 51, 975-983. doi:10.1001/archpsyc.1994.03950120047008
22.
de JongP. J.SportelB. E.de HulluE.NautaM. H. (2012). Co-occurrence of social anxiety and depression symptoms in adolescence: Differential links with implicit and explicit self-esteem?Psychological Medicine, 42, 475-484. doi:10.1017/s0033291711001358
23.
DimidjianS.HollonS. D.DobsonK. S.SchmalingK. B.KohlenbergR. J.AddisM. E.. . . JacobsonN. S. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74, 658-670. doi:10.1037/0022-006x.74.4.658
24.
DobsonK. S.HollonS. D.DimidjianS.SchmalingK. B.KohlenbergR. J.GallopR. J.. . . JacobsonN. S. (2008). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of Consulting and Clinical Psychology, 76, 468-477. doi:10.1037/0022-006x.76.3.468
25.
ErwinB.A.HeimbergR.G.JusterH.MindlinM. (2002). Comorbid anxiety and mood disorders among persons with social anxiety disorder. Behavior Research and Therapy, 40, 19-35.
26.
FedoroffI. C.TaylorS. (2001). Psychological and pharmacological treatments of social phobia: A meta-analysis. Journal of Clinical Psychopharmacology, 21, 311-324. doi:10.1097/00004714-200106000-00011
27.
FranckE.De RaedtR.DereuM.Van den AbbeeleD. (2007). Implicit and explicit self-esteem in currently depressed individuals with and without suicidal ideation. Journal of Behavior Therapy and Experimental Psychiatry, 38, 75-85.10.1916/j/jbtep.2006.05.003
28.
FyerA. J. (1993). Heritability of social anxiety: A brief review. Journal of Clinical Psychiatry, 54, 10-12.
29.
GemarM. C.SegalZ. V.SagratiS.KennedyS. J. (2001). Mood-induced changes on the Implicity Association Test in recovered depressed patients. Journal of Abnormal Psychology, 110, 282-289.
30.
HatcherR. L.GillaspyJ. A. (2006). Development and validation of a revised short version of the Working Alliance Inventory. Psychotherapy Research, 16, 12-25. doi:10.1080/10503300500352500
31.
HayesS. C.StrosahlK. D.WilsonK. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York, NY: Guilford Press.
32.
HofmannS. G.AsnaaniA.VonkI. J. J.SawyerA. T.FangA. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36, 427-440. doi:10.1007/s10608-012-9476-1
33.
JacobsonN. S.TruaxP. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12-19.
34.
JoormannJ.KosfelderJ.SchulteD. (2005). The impact of comorbidity of depression on the course of anxiety treatments. Cognitive Therapy and Research, 29, 569-591. doi:10.1007/s10608-005-3340-5
35.
KesslerR. C.BerglundP.DemlerO.JinR.MerikangasK. R.WaltersE. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.
36.
LedleyD. R.HuppertJ. D.FoaE. B.DavidsonJ. R. T.KeefeF. J.PottsN. L. S. (2005). Impact of depressive symptoms on the treatment of generalized social anxiety disorder. Depression and Anxiety, 22, 161-167. doi:10.1002/da.20121
37.
LovibondP. F.LovibondS. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33, 335-343.
38.
MaromS.Gilboa-SchechtmanE.AderkaI. M.WeizmanA.HermeshH. (2009). Impact of depression on treatment effectiveness and gains maintenance in social phobia: A naturalistic study of cognitive behavior group therapy. Depression and Anxiety, 26, 289-300. doi:10.1002/da.20390
39.
MattickR. P.ClarkeJ. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-470. doi:10.1016/s0005-7967(97)10031-6
40.
MunderT.WilmersF.LeonhartR.LinsterH. W.BarthJ. (2010). Working Alliance Inventory-Short Revised (WAI-SR): Psychometric properties in outpatients and inpatients. Clinical Psychology & Psychotherapy, 17, 231-239. doi:10.1002/cpp.658
41.
NelsonE. C.GrantJ. D.BucholzK. K.GlowinskiA.MaddenP. A. F.ReichW.HeathA. C. (2000). Social phobia in a population-based female adolescent twin sample: Co-morbidity and associated suicide-related symptoms. Psychological Medicine, 30, 797-804.
42.
O’NeilK. A.KendallP. C. (2012). Role of comorbid depression and co-occurring depressive symptoms in outcomes for anxiety-disordered youth treated with cognitive-behavioral therapy. Child & Family Behavior Therapy, 34, 197-209. doi:10.1080/07317107.2012.707086
43.
OrmelJ.OldehinkelA. J.VolleberghW. (2004). Vulnerability before, during and after a major depressive episode. Archives of General Psychiatry, 61, 990-996.
44.
OrthU.RobinsR. W.TrzesniewskiK. H.MaesJ.SchmittM. (2009). Low self-esteem is a risk factor for depressive symptoms from young adulthood to old age. Journal of Abnormal Psychology, 118, 472-478. doi:10.1037/a0015922
45.
PersonsJ. B. (2008). The case formulation approach to cognitive-behavior therapy. New York, NY: Guilford Press.
46.
RosenbergM. (1986). Conceiving the self. Malabar, FL: Krieger.
47.
RosenbergM. (1989). Society and the adolescent self-image (Rev. ed.). Middletown, CT: Wesleyan University Press.
48.
SchmittD. P.AllikJ. (2005). Simultaneous administration of the Rosenberg Self-Esteem Scale in 53 nations: Exploring the universal and culture-specific features of global self-esteem. Journal of Personality and Social Psychology, 89, 623-642.
49.
SheehanD. V.LecrubierY.SheehanK. H.AmorimP.JanavsJ.WeillerE.. . . DunbarG. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22-33.
50.
SmithT. B.DeanB.FloydS.SilvaC.YamashitaM.DurtschiJ.HeapsR. A. (2007). Pressing issues in college counseling: A survey of American college counseling association members. Journal of College Counseling, 10, 64-78. doi:10.1002/j.2161-1882.2007.tb00007.x
51.
SprinkleS. D.LurieD.InskoS. L.AtkinsonG.JonesG. L.LoganA. R.BissadaN. N. (2002). Criterion validity, severity cut scores, and test-retest reliability of the Beck Depression Inventory-II in a university counseling center sample. Journal of Counseling Psychology, 49, 381-385. doi:10.1037/0022-0167.49.3.381
52.
TurkC. L.HeimbergR. G.MageeL. (2008). Social anxiety disorder. In BarlowD. H. (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 123-163). New York, NY: Guilford Press.
53.
TwengeJ. M.CampbellW. K. (2001). Age and birth cohort differences in self-esteem: A cross-temporal meta-analysis. Personality and Social Psychology Review, 5, 321-344. doi:10.1207/s15327957pspr0504_3
54.
ZimmermanM.ChelminskiI. (2003). Clinician recognition of anxiety disorders in depressed outpatients. Journal of Psychiatric Research, 37, 325-333. doi:10.1016/s0022-3956(03)00020-7
55.
ZimmermanM.ChelminskiI.McDermutW. (2002). Major depressive disorder and axis I diagnostic comorbidity. The Journal of Clinical Psychiatry, 63, 187-193.
