A continuous publication, open access, peer-reviewed journal

ACCESS ONLINE
REVIEW
Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges
Ahmet Koyuncu MD1, Ezgi İnce MD2 , Erhan Ertekin MD2 , Raşit Tükel MD2
1Academy Social Phobia Center, Atatürk Mah. İkitelli Cad. No:126 A/Daire:6 Küçükçekmece/Istanbul, Turkey;
2Department of Psychiatry, Istanbul Medical School, Istanbul University, Istanbul, Turkey

Abstract encountered over the course of SAD as well as comorbidity

Comorbid disorders are highly prevalent in patients with associated diagnostic and therapeutic challenges will be
social anxiety disorder, occurring in as many as 90% of discussed.
patients. The presence of comorbidity may affect the Keywords: alcohol use disorder, anxiety, bipolar disorder,
course of the disease in several ways such as comorbidity in comorbidity, major depression, mood disorders, personality
patients with social anxiety disorder (SAD) is related to earlier disorder, social anxiety disorder.
treatment-seeking behavior, increased symptom severity,
treatment resistance and decreased functioning. Moreover, Citation
comorbidities cause significant difficulties in nosology Koyuncu A, İnce E, Ertekin E, Tükel R. Comorbidity in social
and diagnosis, and may cause treatment challenges. In anxiety disorder: diagnostic and therapeutic challenges. Drugs
this review, major psychiatric comorbidities that can be in Context 2019; 8: 212573. DOI: 10.7573/dic.212573

Introduction begins earlier than the comorbid disorder.15,19,21–23 Moreover,

the presence of SAD was found to be a predictor for the
Social anxiety disorder (SAD) is characterized by persistent and development of subsequent major depression (MD) and
marked fear/anxiety about one or more social or performance alcohol use disorder (AUD).10,13,19,24–27 Patients with SAD
situations in social settings. The individual recognizes that who have comorbid psychiatric disorders are more likely
the fear or anxiety is excessive and unreasonable, and some to have increased symptom severity, treatment resistance,
individuals fear offending others or being rejected as a result. and decreased functioning (such as missed days at work or
SAD affects different aspects of a person’s life such as social dropping out from school), and they also have higher rates of
activities, relationships, work, and academic functioning suicide when compared to ones without comorbidity.9,28,29
(American Psychiatric Association, 2013).1–3
Comorbidity is important for several reasons in clinical practice.
Epidemiological studies have established that SAD is a common First, it is highly common and significantly affects the clinical
disorder with a current prevalence between 5 and 10%, and course. The presence of a condition may disguise the other
lifetime prevalence between 8.4 and 15%.4–10 SAD typically condition or lead to a more complicated clinical presentation.
begins in early adolescence, and it is usually persistent unless Overlapping symptoms may also increase the risk of
treated effectively. Treatment-seeking behavior is generally misdiagnosis.30 Second, as one disorder can cause the emergence
rare, delayed, and often accompanied by another psychiatric of another or worsen its clinical course, detecting and treating
disorder.6–15 In other terms, the presence of comorbidity results the comorbidity increase the opportunity for early intervention.31
in earlier treatment-seeking behavior in patients with SAD.16–18 Third, comorbidity may result in worse treatment outcomes. This
Moreover, Crome and colleagues (2015) reported that only is partially because of the fact that treatment is more difficult
around 30% of patients with SAD considered social anxiety as when more than one diagnosis exists. In addition, failing to
their primary complaint, and among those, 20% of them went notice one of the comorbid conditions might lead to inadequate
to a health facility about these complaints in the past year.4 treatment and might be misinterpreted as treatment resistance.29
Community studies have reported a high frequency of In general, comorbidity in psychiatry is a controversial topic
psychiatric comorbidity in patients with SAD, occurring in and patients with comorbidities have often been excluded
as many as 90% of patients.9–11,15,19–22 In most cases, SAD from treatment studies in SAD.32 This also makes it difficult

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 1 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

for clinicians to choose the most appropriate options for The comorbidity between SAD and MD may lead to several
treatment. In this review, we will focus on major psychiatric diagnostic difficulties. It is important to acknowledge that
comorbidities that can be encountered over the course of there might be overlapping symptoms between the two
SAD, and how comorbidity affects diagnosis and treatment of disorders. For example, social withdrawal might result from
SAD, in the light of currently available information. A literature fear of embarrassment in SAD, but it might also be found
search was conducted in PubMed with the following terms: in patients with MD, usually as a mood-related, temporary
‘social anxiety disorder’, ‘social phobia’, ‘comorbidity’, ‘major phenomenon.46 Fear of negative evaluation is the cornerstone
depression’, ‘bipolar disorder’, ‘anxiety disorders’, ‘obsessive- of diagnosing SAD, while individuals with MD may also be
compulsive and related disorders’, ‘avoidant personality concerned about being negatively evaluated by others
disorder’, ‘diagnostic difficulties’, ‘treatment’. References because they feel that they are bad or not worthy of being
from the articles derived from the literature search were also liked. In contrast, individuals with SAD are worried about being
investigated. Only original articles, brief reports, review articles, negatively evaluated because of certain social behaviors or
and case reports/series that were published in English language physical symptoms.1 More importantly, social anxiety can be
were considered for the review. misinterpreted in society as a personality trait such as shyness
rather than a disorder; whereas, the onset of major depression
is generally more acute and marked.16 Therefore, it is possible
Mood disorders to overlook SAD in the presence of comorbid depression.29,45,47
Population-based studies have shown that mood disorders are Overlooking one disorder over the course of the other might
common in patients with SAD.4,5,9–11,15,19,21,22 The difficulties leads to inadequate treatment of the symptoms, which might
in diagnosis and/or treatment derived from comorbidity of be misinterpreted as treatment resistance.29 According to
commonly encountered mood disorders will be discussed in Dalrymple and Zimmerman (2007), almost 75% of patients
detail later. are willing to accept treatment for social anxiety in addition
to treatment for MD, only when asked frankly. Patients with
SAD and major depression major depression should be carefully assessed in terms of
MD is the most frequently observed comorbid disorder in social anxiety, particularly when shyness or a more persistent
clinical studies with comorbidity rates ranging between 35 social withdrawal is suspected.47 On the other hand, depression
and 70%,33–37 and it may influence several disease-related should not be forgotten when the diagnosis of SAD is made
outcomes. Patients with SAD who have comorbid MD have because this comorbidity can lead to dramatic outcomes
higher SAD severity, increased risk of relapse, and decreased such as increased risk for suicide or a more rapid decline
functionality.20,37–39 Especially, lack of social support may in functioning, besides leading to a need for change in the
cause more severe depressive episodes and higher probability treatment plan such as prioritizing behavioral activation.
of suicide in patients with SAD.40 On the other hand, SAD
comorbidity is also prevalent in patients with MD, to the degree It is also possible that SAD and MD comorbidity will lead to
that approximately 20–30% of patients with MD also have several therapeutic challenges. Interestingly, although SAD and
comorbid SAD.19,41–43 In a study of 255 patients with major MD have such high comorbidity rates and clinical presentation
depression, Fava and colleagues reported that the prevalence is more severe, placebo-controlled studies are very limited
of comorbid anxiety disorders and particularly SAD were 50.6 and most patients with comorbidities have been usually
and 27%, respectively. In the same study, the presence of an excluded from medication trials.32 In only one double-blind
anxiety disorder was related to earlier onset of MD.44 placebo-controlled study on the treatment of this comorbidity,
vortioxetine was found to be more effective in alleviating
As for the age of onset, symptoms of SAD generally emerge symptoms of both SAD and MD when compared to placebo.32
at an earlier age than comorbid mood disorders do,5,19,45 such None of the other antidepressants with efficacy in SAD have
that SAD predated comorbid mood disorders in 69% of the been studied in placebo-controlled trials to demonstrate
patients.5 As reported by Stein and colleagues (2001), the risk their efficacy in SAD patients with comorbid MD. In an open
of developing MD is increased 3.5 times in patients with SAD.26 study conducted with MD patients, treatment with citalopram
In another follow-up study, the risk for subsequent MD was showed improvement in symptoms of both MD and comorbid
approximately two times (relative risk ranges between 1.49 and social anxiety.48 In both studies, MD was reported to have
1.85) higher in patients with SAD than in healthy controls.25 improved earlier than social anxiety. More studies are needed
In other studies, the presence of SAD in patients with MD to evaluate the most appropriate treatment options for SAD
increased the risk of subsequent development of depressive patients with MD.32
symptoms and suicide attempts.10,13,19,24–26 There may be
several explanations why major depression follows SAD in those Some authors suggested that cognitive behavioral therapy
cases. Belzer and Schneier (2004) proposed that SAD might (CBT) can be recommended as a treatment of choice in SAD
contribute to the development of major depression through patients with comorbid MD.49 However, the results of studies
stressful life events such as job loss, educational difficulties, showing how the presence of depressive symptoms affects CBT
peer problems, and despair due to poor social functioning.40 outcome in patients with SAD are contradictory.50 Two studies

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 2 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

reported that patients with SAD who have higher depressive Considering the presence of atypical depression in patients with
symptoms seemed to benefit less from CBT, especially in the SAD leads to increased symptom severity and more disability,63
short term.51,52 Other studies found that the presence of MD atypicality of depression that is overlooked may cause treatment
at the beginning of the treatment did not interfere with the challenges. As atypical depression includes symptoms such
outcomes of CBT in patients with SAD,53–56 although symptoms as Leiden paralysis and over sleeping, it may be difficult for
of SAD exacerbated during long-term follow-up in one study.54 patients to perform exposure tasks. On the other hand, if the
presence of SAD is missed, it is less likely for patients to be
In general, both CBT and antidepressant medications are
referred for a therapy that may be beneficial, such as exposure
effective in both conditions, suggesting that they are effective
therapy. In addition, therapy options to improve IPS, which is a
in the case of comorbidity as well. However, this has not been
shared symptom, can be emphasized in these patients. Earlier
extensively studied in trials with high evidence base. Current
findings from treatment studies proposed that monoamine
evidence regarding to the treatment of comorbid SAD and MD
oxidase inhibitors (MAOIs) were highly effective in both
seems insufficient and inconsistent. Therefore, there is a need
disorders.68 However, after SSRIs and serotonin–norepinephrine
for comprehensive studies that assess the efficacy of available
reuptake inhibitors (SNRIs) have been introduced and proved
treatment options as well as for comparative studies that guide
to be effective in both disorders, they become the preferred
clinical decision to select better treatment options among
agents because of their milder side-effect profile.
antidepressant alone, CBT alone, or combination treatment of
selective serotonin reuptake inhibitor (SSRI) and CBT. Another
point is that considering SAD typically predates comorbid SAD and bipolar disorder
disorders, early treatment of SAD might prevent subsequent The rates of bipolar disorder (BD) comorbidity in patients with
development of comorbid depression.4 SAD range between 3.5 and 21%.34–37 Only a few studies have
investigated how bipolar disorder comorbidity affects patients
with SAD. Perugi and colleagues (2001) indicated that patients
SAD and atypical depression
with SAD who have comorbid MD or BD have higher symptom
Patients with MD who have atypical features constitute a
severity, higher rates of other anxiety disorder comorbidities,
specific subgroup of depressed patients who have drawn
and lower functioning than those without mood disorder
considerable interest with regards to SAD comorbidity. Various
comorbidity.36 In another study, atypical depression, total
studies demonstrated the connection between SAD and
number of depressive episodes, and post-traumatic stress
atypical depression.42,57–63 Rates of atypical MD are especially
disorder (PTSD) comorbidity were higher in the SAD+BD group
higher in the generalized type of SAD than in nongeneralized
than in the SAD+MD group. Obsessive-compulsive disorder
type.64 Alternatively, patients with atypical depression showed
(OCD) comorbidity was higher in SAD+BD than in patients with
higher SAD comorbidity than other patients with MD.42,62 In
SAD who have no comorbid mood disorder.37
a study investigating the impact of atypical MD comorbidity
on SAD, Koyuncu and colleagues found that 77.1% of mood Another important point in the relationship between SAD
episodes (either unipolar or bipolar) included atypical features and bipolar is the risk hypomanic/manic switches observed
among individuals with comorbid MD and SAD.63 In the same during the treatment of social anxiety.35 In one of the studies,
study, the atypical MD group had higher SAD and depression 32 patients with SAD were treated with MAOIs and 14 of
severity and lower functioning than patients with SAD+MD the 18 patients remitted with antidepressant treatment
without atypical features and SAD alone. In addition, age at switched to hypomania.69 It was argued that patients with
onset of SAD was earlier in patients with atypical MD.63 SAD who switched might belong to the bipolar spectrum,
and antidepressant treatment might uncover an underlying
Moreover, there are some common features between SAD
bipolarity. Holma and colleagues (2008) also reported that SAD
and atypical depression such as interpersonal sensitivity (IPS).
comorbidity might increase the risk of hypomania/mania in MD
It is included in diagnostic criteria for atypical depression,1
patients who were treated with antidepressant medications.70
and it is a core feature related to SAD.65,66 The overlap in SAD
Valença and colleagues (2005) mentioned a subgroup of SAD
and atypical depression criteria, specifically IPS, may account
presenting with an explicit hypomanic episode while receiving
for the high rates of comorbidity.67 Because IPS is a shared
antidepressants treatment. In this study, patients with SAD
feature between the two disorders, it may lead to difficulties
and BD-2 patients were found to be similar in terms of past
in differential diagnosis. Assessing cautiously whether IPS is a
depressive episodes, alcohol abuse, suicide, and family history
long-standing personality trait as in SAD or a mood-episode-
of BD.71 It is important for clinicians to be aware of comorbidity
limited phenomenon is important for accurate diagnosis in
rates of SAD and BD, as BD may be commonly missed and may
both atypical depression and SAD patients. Second, it is also
lead to inappropriate treatment choice.
important to consider other symptoms that accompany IPS
while differentiating between SAD and atypical depression. On the other hand, there are more studies assessing SAD
For example, the presence of other symptoms such as comorbidity in patients with a primary diagnosis of BD and
hypersomnia, hyperphagia, and mood reactivity suggests the reported rates range between 7.8 and 47.2%.6,38,72–81 Kessler and
diagnosis of atypical depression.1,46 colleagues (1994) reported in the National Comorbidity Survey

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 3 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

that SAD comorbidity was found to be higher in patients with

Other anxiety disorders
BD (odds ratio=4.6) than in patients with MD (odds ratio=3.6).6
The presence of an anxiety disorder might be associated with Excessive fear, anxiety, and related behavioral disturbances
greater BD symptom severity.76,78,82 Simon and colleagues represent shared keystones of all anxiety disorders. Most
(2004) reported that the rate of SAD comorbidity was 22% individuals with one anxiety disorder meet the criteria for
in 475 patients with bipolar I and II disorder and that anxiety additional comorbid anxiety disorders.1 Both community
disorder comorbidity was associated with earlier onset of and clinical studies have reported that approximately
bipolar disorder, more disability, less time spent in euthymia, one-half of SAD patients had at least one of any other lifetime
and greater number of suicidal attempts compared to the anxiety disorder comorbidity.22,23,28,37 As earlier studies
nonanxious bipolar patients.78 Boylan and colleagues (2003) were conducted with DSM-III-R and IV, OCD and PTSD were
found that the presence of a comorbid anxiety disorder in included in these rates. However, as DSM-5 is being utilized
bipolar patients led to significantly worse prognosis.79 In this at the time of this review has been written, anxiety disorder
study, among other anxiety disorders, SAD and generalized comorbidity will be discussed in accordance with the structure
anxiety disorder were the diagnoses with the most adverse of DSM-5.
effects on the outcome of BD. Pini and colleagues found that The most common lifetime anxiety disorder comorbidity
12.7% of bipolar patients fulfilled SAD criteria according to DSM- in SAD is specific phobia, which ranges between 14.1 and
III-R and the presence of SAD comorbidity was related with an 60.8%.11,15,22,28,37 Different from other comorbidities, specific
earlier age at onset of bipolar disorder.74 Perlis and colleagues phobia generally begins earlier than SAD does.1 Panic disorder
(2004) indicated that there was a significant relationship comorbidity is between 4.7 and 26.9%,11,15,22,37,64,88 and
between SAD and early-onset bipolar disorder, while Perroud agoraphobia is between 8 and 45%.11,23 Lifetime-generalized
and colleagues (2007) underlined that SAD comorbidity is an anxiety disorder (GAD) comorbidity rates were found to be
important risk factor for suicidal behavior in bipolar patients.83,84 between 0.6 and 27%.11,22,23,28,37
To the best of our knowledge, no studies examined the Anxiety-related outcomes were found to be influenced
treatment of SAD with BD comorbidity specifically. However, by the presence of comorbid anxiety disorders. For example,
studies reported that bipolar patients with higher anxiety had in a follow-up study of 12 years, patients with SAD showed the
poorer treatment response than the ones with lower anxiety.80 lowest rates of recovery among all other anxiety-disordered
Two studies investigated lithium response in bipolar disorder and patients.89 In addition to that, the presence of GAD comorbidity
found that the presence of anxiety was associated with poorer in SAD was associated with even decreased chance of recovery
response to treatment with lithium.85,86 Henry and colleagues and increased risk of recurrence when compared to no GAD
(2003) found that bipolar patients with anxiety responded less to comorbidity condition.89,90 It should be kept in mind that
anticonvulsants than bipolar patients without anxiety. However, GAD comorbidity could be the reason behind the treatment
lithium efficacy did not differ between the two groups in that resistant in some of the cases. Note that OCD and PTSD were
study.77 There are also studies investigating the effects of mood also included in this study, as they used DSM-IV.
stabilizers in patients with SAD who do not have comorbid mood
Although all anxiety disorders consist of features such as
disorder. Trials with valproate produced inconsistent results.72
excessive fear, anxiety, and avoidance in common, they also
Overall, in the comorbidity of bipolar disorder with anxiety carry dissimilarities from each other such as fear inducing
disorders, prioritizing the treatment of bipolar disorder is situations, type of avoidance behavior, and accompanied
essential and starting mood stabilizer agents as first-line cognitions. Differential diagnosis can be achieved by a
treatment is recommended. Hypomanic/manic switch with thorough examination. Patients with specific phobia may
antidepressants used for treating SAD may complicate the exhibit fear of embarrassment or humiliation because of
treatment of SAD. Because of this risk, the potential benefits the reactions given to feared situation; however, according
and risks of antidepressant treatment should be evaluated to DSM-5, if social situations are feared because of negative
carefully.71 and they should be started only with mood stabilizers evaluation, social anxiety disorder should be diagnosed instead
in comorbidity situation. Benzodiazepines can be used to treat of specific phobia. Patients with SAD can exhibit panic attacks
anxiety symptoms; however, it is advisable to be cautious when as well due to fear of negative evaluation, but these are not
using alprazolam because of hypomanic switch risk. unexpected panic attacks as seen in panic disorder where
the concern is about panic attacks themselves.1 Social- or
In addition, CBT can be considered as a treatment option
performance-related worries are observed as a part of both
for anxiety symptoms, especially after stabilization of mood
GAD and SAD; however, while they are restricted to these
symptoms.72 Fracalanza and colleagues (2014) reported that
situations in SAD, GAD is often associated with more expanded
SAD+MD and SAD+BD groups had higher pretreatment
worrisome situations and evaluation by others does not usually
symptom severity of SAD than SAD alone and SAD plus
accompany GAD.1
other anxiety disorder groups. Although all groups showed
improvement with CBT, SAD+MD, and SAD+BD groups As comorbid disorders were generally excluded from
remained symptomatic87 after treatment. treatment studies, evidence is not available with regard to

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 4 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

treatment of comorbid anxiety disorders and SAD. SSRIs and

Alcohol use disorder
SNRIs are generally considered as first-line pharmacological
treatments for anxiety disorders, except specific phobia Epidemiological studies have found high rates of relationship
where efficacy of pharmacotherapy is very limited.91 On between SAD and AUD.14,27,98 The rate of AUD can be up to
the other hand, CBT has been found to be effective for all 50% in patient with SAD.14 Inpatients with AUD and comorbid
anxiety disorders in several randomized controlled studies.92 SAD had more Axis I and II comorbidity rates compared to
In one study, there was no significant difference in cognitive AUD inpatients without SAD according to DSM-IV.99 Moreover,
behavioral group therapy results between SAD patients with Perugi and colleagues (2002) also found that the presence of
and without GAD comorbidity.90 It is important to carefully comorbid Bipolar II and AUD predicted a number of important
assess patients with SAD for anxiety disorder comorbidities clinical outcomes in social phobia patients.100
as they would lead patients to receive inappropriate or The coexistence of these diseases was associated with
insufficient treatment if missed. CBT should be tailored to heightened severity in both diseases, increased numbers
include techniques for comorbid anxiety disorder in addition of psychiatric or medical comorbidities and deterioration
to SAD. in functioning when compared to either AUD or BD
alone.14,99,101–105 Although there are studies showing a strong
association between SAD and AUD, the causality and the
Obsessive-compulsive and direction of the relationship between the two disorders are
related disorders unknown.106–108
OCD comorbidity rates were reported to be between 2 and SAD generally begins earlier than AUD, and it is considered as a
19% in patients with SAD.11,15,23,28,37 On the other hand, when risk factor for later AUD development.109–112 Patients with SAD
evaluating the studies conducted with OCD patients, the may use alcohol as a self-medication to reduce anxiety. This
prevalence of SAD was found to be between 8 and 42%.93 In feature may explain why the risk of alcoholism was increased
a study, lifetime history of comorbid OCD was associated with following SAD.113 According to another hypothesis, there is
earlier treatment-seeking behavior in patients with SAD.16 There often a genetic predisposition to both SAD and AUD. However,
are studies showing that bipolar disorder and SAD comorbid only a small proportion of the association of SAD and AUD can
patients had higher rates of OCD diagnosis compared to SAD be explained by overlapping genetic risk or shared etiology.98
group without bipolar disorder.36,37 Treatment-seeking behavior has been found to decrease in the
Body dysmorphic disorder (BDD) is an OCD-related disorder case of comorbid SAD and AUD, and the patients frequently
that contains preoccupations about one’s physical appearance, remain without treatment.14,114,115 In treatment, it is important
where social anxiety and avoidance are common and cause to investigate whether there is SAD in alcohol-dependent
impairment in social functioning. Moreover, the core features patients, and if present, treatment of SAD should not be
related to SAD such as fear of embarrassment and rejection overlooked.46,116 As comorbidity is not included in drug efficacy
are also common in BDD patients. BDD mostly begins in studies in patients with SAD, it is not known whether similar
preadolescence and adolescence, as SAD does. However, treatment approaches are effective in SAD and AUD comorbid
in the case of comorbidity, SAD starts earlier than BDD.94 While patients.98 Therefore, treatment studies are needed to evaluate
the rate of BDD was found to be 8–12% among patients with this particular comorbidity.
SAD,94,95 the rate of SAD was about 40% in patients
with BDD.96
Differential diagnosis of BDD and SAD can be challenging,
Avoidant personality disorder
as social anxiety and avoidance are also common in BDD According to DSM-5, avoidant personality disorder (AUD)
because of the discomfort related to one’s appearance; represents a pervasive pattern of social inhibition, feelings
however, persistent preoccupations about appearance and of inadequacy, and hypersensitivity to negative evaluation.1
frequent repetitive behaviors such as checking on the mirror The association between APD and SAD has been a matter
may represent useful cues that favor BDD. Instead, individuals of debate since they were first introduced in DSM-III. It has
with SAD may be more concerned with the thoughts that been argued that there is more evidence to support that the
others will ridicule or negatively evaluate them because of a two disorders belong to the same continuum where they differ
mistake they do.1 Accurate detection of BDD, when comorbid primarily in symptom severity and impairment, rather than
with SAD, would be important, as patients with comorbid representing distinct categories.117–120 On the other hand, other
BDD may benefit from specific treatment techniques based studies suggested that besides quantitative differences, there
on CBT for BDD.97 BDD treatment would focus more on are also qualitative differences between SAD and APD. For
preventing rituals and avoidance behaviors related to example, patients with more APD features have higher levels
body concerns; whereas, CBT for SAD focuses more on of social or nonsocial avoidance, more persistent interpersonal
reducing anxiety and avoidance of social situations more problems, feelings of inferiority, and social inadequacy
generally. compared to patients with less APD features.121–124 While the

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 5 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

discussions are ongoing, the diagnostic distinction of APD and SAD is the most common anxiety disorder comorbidity in
SAD remained unchanged in DSM-5, acknowledging that there eating disorders (ED), and its rates were detected as high as
is a great deal of overlap between the two disorders, as much 60%.151,152 In contrast, ED comorbidity is only slightly more
as that they may be alternative conceptualizations of the same prevalent in patients with SAD compared to healthy controls.23
or similar conditions.1 SAD is hypothesized to play a part in the development of ED as
it emerges earlier.153
APD is particularly overlapping with generalized type of
SAD125 and comorbidity rates range between 22 and 89% in Separation anxiety disorder (SEPAD), such as specific phobia,
earlier studies.42,126–130 In more recent population-based and is a disorder that generally begins earlier than SAD, and
clinical studies, comorbidity rates were found to be moderate, comorbidity between them are expected.154 Studies evaluating
around 32–48% of the patients with APD appeared to have the relationship between these two disorders found that the
both conditions at the same time.14,118,121,131–134 There seems rates of comorbid SAD in child and adult SEPAD patients are
to be a shared genetic vulnerability between the two disorders, 33.4 and 34.5%, respectively.155 Silove et al. (2010) examined
family studies reported that SAD patients with APD have 520 outpatients in an anxiety clinic and reported the rates of
higher rates of first degree relatives with SAD.135 Reichborn- comorbid adult SEPAD as 14% in SAD patients.156
Kjennerud and colleagues (2007) investigated 1427 female
Attention-deficit/hyperactivity disorder (ADHD), another
twin pairs and found that genetic features of both SAD and
childhood disorder that extends over adulthood, is an
APD are similar.133 After following up the same twin pairs for
overlooked condition that has high rates of comorbidity
10 years, it was concluded that the environmental risk
with SAD.31 Only recently increasing evidence suggests that
factors for the two disorders were highly correlated but
the relationship between the two disorders is closer than
distinct.136
that was thought before. Several studies found high rates
As for the effect on clinical picture, patients with SAD+APD (up to 60–70%) of childhood ADHD comorbidity, especially
had higher levels of anxiety, higher rates of comorbidity, and predominantly inattentive type, in adults with SAD.67,157,158 In
decreased functionality compared to the patients with SAD al addition, follow-up studies showed that the lifetime prevalence
one.42,121–123,127,130,132,137–141 Several studies conducted on this of SAD among ADHD patients is higher compared to healthy
comorbidity reported that anxiety and avoidance scores of controls.159 In treatment studies investigating patients with SAD
Liebowitz Social Anxiety Scale were higher in SAD patients with plus ADHD comorbidity found that ADHD medications such
APD than those without APD.137,141,142 In a study by Lampe et al. as methylphenidate or atomoxetine could effectively improve
(2015), the rates of depression, suicidal ideation, and suicidal symptoms of both disorders at the same time.160–163 According
attempt were higher in SAD+ADP group than in SAD without to a developmental hypothesis, SAD may be etiologically linked
APD group.134 to ADHD in a subgroup of patients, and thus SAD may develop
secondary to ADHD.31 In other words, ADHD can be considered
Even if it has still been debated whether they should be
as a vulnerability factor for later development of SAD.31 Further
considered as a single disorder, several pharmacological and
studies are needed to investigate this relationship.
psychological treatment (e.g. benzodiazepine, SSRIs, MAOI)
studies conducted on SAD and APD comorbidity have shown
that treatments were effective on symptoms of both SAD Conclusions
and concurrent APD to some degree.143,144 There are studies
reporting that SAD+APD yielded worse treatment outcomes Comorbidity is very common in SAD, particularly in
such as less likelihood of remission, higher symptom severity, generalized subtype, and its lifetime prevalence has reached
and lower functioning at the end of the treatment145–147 when up to 90%. These high rates bring the validity of the
compared to SAD alone. CBT for SAD seems to be a useful comorbidity concept into question, suggesting that SAD
approach for alleviating the symptoms, but an emphasis on may be a vulnerability factor for later development of
avoidance and inclusion of social skills training have been accompanying disorders. In fact, SAD generally begins
proposed for patients who have comorbid SAD and APD.148 earlier than the comorbid disorder in many cases, except
specific phobia, ADHD, and separation anxiety disorder. SAD
particularly increases the risk of subsequent development of
Other psychiatric conditions major depression, alcoholism, and suicide. On the other hand,
SAD comorbidity is expected to be higher in patients with
The rate of PTSD is found to be 3.2–16% in patients with
other psychiatric disorders such as OCD, PTSD, and ED and
SAD;11,22,23,37 however, in veteran and community studies,
childhood disorders such as ADHD.
PTSD and SAD were reported to be frequently comorbid
conditions.149 Zayfert and colleagues (2005) found that SAD Comorbidity affects several SAD-related outcomes, because
comorbidity rate was 43% in primary PTSD patients; whereas, it increases the chances to observe higher symptom severity,
PTSD comorbidity rate was 7% in primary SAD patients.150 In more treatment resistance, and lower functioning compared to
these studies, PTSD with SAD had higher guilty feeling and comorbidity free conditions. Comorbidity also leads to earlier
childhood abuse than those without SAD. treatment-seeking behavior in patients with SAD.

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 6 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

Additionally, the presence of comorbid disorders is associated studies. As comorbidity is more of a rule than an exception,
with difficulties in diagnosis and treatment; therefore, a comprehensive studies are needed to identify the best
thorough diagnostic examination is necessary to differentiate treatment solutions for patients who have SAD and another
other psychiatric conditions. Evidence is limited concerning psychiatric disorder. In addition, follow-up studies investigating
the treatment of patients with SAD who have comorbidities, causal relationship between SAD and comorbid disorder are
because these patients are often excluded from the treatment warranted.

Contributions: Ahmet Koyuncu contributed to the design, literature search, acquisition and interpretation of the findings, drafted the
manuscript, and gave final approval. Ezgi İnce contributed to the design, literature search, acquisition and interpretation of the findings, drafted
the manuscript, and gave final approval. Erhan Ertekin contributed to the design, critically revised the manuscript, and gave final approval. Raşit
Tükel contributed to the design, critically revised the manuscript, and gave final approval. All named authors meet the International Committee
of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have
given their approval for this version to be published.
Disclosure and potential conflicts of interest: The authors declare that they have no conflicts of interest. The International Committee
of Medical Journal Editors (ICMJE) Potential Conflicts of Interests form for the authors are available for download at
http://www.drugsincontext.com/wp-content/uploads/2019/02/dic.212573-COI.pdf
Acknowledgements: None.
Funding declaration: The authors received no financial support for the research, authorship, and publication of this article.
Copyright: Copyright © 2019 Koyuncu A, İnce E, Ertekin E, Tükel R. Published by Drugs in Context under Creative Commons License Deed CC
BY NC ND 4.0 which allows anyone to copy, distribute, and transmit the article provided it is properly attributed in the manner specified below.
No commercial use without permission.
Correct attribution: Copyright © 2019 Koyuncu A, İnce E, Ertekin E, Tükel R. https://doi.org/10.7573/dic.212573. Published by Drugs in
Context under Creative Commons License Deed CC BY NC ND 4.0.
Article URL: https://drugsincontext.com/comorbidity-in-social-anxiety-disorder:-diagnostic-and-therapeutic-challenges
Correspondence: Ahmet Koyuncu, Academy Social Phobia Center, Atatürk Mah. İkitelli Cad. No:126 A/Daire:6 Küçükçekmece/Istanbul,
Turkey. [email protected]
Provenance: invited; externally peer reviewed.
Submitted: 1 November 2018; Peer review comments to author: 11 December 2018; Revised manuscript received: 21 February 2019;
Accepted: 22 February 2019; Publication date: 2 April 2019.
Drugs in Context is published by BioExcel Publishing Ltd. Registered office: Plaza Building, Lee High Road, London, England, SE13 5PT.
BioExcel Publishing Limited is registered in England Number 10038393. VAT GB 252 7720 07.
For all manuscript and submissions enquiries, contact the Editor-in-Chief [email protected]
For all permissions, rights and reprints, contact David Hughes [email protected]

References
1. American Psychiatric Association. (APA). Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: APA; 2013.
2. Heimberg RG, Hofmann SG, Liebowitz MR, et al. Social anxiety disorder in DSM-5. Depress Anxiety. 2014;31(6):472–479.
http://dx.doi.org/10.1002/da.22231
3. Bögels SM, Alden L, Beidel DC, et al. Social anxiety disorder: questions and answers for the DSM-V. Depress Anxiety.
2010;27(2):168–189. http://dx.doi.org/10.1002/da.20670
4. Crome E, Grove R, Baillie AJ, et al. DSM-IV and DSM-5 social anxiety disorder in the Australian community. Aust N Z J Psychiatry.
2015;49(3):227–235. http://dx.doi.org/10.1177/0004867414546699
5. Stein MB, Craske MG. Treating anxiety in 2017: optimizing care to improve outcomes. JAMA. 2017;318(3):235–236.
http://dx.doi.org/10.1001/jama.2017.6996
6. Kessler RC, Mc Gonagle KA, Zhao S. Lifetime and 12-month prevalence of DSM-IIIR psychiatric disorders in the United States.
Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:8–19.
http://dx.doi.org/10.1001/archpsyc.1994.03950010008002
7. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National
Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593–768. http://dx.doi.org/10.1001/archpsyc.62.6.593
8. Stein MB. An epidemiologic perspective on social anxiety disorder. J Clin Psychiatry. 2006;67(suppl 12):3–8. PMID:17092189

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 7 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

9. Acarturk C, de Graaf R, van Straten A, et al. Social phobia and number of social fears, and their association with comorbidity,
health-related quality of life and help seeking: a population-based study. Soc Psychiatry PsychiatrEpidemiol. 2008;43:273–279.
http://dx.doi.org/10.1007/s00127-008-0309-1
10. Ohayon MM, Schatzberg AF. Social phobia and depression: prevalence and comorbidity. J Psychosom Res. 2010;68:235–243.
http://dx.doi.org/10.1016/j.jpsychores.2009.07.018
11. Davidson JRT, Huges DL, George LK. The epidimiological of social phobia: findings from the Duke Epidemiological Catchment
Area study. Psychol Med. 1993;23:709–718. http://dx.doi.org/10.1017/S0033291700025484
12. Mather AA, Stein MB, Sareen J. Social anxiety disorder and social fears in the Canadian military: prevalence, comorbidity,
impairment, and treatment-seeking. J Psychiatr Research. 2010;44:887–893. http://dx.doi.org/10.1016/j.jpsychires.2010.02.013
13. Weiller E, Bisserbe JC, Boyer P, et al. Social phobia in general health care: an unrecognized undertreated disabling disorder.
Br J Psychiatry.1996;168:169–174. http://dx.doi.org/10.1192/bjp.168.2.169
14. Grant BF, Hasin DS, Blanco C, et al. The epidemiology of social anxiety disorder in the United States: results from the National
Epidemiologic Survey on alcohol and related conditions. J Clin Psychiatry. 2005;66:1351–61. http://dx.doi.org/10.4088/JCP.v66n1102
15. Schneier FR, Johnson J, Hornig CD, et al. Social phobia: comorbidity and morbidity in an epidemiologic sample. Arch Gen
Psychiatry. 1992;49:282–288. http://dx.doi.org/10.1001/archpsyc.1992.01820040034004
16. Ertekin E, Çelebi F, Koyuncu A, et al. Predictors of early or late treatment seeking in patients with social anxiety disorder. Ann Clin
Psychiatry. 2015;27(4):236–241. PMID: 26554364
17. Wang PS, Berglund P, Olfson M, et al. Delays in initial treatment contact after first onset of a mental disorder. Health Serv Res.
2004;39:393–415. http://dx.doi.org/10.1111/j.1475-6773.2004.00234.x
18. Fikretoglu D, Liu A, Pedlar D, et al. Patterns and predictors of treatment delay for mental disorders in a nationally representative,
active Canadian military sample. Med Care. 2010;48:10–17. http://dx.doi.org/10.1097/MLR.0b013e3181bd4bf9
19. Kessler RC, Stang P, Wittchen HU, et al. Lifetime co-morbidities between social phobia and mood disorders in the US national
comorbidity survey. Psychol Med. 1999;29:555–567. http://dx.doi.org/10.1017/S0033291799008375
20. Ruscio AM, Brown TA, Chiu WT, et al. Social fears and social phobia in the USA: results from the National Comorbidity Survey
Replication. PsycholMed. 2008;38:15–28. http://dx.doi.org/10.1017/S0033291707001699
21. Chartier MJ, Walker JR, Stein MB. Considering comorbidity in social phobia. Soc Psychiatry Psychiatr Epidemiol. 2003;38:728–734.
http://dx.doi.org/10.1007/s00127-003-0720-6
22. Magee WJ, EatonWW, Wittchen HU, et al. Agoraphobia, simple phobia, and social phobia in the national comorbidity survey.
Arch Gen Psychiatry. 1996;53:159–168. http://dx.doi.org/10.1001/archpsyc.1996.01830020077009
23. Wittchen HU, Stein MB, Kessler RC. Social fears and social phobia in a community sample of adolescents and young adults:
prevalence, risk factors and comorbidity. Psychol Med. 1999;29:309–323. http://dx.doi.org/10.1017/S0033291798008174
24. Bittner A, Goodwin RD, Wittchen HU, et al. What characteristics of primary anxiety disorders predict subsequent major
depressive disorder? J Clin Psychiatry. 2004;65:618–626. http://dx.doi.org/10.4088/JCP.v65n0505
25. Beesdo K, Bittner A, Pine DS, et al. Incidence of social anxiety disorder and the consistent risk for secondary depression in the
first three decades of life. Arch Gen Psychiatry. 2007;64:903–912. http://dx.doi.org/10.1001/archpsyc.64.8.903
26. Stein MB, Fuetsch M, Muller N, et al. Social anxiety disorder and the risk of depression: a prospective community study of
adolescents and young adults. Arch Gen Psychiatry. 2001;58:251–256. http://dx.doi.org/10.1001/archpsyc.58.3.251
27. Oliveira LM, Bermudez MB, Macedo MJA, et al. Comorbid social anxiety disorder in patients with alcohol use disorder: a
systematic review. Psychiatr Res. 2018;106:8–14. http://dx.doi.org/10.1016/j.jpsychires.2018.09.008
28. Wenzel, A. Relation to clinical syndromes in adulthood. In: Hofmann SG, DiBartolo PM, eds. Social Anxiety: Clinical, Developmental,
and Social Perspectives (Second Edition). London: Academic Press; 2010:183–205.
29. Nagata T, Suzuki F, Teo AR. Generalized social anxiety disorder: a still-neglected anxiety disorder 3 decades since Liebowitz’s
review. Psychiatry Clin Neurosci. 2015;69(12):724–740. http://dx.doi.org/10.1111/pcn.12327
30. Kessler RC, Anthony JC, Blazer DG, et al. The US National Comorbidity Survey: overview and future directions. Epidemiol Psychiatr
Sci. 1997;6(1):4–16. http://dx.doi.org/10.1017/S1121189X00008575
31. Koyuncu A, Alkın T, Tükel R. Development of social anxiety disorder secondary to attention deficit/hyperactivity disorder
(the developmental hypothesis). Early Interv Psychiatry. 2018; 12(2):269–272. http://dx.doi.org/10.1111/eip.12372
32. Liebowitz MR, Careri J, Blatt K, et al. Vortioxetine versus placebo in major depressive disorder comorbid with social anxiety
disorder. Depress Anxiety. 2017;34(12):1164–1172. http://dx.doi.org/10.1002/da.22702
33. Stein MB, Tancer ME, Gelerntner CS, et al. Major depression in patients with social phobia. Am J Psychiatry. 1990;147:637–639.
http://dx.doi.org/10.1176/ajp.147.5.637
34. Van Ameringen M, Mancini C, Styan G, et al. Relationship of social phobia with other psychiatric illness. J Affect Disord.
1991;21;93–99. http://dx.doi.org/10.1016/0165-0327(91)90055-W
35. Perugi G, Akiskal HS, Ramaciotti S, et al. Depressive comorbidity of panic, social phobic, and obsessive-compulsive disorders re-
examined: is there a bipolar II connection? Psychiatr Res. 1999;33(1):53–61. http://dx.doi.org/10.1016/S0022-3956(98)00044-2

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 8 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

36. Perugi G, Frare F, Toni C, et al. Bipolar II and unipolar comorbidity in 153 outpatients with social phobia. Compr Psychiatry.
2001;42:375–381. http://dx.doi.org/10.1053/comp.2001.26270
37. Koyuncu A, Ertekin E, Binbay Z, et al. The clinical impact of mood disorder comorbidity on social anxiety disorder. Compr
Psychiatry. 2014;55(2):363–369. http://dx.doi.org/10.1016/j.comppsych.2013.08.016
38. Fracalanza KA, McCabe RE, Taylor VH, et al. Bipolar disorder comorbidity in anxiety disorders: relationship to demographic
profile, symptom severity, and functional impairment. Eur J Psychiatry. 2011;25:223–233.
http://dx.doi.org/10.4321/S0213-61632011000400005
39. Aderka IM, Hofmann SG, Nickerson A, et al. Functional impairment in social anxiety disorder. J Anxiety Disord. 2012;26(3):393–400.
http://dx.doi.org/10.1016/j.janxdis.2012.01.003
40. Belzer K, Schneier FR. Comorbidity of anxiety and depressive disorders: issues in conceptualization, assessment, and treatment.
J Psychiatr Pract. 2004;10:296–306. http://dx.doi.org/10.1097/00131746-200409000-00003
41. Brown TA, Campbell LA, Lehman CL, et al. Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large
clinical sample. J Abnorm Psychol. 2001;110:585–599. http://dx.doi.org/10.1037/0021-843X.110.4.585
42. Alpert KE, Uebelacker LA, McLean NE, et al. Social phobia, avoidant personality disorder and atypical depression: co-occurrence
and clinical implications. Psychol Med. 1997;27:627–633. http://dx.doi.org/10.1017/S0033291797004765
43. Rush AJ, Zimmerman M, Wisniewski SR, et al. Comorbid psychiatric disorders in depressed outpatients: demographic and clinical
features. J Affect Disord. 2005;87:43–55. http://dx.doi.org/10.1016/j.jad.2005.03.005
44. Fava M, Rankin MA, Wright EC, et al. Anxiety disorders in major depression. Compr Psychiatry. 2000;41:97–102.
http://dx.doi.org/10.1016/S0010-440X(00)90140-8
45. Dalrymple KL, Zimmerman M. Age of onset of social anxiety disorder in depressed outpatients. J Anxiety Disord.
2011;1:25(1):131–137. https://doi.org/10.1016/j.janxdis.2010.08.012
46. Lydiard RB. Social anxiety disorder: comorbidity and its implications. J Clin Psychiatry. 2001;62(Suppl 1):17–24. PubMed PMID: 11206030
47. Dalrymple KL, Zimmerman M. Does comorbid social anxiety disorder impact the clinical presentation of principal major
depressive disorder? J Affect Disord. 2007;100(1–3):241–247. http://dx.doi.org/10.1016/j.jad.2006.10.014
48. Schneier FR, Blanco C, Campeas R, et al. Citalopram treatment of social anxiety disorder comorbid with major depression.
Depress Anxiety. 2003;17:191–196. https://doi.org/10.1002/da.10112
49. Canadian Psychiatric Association. Clinical practice guidelines. Management of anxiety disorders. Can J Psychiatry.
2006;51(8 Suppl 2):9S. PMID: 16933543
50. Bauer I, Wilansky-Traynor P, Rector NA. Cognitive-Behavioral therapy for anxiety disorders with comorbid depression: a review.
Int J Cogn Ther. 2012;5:118–156. https://doi.org/10.1521/ijct.2012.5.2.118
51. Chambless DL, Tran GQ, Glass CR. Predictors of response to cognitive-behavioral group therapy for social phobia. J Anxiety
Disord. 1997;11;221–240. https://doi.org/10.1016/S0887-6185(97)00008-X
52. Ledley DR, Huppert JD, Foa HB, et al. Impact of depressive symptoms on the treatment of generalized social anxiety disorder.
Depress Anxiety. 2005;22;161–167. https://doi.org/10.1002/da.20121|
53. Erwin BA, Heimberg RG, Juster H, et al. Comorbid anxiety and mood disorders among persons with social anxiety disorder.
Behav Res Ther. 2002;40:19–35. https://doi.org/10.1016/S0005-7967(00)00114-5
54. Marom S, Gilboa‐Schechtman E, Aderka IM, et al. Impact of depression on treatment effectiveness and gains maintenance in
social phobia: a naturalistic study of cognitive behavior group therapy. Depress Anxiety. 2009;26:289–300.
https://doi.org/10.1002/da.20390
55. Joorman J, Kosfelder J, Schulte D. The impact of comorbidity of depression on the course of anxiety treatments. Cogn Ther Res.
2005;29:569–591. http://dx.doi.org/10.1007/s10608-005-3340-5
56. Van Velzen CJ, Emmelkamp PM, Scholing A. The impact of personality disorders on behavioral treatment outcome for social
phobia. Behav Res Ther. 1997;35(10):889–900. PMID: 9401130
57. Perugi G, Akiskal HS, Lattanzi L, et al. The high prevalence of ‘soft’ bipolar (2) Features in atypical depression. Comp Psychiatry.
1998;39:63–71. http://dx.doi.org/10.1016/S0010-440X(98)90080-3
58. Sullivan PF, Kessler RC, Kendler KS. Latent class analysis of lifetime depressive symptoms in the National Comorbidity Survey.
Am J Psychiatry. 1998;155:1398–1406. http://dx.doi.org/10.1176/ajp.155.10.1398
59. Matza LS, Revicki DA, Davidson JR, et al. Depression with atypical features in the National comorbidity Survey: classification,
descirption, and consequences. Arch Gen Psychiatry. 2003;141:288–289. http://dx.doi.org/10.1001/archpsyc.60.8.817
60. Parker G, Roy K, Mitchell P, et al. Atypical depression: a reappraisal. Am J Psychiatry. 2002;159:1470–1479.
http://dx.doi.org/10.1176/appi.ajp.159.9.1470
61. Angst J, Gamma A, Sellaro R, et al. Toward validation of atypical depression in the community: results of the Zurich Cohort Study.
J Affect Disord. 2002;72:125–138. http://dx.doi.org/10.1016/S0165-0327(02)00169-6
62. Posternak MA, Zimmerman M. Partial validation of the atypical features subtype of major depressive disorder. Arch Gen
Psychiatry. 2002;59:70–76. http://dx.doi.org/10.1001/archpsyc.59.1.70

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 9 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

63. Koyuncu A, Ertekin E, Ertekin BA, et al. Relationship between atypical depression and social anxiety disorder. Psychiatry Res.
2014;225(1–2):79–84. http://dx.doi.org/10.1016/j.psychres.2014.10.014
64. Mannuzza S, Schneier FR, Chapman TF, et al. Generalized social phobia: reliability and validity. Arch Gen Psychiatry.
1995;52:230–237. http://dx.doi.org/10.1001/archpsyc.1995.03950150062011
65. Liebowitz MR, Gorman JM, Fyer AL, et al. Social phobia: review of neglected anxiety disorder. Arch Gen Psychiatry.
1985;42:729–736. http://dx.doi.org/10.1001/archpsyc.1985.01790300097013
66. Harb GC, Heimberg RG, Fresco DM, et al. The psychometric properties of the interpersonal sensitivity measure in social anxiety
disorder. Behav Res Ther. 2002;40:961–979. http://dx.doi.org/10.1016/S0005-7967(01)00125-5
67. Koyuncu A, Çelebi F, Ertekin E, et al. The presence of childhood attention deficit/ hyperactivity disorder may be associated with
interpersonal sensitivity in patients with social anxiety disorder. J Psychiatr Pract. 2017;23(4):254–259.
http://dx.doi.org/10.1097/PRA.0000000000000246
68. Leibowitz MR, Schneier F, CampeasR, et al. Phenelzine vs. atenolol in social phobia: a placebo-controlled comparison. Arch Gen
Psychiatry. 1992;49:290–300. http://dx.doi.org/10.1001/archpsyc.49.4.290
69. Himmelhoch JM. Social anxiety, hypomania and the bipolar spectrum: data, theory and clinical issues. J Affect Disord.
1998;50:203–213. http://dx.doi.org/10.1016/S0165-0327(98)00139-6
70. Holma KM, Melartin TK, Holma IA, et al. Predictors for switch from unipolar major depressive disorder to bipolar disorder type I
or II: a 5-year prospective study. J Clin Psychiatry. 2008;69:1267–1275. http://dx.doi.org/10.4088/JCP.v69n0809
71. Valenca AM, Nardi EA, Nascimento I, et al. Do social anxiety patients belong to a bipolar spectrum subgroup? J Affect Disord.
2005;86:11–18. http://dx.doi.org/10.1007/s10608-005-3340-5
72. Freeman MP, Freeman SA, Susan L, et al. The comorbidity of bipolar and anxiety disorders: prevalence, psychobiology, and
treatment issues. J Affect Disord. 2002;68:1–23. http://dx.doi.org/10.1016/S0165-0327(00)00299-8
73. Szadoczky E, Papp ZS, Vitrai J, et al. The prevalence of major depressive and bipolar disorders in Hungary. Results from a national
epidemiologic survey. J Affect Disord. 1998;50:153–162. http://dx.doi.org/10.1016/S0165-0327(98)00056-1
74. Pini S, Maser JD, Dell’Osso L, et al. Social anxiety disorder comorbidity in patients with bipolar disorder: a clinical replication.
J Anxiety Disord. 2006;20:1148–1157. http://dx.doi.org/10.1016/j.janxdis.2006.03.006
75. Tamam L, Ozpoyraz N. Comorbidity of anxiety disorder among patients with bipolar I disorder in remission. Psychopathology.
2002;35:203–210. http://dx.doi.org/10.1159/000063824
76. McElroy SL, Altshuler LL, Suppes T, et al. Axis I psychiatric comorbidity and its relationship to historical illness variables in 288
patients with bipolar disorder. Am J Psychiatry. 2001;158:420–426. http://dx.doi.org/10.1176/appi.ajp.158.3.420
77. Henry C, Van den Bulke D, Bellivier F, et al. Anxiety disorders in 318 bipolar patients: prevalence and impact on illness severity
and response to mood stabilizer. J Clin Psychiatry. 2003;64:331–335. http://dx.doi.org/10.4088/JCP.v64n0316
78. Simon NM, Otto MW, Wisniewski SR, et al. Anxiety disorder comorbidity in bipolar disorder patients: data from the first 500
participants in the Systematic Treatment Enhancement Program for BD (STEP-BD). Am J Psychiatry. 2004;161:2222–2229.
http://dx.doi.org/10.1176/appi.ajp.161.12.2222
79. Boylan KR, Bieling PJ, Marriott M, et al. Impact of comorbid anxiety disorders on outcome in a cohort of patients with bipolar
disorder. J Clin Psychiatry. 2004;65:1106–1113. http://dx.doi.org/10.4088/JCP.v65n0813
80. Keller MB. Prevalance and impact of comorbid anxiety and bipolar disorder. J Clin Psychiatry. 2006;67(Suppl 1):5–7. PMID: 16426110
81. Koyuncu A, Tukel R, Ozyildirim I, et al. Impact of obsessive compulsive disorder comorbidity on the sociodemographic and
clinical features of patients with bipolar disorder. Compr Psychiatry. 2010;51:293–297.
http://dx.doi.org/10.1016/j.comppsych.2009.07.006
82. Otto MW, Simon NM, Wisniewski SR, et al. (STEP-BD) Prospective 12-month course of bipolar disorder in out-patients with and
without comorbid anxiety disorders. Br J Psychiatry. 2006;189:20–25. http://dx.doi.org/10.1192/bjp.bp.104.007773
83. Perlis RH, Miyahara S, Marangell LB, et al. Long-term implications of early onset in bipolar disorder: data from the first 1000
participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biol Psychiatry. 2004;55:875–881.
http://dx.doi.org/10.1016/j.biopsych.2004.01.022
84. Perroud N, Baud P, Preisig M, et al. Social phobia is associated with suicide attempt history in bipolar inpatients. Bipolar Disord.
2007;9:713–721. http://dx.doi.org/10.1111/j.1399-5618.2007.00471.x
85. Young LT, Cooke RG, Robb JC, et al. Anxious and non-anxious bipolar disorder. J Affect Disord. 1993;29:49–52.
https://doi.org/10.1016/0165-0327(93)90118-4
86. Feske U, Frank E, Mallinger AG, et al. Anxiety as a correlate of response to the acute treatment of bipolar I disorder. Am J
Psychiatry. 2000;157:956–962. http://dx.doi.org/10.1176/appi.ajp.157.6.956
87. Fracalanza K, McCabe RE, Taylor VH, et al. The effect of comorbid major depressive disorder or bipolar disorder on cognitive
behavioral therapy for social anxiety disorder. J Affect Disord. 2014;162:61–66. https://doi.org/10.1016/j.jad.2014.03.015
88. Degonda M, Angst J. The Zürich Study XX. Social phobia and agoraphobia. Eur Arch Psychiatr Clin Neurosci. 1993;243:95–102.
http://dx.doi.org/10.1007/BF02191571

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 10 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

89. Bruce SE, Yonkers KA, Otto MW, et al. Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety
disorder, social phobia, and panic disorder: a 12-year prospective study. Am J Psychiatry. 2005;162(6):1179–1187.
http://dx.doi.org/10.1176/appi.ajp.162.6.1179
90. Mennin DS, Heimberg RG, Jack MS. Comorbid generalized anxiety disorder in primary social phobia: symptom severity,
functional impairment, and treatment response. J Anxiety Disord. 2000;14(4):325–343. PubMed PMID: 11043884
91. Bandelow B, Zohar J, Hollander E, et al. WFSBP task force on treatment guidelines for anxiety obsessive-compulsive post-
traumatic stress disorders. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological
Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders –First Revision. World J Biol Psychiatry.
2008;9(4):248–312. http://dx.doi.org/10.1080/15622970802465807
92. Bandelow B, Michaelis S, Wedekind D. Treatment of anxiety disorders. Dialogues Clin Neurosci. 2017;19(2):93–107. PMID:28867934;
PMCID:PMC5573566
93. Torres AR, Prince MJ, Bebbington PE, et al. Obsessive-compulsive disorder: prevalence, comorbidity, impact, and help-seeking in
the British National Psychiatric Morbidity Survey of 2000. Am J Psychiatry. 2006;163(11):1978–1985.
http://dx.doi.org/10.1176/ajp.2006.163.11.1978
94. Wilhelm S, Otto MW, Zucker BG, et al. Prevalence of body dysmorphic disorder in patients with anxiety disorders. J Anxiety
Disord. 1997;11(5):499–502. http://dx.doi.org/10.1016/S0887-6185(97)00026-1
95. Zimmerman M, Mattia JI. Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity,
demographic, and clinical correlates. Compr Psychiatry. 1998;39:265–270. http://dx.doi.org/10.1016/S0010-440X(98)90034-7
96. Coles ME, Phillips KA, Menard W, et al. Body dysmorphic disorder and social phobia: cross-sectional and prospective data.
Depress Anxiety. 2006;23(1):26–33. http://dx.doi.org/10.1002/da.20132
97. Phillips KA, Didie ER, Feusner J, et al. Body dysmorphic disorder: treating an underrecognized disorder. Am J Psychiatry.
2008;165(9):1111–1118. http://dx.doi.org/10.1176/appi.ajp.2008.08040500
98. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic
Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757–766.
http://dx.doi.org/10.1001/jamapsychiatry.2015.0584
99. Bakken K, Landheim AS, Vaglum P. Substance-dependent patients with and without social anxiety disorder: occurrence
and clinical differences a study of a consecutive sample of alcohol-dependent and poly-substance-dependent patients
treated in two counties in Norway. Drug Alcohol Depend. 2005;80:321–328.
http://dx.doi.org/10.1016/j.drugalcdep.2005.04.011
100. Perugi G, Frare F, Madaro D, et al. Alcohol abuse in social phobia patients: is there a bipolar connection? J Affect Disord.
2002;68:33–39. http://dx.doi.org/10.1016/S0165-0327(00)00316-5
101. Thevos AK, Thomas SE, Randall CL. Baseline differences in social support among treatment-seeking alcoholics with and without
social phobia. Subst Abus. 1999;20:107–118. http://dx.doi.org/10.1080/08897079909511399
102. Thomas SE, Thevos AK, Randall CL. Alcoholics with and without social phobia: a comparison of substance use and psychiatric
variables. J Stud Alcohol. 1999;60:472–479. http://dx.doi.org/10.15288/jsa.1999.60.472
103. Buckner JD, Schmidt NB, Lang AR, et al. Specificity of social anxiety disorder as a risk factor for alcohol and cannabis
dependence. J Psychiatr Res. 2008;42:230–239. http://dx.doi.org/10.1016/j.jpsychires.2007.01.002
104. Buckner JD, Schmidt. Understanding social anxiety as a risk for alcohol use disorders: fear of scrutiny, not social interaction fears,
prospectively predicts alcohol use disorders. J Psychiatr Res. 2009;43:477–483.
http://dx.doi.org/10.1016/j.jpsychires.2008.04.012
105. Kushner MG, Abrams K, Borchardt C. The relationship between anxiety disorders and alcohol use disorders: a review of major
perspectives and findings. Clin Psychol Rev. 2000;20:149–171. http://dx.doi.org/10.1016/S0272-7358(99)00027-6
106. Kidorf M, Lang AR. Effects of social anxiety and alcohol expectancies on stress induced drinking. Psychol Addict Behav.
1999;13:134–142. http://dx.doi.org/10.1037/0893-164X.13.2.134
107. Lewis BA, O’Neill HK. Alcohol expectancies and social deficits relating to problem drinking among college students. Addict
Behav. 2000;25:295–299. http://dx.doi.org/10.1016/S0306-4603(99)00063-5
108. Ham LS, Hope DA. Incorporating social anxiety into a model of college student problematic drinking. Addict Behav.
2005;30:127–150. http://dx.doi.org/10.1016/j.addbeh.2004.04.018
109. Buckner JD, Timpano KR, Zvolensky MJ, et al. Implication of comorbid alcohol dependence among individuals with social
anxiety disorder. Depress Anxiety. 2008;25:1028–1037. http://dx.doi.org/10.1002/da.20442
110. Kessler RC, Crum RM, Warner LA, et al. Lifetime cooccurrence of DSM-III-R alcohol abuse and dependence with other psychiatric
disorders in the National Comorbidity Survey. Arch Gen Psychiatry. 1997;54:313–321.
http://dx.doi.org/10.1001/archpsyc.1997.01830160031005
111. Randall CL, Thomas S, Thevos AK. Concurrent alcoholism and social anxiety disorder: a first step toward developing effective
treatments. Alcohol Clin Exp Res. 2001;25:210–220. http://dx.doi.org/10.1111/j.1530-0277.2001.tb02201.x

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 11 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

112. Schneier FR, Martin LY, Liebowitz MR, et al. Alcohol abuse in social phobia. J Anxiety Disord. 1989;3:15–23.
https://dx.doi.org/10.1016/0887-6185(89)90025-X
113. Carrigan MH, Randall CL. Self-medication in social phobia: a review of the alcohol literature. Addict Behav. 2003;28(2):269–284.
https://doi.org/10.1016/S0306-4603(01)00235-0
114. Cohen E, Feinn R, Arias A, et al. Alcohol treatment utilization: findings from the National Epidemiologic Survey on Alcohol and
Related Conditions. Drug Alcohol Depend. 2007;86(2–3):214–221. http://dx.doi.org/10.1016/j.drugalcdep.2006.06.008
115. Hasin DS, Stinson FS, Ogburn E, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and
dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen
Psychiatry. 2007;64(7):830–842. http://dx.doi.org/10.1001/archpsyc.64.7.830
116. Randall CL, Thomas SE, Thevos AK. Gender comparison in alcoholics with concurrent social phobia: implications for alcoholism
treatment. Am J Addict. 2000;9:202–215. http://dx.doi.org/10.1080/10550490050148035
117. Tillfors M, Furmark T, Ekselius L, et al. Social phobia and avoidant personality disorder: one spectrum disorder? Nord J Psychiatry.
2004;58:147–152. https://doi.org/10.1080/08039480410005530
118. Ralevski E, Sanislow CA, Grilo CM, et al. Avoidant personality disorder and social phobia: distinct enough to be separate
disorders? Acta Psychiatr Scand. 2005;112(3):208–214. http://dx.doi.org/10.1111/j.1600-0447.2005.00580.x
119. Reich J. Avoidant personality disorder and its relationship to social phobia. In: Hofmann SG, DiBartolo PM, eds. Social Anxiety:
Clinical, Developmental, and Social Perspectives (Second Edition). London: Academic Press; 2010:207–219.
120. Isomura K, Boman M, Ruck C, et al. Population-based, multi-generational family clustering study of social anxiety disorder and
avoidant personality disorder. Psychol Med. 2015;45(8):1581–1589. https://doi.org/10.1017/S0033291714002116
121. Hummelen B, Wilberg T, Pedersen G, et al. The relationship between avoidant personality disorder and social phobia. Compr
Psychiatry. 2007;48(4):348–356. http://dx.doi.org/10.1016/j.comppsych.2007.03.004
122. Huppert JD, Strunk DR, Ledley DR, et al. Generalized social anxiety disorder and avoidant personality disorder: structural analysis
and treatment outcome. Depress Anxiety. 2008;25(5):441–448. http://dx.doi.org/10.1002/da.20349
123. Lampe L. Social anxiety disorders in clinical practice: differentiating social phobia from avoidant personality disorder. Australas
Psychiatry. 2015;23(4):343–346. http://dx.doi.org/10.1177/1039856215592319
124. Taylor CT, Laposa JM, Alden LE. Is avoidant personality disorder more than just social avoidance? J Pers Disord. 2004;18:571–594.
https://doi.org/10.1521/pedi.18.6.571.54792
125. Schneier FR, Spitzer RL, Gibbon M, et al. The relationship of social phobia subtypes and avoidant personality disorder. Compr
Psychiatry. 1991;32:496–502. http://dx.doi.org/10.1016/0010-440X(91)90028-B
126. Turner SM, Beidel DC, Borden JW, et al. Social phobia: axis I and axis II correlates. J Abnorm Psychol. 1991;100:102–106.
http://dx.doi.org/10.1037/0021-843X.100.1.102
127. Herbert JD, Hope DA, Bellak AS. Validity of the distinction between generalized social phobia and avoidant personality disorder.
J Abnorm Psychol. 1992;101:332–339. http://dx.doi.org/10.1037/0021-843X.101.2.332
128. Jansen MA, Arntz A, Merckelbach H, et al. Personality disorders and features in social phobia and panic disorder. J Abnorm
Psychol. 1994;103:391–395. http://dx.doi.org/10.1037/0021-843X.103.2.391
129. Hope AH, Herbert JD, White C. Diagnostic subtype, avoidant personality disorder, and efficacy of cognitive-behavioral group
therapy for social phobia. Cogn Ther Res. 1995;19:399–417. http://dx.doi.org/10.1007/BF02230408
130. Feske U, Perry KJ, Chambless DL, et al. Avoidant personality disorder as a predictor for treatment outcome among generalized
social phobics. J Pers Disord. 1996;10:174–184. http://dx.doi.org/10.1521/pedi.1996.10.2.174
131. Cox BJ, Pagura J, Stein MB, et al. The relationship between generalized social phobia and avoidant personality disorder in a
national mental health survey. Depress Anxiety. 2009;26(4):354–362. http://dx.doi.org/10.1002/da.20475
132. Lampe L, Slade T, Issakidis C, et al. Social phobia in the Australian National Survey of Mental Health and Well-Being (NSMHWB).
Psychol Med. 2003;33(4):637–646. PMID: 12785465
133. Reichborn-Kjennerud T, Czajkowski N, Torgersen S, et al. The relationship between avoidant personality disorder and social
phobia: a population based twin study. Am J Psychiatry. 2007;164:1722–1728. http://dx.doi.org/10.1176/appi.ajp.2007.06101764
134. Lampe L, Sunderland M. Social phobia and avoidant personality disorder: similar but different. J Personal Disord. 2015;29:115–130.
http://dx.doi.org/10.1521/pedi_2013_27_079
135. Stein MB, Chartier MJ, Hazen AL, et al. A direct-interview family study of generalized social phobia. Am J Psychiatry.
1998;155(1):90–97. http://dx.doi.org/10.1176/ajp.155.1.90
136. Torvik FA, Welander-Vatn A, Ystrom E, et al. Longitudinal associations between social anxiety disorder and avoidant personality
disorder: a twin study. J Abnorm Psychol. 2016;125(1):114–124. http://dx.doi.org/10.1037/abn0000124
137. Holt CS, Heimberg GH, Hope HA. Avoidant personality disorder and the generalized subtype of social phobia. J Abnorm Psychol.
1992;101(2):318–325. http://dx.doi.org/10.1037/0021-843X.101.2.318
138. Ansell EB, Pinto A, Edelen MO, et al. The association of personality disorders with the prospective 7-year course of anxiety
disorders. Psychol Med. 2011;41(5):1019–1028. http://dx.doi.org/10.1017/S0033291710001777

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 12 of 13
ISSN: 1740-4398
REVIEW – Comorbidity in social anxiety disorder drugsincontext.com

139. van Velzen CJ, Emmelkamp PM, Scholing A. Generalized social phobia versus avoidant personality disorder: differences in
psychopathology, personality traits, and social and occupational functioning. J Anxiety Disord. 2000;14(4):395–411. PMID: 11043888
140. Eikenaes I, Hummelen B, Abrahamsen G, et al. Personality functioning in patients with avoidant personality disorder and social
phobia. J Personal Disord. 2013;27(6):746–763. http://dx.doi.org/10.1521/pedi_2013_27_109
141. Marques L, Porter E, Keshaviah A, et al. Avoidant personality disorder in individuals with generalized social anxiety disorder:
what does it add? J Anxiety Disord. 2012;26(6):665–672. http://dx.doi.org/10.1016/j.janxdis.2012.05.004
142. Brown EJ, Heimberg RG, Juster HR. Social phobia subtype and avoidant personality disorder: effect on severity of social phobia,
impairment, and outcome of cognitive behavioral treatment. Behav Ther. 1995;26:467–486.
http://dx.doi.org/10.1016/S0005-7894(05)80095-4
143. van Velzen CJ, Emmelkamp PM, Scholing A. The impact of personality disorders on behavioral treatment outcome for social
phobia. Behav Res Ther. 1997;35:889–900. https://doi.org/10.1016/S0005-7967(97)00052-1
144. Kamaradova D, Prasko J, Sandoval A, et al. Therapeutic response to complex cognitive-behavioral and pharmacological
treatment in patients with social phobia. Activ Nerv Super Rediviva. 2014;56(3–4):91–99.
145. Fava GA, Grandi S, Rafanelli C, Ruini C, Conti S, Belluardo P. Long term outcome of social phobia treated by exposure. Psychol
Med. 2001;31(5):899–905. https://doi.org/10.1017/S0033291701004020
146. Feske U, Perry KJ, Chambless DL, Renneberg B, Goldstein AJ. Avoidant personality disorder as a predictor for treatment outcome
among generalized social phobics. J Pers Disord. 1996;10:174–184. https://doi.org/10.1521/pedi.1996.10.2.174
147. Eikenaes I, Gude T, Hoffart A. Integrated wilderness therapy for avoidant personality disorder. Nord J Psychiatry. 2006;60(4):
275–281. https://doi.org/10.1080/08039480600790093
148. Weinbrecht A, Schulze L, Boettcher J, Renneberg B. Avoidant personality disorder: a current review. Curr Psychiatry Rep.
2016;18(3):29. https://doi.org/10.1007/s11920-016-0665-6
149. Collimore KC, Carleton RN, Hofmann SG, et al. Posttraumatic stress and social anxiety: the interaction of traumatic events and
interpersonal fears. Depress Anxiety. 2010;27(11):1017–1026. http://dx.doi.org/10.1002/da.20728
150. Zayfert C, DeViva JC, Hofmann SG. Comorbid PTSD and social phobia in a treatment-seeking population: an exploratory study.
J Nerv Ment Dis. 2005;193(2):93–101. http://dx.doi.org/10.1097/01.nmd.0000152795.47479.d9
151. Godart NT, Flament MF, Lecrubier Y, et al. Anxiety disorders in anorexia nervosa and bulimia nervosa: co-morbidity and
chronology of appearance. Eur Psychiatry. 2000;15:38–45. PubMed PMID: 10713801
152. Schwalberg MD, Barlow DH, Alger SA, et al. Comparison of bulimics, obese binge eaters, social phobics, and individuals with
panic disorder on comorbidity across. DSM-III-R anxiety disorders. J Abnorm Psychol. 1992;101(4):675–681.
http://dx.doi.org/10.1037/0021-843X.101.4.675
153. Swinbourne JM, Touyz SW. The comorbidity of eating disorders and anxiety disorders: a review. Eur Eat Disord Rev.
2007;15:253–274. http://dx.doi.org/10.1002/erv.784
154. Ferdinand RF, Bongers IL, van der Ende J, et al. Distinctions between separation anxiety and social anxiety in children and
adolescents. Behav Res Ther. 2006;44(11):1523–1535. http://dx.doi.org/10.1016/j.brat.2005.11.006
155. Shear K, Jin R, Ruscio AM, et al. Prevalance and correlates of estimated DSM-IV child and adult separation anxiety disorder in the
National Comorbidity Survey Replication. Am J Psychiatry. 2006;163:1074–1083. http://dx.doi.org/10.1176/ajp.2006.163.6.1074
156. Silove DM, Marnane CL, Wagner R, et al. The prevalence and correlates of adult separation anxiety disorder in an anxiety clinic.
BMC Psychiatry. 2010;10:10–21. http://dx.doi.org/10.1186/1471-244X-10-21
157. Koyuncu A, Ertekin E, Yüksel C, et al. Inattention predominant type ADHD is associated with social anxiety disorder. J
AttenDisord. 2015;19(10):856–864. http://dx.doi.org/10.1177/1087054714533193
158. Koyuncu A, Çelebi F, Ertekin E, et al. Clinical effects of attention-deficit/hyperactivity disorder subtypes in patients with social
anxiety disorder. J Atten Disord. 2015 Dec 4. pii:1087054715617533. [Epub ahead of print].
http://dx.doi.org/10.1177/1087054715617533
159. Biederman J, Monuteaux MC, Mick E, et al. Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year
follow-up study. Psychol Med. 2006;36(02):167–179. http://dx.doi.org/10.1017/S0033291705006410
160. Adler LA, Liebowitz M, Kronenberger W, et al. Atomoxetıne treatment in adults with attention-deficit/hyperactivity disorder and
comorbid social anxiety disorder. Depress Anxiety. 2009;26:212–221. http://dx.doi.org/10.1002/da.20549
161. Koyuncu A, Çelebi F, Ertekin E, et al. Extended-release methylphenidate treatment and outcomes in comorbid social anxiety
disorder and ADHD: 2 case reports. J Psychiatr Pract. 2015;21(3):225–231. http://dx.doi.org/10.1097/PRA.0000000000000070
162. Koyuncu A, Çelebi F, ErtekinE, et al. Extended-release methylphenidate monotherapy in patients with comorbid social anxiety
disorder and adult attention-deficit/hyperactivity disorder: retrospective case series. Ther Adv Psychopharmacol.
2017;7(11):241–247. http://dx.doi.org/10.1177/2045125317714193
163. Golubchik P, Sever J, Weizman A. Methylphenidate treatment in children with attention deficit hyperactivity disorder and
comorbid social phobia. Int Clin Psychopharmacol. 2014;29:212–215. http://dx.doi.org/10.1097/YIC.0000000000000029

Koyuncu A, İnce E, Ertekin E, Tükel R. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573 13 of 13
ISSN: 1740-4398