July 1, 2011 A new study from Rhode Island Hospital researchers shows that obese individuals with social anxiety related only to their weight may experience anxiety as severe as individuals with social anxiety disorder (SAD). The findings directly conflict with the criteria for SAD in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). The study is now published online in advance of print in the journal Depression and Anxiety.
The DSM-IV indicates that an individual with a medical condition should only be diagnosed with social anxiety disorder (SAD) if the anxiety is unrelated to the medical condition. A workgroup for the proposed draft of the upcoming edition of the manual, DSM-5, has recommended modifying the criteria so that individuals with medical conditions such as stuttering, Parkinson's Disease, and obesity can be diagnosed with SAD if the anxiety is excessive or is unrelated to the medical condition.
Since the DSM-IV was published, researchers have examined whether or not individuals with a medical condition who suffered with SAD should be excluded from the diagnosis, with several studies focused on individuals who stutter. To date, however, no research has been done among individuals who are obese and the anxiety is related only to obesity and is considered severe.
The new research from Rhode Island Hospital, led by Kristy Dalrymple, Ph.D., evaluated a group of individuals who were seeking clearance for bariatric surgery. The researchers identified three separate groups: 135 individuals diagnosed with DSM-IV SAD; 40 individuals classified as "modified SAD" who experienced clinically significant social anxiety related to weight only; and 616 individuals with no history of psychiatric disorders.
In their study, both the SAD and modified SAD groups were rated as having poorer social functioning as an adolescent compared to the no disorder group, but there was no difference between the SAD and modified SAD groups in this respect, with similar results found in social functioning over the past five years. In addition, the SAD group was rated as having more time out of work in the past five years due to psychopathology or emotional reasons compared to both the modified SAD group and the no disorder group.
Results also showed that those in the modified SAD group experienced more disruption in their social life and were more distressed about having social anxiety in the past month compared to those in the SAD group. Dalrymple says, "We found it particularly interesting that the modified SAD group reported greater levels of disruption in social life and distress about their social anxiety compared to the DSM-IV SAD group. This suggests that although our modified SAD group had social anxiety that was related to obesity only, their level of impairment was significant." She explains, "It could be that for individuals in which anxiety is related only to obesity, the change in social life functioning is more recent due to weight changes, and therefore, more distressing than for individuals who have experienced more generalized forms of social anxiety over a longer period of time."
The researchers state that these findings, combined with others in their study, lead to the conclusion that obese individuals who have weight-related social anxiety experience significant social anxiety when compared to individuals with DSM-IV SAD. Dalrymple says, "These individuals could potentially benefit from treatment of this disorder and therefore, excluding the diagnosis of SAD in obese individuals who experience anxiety related only to their weight may hinder the identification of the disorder. We believe the results of this study support adoption of the proposed change to the medical exclusion for SAD criterion in the DSM-5."
The principle affiliation of Dalrymple is Rhode Island Hospital, a member hospital of the Lifespan health system in Rhode Island, and direct financial and infrastructure support for this project was received through the Lifespan Office of Research Administration. The researcher also has an academic appointment at The Warren Alpert Medical School of Brown University.
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- Kristy L. Dalrymple, Janine Galione, Joshua Hrabosky, Iwona Chelminski, Diane Young, Erin O'Brien, Mark Zimmerman. Diagnosing social anxiety disorder in the presence of obesity: implications for a proposed change in DSM-5. Depression and Anxiety, 2011; DOI: 10.1002/da.20794
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