ORIGINAL ARTICLE
Social phobia, depression and eating disorders during middle adolescence: longitudinal associations and treatment seeking
Klaus Rantaa, Juha V€a€an€anenb, Sari Fr€ojdc, Rasmus Isomaad, Riittakerttu Kaltiala-Heinob,e and Mauri Marttunena,f,g
aDepartment of Adolescent Psychiatry, Helsinki University Central Hospital, Helsinki, Finland; bDepartment of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland; cSchool of Health Sciences, University of Tampere, Tampere, Finland; dCity of Jakobstad, Department of Social Services and Health Care, Jakobstad, Finland; eMedical School, University of Tampere, Tampere, Finland; fDepartment of Adolescent Psychiatry, University of Helsinki, Helsinki, Finland; gDepartment of Mental Health and Substance Use Services, National Institute for Health and Welfare, Helsinki, Finland
ABSTRACT Background: Longitudinal associations between social phobia (SP), depression and eating disorders (EDs), and the impact of antecedent SP and depression on subsequent treatment seeking for EDs have rarely been explored in prospective adolescent population studies. Aim: We aimed to examine these associations in a large-scale follow-up study among middle adolescents. Method: We surveyed 3278 Finnish adolescents with a mean age of 15 years for these disorders. Two years later, 2070 were reached and again surveyed for psychopathology and treatment seeking. Longitudinal associations between the self-reported disorders and treatment-seeking patterns for self- acknowledged ED symptoms were examined in multivariate analyses, controlling for SP/depression comorbidity and relevant socioeconomic covariates. Results: Self-reported anorexia nervosa (AN) at age 15 years predicted self-reported depression at age 17 years. Furthermore, self-reported SP at age 15 years predicted not seeking treatment for bulimia nervosa (BN) symptoms, while self-reported depression at age 15 years predicted not seeking treat- ment for AN symptoms during the follow-up period. Conclusions: Adolescents with AN should be monitored for subsequent depression. Barriers caused by SP to help seeking for BN, and by depression for AN, should be acknowledged by healthcare professio- nals who encounter socially anxious and depressive adolescents, especially when they present with eating problems.
ARTICLE HISTORY Received 13 September 2016 Revised 1 June 2017 Accepted 7 August 2017
KEYWORDS Social phobia; depression; eating disorders; adolescents; comorbidity; treatment seeking
The mean onset of eating disorders (EDs) in the population is during adolescence. The peak of incidence for both bulimia nervosa (BN) and anorexia nervosa (AN) is between 15 and 19 years [1–3]. Both population [1,2] and clinical studies [4,5] indicate that BN is associated with a range of anxiety, mood, disruptive and substance use disorders in both adolescents and adults. Of the anxiety disorders, social phobia (SP) may be especially comorbid with adolescent BN [6]. Adolescent AN, as identified in the community, seems less strongly asso- ciated with other disorders [2], but clinical studies indicate that mood disorders are frequently involved [7]. In young adult populations, AN seems broadly comorbid with anxiety, mood and alcohol use disorders [1,8].
Longitudinal studies suggest that the onset of comorbid anxiety disorders generally occurs prior to that of EDs. In clin- ical studies, this order is found in �60–90% of cases [4,6,8,9], offering support for the notion of an anxiety pathway in the genesis of EDs. The association between SP and EDs in par- ticular has been found to be largely of this type [6].
With regard to depression, there is evidence of bidirec- tional connections, depression elevating the risk for EDs [10],
as well as of a heightened risk for subsequent depression in adolescents with AN and BN [11,12]. Studies with long fol- low-up spans indicate that depression may both precede and follow AN [13]. Thus, although not entirely consistent, research does indicate somewhat different types of longitu- dinal associations between SP, depression and EDs.
The mechanisms by which SP, depression and EDs are lon- gitudinally linked are not well-known [14]. Social anxiety may predispose an adolescent to subsequent EDs by participants’ preoccupation with the fear of being negatively evaluated, high performance standards, dependence on others’ opinions or negative beliefs about the public self [15,16]. In girls, a preoccupation with appearance [15] while pubertal physical changes progress may lead to ‘social appearance anxiety’ and symptoms of EDs, such as the strict pursuit of ideal body weight [17].
Regarding associations between depression and EDs, such factors as a self-deprecating thinking style, linked with both [18], may mediate bidirectional links. Moreover, biological and psychological consequences of malnutrition (e.g. apathy and numbness) could lead to the development of depression
CONTACT Klaus Ranta klaus.ranta@hus.fi Department of Adolescent Psychiatry, Helsinki University Hospital, P.O. Box 590, FI-00029 HUS, Helsinki, Finland � 2017 The Nordic Psychiatric Association
NORDIC JOURNAL OF PSYCHIATRY, 2017 VOL. 71, NO. 8, 605–613 https://doi.org/10.1080/08039488.2017.1366548
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following AN [19]. Antecedent disorders may also affect treat- ment seeking for EDs. It remains unknown whether comor- bidity in fact increases or decreases treatment seeking or engagement in treatment [20,21]. Treatment seeking may vary according to the type of comorbidity.
SP could act as a barrier to seeking treatment for EDs because only very few, �9% of adolescents with SP, seek help for their anxiety [22]; furthermore, SP is typically associated with feelings of shame that may inhibit treatment- seeking behavior [21]. Indeed, some evidence suggests that high social anxiety prevents participants from engaging in treatment for EDs [23], but no studies addressing this issue in general population samples or among adolescents have been conducted [21,24].
Associated with depression, decreased activity or apathy [25], pessimism about the possibility of being helped [21,26] or negative self-evaluations and internalized feelings of shame [21] may prevent treatment seeking. Indeed, the find- ings of one large-scale adolescent population study indicated that the higher the level of depression symptoms, the lower the possibility that the adolescent will seek help [27]. The available research on treatment seeking for EDs suggests that emotional suffering or disorders may even facilitate treatment seeking. However, all studies do not report such an effect [21]. As this research is conducted mainly among adults with EDs using retrospective analyses, they likely miss a significant part of the disorders in the population. Overall, a mixed and contradictory picture emerges from this field. Studies examining treatment seeking for EDs in adolescents, in prospective designs and large population samples, are lacking.
In sum, gaps exist in knowledge on independent pro- spective associations between specific EDs (AN/BN) with SP and depression. Moreover, little is known about the possible impact of antecedent SP and depression on treatment seek- ing for EDs in adolescence. There is a need for longitudinal, controlled studies.
Aims
To address the knowledge gaps in prior research, we aimed to answer two research questions. First: Are there independ- ent, longitudinal associations between self-reported SP and depression at age 15 years and BN/AN at age 17 years, or conversely, do self-reported BN and AN symptoms at age 15 years predict self-reported SP and depression at age 17 years? Second: Are self-reported SP or depression at age 15 years associated with a reduced rate of seeking help for self-acknowledged symptoms of BN/AN at a two-year follow-up?
Three hypotheses based on the literature search were tested. 1. SP at age 15 years will increase the risk of BN and AN at age 17 years. 2. Depression at age 15 years will increase the risk of BN and AN at age 17 years, but BN and AN at age 15 years will also increase the risk for depression at age 17 years. 3. SP at age 15 years will be associated with a heightened risk of not seeking help for BN and AN during the follow-up period. We made no specific hypothesis
concerning the role of depression as affecting help-seeking behavior because the research is inconclusive and contradictory.
Material and methods
Design, procedure and sampling
The data came from the Finnish Adolescent Mental Health Cohort Study [28]. At baseline (T1), ninth-grade students aged 15–16 years from all secondary schools in the Finnish cities of Tampere and Vantaa completed a person-identifiable questionnaire containing measures on mental health (i.e. depression, anxiety, conduct disorder, EDs and substance use), health behavior and associated psychosocial variables in their schools. The survey assessment tool took one lesson (i.e. 30–45min) to complete.
The T1 sample consisted of 3278 adolescents (1609 girls, 1669 boys) with a mean age of 15.5 (SD ¼0.39) years. The response rate for the baseline survey was 94.4%. Participants were contacted after a 2-year follow-up period (T2) by mul- tiple methods: surveys in high/vocational schools, surface mail and finally by email. In all, 2082 responses were received. Ten responses were excluded due to obvious facetiousness and due to double responding. The study was approved by the Ethics Committee of Tampere University Hospital (Study Approval No. 9924).
The 2070 adolescents who responded both times (repre- senting 63.1% of those who responded at T1) comprise the participants of the present study. At T2, their mean age was 17.6 (SD¼ 0.41) years, and 56.4% (1167) were girls. Of the participants studying at T2, 62% were in high school and 38% in vocational school. The sample…
