Relationship between atypical depression and social anxiety disorder [628732]

Relationship between atypical depression and social anxiety disorder
Ahmet Koyuncua, Erhan Ertekinb,n, Banu Aslanta șErtekinc, Zerrin Binbayd,Ç a ğrıYükselb,
Erdem Devecie,R a șit Tükelb
aBahat Group Hospitals, Psychiatry Unit, Istanbul, Turkey
bIstanbul University, Istanbul Medical Faculty, Psychiatry Department, Istanbul, Turkey
cIstanbul Bilim University, Medical Faculty, Psychiatry Department, Istanbul, Turkey
dKanuni Sultan Süleyman Hospital, Psychiatric Clinic, Istanbul, Turkey
eBezmialem Vakif University, Medical Faculty, Psychiatry Department, Istanbul, Turkey
article info
Article history:
Received 13 March 2014Received in revised form2 October 2014Accepted 8 October 2014
Available online 11 November 2014
Keywords:
Social anxiety disorder
Atypical depression
Mood disordersBipolar disorderabstract
In this study, we aimed to investigate the effects of atypical and non-atypical depression comorbidity on
the clinical characteristics and course of social anxiety disorder (SAD). A total of 247 patients with SADwere enrolled: 145 patients with a current depressive episode (unipolar or bipolar) with atypical
features, 43 patients with a current depressive episode with non-atypical features and 25 patients
without a lifetime history of depressive episodes were compared regarding sociodemographic andclinical features, comorbidity rates, and severity of SAD, depression and functional impairment. Thirtyfour patients with a past but not current history of major depressive episodes were excluded from the
comparisons. 77.1% of current depressive episodes were associated with atypical features. Age at onset of
SAD and age at initial major depressive episode were lower in the group with atypical depression than inthe group with non-atypical depression. History of suicide attempts and bipolar disorder comorbidity
was more common in the atypical depression group as well. Atypical depression group has higher SAD
and depression severity and lower functionality than group with non-atypical depression. Our resultsindicate that the presence of atypical depression is associated with more severe symptoms and more
impairment in functioning in patients with SAD.
&2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Social anxiety disorder (SAD) is common in the general
population with a lifetime prevalence of 10 –15% and a 1-year
prevalence of 5 –10% ( Kessler et al., 1994, 2005; Stein, 2006;
Acarturk et al., 2008; Ohayon and Schatzberg, 2010 ).
SAD and major depressive disorder (MDD) are closely asso-
ciated with each other; the frequency of comorbid MDD in
patients with SAD is reported to be between 35% and 74.5%
(Stein et al., 1990; Van Ameringen et al., 1991; Perugi et al., 1999,
2001; Koyuncu et al., 2014 ) whereas the frequency of comorbid
SAD in patients with MDD is reported to be approximately 20 –30%
(Alpert et al., 1997; Kessler et al., 1999; Brown et al., 2001; Rush
et al., 2005 ). Furthermore, SAD was found to be a predictor for the
subsequent development of MDD ( Weiller et al., 1996; Kessler
et al., 1999; Stein et al., 2001; Bittner et al., 2004; Beesdo et al.,
2007; Ohayon and Schatzberg, 2010 ). In addition, SAD was found
to be associated with severity and persistence of comorbid mood
disorders ( Kessler et al., 1999; Stein et al., 2001 ).Atypical depression was de fined as a subgroup of MDD in DSM-
IV (American Psychiatric Association: APA, 1994 ). According to the
DSM-IV, the main criterion of atypical depression is the presence
of mood reactivity in combination with at least two of four
secondary criteria (hypersomnia, increased appetite or weight
gain, leaden paralysis, and interpersonal rejection sensitivity). In
community samples, it was suggested that 15 –29% of patients with
MDD had atypical depression and this rate corresponded to a
1-year prevalence of approximately 1 –4% in the community
(Thase, 2007 ). Considerably similar estimates were reported in
the studies performed with clinical samples: atypical depression
was encountered in 18 –36% of patients with MDD ( Thase, 2007 ).
It was reported that female gender was more common in
patients with atypical MD episodes compared to patients with
non-atypical MD episodes ( Thase et al., 1991; Asnis et al., 1995 ;
Benazzi, 1999a ,1999b ;Agosti and Stewart, 2001; Angst et al., 2002;
Posternak and Zimmerman, 2002a; Matza et al., 2003; Novick et al.,
2005; Thase, 2007, 2009; Blanco et al., 2012 ). Overall, patients with
atypical depression have an earlier age of onset compared to the
patients with non-atypical depression ( Thase et al., 1991; Horwath
et al., 1992 ;Benazzi, 1999b ;Angst et al., 2002; Posternak and
Zimmerman, 2002a; Matza et al., 2003; Novick et al., 2005;Thase, 2007, 2009; Blanco et al., 2012 ). In addition to these,Contents lists available at ScienceDirect
journal homepage: www.elsevier.com/locate/psychresPsychiatry Research
http://dx.doi.org/10.1016/j.psychres.2014.10.014
0165-1781/ &2014 Elsevier Ireland Ltd. All rights reserved.
nCorresponding author. Tel.: ț90 212 4142000; fax: ț90 212 6351204.
E-mail address: erhanert76@yahoo.com (E. Ertekin).Psychiatry Research 225 (2015) 79 –84

it was reported that depression with atypical features is associated
with longer disease duration ( Thase et al., 1991; Angst et al., 2002;
Posternak and Zimmerman, 2002a ), more depressive recurrences
(Horwath et al., 1992; Blanco et al., 2012 ), more chronic disease
course ( McGinn et al., 1996 ;Benazzi, 1999b ;Posternak and
Zimmerman, 2002a; Angst et al., 2002; Thase, 2007, 2009; Stewart
et al., 2009 ), more suicidality ( Horwath et al., 1992; Matza et al.,
2003; Blanco et al., 2012 ) and more severe symptoms ( Novick et al.,
2005; Thase, 2009; Blanco et al., 2012 ).
The presence of atypical depression was found to be associated
with the presence of more comorbid diagnoses ( Alpert et al., 1997;
Novick et al., 2005; Thase, 2009; Blanco et al., 2012 ). There are also
studies reporting that atypical depression is associated with SAD
as a highly comorbid condition ( Perugi et al., 1998; Sullivan et al.,
1998; Parker et al., 2002; Angst et al., 2002; Matza et al., 2003;
Blanco et al., 2012 ).Posternak and Zimmerman (2002a) have
reported that SAD comorbidity in atypical MD group was signi fi-
cantly higher than in non-atypical MD group. Although many
studies have found an association between SAD and atypical
depression, it must be acknowledged that these findings are nor
unequivocal. For example, in a pharmacological trial, Schneier
et al. (2003) found atypical depression in only three patients
(14.3%), although 18 (85.7%) ful filled the criterion for interpersonal
rejection sensitivity. They concluded that the overlap of social
anxiety disorder with atypical features of depression may primar-
ily be due to the shared feature of rejection sensitivity.
Additionally, in a study performed with 129 SAD patients, the
group with generalized SAD had higher rates of atypical depres-
sion than the group with non-generalized SAD ( Mannuzza et al.,
1995 ). In another study performed with adult patients with MDD,
atypical depression was signi ficantly higher in the group with
SADțavoidant personality disorder compared to the group with
SAD without avoidant personality disorder ( Alpert et al., 1997 ).
This association between atypical MD and SAD might be related
to the common features which have a role in both disorders.
Interpersonal rejection sensitivity is de fined as a cognitive –affective
processing disposition to anxiously expect, readily perceive and
overreact to social rejection ( Feldman and Downey, 1994 ). Inter-
personal rejection sensitivity is seen as a common feature of both
SAD ( Liebowitz et al., 1985 ) and depression with atypical features
(APA, 1994 ). This feature may represent an underlying personality
trait of individuals with SAD and especially with the generalized
subtype of SAD ( Harb et al., 2002 ). In atypical depression, the
primacy of mood reactivity in relation to the other diagnostic criteria
has been questioned and reformulated de finitions of atypical
depression arguing for the primacy of rejection sensitivity as against
mood reactivity have been suggested ( Parker, 2007 ). Although it was
reported that when major depression existed in the presence of a
comorbid anxiety disorder, the likelihood of presenting with atypical
features doubled ( Posternak and Zimmerman, 2002b ), this common
feature of atypical depression and SAD helps explaining the question
of why to study SAD speci fically with atypical depression, rather
than anxiety disorders more generally.
To the best of our knowledge, there is no study in SAD patients
investigating the effects of comorbid atypical depression or non-
atypical depression on clinical characteristics of SAD in detail. In
this study, our aim is to investigate the effects of the presence of
major depression (unipolar or bipolar) with or without current
atypical features on the clinical characteristics of SAD. It would be
important to know about any differences in clinical characteristics
between SAD patients with atypical versus non-atypical depres-
sion also because of possible treatment implications. For example,
interpersonal rejection sensitivity may be a focus for psychother-
apy in SAD patients with atypical depression. Additionally, there
are reports of differential response to different classes of anti-
depressant medications in treating subgroups of patients withMDD with atypical features ( Zisook et al., 1985; Quitkin et al.,
1991 ). Therefore, such discrimination may provide information to
guide selecting an effective antidepressant medication for the
patients according to their comorbidity pro file.
2. Methods
Two hundred forty seven patients with a primary diagnosis of SAD presenting
to the Outpatient Clinic of the Psychiatry Department between November 2008 and
June 2011 were included in this study. The outpatient unit, although a general
psychiatry clinic, is known for its expertise in treatment of SAD in Istanbul. As partof a routine assessment protocol of our unit, an interview was performed with all ofthe patients by using the Structured Clinical Interview for DSM-IV/Clinical Version(SCID-I/CV) ( First et al., 1997 ). Diagnoses of SAD and all comorbid disorders were
made according to SCID-I/CV interview. SAD was considered as the primarydiagnosis when clinicians' judgment were accordant with patient reports declaringthat their main problems are related to SAD and that they had applied for receiving
treatment for SAD. Patients who applied consecutively to receive treatment for SAD
and whose diagnosis of SAD was con firmed were invited to participate. Patients
who agreed to participate in the study and signed informed consent were enrolled.This study adheres to the Declaration of Helsinki.
The inclusion criteria were as follows: 1) being between 18 and 65 years of age,
2) diagnosis of generalized type social anxiety disorder according to SCID-I/CVinterview, and 3) not using any psychotropic drugs within the last month prior to thestudy enrollment. Since we were investigating the effects of current depression, we
excluded patients on psychotropic medications because their potential confounding
has effects on our findings. Patients with schizophrenia or related psychotic
disorders or organic mental syndromes were also excluded from the study.
In our study, DSM-IV ( APA, 1994 ) criteria were used to evaluate the presence of
atypical features in the patients meeting criteria for a current depressive episode(unipolar or bipolar) according to SCID-I/CV. Accordingly, patients whose depressivesymptoms included mood reactivity plus at least two of four other DSM-IVsymptoms of atypical depression were considered as having comorbid atypical
depression. Patients with MD who did not have mood reactivity or who did have
mood reactivity but have less than two secondary symptoms of atypical depressionwere considered to have non-atypical depression. Current depressive episode withatypical features and with non-atypical features was found in 145 and 43 patients,respectively. Thirty four patients who had a history of major depressive episodes butwho were not currently depressed were excluded from the comparisons becausethey were not homogenous in terms of depressive episode types (most of them
reported both atypical and non-atypical episodes) and because the dif ficulties of
determining the type of episodes reliably correct in a retrospective fashion. Therewere no current or past depressive episodes in 25 patients and they were consideredas a control group to allow analyzing whether both groups of patients withdepression differ signi ficantly from patients without a history of depression.
Diagnoses were made at the first interview and the aforementioned assessments
were performed at the second interview. In addition, a sociodemographical andclinical data form (including information about age of onset of SAD, age of onset of
first depressive episode, age of first treatment contact, history of suicidal attempts
etc.) was filled out by the study clinicians who are trained and experienced in using
SCID and rating scales. All SAD patients were assessed by using Liebowitz SocialAnxiety Scale (LSAS) ( Liebowitz, 1987 ), Beck Depression Inventory (BDI) ( Beck et al.,
1961 ), and Global Assessment of Functioning Scale (GAF) ( APA, 1994 ).
LSAS was developed to assess the range of social interaction and performance
situations in which SAD patients exhibited fear and/or avoidance behaviors. Assess-ment is performed on a 0 –3 Likert scale by considering the level of fear and the
severity of avoidance. Total score is obtained by summing the scores for fear and
avoidance. Reliability and validity study of the Turkish version was performed bySoykan et al. (2003) . Clinician administered version of the LSAS was used.
The BDI was developed by Beck et al. (1961) to measure the cognitive,
emotional and physical symptoms of depression. It is a self-rating scale including21 symptom categories. Rating is performed between 0 and 3 scores. Themaximum score is 63. Higher total scores indicate more severe depressive
symptoms. Validity and reliability study of the Turkish version was performed by
Hisli (1988) .
In accordance with the purpose of our study, 145 patients with a current
depressive episode with atypical features, 43 patients with a current depressiveepisode with non-atypical features and 25 patients without lifetime depressiveepisodes were grouped and named as the atypical MD group, the non-atypical MDgroup and the non-MD group, respectively. The groups were compared withrespect to sociodemographical and clinical characteristics, comorbidity rates and
the rating scale scores.
Statistical analysis was performed by using the SPSS version 11.0. The
χ2test or
Fisher's exact test was used to compare categorical variables. One-way ANOVA wasused to assess data obtained from the scales and Scheffe Test was used for post-hocassessment. Signi ficance value was considered as 0.05.A. Koyuncu et al. / Psychiatry Research 225 (2015) 79 –84 80

3. Results
Eighty- five (34.4%) of 247 patients were females and 162
(65.6%) of them were males. Fifty- five patients (22.3%) were
married, 185 patients (74.9%) were single and seven patients
(2.8%) were divorced. Mean age of the patients was 27.61 years
(S.D.: 6.22), mean of total years spent in education was 12.89 years
(S.D.: 2.84), mean age of onset of SAD was 13.64 years (S.D.: 5.61)
and mean age of first MD episode was 17.61 years (S.D.: 5.12).
There was a history of psychiatric treatment in 128 (51.8%) of
the patients. One hundred nineteen patients (48.2%) had never
received psychiatric treatment. There was at least one suicidal
attempt history in 15 (6.1%) of the patients.
No statistically signi ficant difference was determined between
the three groups with regard to sociodemographical variables such
as gender distribution, mean age, educational level and maritalstatus ( Table 1 ). Also, no signi ficant difference was found between
the groups regarding history of psychiatric treatment.
The mean age of onset of SAD in atypical MD group was lower
than in non-atypical MD group. Th ere was no difference between the
other groups in terms of age at SAD onset. Mean age of first
depressive episode in atypical MD group was also lower than in
non-atypical MD group. Patients in both atypical and non-atypical
MD groups had their first treatment contact at an earlier age than the
patients in non-MD group. Compar ed to the non-atypical MD group,
atypical MD group had a higher mean number of total depressive
episodes and also higher rates of suicidal attempt history ( Table 1 ).
There was no difference between the two MD groups in terms of
number of comorbid diagnoses while they both had higher numbers
of lifetime psychiatric comorbid diagnoses than the non-MD group
(Table 1 ). Psychiatric comorbidity pro files of the groups are presented
inTable 2 .T h r e es i g n i ficantfindings are as follows: 1) bipolar disorder
c o m o r b i d i t yi na t y p i c a lM Dg r o u pw a sm o r ef r e q u e n tt h a ni nt h e
other two groups, 2) OCD in atypical MD group was higher than in
non-MD group and 3) speci fic phobia was more frequent in both
atypical MD and non-atypical MD groups than in non-MD group.
Mean LSAS anxiety, avoidance and total scores of atypical MD
group were signi ficantly higher than both of non-atypical MD and
non-MD groups. However, there was no difference between non-
atypical MD and non-MD groups. Apart from higher SAD severity, the
atypical MD group was also associated with more impairment in
functionality: the mean scores of current GAF and GAF in the past year
were signi ficantly lower in the atypical MD group compared to the
other two groups. Additionally, GAF scores of non-atypical MD group
were lower than those of non-MD group. As it was expected, mean
BDI scores of both atypical MD and non-atypical MD groups were
significantly higher than those of non-MD group. Furthermore, mean
B D Is c o r e si na t y p i c a lM Dg r o u pw a sa l s oh i g h e rt h a ni nn o n – a t y p i c a l
MD group ( Table 3 ).Since the differences found on symptom severity and func-
tional status might have been due to the fact that bipolar disorder
was signi ficantly more present in the atypical depression group,
we repeated the analyses on severity and functioning excluding
patients with bipolar disorder (37 patients from the atypical
depression group and one patient from the non-atypical depres-
sion group have been excluded). One hundred eight patients
remaining in the atypical group were compared with 42 patients
from the non-atypical group and it was found that all severity and
functioning scores remained signi ficantly different between the
two groups: atypical depression was associated with higher scores
in LSAS anxiety, avoidance, total ( po0.001, p¼0.001, po0.001,
respectively) and BDI scores ( po0.001) and lower GAF scores
(p¼0.001 for current and po0.001 for last year) compared to non-
atypical depression. However, suicide attempt rates were no
longer signi ficantly different between the two groups after the
exclusion of patients with bipolar disorder.
4. Discussion
According to SCID-I interview, we diagnosed a current depres-
sive episode (unipolar or bipolar) in 188 of our patients. Depressive
episode with atypical features was determined in 77.1% of these
patients. In the study performed by Mannuzza et al. (1995) , atypical
depression was higher in patients with generalized subtype of SAD
than in patients with non-generalized subtype. Nearly two thirds of
the depressed patients in that study displayed atypical features.
Since all patients were diagnosed with generalized subtype in our
study, this was interpreted as consistent with the aforementioned
finding. Besides there are other studies reporting an association
between atypical MD and SAD ( Alpert et al., 1997; Perugi et al.,
1998; Sullivan et al., 1998; Angst et al., 2002; Parker et al., 2002;
Posternak and Zimmerman, 2002a; Matza et al., 2003 ).
In our study, mean scores of all LSAS subscales (i.e. fear,
avoidance and total) in atypical MD group were signi ficantly higher
than in both non-atypical MD and non-MD groups. These results
indicated that social anxiety and avoidance were more severe when
the depression was atypical. One might expect that more severe
symptoms might be due to the mere existence of a comorbid
diagnosis in that two diagnoses implying more symptoms than one
diagnosis. However, we found higher LSAS scores than non-MD
group only in the atypical-MD group, but not in the non-atypicalMD group. Therefore, our results suggest that there might be some
speci ficity in the relationship between atypical depression and
severity of SAD. This relationship remained signi ficant even after
excluding patients with bipolar disorder. Additionally, mean age of
onset of SAD in atypical MD group was lower than in non-atypical
MD group, suggesting that onset of SAD is earlier when theTable 1
Comparison of sociodemographical and clinical characteristics of atypical MD, non-atypical MD and non-MD groups.
Sociodemographical and clinical characteristics Atypical MD ( n¼145) Non-atypical MD ( n¼43) Non-MD ( n¼25) Chi-square p
Marital status —married 28 (19.3%) 7 (16.3%) 9 (36.0%) 5.00 0.304
Gender —female 54 (37.2%) 13 (30.2%) 5 (20.0%) 3.14 0.208
Suicidal attempt (%) 15 (10.3%) 0 0 7.56 0.017
Mean (S.D.) Mean (S.D.) Mean (S.D.) Fp
Mean age 27.0 (6.3) 27.1 (5.1) 29.8 (6.1) 2.32 0.100Mean educational level (years) 12.6 (2.7) 12.6 (3.2) 13.7 (2.7) 1.41 0.247
Mean age of onset of SAD 12.8 (5.6) 15.2 (5.0) 14.4 (6.5) 3.57 0.030
Mean age of first treatment contact 24.3 (5.9) 25.1 (4.6) 29.5 (6.1) 8.54 o0.001
Mean age of first MD episode 18.1 (4.9) 20.5 (5.7) N/A 7.62 0.006
Number of lifetime comorbidities 1.7 (0.9) 1.5 (0.6) 0.0 (0.0) 48.59 o0.001
Number of lifetime total depressive episodes 5.9 (3.8) 3.4 (2.4) N/A 37.68 o0.001A. Koyuncu et al. / Psychiatry Research 225 (2015) 79 –84 81

depression is atypical. Earlier onset of SAD might lead patients to
experience social frustrations at an early age and this may make
them more likely to develop depression later in life. However, as is
the case in severity of SAD, our results suggest speci ficity at least to
a certain extent for the relationship between atypical depression
and earlier onset of SAD. In other words, earlier onset of SAD is not
related to non-atypical depression, but only with atypical depres-
sion in our sample. Interpersonal rejection sensitivity might play a
role here but prospective follow-up studies are required to better
establish the possible relationship between early onset SAD and the
later development of atypical depression.
In post-hoc evaluation, mean age at first treatment contact in
both atypical MD group and non-atypical MD group was lower than
in non-MD group. In other words, regardless of the type of depres-
sion (i.e. atypical or non-atypica l), we found that comorbid MDD is
associated with earlier treatment seeking in patients with SAD. The
presence of comorbidity in SAD patients was found to be correlated
with shorter delay of fir s tt r e a t m e n tc o n t a c t( Fikretoglu et al., 2010 ).
We can conclude that the presence of comorbid MDD is associated
with shorter delay of initial treat ment contact in patients with SAD.
Mean age of first depressive episode in atypical MD group was
lower than in non-atypical MD group. Studies performed in
samples with MDD were consistent in showing that the patients
with atypical features had earlier age of onset compared to the
patients with non-atypical MD ( Thase et al., 1991; Horwath et al.,
1992 ;Benazzi, 1999b ;Angst et al., 2002; Posternak and
Zimmerman, 2002a; Matza et al., 2003; Novick et al., 2005;
Thase, 2007, 2009; Blanco et al., 2012 ). In another study, the
presence of early onset depression and atypical features was
correlated ( Zisook et al., 2004 ).
In our study, mean BDI score of atypical MD group was higher
than that of the non-atypical MD group. In studies of patients with
MDD, atypical MD group has more severe episodes than non-atypical MD group ( Novick et al., 2005; Thase, 2009; Blanco et al.,
2012 ). Our study shows that this finding is also valid in a speci fic
sample of patients with SAD.
GAF scores can be assigned based on either functioning or
symptoms. Since we used speci fic severity rating scales for SAD
and MDD (LSAS and BDI, respectively), we scored the GAF based
only on functioning. The lower GAF scores in two groups with
current MD than in non-MD group suggest that comorbid MD
adds to the functional impairment in SAD. However, GAF scores for
current and previous year of atypical MD group were also lower
than those of the non-atypical MD group. This might indicate a
more severe clinical course of SAD when it was comorbid with
atypical depression. It was reported in studies of MDD that there
was much more deterioration in functioning in atypical MD than
in non-atypical MD ( Agosti and Stewart, 2001; Posternak and
Zimmerman, 2002a; Matza et al., 2003 ). Our results suggest that
this might be the case as well in patients with SAD.
The rates of suicidal attempt in atypical MD group were
significantly higher than the rates in non-atypical MD group. All
15 patients with a history of suicide attempts were in atypical MDgroup. It was reported that the patients with atypical depression
have higher suicide rates compared to the patients without atypical
depression ( Horwath et al., 1992; Matza et al., 2003; Blanco et al.,
2012 ). Additionally, a correlation was found between atypical MD
and suicide attempt in the study performed by Angst et al. (2002) .
Furthermore, SAD was found to increase the suicidal behaviors
(Davidson et al., 1993 ) and to be a predictor for subsequent suicidal
behaviors ( Weiller et al., 1996; Sareen et al., 2005; Cougle et al.,
2009 ). However, when we excluded the patients with bipolar
disorder, suicide attempt rates were no longer signi ficantly different
between atypical and non-atypical depression groups. This finding
suggests that the difference we found in suicidality might be an
effect of high bipolar disorder comorbidity in our atypical depres-
sion group. New studies are required to investigate whether the
correlation between SAD and suicidality is more marked or not
when the comorbid depression is atypical.
Mean number of total depressive episodes in atypical MD
group was found to be higher than in non-atypical MD group.
There are studies reporting atypical depression which has higher
recurrence rates ( Horwath et al., 1992; Kendler et al., 1996; Blanco
et al., 2012 ). Our study demonstrates that this result can be valid
for comorbid atypical MD in patients with SAD.
Mean number of lifetime total comorbidities and the rates of
comorbid speci fic phobia in both MD groups were found to be
higher than in non-MD group. Besides, the rate of comorbid OCD
in atypical MD group was higher than in non-MD group in our
study. Previously, the presence of atypical depression was found to
be associated with the presence of more comorbidities ( Alpert
et al., 1997; Novick et al., 2005; Thase, 2009; Blanco et al., 2012 ).
Furthermore, it was reported that comorbidity was higher in
atypical MD than in non-atypical MD ( Novick et al., 2005; Thase,
2009 ). In that case, the presence of atypical MD in SAD patients
might be associated with other psychopathologies.Table 2
Rates of lifetime comorbidities in atypical MD, non-atypical MD and non-MD groups.
Comorbid diagnosis Atypical MD ( n¼145) Non-atypical MD ( n¼43) Non-MD ( n¼25) Chi-square p
Bipolar disorder 37 (25.5%) 1 (2.3%) 0 (0%) 18.32 o0.001
PD 12 (8.3%) 1 (2.3%) 0 (0.0%) 3.89 0.200OCD 21 (14.5%) 2 (4.7%) 0 (0%) 6.75 0.032SP 16 (17.3%) 6 (15.8%) 0 (0%) 5.11 0.045PTSD 9 (6.2%) 1 (2.3%) 0 (0%) 2.51 0.392Alcohol –substance use disorder 14 (9.7%) 3 (7.0%) 0 (0.0%) 2.78 0.354
PD: panic disorder, OCD: obsessive compulsive disorder, GAD: generalized anxiety disorder, SP: speci fic phobia, PTSD: post-traumatic stress disorder.
Table 3
Comparison of atypical MD, non-atypical MD and non-MD groups in terms of ratingscales scores.
The rating
scalesAtypical
MD(n¼145)
Mean(S.D.)Non-
atypicalMD(n¼43)
Mean
(S.D.)Non-MD
(n¼25)
Mean(S.D.)Fp
LSAS-fear 71.6 (11.5) 63.0 (13.2) 62.0 (14.9) 12.27 o0.001
LSAS-avoidance 68.5 (11.2) 60.4 (14.1) 59.4 (16.5) 10.56 o0.001
LSAS-total 140.0 (22.0) 123.4 (26.4) 121.0 (30.8) 12.24 o0.001
GAF-current 59.8 (6.9) 65.2 (8.3) 74.2 (4.9) 48.62 o0.001
GAF-past year 62.1 (7.5) 67.5 (8.6) 75.0 (4.3) 35.17 o0.001
BDI 25.2 (8.6) 17.1 (5.7) 5.1 (3.9) 80.05 o0.001
LSAS: Liebowitz Social Anxiety Scale; GAF: Global Assessment of Functioning, BDI:
Beck Depression Inventory.A. Koyuncu et al. / Psychiatry Research 225 (2015) 79 –84 82

In our study, the rates of comorbid bipolar disorder of atypical
MD group were higher than the rates of both non-atypical MD and
non-MD groups. To the best of our knowledge, there is no study
comparing the comorbid bipolar disorder in SAD with or without
atypical depression. However, there are studies indicating that
atypical MD and bipolar disorder are correlated ( Perugi et al.,
1998; Angst et al., 2002 ) and studies reporting that the rate of
comorbid bipolar II disorder in atypical MD is higher ( Benazzi,
1999a, 1999b; Agosti and Stewart, 2001; Akiskal and Benazzi,
2005 ). Additionally, in the study performed by Akiskal and Benazzi
(2005) , atypical MD was found to be correlated with all bipolar
validators with family history of bipolar disorder being the most
prominent.
Comorbid bipolar disorder is reported approximately 3 –21% in
patients with SAD ( Van Ameringen et al., 1991; Perugi et al., 1999,
2001; Koyuncu et al., 2014 ) and comorbid SAD was reported in
7.8–47% of the patients with bipolar disorder ( Kessler et al., 1994;
Szadoczky et al., 1998; McElroy et al., 2001; Freeman et al., 2002;
Tamam and Ozpoyraz, 2002; Henry et al., 2003; Simon et al., 2004;
Boylan et al., 2004; Keller, 2006; Pini et al., 2006 ). SAD and atypical
depression are associated with increased rates of bipolar disorder
and when they both exist in an individual, the risk of developing
bipolar disorder might be particularly high. Comprehensive future
surveys investigating the correlation among SAD, atypical MD and
bipolar disorder are needed since each of these conditions is
related to the other two.
Approximately two thirds of our patients were males. There are
epidemiological studies that reported an equal gender distribution
(Boyd et al., 1990; Degonda and Angst, 1993 ) or a female pre-
ponderance ( Ohayon and Schatzberg, 2010 ) in SAD. However, in
clinical populations males are found in equal or higher numbers
compared to females ( Rapee and Spence, 2004 ). This difference in
gender distribution between epidemiological and clinical studiesmight arise from the possibility that males might be more likely to
seek treatment for SAD because of higher social expectations or
demands upon them and this is a possible explanation for the
male preponderance in our sample.
The following limitations should be considered when evaluat-
ing the results of our study. Since our study was based largely on
anamnestic information, it may have been biased by the potential
unreliability of patients' retrospective recall. Besides, the follow-up
findings of the patients are lacking. Another possible limitation in
our study was the relatively small number of patients in each
group, especially the non-atypical MD and non-MD groups.
In conclusion, a high rate of atypical depression was found in
patients with SAD. Symptoms of SAD were more severe and the
age of onset of SAD was younger in the presence of atypical MD.
Comorbid atypical depression in patients with SAD should warn
the clinicians about a more severe SAD presentation, more
impairment in functioning and the possible development of
bipolar disorder. New surveys evaluating this subject comp-
rehensively are needed. One future study should be to follow such
patients to test whether those comorbid for SAD and
atypical depression develop bipolar disorder more often than
other patients with SAD.
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