Social anxiety disorder with comorbid major depression - why fearful attachment style is relevant

Individuals with social anxiety disorder (SAD) often suffer from comorbid major depressive disorder (MDD), which goes along with increased clinical and functional impairment. There has been little research on underlying differences regarding childhood adversities and attachment styles between individuals with SAD with and without comorbid MDD. In the present study, the consecutive sample comprised 612 SCID-diagnosed participants. Of these, n = 472 (62.3% women, 40.7 ± 13.8 years) showed SAD and comorbid MDD (SAD-MDD group) and n = 140 (47.9% women, 43.7 ± 14.7 years) showed just SAD (SAD group). The two groups were compared regarding SAD symptom severity (Social Phobia Inventory; SPIN), childhood adversities (Adverse Childhood Experience Questionnaire; ACE) and attachment styles (Attachment Style Questionnaire, ASQ). The SAD-MDD group reported significantly more severe SAD symptoms (p = .002, d = 0.30), more childhood adversities (p < .001, d = 0.35) and a higher level of fearful attachment style (p < .001, d = 0.30). Group significantly moderated the association between fearful attachment style and SAD symptom severity (β = .292, p < .05) but not between preoccupied attachment style and SAD symptom severity (β = -.184, p = .124; R²_adj = .168, p < .05). Fearful attachment style mediated the association between childhood adversities and SAD symptom severity in the SAD-MDD group. Our study could identify a specific significance of fearful attachment style for the association between negative childhood experiences and social anxiety symptoms in SAD-MDD. Findings have specific implications for the therapeutic relationship.