The natural course of social anxiety disorder among adolescents and young adults Beesdo-Baum K, Knappe S, Fehm L, Ho¨fler M, Lieb R, Hofmann SG, Wittchen H-U. The natural course of social anxiety disorder among adolescents and young adults. Objective: To examine the natural course of social anxiety disorder (SAD) in the community and to explore predictors for adverse long- term outcomes. Method: A community sample of N = 3021 subjects aged 14–24 was followed-up over 10 years using the DSM-IV ⁄ M-CIDI. Persistence of SAD is based on a composite score reflecting the proportion of years affected since onset. Diagnostic stability is the proportion of SAD subjects still affected at follow-up. Results: SAD reveals considerable persistence with more than half of the years observed since onset spent with symptoms. 56.7% of SAD cases revealed stability with at least symptomatic expressions at follow- up; 15.5% met SAD threshold criteria again. 15.1% were completely remitted (no SAD symptoms and no other mental disorders during follow-up). Several clinical features (early onset, generalized subtype, more anxiety cognitions, severe avoidance and impairment, co-occurring panic) and vulnerability characteristics (parental SAD and depression, behavioural inhibition, harm avoidance) predicted higher SAD persistence and – less impressively – diagnostic stability. Conclusion: A persistent course with a considerable degree of fluctuations in symptom severity is characteristic for SAD. Both consistently meeting full threshold diagnostic criteria and complete remissions are rare. Vulnerability and clinical severity indicators predict poor prognosis and might be helpful markers for intervention needs. K. Beesdo-Baum 1 , S. Knappe 1 , L. Fehm 2 , M. Hçfler 1 , R. Lieb 3,4 , S. G. Hofmann 5 , H.-U. Wittchen 1,4 1 Institute of Clinical Psychology and Psychotherapy, Technische Universitaet Dresden, Dresden, Germany, 2 Department of Psychology, Humboldt University Berlin, Berlin, Germany, 3 Clinical Psychology and Epidemiology, University of Basel, Basel, Switzerland, 4 Max Planck Institute of Psychiatry, Munich, Germany and 5 Department of Psychology, Boston University, Boston, MA, USA Key words: social phobia; stability; remission; persistence; epidemiology Katja Beesdo-Baum, Institute of Clinical Psychology and Psychotherapy, Technische, Universitaet Dresden, Chemnitzer Str. 46, 01187 Dresden, Germany. E-mail: beesdo@psychologie.tu-dresden.de Accepted for publication April 24, 2012 Significant outcomes • Diagnostic stability of social anxiety disorder (SAD) above the DSM-IV threshold level over long periods of time but also complete remission (neither SAD symptoms nor other psychopathology) is rare. SAD has considerable persistence considering subthreshold and symptomatic expressions. • Isolated fears of examinations ⁄ tests in adolescence have the lowest persistence, whereas generalized and early onset social fears show the highest persistence and stability. • Symptom complexity and severity as measured with SAD diagnostic criteria as well as co-occurring conditions are important clinical characteristics that predict a persistent and stable course of SAD, suggesting that this diagnostic information is useful and practical to inform about prognosis and need for intervention. Limitations • Stability and persistence estimates were based on up to four symptom and diagnostic assessments conducted with standardized diagnostic interview (DIA-X ⁄ M-CIDI) across a time period of up to 10 years. Assessments did not include specific questions on course patterns of SAD, which impedes the differentiation of recurrence vs. chronicity. • Stability and persistence estimates are conservative given that maximum age of respondents was 34 years at last follow-up and given that some SAD cases had short follow-up periods. Acta Psychiatr Scand 2012: 126: 411–425 All rights reserved DOI: 10.1111/j.1600-0447.2012.01886.x Ó 2012 John Wiley & Sons A/S ACTA PSYCHIATRICA SCANDINAVICA 411