Social phobia and alcoholism: a complex relationship

Should responsibility be used as a tiebreaker in allocation of deceased donor organs for patients suffering from alcohol-related end-stage liver disease?

There is a long-standing debate concerning the eligibility of patients suffering from alcohol-related end-stage liver disease (ARESLD) for deceased donor liver transplantation. The question of retrospective and/or prospective responsibility has been at the center of the ethical discussion. Several authors argue that these patients should at least be regarded as partly responsible for their ARESLD. At the same time, the arguments for retrospective and/or prospective responsibility have been strongly criticized, such that no consensus has been reached. A third option was proposed as a form of compromise, namely that responsibility should only be used as a tiebreaker in liver allocation. The present study provides an ethical investigation of this third option. First, we will provide an overview of the main arguments that have been offered for and against the use of responsibility as an allocation criterion. Second, we will explore the concept of responsibility as a tiebreaker in detail and discuss several types of situations, in which responsibility could be used as a tiebreaker, as well as the main ethical challenges associated with them. As we will show, an ethical justified use of responsibility as a tiebreaker is limited to a very restricted number of cases and is associated with a number of ethical concerns. For this reason, waiting time should be preferred as a tiebreaker in liver allocation, even though the criterion of waiting time, too, raises a number of equity-related concerns.

A new conception and subsequent taxonomy of clinical psychological problems

BACKGROUND

A taxonomy of the objects of study, theory, assessment, and intervention is critical to the development of all clinical sciences. Clinical psychology has been conceptually and administratively dominated by the taxonomy of an adjacent discipline - psychiatry's Diagnostic and statistical manual of mental disorders (DSM). Many have called for a 'paradigm shift' away from a medical nosology of diseases toward clinical psychology's own taxonomy of clinical psychological problems (CPPs), without being able to specify what is to be listed and classified.

MAIN TEXT

An examination of DSM's problems for clinical psychology, especially its lack of clinical utility, and a search for the essence of CPPs in what clinical psychologists actually do, leads to the proposal that: The critical psychological-level phenomenon underlying CPPs is the occurrence of 'problem-maintaining circles' (PMCs) of causally related cognitions, emotions, behaviours, and/or stimuli. This concept provides an empirically-derived, theory-based, treatment-relevant, categorical, essentialist, parsimonious, and nonstigmatizing definition of CPPs. It distinguishes psychological problems in which PMCs have not (yet?) formed, and which may respond to 'counseling', clinical psychological problems in which active PMCs require clinical intervention, and psychopathological problems which are unlikely to be 'cured' by PMC-breaking alone.

CONCLUSION

A subsequent classification and coding system of PMCs is proposed, and expected benefits to research, communication, and the quality of case formulation in clinical psychology are described, reliant upon a development effort of some meaningful fraction of that which has been devoted to the DSM.

Childhood adversities, bonding, and personality in social anxiety disorder with alcohol use disorder

Social anxiety disorder (SAD) is frequently associated with alcohol use disorders (abuse/dependence). However, there has been little research on the characteristics of this subgroup so far. In the current study we investigated individuals with SAD and comorbid alcohol use disorder (AUD) with regard to socialization experiences and personality. The sample comprised 410 individuals diagnosed with SAD by the Structured Clinical Interview of DSM-IV. 108 participants with comorbid AUD were compared to 302 participants without comorbid AUD concerning traumatic experiences during childhood and adolescence (Adverse Childhood Experiences Questionnaire; ACE), parental bonding (Parental Bonding Instrument; PBI), and personality (Temperament and Character Inventory; TCI). MANCOVA with covariates sex and depression displayed that individuals with SAD plus AUD reported significantly more traumatic events during childhood and adolescence, lower levels of maternal care, as well as lower cooperativeness. Our results highlight that adverse childhood experiences and unfavourable maternal bonding characterize individuals suffering from SAD plus AUD. These experiences might be reflected in a personality-based tendency to distance themselves from others, which corresponds to low scores on the character dimension cooperativeness. A deeper understanding of personality and specific socialization experiences is necessary to develop new treatment options in this clinically challenging subgroup.

Drug effects on responses to emotional facial expressions: recent findings

Many psychoactive drugs increase social behavior and enhance social interactions, which may, in turn, increase their attractiveness to users. Although the psychological mechanisms by which drugs affect social behavior are not fully understood, there is some evidence that drugs alter the perception of emotions in others. Drugs can affect the ability to detect, attend to, and respond to emotional facial expressions, which in turn may influence their use in social settings. Either increased reactivity to positive expressions or decreased response to negative expressions may facilitate social interaction. This article reviews evidence that psychoactive drugs alter the processing of emotional facial expressions using subjective, behavioral, and physiological measures. The findings lay the groundwork for better understanding how drugs alter social processing and social behavior more generally.

Social phobia in obsessive-compulsive disorder: prevalence and correlates

BACKGROUND

Social Phobia (SP) is an anxiety disorder that frequently co-occurs with obsessive-compulsive disorder (OCD); however, studies that evaluate clinical factors associated with this specific comorbidity are rare. The aim was to estimate the prevalence of SP in a large multicenter sample of OCD patients and compare the characteristics of individuals with and without SP.

METHOD

A cross-sectional study with 1001 patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders using several assessment instruments, including the Dimensional Yale-Brown Obsessive-Compulsive Scale and the Structured Clinical Interview for DSM-IV Axis I Disorders. Univariate analyses were followed by logistic regression.

RESULTS

Lifetime prevalence of SP was 34.6% (N=346). The following variables remained associated with SP comorbidity after logistic regression: male sex, lower socioeconomic status, body dysmorphic disorder, specific phobia, dysthymia, generalized anxiety disorder, agoraphobia, Tourette syndrome and binge eating disorder.

LIMITATIONS

The cross-sectional design does not permit the inference of causal relationships; some retrospective information may have been subject to recall bias; all patients were being treated in tertiary services, therefore generalization of the results to other samples of OCD sufferers should be cautious. Despite the large sample size, some hypotheses may not have been confirmed due to the small number of cases with these characteristics (type 2 error).

CONCLUSION

SP is frequent among OCD patients and co-occurs with other disorders that have common phenomenological features. These findings have important implications for clinical practice, indicating the need for broader treatment approaches for individuals with this profile.

Drinking behaviors by stress level in Korean university students

The purposes of this study are to estimate the stress level of university students, and to verify the relationships between stress level and drinking behavior. A questionnaire survey was administered to 430 university students in the Gangwon area in Korea from November 5 to November 28, 2008, and data from 391 students were used for the final statistical analysis. The most stressful factor was "Worry about academic achievements" (2.86 by Likert-type 4 point scale). The subjects were divided into two groups, a low stress group (≤ 65.0) and a high stress group (≥ 66.0), by the mean value (65.1) and median value (66.0) of the stress levels. The drinking frequency was not different between the two stress groups, but the amount of alcohol consumption was significantly different (P < 0.05). The portion of students reporting drinking "7 glasses or over" was higher in the lower stress group than in the higher stress group. In addition, factor 6, "Lack of learning ability", was negatively correlated with drinking frequency and the amount of alcohol consumption (P < 0.05), and factor 3, "Worry about academic achievements", was negatively correlated with the amount of drinking (P < 0.05). The major motive for drinking was "When overjoyed or there is something to celebrate" (2.62), and the main expected effect of drinking was "Drinking enables me to get together with people and shape my sociability" (2.73). The higher stress group showed significantly higher scores on several items in the categories of motives (P < 0.01), negative experience (P < 0.05), and expected effects (P < 0.05) of drinking than the lower stress group. Our results imply that university students at the lower stress level may drink more from social motives in positive drinking environments, while those at the higher stress level may have more problematic-drinking despite their smaller amount of alcohol consumption.

Integrating psychoeducation in a basic computer skills course for people suffering from social anxiety: participants' experiences

We describe a psychoeducational program integrated in a basic computer skills course for participants suffering from social anxiety. The two main aims of the course were: that the participants learn basic computer skills, and that the participants learn to cope better with social anxiety. Computer skills were taught by a qualified teacher. Psychoeducation and cognitive therapy skills, including topics such as anxiety coping, self-accept, and self-regulation, were taught by a clinical psychologist. Thirteen of 16 participants completed the course, which lasted 11 weeks. A qualitative analysis was performed, drawing on observations during the course and on interviews with the participants. The participants were positive about the integration of psychoeducation sessions in the computer course, and described positive outcomes for both elements, including improved computer skills, improved self-esteem, and reduced social anxiety. Most participants were motivated to undertake further occupational rehabilitation after the course.

Relationship between social anxiety disorder and body dysmorphic disorder

Social anxiety disorder (SAD) and body dysmorphic disorder (BDD) are two separate, but conceptually overlapping nosological entities. In this review, we examine similarities between SAD and BDD in comorbidity, phenomenology, cognitive biases, treatment outcome, and cross-cultural aspects. Our review suggests that SAD and BDD are highly comorbid, show a similar age of onset, share a chronic trajectory, and show similar cognitive biases for interpreting ambiguous social information in a negative manner. Furthermore, research from treatment outcome studies have demonstrated that improvements in SAD were significantly correlated with improvements in BDD. Findings from cross-cultural research suggest that BDD may be conceived as a subtype of SAD in some Eastern cultures. Directions for future research and clinical implications of these findings are discussed.

Social anxiety disorder and alcohol use disorder co-morbidity in the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND

To assess the prevalence and clinical impact of co-morbid social anxiety disorder (SAD) and alcohol use disorders (AUD, i.e. alcohol abuse and alcohol dependence) in a nationally representative sample of adults in the United States.

METHOD

Data came from a large representative sample of the US population. Face-to-face interviews of 43093 adults residing in households were conducted during 2001-2002. Diagnoses of mood, anxiety, alcohol and drug use disorders and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule - DSM-IV version.

RESULTS

Lifetime prevalence of co-morbid AUD and SAD in the general population was 2.4%. SAD was associated with significantly increased rates of alcohol dependence [odds ratio (OR) 2.8] and alcohol abuse (OR 1.2). Among respondents with alcohol dependence, SAD was associated with significantly more mood, anxiety, psychotic and personality disorders. Among respondents with SAD, alcohol dependence and abuse were most strongly associated with more substance use disorders, pathological gambling and antisocial personality disorders. SAD occurred before alcohol dependence in 79.7% of co-morbid cases, but co-morbidity status did not influence age of onset for either disorder. Co-morbid SAD was associated with increased severity of alcohol dependence and abuse. Respondents with co-morbid SAD and alcohol dependence or abuse reported low rates of treatment-seeking.

CONCLUSIONS

Co-morbid lifetime AUD and SAD is a prevalent dual diagnosis, associated with substantial rates of additional co-morbidity, but remaining largely untreated. Future research should clarify the etiology of this co-morbid presentation to better identify effective means of intervention.

TPH2 gene variants and anxiety during alcohol detoxification outcome

Clinical outcome of alcoholism may be partly under genetic control. The serotonergic system is involved in alcohol intake, and it has been widely investigated in alcohol dependence. Recently, attention has been focused on the neuronal tryptophan hydroxylase 2 gene (TPH2). TPH2 variants have been consistently associated with anxiety-related traits; since anxiety is critical for alcohol dependence treatment, in the present paper we investigated 9 SNPs within the THP2 gene in anxiety symptoms during the detoxification procedure. The sample comprised 68 alcohol-dependent patients who where evaluated with the Hamilton Rating Scale for Anxiety, before and after the detoxification procedure. Other psychopathological indicators of outcome, such as depression and anxiety sub-features were also investigated. We did not observe a role for TPH2 variants in the efficacy of treatment in relieving anxiety and other psychopathological symptoms. However, a haplotype that included the promoter rs4570625 polymorphism (associated with anxiety-related traits in previous studies) showed an association with the severity of anxiety symptoms on admission. This preliminary finding, although obtained on a small sample, may provide further support for a role of the TPH2 gene in emotional behaviors. Furthermore, the present study suggests the possible functional significance of the promoter rs4570625 polymorphism. The present preliminary results are of interest in alcoholism, given that comorbidity with anxiety represents a critical problem in treatment settings and response to detoxification.

Selbstmedikation und Sozialphobie

Zusammenfassung. Hintergrund: Der Fragebogen „Trinken wegen sozialer Angst” (TWSA; Wagner, Stangier, Heidenreich & Schneider, 2004 ) erfasst das Motiv, Alkohol zur Reduktion sozialer Angst einzusetzen. Das Instrument wurde bisher nur bei Alkoholabhängigen untersucht. Hier sollen Reliabilität und konvergente Validität in einer sozialphobischen sowie einer gesunden Stichprobe geprüft werden. Methode: 120 Patienten mit Sozialphobie und 120 Gesunde bearbeiteten den TWSA. Zur Überprüfung der Konstruktvalidität wurden Maße zur Psychopathologie, die Alkoholwirkungserwartungen und die Höhe des Alkoholkonsums erfasst. Ergebnisse: Der TWSA hat eine gute Reliabilität (Cronbachs α = .96). Es zeigen sich bedeutsame Korrelationen mit Maßen zur sozialen Angst. Ebenfalls ergeben sich Zusammenhänge zu Alkoholwirksamkeitserwartungen sowie zur konsumierten Alkoholmenge. Teilnehmer mit Sozialphobie erzielten höhere Werte als Gesunde. Diskussion: Die Ergebnisse belegen, dass der TWSA auch bei Patienten mit Sozialphobie und gesunden Personen reliabel und valide eingesetzt werden kann. Die für Patienten mit Sozialphobie erhöhten Werte unterstreichen die Notwendigkeit der Diagnostik komorbider substanzbezogener Störungen.

Effects of alcohol on ratings of emotional facial expressions in social phobics

Social phobics have an increased risk of alcoholism. The mechanism behind this co-morbidity is not well understood. According to the appraisal-disruption model [Sayette, M. A. (1993). An appraisal-disruption model of alcohol's effects on stress responses in social drinkers. Psychological Bulletin, 114, 459-476], alcohol disrupts appraisal of threat stimuli unless the stimuli are easy to process. We investigated whether alcohol alters the judgment of emotional facial expressions in social phobics and controls. We also tested the judgment of emotionally ambiguous faces which should be more difficult to process. Forty social phobics and controls rated faces depicting five emotional expressions on an animosity rating scale. For two ambiguous facial expressions, angry, respectively, happy faces were blended with neutral faces. Half of the participants consumed alcohol. Socially phobic participants rated neutral and happy facial expressions as less friendly than controls, irrespective of alcohol consumption. In both groups, consuming alcohol reduced the perceived rejection of angry faces. In line with current theories of social phobia, patients interpreted neutral facial expressions as more rejecting than controls. The rejection perceived in explicitly angry facial expressions was less after drinking alcohol. This reduction of the adversity of socially threatening stimuli by alcohol might act as negative reinforcement and thus contributes to alcohol problems.

Social phobia in an outpatient alcohol and drug treatment sample

OBJECTIVE

To examine characteristics of patients with social phobia (SP) in alcohol and drug treatment settings and to identify features distinguishing this group from patients with and without other psychiatric conditions.

METHOD

A random sample of 105 patients completing an initial assessment at two outpatient alcohol and drug treatment services were assessed and agreed to a 9 month follow-up interview, completed by n=102 (97%). At baseline the Composite International Diagnostic Interview (CIDI) was administered. Current diagnoses at baseline were used to separate the sample into those with SP (n=33), other current psychiatric disorders (OPD, n=40), and those with no current psychiatric diagnosis other than a substance use disorder (NPD, n=29). The novel methodology used in this study compared the SP group first to the NPD group to see if SP was associated with a different presentation, and then compared the SP group to the OPD group to see if any identified differences were associated with SP per se or psychopathology generally. The three groups were compared on demographic, current clinical, and past treatment utilization variables at baseline, while follow-up data were used to compare the groups on treatment outcome and treatment utilization.

RESULTS

The SP group did not differ from either group in a systematic way. What differences did emerge tended to show a difference between OPD and NPD, with SP intermediate between the two, or that SP and OPD together were different from NPD.

CONCLUSIONS

Despite the relatively small sample size, these findings suggest that in substance use disorder treatment settings, patients with coexisting SP do not represent a distinctly high-needs or at-risk group in the broader context of patient populations, for which coexisting psychiatric diagnoses are the norm rather than the exception.

Pharmacotherapy of alcoholism in patients with co-morbid psychiatric disorders

There has been an exponential increase in recent years of literature pertaining to the treatment of individuals with alcohol use disorders and co-morbid psychiatric disorders. Patients with mood and anxiety disorders in particular have a very high prevalence of alcoholism. Alcoholism confers significant morbid risks to patients with psychiatric disorders, and vice versa, including markedly increased risk of suicide. Only recently have studies examined the impact of various psychiatric medications on alcohol use among patients with these disorders. Evidence supporting the benefits of antidepressants for co-morbid alcoholism and depression continues to mount. Although these studies have demonstrated benefits in terms of quantitative decreases in the volume and frequency of consumption, the benefits in terms of remission from alcoholism have yet to be shown conclusively. The first randomised, controlled trial involving subjects with co-morbid alcoholism and bipolar disorder was recently conducted, yielding promising results for valproate in this population. The literature regarding co-morbid alcoholism and anxiety disorders has also seen recent progress, particularly in the study of post-traumatic stress disorder (PTSD). A placebo-controlled study of sertraline suggests some benefit in terms of alcohol use among individuals with early-onset PTSD and less severe alcohol dependence. Atypical antipsychotics such as olanzapine and quetipaine have been examined in several open studies of subjects with alcoholism co-morbid with a variety of psychiatric conditions including bipolar disorder, PTSD and schizophrenia. This paper selectively reviews the evidence that is currently available for the pharmacological management of alcoholism among persons with co-morbid psychiatric illness. Effectiveness, safety and tolerability are considered, and directions for future study are discussed.

Does co-occurring social phobia interfere with alcoholism treatment adherence and relapse?

This study investigates the impact of social phobia on adherence to and outcomes 6 months following standard alcohol treatment and Alcoholics Anonymous (AA) group meetings among alcohol-dependent patients with and without social phobia. In a cohort study, 300 detoxified alcohol-dependent individuals in Porto Alegre, Brazil, were interviewed during, as well as 3 and 6 months after hospital detoxification. At both follow-up points, treatment adherence was low and relapse rates were high among patients with and without social phobia, and no significant differences were seen between the two groups of patients in relapse, adherence to AA, or adherence to psychotherapy. Findings from this sample suggest that although alcohol-dependent patients with social phobia showed a tendency for less adherence at AA and felt less integrated with their AA group, social phobia comorbidity was not a significant risk factor for alcohol use relapse or for nonadherence to AA or psychotherapy.

Social anxiety disorder in 300 patients hospitalized for alcoholism in Brazil: high prevalence and undertreatment

BACKGROUND

Although the frequency of social phobia is high among alcoholic patients, this anxiety disorder is often neglected because treatment tends to be focused exclusively on alcohol dependence.

METHODS

A total of 300 hospitalized alcoholic patients were interviewed using Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and Liebowitz Social Anxiety Scale as well a questionnaire to check the use of medication for social phobia among alcoholics and the relationship between social phobia and alcohol use.

RESULTS

A prevalence of 30.6% was found for specific phobia, 24.7% for social phobia, 22.2% for anxiety disorder induced by alcohol, 19.3% for generalized anxiety disorder, 5% for obsessive-compulsive disorder, 4.6% for posttraumatic stress disorder, and 2% for panic disorder with agoraphobia. Social phobia preceded alcohol dependence in 90.2% of the patients. The frequency of the use of medication for social phobia among social phobic alcoholics was 20.3%.

CONCLUSIONS

The study confirms the high prevalence of anxiety disorders among alcoholics, particularly of social phobia. It also suggests that social phobia precedes alcohol dependence but shows that the use of medication for social phobia is still infrequent. Further studies are required to check if the failure to identify this comorbidity can make the recovery of alcoholics even more difficult.

Internal consistency and factor structure of the Portuguese version of the Liebowitz Social Anxiety Scale among alcoholic patients

OBJECTIVE: Liebowitz Social Anxiety Scale is an instrument used to evaluate the severity of social phobia. It has been widely used in different contexts and cultures, presenting variable psychometric properties. The objective of this article is to investigate the internal consistency and the factor structure of this scale. METHOD: In a sample of 300 alcoholic patients hospitalized in 3 mental clinics in Southern Brazil, 74 of them were social phobics (24.6%). The Structured Clinical Interview for DSM-IV-Axis I Disorders - Patient Edition, a semi-structured clinical interview based on DSM-IV, was used to check for the diagnosis of social phobia. The internal consistency was measured by Cronbach's alpha. Data were subjected to a factor analysis with the principal component method of parameter estimation. Questionnaire items loading at 0.35 or above were considered in the final factor solution. RESULTS: The coefficient of internal consistency was 0.95. All items showed corrected item-total correlation coefficient above 0.15, considered the minimum requested index. The factor analysis resulted in 5 dimensions which corresponded to 52.9% of the total variance. The five factors extracted were: factor I - speaking in a group, factor II - activity in public, factor III - social interaction with unknown person, factor IV - attitude of disagreement or disapproval and factor V - social interaction in leisure activity. CONCLUSIONS: The scale proved to be reliable and structurally valid instrument for use in a population of alcoholic patients. The possibility of screening for social phobia through the use of the instrument may be helpful in identifying probable cases of the disorder among alcoholics.

Illicit drug use and anxiety disorders: findings from two community surveys

The focus of this investigation was the relationship between anxiety disorders and lifetime use of amphetamines, cocaine, hallucinogens and heroin in two contemporaneous samples. Data from two independent community surveys conducted in the US (N=5877) and Ontario (N=8116) were used to assess whether a lifetime anxiety disorder diagnosis (social phobia, panic disorder, agoraphobia, specific phobia, and generalized anxiety disorder) was significantly associated with lifetime use of amphetamines, hallucinogens, cocaine, and heroin. Posttraumatic stress disorder was assessed only in the US survey. After controlling for sociodemographics, a significant association between any anxiety disorder diagnosis and lifetime stimulant use, cocaine use, and hallucinogen use was found in both surveys (OR approximately 1.5-3.0). Any anxiety disorder diagnosis was significantly associated with lifetime heroin use in the US survey (OR approximately 3.0). Clinicians and researchers need to be aware of the relationship between anxiety disorders and illicit drug use.

Substance-dependent patients with and without social anxiety disorder: occurrence and clinical differences. A study of a consecutive sample of alcohol-dependent and poly-substance-dependent patients treated in two counties in Norway

AIMS

(1) To identify clinically important differences between patients with and without social anxiety disorder (SAD) among alcohol-dependent and poly-substance-dependent patients. (2) To explore if primary SAD is a predictor of alcohol-dependency or poly-substance dependency when controlling for other Axes I and II disorders.

METHODS

A consecutive sample of in- and outpatient alcohol-dependent (N = 146) and poly-substance-dependent patients (N = 114) from public treatment programmes in two catchment areas was assessed by personal interview, the Composite International Diagnostic Interview and the Millon Clinical Multiaxial Inventory.

RESULTS

The frequency of current SAD was 42%; SAD was significantly more frequent among poly-substance-dependent patients (51%) than among alcohol-dependent patients (34%). Patients with SAD do not represent a distinct clinical subgroup, but the occurrence of SAD is combined with the occurrence of other anxiety disorders, affective disorders and personality disorders in both substance groups. The analysis showed a trend towards primary SAD as a predictor for developing poly-substance dependency.

CONCLUSIONS

Patients with SAD in both substance groups exhibited more comorbid Axis I and II disorders. They may need specific psychiatric treatment for such disorders in addition to treatment for SAD. Treatment of primary SAD could be a target for preventing poly-substance dependency in young populations.

Size and burden of social phobia in Europe

This paper provides a critical review of the prevalence of social phobia in European countries, a description of associated disability and burden and of clinical correlates and risk factors associated with social phobia. On the basis of a comprehensive literature search we identified 21 community studies and two primary care studies. The median lifetime and 12-month prevalence rates of social phobia in community samples referring to DSM-III-R and DSM-IV criteria were 6.65% and 2.0%, respectively. Younger individuals showed the highest rates, and women were more frequently affected than men. Social phobia was shown to be a persistent condition with a remarkably high degree of comorbid conditions, associated impairment and disability. Research deficits lie in a lack of data for most EU countries and in a lack of studies in children and the elderly. No data are available addressing met and unmet needs for intervention and costs, and data for vulnerability and risk factors of malignant course are scarce.

Social anxiety disorder in primary care

OBJECTIVE

To examine the prevalence, comorbidity, disability and mental health treatment associated with social anxiety disorder (SAD) in primary care, and to determine whether patients with SAD avoid seeking help from their primary care providers.

DESIGN

We analyzed data from a health survey conducted on a systematic sample of patients. Data were then cross-linked to the practice's automated database in order to compare primary health care utilization by patients with SAD to that of patients with other psychiatric disorders and well controls.

SETTING

Urban primary care practice at a teaching hospital.

PATIENTS

A systematic sample (n=207) of primary care patients.

MEASUREMENTS AND MAIN RESULTS

Patients were interviewed by mental health professionals using the Composite International Diagnostic Interview. Lifetime prevalence of SAD was 5.7%. Substance use disorders were far more common among patients with SAD than patients with other psychiatric disorders (33.3% vs. 3.3%, P=.01). Social anxiety disorder patients were functionally impaired and made fewer primary care visits per year (mean 4.1) compared to patients with other psychiatric disorders (mean 6.9; P=.016) or well controls (mean 6.4; P=.031); 41.7% reported receiving mental health treatment in the past year.

CONCLUSION

Patients with SAD made fewer primary care visits compared to patients with other psychiatric disorders and well controls. These results, together with the high prevalence of substance use in SAD, and the finding that less than one half received past year mental health treatment, suggest substantial unmet need for care and are especially important in view of available effective treatments for SAD.

Substantial decrease of psychiatric comorbidity in chronic alcoholics upon integrated outpatient treatment - results of a prospective study

It is far from clear how comorbidity changes during alcoholism treatment. This study investigates: (1) the course of comorbid Axis I disorders in chronic alcoholics over 2 years of controlled abstinence in the outpatient long-term intensive therapy for alcoholics (OLITA) and (2) the effect of comorbid Axis I and II disorders in this group of patients on subsequent drinking outcome over a four-year follow-up. This prospective treatment study evaluates psychiatric variables of 89 severely affected chronic alcohol dependent patients on admission (t(1)), month 6 (t(2)), 12 (t(3)) and 24 (t(4)). Drinking outcomes have been analyzed from 1998 to 2002. On admission, 61.8% of the patients met criteria for a comorbid Axis I disorder, 63.2% for a comorbid personality disorder. Axis I disorders remit from t(1) (59.0% ill), t(2) (38.5%), t(3) (28.2%) to t(4) (12.8%) (p < 0.0001). Anxiety disorders remit more slowly from t(1) (43.6%) to t(3) (20.5%, p = 0.0086), whereas mood disorders remit early between t(1) (23.1%) and t(2) (5.1%, p = 0.0387) with a slight transient increase at t(3) (10.3%). During the four-year follow-up, the cumulative probability of not having relapsed amounts to 0.59. Two predictors have a strong negative impact on abstinence probability: number of inpatient detoxifications (p = 0.0013) and personality disorders (p = 0.0106). The present study demonstrates a striking remission of comorbid Axis I disorders upon abstinence during comprehensive long-term outpatient alcoholism treatment. The presence of an Axis II rather than an Axis I disorder on admission strongly predicts drinking outcome over a four-year follow-up.

“Trinken wegen sozialer Angst“ und “Soziale Angst wegen Trinken“:

Zusammenfassung. Theoretischer Hintergrund: Zur Erfassung von Aspekten sozialer Ängste bei Alkoholabhängigkeit wurden die beiden Fragebögen “Trinken wegen sozialer Angst“ (TWSA) und “Soziale Angst wegen Trinken“ (SAWT) entwickelt. TWSA erfasst Trinken zur Reduzierung von sozialen Ängsten. SAWT misst alkoholinduzierte soziale Ängste. Fragestellung: Es wurden die Reliabilität, faktorielle Validität und Konstruktvalidität überprüft. Methode: Psychometrische Analysen wurden an zwei Stichproben (n = 116 und n = 205) von alkoholabhängigen Patienten durchgeführt. Ergebnisse: Cronbachs a von TWSA ist .97 und von SAWT .95. Die Ergebnisse zweier Hauptkomponentenanalysen stützen die faktorielle Validität der Fragebögen, und die Korrelationen zu anderen Maßen sprechen für ihre Konstruktvalidität. Schlussfolgerungen: Die Ergebnisse ergeben erste Hinweis dafür, daß Alkoholkonsum zur “Selbstmedikation“ sozialer Ängste durch den TWSA und alkoholinduzierte soziale Ängste durch den SAWT reliabel und valide erfasst werden können.

Social Anxiety Disorder: More Than Just a Little Shyness

Social anxiety is defined as a "marked and persistent fear of social or performance situations" and includes such symptoms as sweating, palpitations, shaking, and respiratory distress. Social anxiety is fairly common, occurring in as much as 13% of the population, and can be extremely disabling. It can be either specific (confined to 1 or 2 performance situations) or generalized, and can be diagnosed with a scale-based questionnaire. Social anxiety may coexist with other disorders, such as depression and dysthymia. The differential diagnosis for social anxiety includes panic disorder, agoraphobia, atypical depression, and body dysmorphic disorder. Treatment for social anxiety can be quite effective and consists of psychotherapy, pharmacotherapy (including such medications as beta-blockers, anxiolytics, antidepressants, and anticonvulsants), or a combination. This article details the prevalence, onset, disease impact, and etiology of social anxiety. Specific treatments, including both psychotherapy and pharmacotherapy, are presented in detail, along with other treatment considerations, such as comorbidity.

The impact of anxiety disorders on educational achievement

Anxiety disorders typically have an age of onset in childhood and adolescence, resulting in significant disability in social and occupational functioning. Epidemiological evidence suggests that persons with psychiatric disorders and perhaps especially social phobia are at increased risk for premature withdrawal from school [Am. J. Psychiatry 157 (2000) 1606]. In order to further determine the impact of anxiety disorders on school functioning and/or premature withdrawal from school, 201 patients meeting DSM-IV criteria for a primary anxiety disorder completed a school leaving questionnaire as well as self-report measures of anxiety, depression, and social adjustment. About 49% (n = 98) reported leaving school prematurely and 24% of those indicated that anxiety was the primary reason for this decision. Patients who had left school prematurely were significantly more likely to have a lifetime diagnosis of generalized social phobia, a past history of alcohol abuse/dependence and a greater number of lifetime diagnoses than those who completed their desired level of education. This study suggests that anxiety disorders, and perhaps especially generalized social phobia, are associated with premature withdrawal from school. Further studies are required to determine methods for early identification and treatment of anxiety disorders in school aged children to enable these students to reach their full potential.

Impact of alcohol intoxication and withdrawal syndrome on social phobia and panic disorder in alcoholic inpatients

PURPOSE: To investigate the impact of alcohol intoxication and withdrawal on the course of social phobia and panic disorder. METHOD: A group of 41 alcoholic inpatients undergoing detoxification therapy were interviewed using the SCID-I (DSM-IV) and questions to detect fluctuations in the course of social phobia and panic disorder as a function of the different phases in alcohol dependence (intoxication, withdrawal, and lucid interval). RESULTS: Only 1 (2.4%) patient presented panic disorder throughout life, and 9 (21.9%) had panic attacks during alcohol intoxication or during the withdrawal syndrome. Sixteen (39%) alcoholic patients showed social phobia with onset prior to drug use. However, drinking eventually became unable to alleviate social phobia symptoms or worsened such symptoms in 31.2% of social-phobic patients. While patients with social phobia reported a significant improvement in psychiatric symptoms during alcohol intoxication, patients experiencing panic attacks worsened significantly during intoxication. In the withdrawal phase, patients with social phobia tended to have more and more intense phobic symptoms. CONCLUSION: Our findings indicate that the impact of alcohol intoxication is different for social phobia as compared to panic disorder, at first decreasing the social-phobic symptoms but later aggravating them. In panic disorder, the impact of intoxication by alcohol is more harmful, at least in the short term.

WCA recommendations for the long-term treatment of social phobia

What is the best approach for treating patients with social phobia (social anxiety disorder) over the long term? Social phobia is the most common anxiety disorder, with reported prevalence rates of up to 18.7%. Social phobia is characterized by a marked and persistent fear of being observed or evaluated by others in social performance or interaction situations and is associated with physical, cognitive, and behavioral (ie, avoidance) symptoms. The onset of social phobia typically occurs in childhood or adolescence and the clinical course, if left untreated, is usually chronic, unremitting, and associated with significant functional impairment. Social phobia exhibits a high degree of comorbidity with other psychiatric disorders, including mood disorders, anxiety disorders, and substance abuse/dependence. Few people with social phobia seek professional help despite the existence of beneficial treatment approaches. The efficacy, tolerability, and safety of the selective serotonin reuptake inhibitors (SSRIs), evidenced in randomized clinical trials, support these agents as first-line treatment. The benzodiazepine clonazepam and certain monoamine oxidase inhibitors (representing both reversible and nonreversible inhibitors) may also be of benefit. Treatment of social phobia may need to be continued for several months to consolidate response and achieve full remission. The SSRIs have shown benefit in long-term treatment trials, while long-term treatment data from clinical studies of clonazepam are limited but support the drug's efficacy. There is also evidence for the effectiveness of exposure-based strategies of cognitive-behavioral therapy, and controlled studies suggest that the effects of treatment are generally maintained at long-term follow-up. In light of the chronicity and disability associated with social phobia, as well as the high relapse rate after short-term therapy, it is recommended that effective treatment be continued for at least 12 months.

Social anxiety disorder

Although social anxiety disorder (SAD) is a common and disabling disorder that may occur in different cultural settings, it is under-diagnosed by clinicians. In order to facilitate accurate diagnosis, the clinical features and differential diagnosis of SAD are described, together with useful assessment instruments for clinicians. Aetiological evidence suggests that the causal pathways for SAD include genetic, neurobiological, temperamental and cognitive factors. A range of effective treatments for SAD are available: current findings suggest that the selective serotonin reuptake inhibitors (SSRIs) are the first-line choice of pharmacotherapy for SAD, while several other agents show promise in treating refractory cases; furthermore, SAD responds well to psychotherapeutic interventions such as exposure therapy and cognitive restructuring.

Self-medication in social phobia: a review of the alcohol literature

It is well documented that many individuals endorse the belief that alcohol reduces social anxiety. Individuals with social phobia, therefore, might be expected to use alcohol as a coping strategy in an attempt at self-medication. The purpose of the present paper was to review the published literature on the relationship between alcohol use and social phobia to test the self-medication hypothesis (SMH). Support for one aspect of the SMH was found; individuals with social phobia use alcohol to reduce anxiety. Support for the second premise, that alcohol actually reduces social anxiety, was less conclusive.

Paroxetine for social anxiety and alcohol use in dual-diagnosed patients

The objective of this study was to compare the efficacy and tolerability of paroxetine to matched placebo in adults with co-occurring social anxiety disorder and alcohol use disorder. Outcome measures included standardized indices of social anxiety and alcohol use. Fifteen individuals meeting DSM-IV criteria for both social anxiety disorder and alcohol use disorder were randomized to treatment. Paroxetine (n = 6) or placebo (n = 9) was given in a double-blind format for 8 weeks using a flexible dosing schedule. Dosing began at 20 mg/d and increased to a target dose of 60 mg/d. There was a significant effect of treatment group on social anxiety symptoms, where patients treated with paroxetine improved more than those treated with placebo on both the Clinical Global Index (CGI) and the Liebowitz Social Anxiety Scale (Ps < or = 0.05). On alcohol use, there was not a significant effect of treatment on quantity/frequency measures of drinking, but there was for the CGI ratings (50% paroxetine patients versus 11% placebo patients were improvers on drinking, P < or = 0.05). This pilot study suggests that paroxetine is an effective treatment for social anxiety disorder in individuals with comorbid alcohol problems, and positive treatment effects can be seen in as little as 8 weeks. Further study is warranted to investigate its utility in helping affected individuals reduce alcohol use.

Gambling in mild-moderate alcohol-dependent outpatients

There is a growing interest in the comorbidity of "substance use disorder" and "problem gambling." although there has been little study specifically on people with "alcohol dependence" who are being treated in general alcohol- and drug-user outpatient settings. This study aimed to determine the nature and extent of gambling in a sample of 124 mild-moderate alcohol-dependent outpatients. Of these, 79.8% had gambled in the previous 6 months and 29.8% on at least a weekly basis. Although a wide range of gambling modes was used, by far the commonest was Lotto, a national weekly lottery, at 60.5%. Some 19.4% were found to manifest current "problem gambling" [i.e., scored at least 1 on the South Oaks Gambling Screen (SOGS) instrument], and a further 4.0% were found to manifest pathological gambling confirmed by Diagnostic and Statistical Manual of Mental Disorders Version IV (DSMIV) diagnosis. "Problem gamblers" were significantly more likely to be involved in all modes of gambling compared with non problem gamblers. However, the most differentiating modes, in order, were gambling machines, dogs, casino, and horses. Treatment implications of these findings are discussed. A two-arm model of intervention for problem gambling within the alcohol- and drug-user treatment setting is proposed.

Comorbidity of phobic disorders with alcoholism in a Canadian community sample

OBJECTIVES

To examine the relation between phobic disorders and alcoholism in a Canadian community sample.

METHOD

Data came from the Mental Health Supplement of the Ontario Health Survey. The University of Michigan revision of the Composite International Diagnostic Interview (UM-CIDI) was used to diagnose DSM-III-R psychiatric disorders in 8116 Canadian respondents between ages 15 and 64 years. Since the cross-system agreement (ICD-10 and DSM-III-R or DSM-IV) on the diagnosis of alcohol abuse is much lower than that for alcohol dependence, we also examined a WHO category, "hazardous alcohol use." Logistic regression controlling for age and sex was used to determine odds ratios (ORs) for phobic disorders and alcohol-use diagnoses.

RESULTS

Individuals with lifetime alcohol abuse or dependence had two- to threefold increased odds of having a phobic disorder. Simple phobia and social phobia with multiple fears were significantly associated (ORs 1.5 to 2) with hazardous alcohol use (which had a prevalence of approximately 10%).

CONCLUSIONS

Given the early onset of most phobic disorders, the findings suggest that these are a risk factor for hazardous patterns of alcohol use.

Anxiety Disorders in Neurologic Illness

Anxiety disorders frequently occur in individuals with neurologic illness. Anxiety may be a symptom of or a reaction to the neurologic disorder, a medication side effect, or a comorbid condition. The most common anxiety disorders seen in neurologic patients are panic disorder, generalized anxiety disorder, social phobia, and obsessive-compulsive disorder (OCD). Very often, these conditions go unrecognized (and therefore untreated) or are attributed to being a normal response to having a neurologic illness. However, if they are not treated, anxiety disorders can significantly increase morbidity and mortality in neurologic patients. Selective serotonin reuptake inhibitors (SSRIs) should be considered the first-line of pharmacologic treatment, because they offer a broad spectrum of efficacy in the anxiety disorders, are generally well tolerated, and are effective in treating comorbid depression. Benzodiazepines, although most effective for acute anxiety, are now considered adjunctive or second-line treatments. Cognitive behavioral therapy and other behavioral treatments are effective in the treatment of anxiety disorders. They should be considered primary treatments for patients who cannot tolerate or prefer not to take medications.