Social phobia in primary care: level of recognition and drug use

Social anxiety disorder in DSM-5

With the publication of DSM-5, the diagnostic criteria for social anxiety disorder (SAD, also known as social phobia) have undergone several changes, which have important conceptual and clinical implications. In this paper, we first provide a brief history of the diagnosis. We then review a number of these changes, including (1) the primary name of the disorder, (2) the increased emphasis on fear of negative evaluation, (3) the importance of sociocultural context in determining whether an anxious response to a social situation is out of proportion to the actual threat, (4) the diagnosis of SAD in the context of a medical condition, and (5) the way in which we think about variations in the presentation of SAD (the specifier issue). We then consider the clinical implications of changes in DSM-5 related to these issues.

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.

Sociocultural interpretations of social phobia in a non-heterosexual female

Social Phobia is a prominent anxiety disorder that is not well-understood, especially among socially marginalized, non-heterosexual individuals. A case description of Social Phobia symptoms in a female who is unsure of her sexual identity is presented and analyzed. The diagnostic assumptions of Social Phobia as applied to the case are critically examined. The goal is to highlight unanswered questions regarding social anxiety among non-heterosexuals and to open a discussion of cultural etiological theory. Implications for treating Social Phobia with a cultural component are discussed.

Prevalence of social phobia in a clinical sample of drug dependent patients

INTRODUCTION

Social phobia is among the most frequent psychiatric disorders and can be classified into two subtypes, nongeneralized and generalized. Whereas it significantly worsens the morbidity of comorbid substance abuse disorders, and it often is associated with reduced treatment responses, there is still lacking data on its prevalence in clinical populations of drug abusing patients.

METHODS

The study sample consisted of 75 inpatients and 75 outpatients meeting DSM-IV criteria for drug dependence. Symptoms of social phobia were assessed with the French-language version of the Liebowitz Social Anxiety Scale (LSAS).

RESULTS

Prevalence rate were 20% for the generalized subtype and 42.6% for the nongeneralized subtype. Gender difference emerged in the severity of fear, women reporting significantly greater fear relating to performance situations than men.

CONCLUSIONS

An important proportion of patients with substance dependence present a comorbid generalized or nongeneralized social phobia. Early recognition of social phobia and adequate interventions is warranted for these patients in order to improve their treatment response with regard to quality of life and relapse prevention.

Epidemiology and natural course of social fears and social phobia

OBJECTIVE

To summarize epidemiological studies providing data on prevalence, incidence, comorbidity, natural course, risk factors and consequences of social phobia (SP).

METHOD

Data from cross-sectional studies and prospective longitudinal studies in particular are considered.

RESULTS

These studies portray SP as a frequent mental disorder, which begins typically in early adolescence, and is highly comorbid with other anxiety disorders, as well as secondary depression and substance abuse disorders. Several possible risk factors have already been identified for the onset and unfavorable course of SP; some of them have been tested in prospective longitudinal studies. SP is a chronic disorder when compared with other mental disorders and when subclinical symptomatic levels are considered. Impairment caused by SP is considerable and increases over a patient's life span. The negative impact of SP is not only reflected in subjective well-being and reduced quality of life but also in social role functioning, and it impacts negatively on career progression.

CONCLUSION

Prospective longitudinal studies in representative samples drawn from the general population provide information that allows the overall direct and indirect costs of the disorder (treatment costs, disability, social welfare) to be determined, and enables an improvement in long-term care strategies as well as preventive efforts to be established.

Anxiety disorders in women

Women have higher overall prevalence rates for anxiety disorders than men. Women are also much more likely than men to meet lifetime criteria for each of the specific anxiety disorders: generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), simple phobia, panic disorder, and agoraphobia. Considerable evidence suggests that anxiety disorders remain underrecognized and undertreated despite their association with increased morbidity and severe functional impairment. Increasing evidence suggests that the onset, presentation, clinical course, and treatment response of anxiety disorders in women are often distinct from that associated with men. In addition, female reproductive hormone cycle events appear to have a significant influence on anxiety disorder onset, course, and risk of comorbid conditions throughout a woman's life. Further investigations concerning the unique features present in women with anxiety disorders are needed and may represent the best strategy to increase identification and optimize treatment interventions for women afflicted with these long-neglected psychiatric disorders.

Screening for social anxiety disorder in the clinical setting: using the Liebowitz Social Anxiety Scale

OBJECTIVE

We sought to determine optimal cutoff values for the Liebowitz Social Anxiety Scale (LSAS) total and subscale scores for the diagnosis of social anxiety disorder (SAD) and designation of the generalized subtype of SAD.

METHOD

Three hundred and sixty-four patients from a multi-site sample who met criteria for SAD according to structured diagnostic interview, 262 of whom met criteria for the generalized subtype, and 34 control participants free of current Axis I disorders participated in this study. All participants were given the Liebowitz Social Anxiety Scale by an independent assessor.

RESULTS

Receiver Operating Characteristics analysis revealed that the LSAS performed well in identifying individuals who met criteria for SAD and for the generalized subtype of SAD. Cutoffs of 30 for SAD and 60 for its generalized subtype on the LSAS total score represented the best balance of specificity and sensitivity.

CONCLUSIONS

These findings provide support for the use of the Liebowitz Social Anxiety Scale for the identification of individuals with SAD and its generalized subtype in clinical settings. Identification of patients with SAD should increase the percentage of these patients who receive appropriate treatment for this impairing disorder.

Pharmacotherapy of anxious disorders

The present paper is a review of the treatment of anxious disorders by the current pharmaceutical medications; a short epidemiological survey is given for anxious disorders including: general anxiety disorder, panic disorder, obsessive compulsive disorder, social anxiety and post-traumatic stress disorder. For all these disorders there are proposals of treatment built on literature data mainly on meta-analysis as well on personal experience.

Epidemiology, patterns of comorbidity, and associated disabilities of social phobia

Social phobia is a common condition, with current prevalence estimates in the range of 4% to 6% and a lifetime risk of 7% to 13%. It has an early onset and, without appropriate intervention, it has a disproportionately higher risk for persistence compared with other anxiety disorders. Presentation differs between age groups; the disorder in teenagers and in those in their early 20s tends to look different in terms of types of problems and the associated distress to that expected in the 30s and 40s age groups, when these individuals have already endured 20 years of suffering and disability. There is an increased risk for depression and substance abuse disorders even in adolescence, in addition to an increased risk for psychosocial impairment and disability resembling that experienced by depressed outpatients. This finding is particularly true in cases affected by generalized SP, which might have slightly different etiologic pathways than the nongeneralized type. Social phobia is in itself a disabling disorder, and individuals who develop comorbid conditions have a more severe level of disability. Early recognition, diagnosis, and treatment of SP could minimize sufferers' problems throughout their subsequent lives, preventing the development of comorbidity and a worsened prognosis. Developing models for early recognition and treatment should improve the outcome for the patient, as well as reduce future demand on health care resources. Epidemiologic studies, with their methodologic strengths and unique methods, can be instrumental in this respect. They may, for example, provide time-efficient, simple screening tools for use by physicians or even patients, based on the existing diagnostic instruments used in epidemiologic surveys. They may provide further guidance in making treatment decisions and developing treatment algorithms by offering criteria, which with additional vulnerability and risk factors, will lead to more severe, chronic, and comorbid course in a given case.

Characteristics of patients with social phobia and their treatment in specialized clinics for anxiety disorders in the Netherlands

BACKGROUND

Social phobia frequently occurs in the general population but is probably underreported due to comorbid disorders which mask the social phobia. Another reason might be that patients do not consult their general pratitioner due to embarrassment or an estimation of their condition. There are several treatments available for social phobia, but not enough is known about the efficacy of the different treatments strategies.

METHODS

A retrospective, medical record-based study was carried out in four outpatient clinics specializing in treatment of anxiety disorders to investigate the characteristics of 64 patients with a DSM-IV axis diagnosis of social phobia who seeked help for their problems. Therapies for social phobia within these clinics and differences between these clinics were evaluated.

RESULTS

Men with a high educational level tended to seek more help and comorbid disorders tended to cause more impairment in functioning. Further, there is a large delay between onset and therapy attendance (mean 14 years). Finally, there was consistency in the treatment of social phobia in these four clinics which consisted of cognitive behavioral therapy and/or medication.

LIMITATIONS

The study is retrospective and based on medical records which means there was no objective measurement of the effectiveness of the therapies.

CONCLUSIONS

Seventy-five percent of patients improved after treatment independent of the kind of therapy, the occurrence of comorbid disorders and the type of social phobia.

Social phobia: diagnosis and epidemiology, neurobiology and pharmacology, comorbidity and treatment

Social phobia is a common disorder associated with significant psychosocial impairment, representing a substantial public health problem largely determined by the high prevalence, and the lifelong chronicity. Social phobia starts in early childhood or adolescence and is often comorbid with depression, other anxiety disorders, alcohol and substance abuse or eating disorders. This cascade of comorbidity, usually secondary to social phobia, increases the disability associated with the condition. The possibility that social phobia may be a trigger for later developing comorbid disorders directs attention to the need for early effective treatment as a preventive measure. The most recent drug class to be investigated for the psychopharmacological treatment of social phobia is the SSRI group for which there is growing support. The other drug classes that have been evaluated are monoamine oxidase inhibitors (MAOIs), benzodiazepines, and beta-blockers. The SSRIs represent a new and attractive therapeutic choice for patients with generalized social phobia. Recently the first, large scale, placebo-controlled study to assess the efficacy of drug treatment in generalized social phobia has been completed with paroxetine. Paroxetine was more effective in reducing the symptoms than placebo and was well tolerated. Many now regard SSRIs as the drugs of choice in social phobia because of their effectiveness and because they avoid the problems of treatment with benzodiazepines or classical MAOIs.

A European perspective on social anxiety disorder

Epidemiologic surveys conducted across Europe indicate that the lifetime prevalence of social anxiety disorder in the general population is close to 7%. The disorder in adulthood rarely presents in its 'pure' form and 70-80% of patients have at least one other psychiatric disorder, most commonly depression. Social anxiety disorder is a risk factor for the development of depression and alcohol/substance use or dependence, especially in cases with an early onset (< 15 years). Individuals with social anxiety disorder have significant functional impairment, notably in the areas of initiation and maintenance of social/romantic relationships and educational and work achievement. The economic consequences of social anxiety disorder are considerable, with a high level of diminished work productivity, unemployment and an increased utilisation of medical services amongst sufferers. Effective treatment of social anxiety disorder would improve its course and its health and economic consequences.

Social phobia: the nature of the disorder

Social phobia is characterized by a fear of social situations, which are either avoided or endured with intense anxiety or distress. There is a high prevalence of social phobia in the community and the course of the condition tends to be chronic. In spite of the personal impact of social phobia, few sufferers seek professional help. This is due to a lack of awareness about the condition on the part of health professionals and the public. Social phobia demands increased awareness, so that sufferers receive the treatment they need and deserve, so giving them the opportunity to improve their quality of life.