Current Medical Diagnosis & Treatment in Psychiatry

Social Phobias

In recent years social phobia has gained more professional and public interest and increasingly is being recognised as a real anxiety disorder for which treatment can offer an improvement of the patient’s quality of life (Kasper, 1998). Social phobia (social anxiety disorder) usually is rather disabling, characterised by marked fear of performance, excessive fear of scrutiny, and fear of acting in a way that may be embarrassing. Most patients are over-sensitive to the assumed opinion of others and have a low self-esteem, although they feel their fears are exaggerated and out of proportion. Going through the feared situations, or even anticipating them, most people suffer from physical symptoms like sweating, trembling or blushing, and these symptoms can become a trigger on their own to worry about social consequences.

This all can lead to avoidance of many social situations, or they endure these situations with extreme anxiety or distress (Liebowitz, 1999). As in all cases of phobias, the individual recognises that his or her fears are unreasonable.

Social phobia can be divided in two subtypes. The first is generalised social phobia (or complex social phobia), patients being anxious in most situations concerning performance and interactional situations. The patient with non-generalised social anxiety disorder is scared of only one or two (usual performance-related) social situations, such as public speaking, or other public performance, such as writing or eating in front of others (Moutier and Stein, 1999; Stein and Chavira, 1998). Both types, however, tend to be underdiagnosed and undertreated (Stein and Chavira, 1998). There are some differences between the subgroups, the generalised type has even less chance of spontaneous recovery than the non-generalised. In the generalised subtype there is a stronger genetic factor (Kessler et al., 1998b). The generalised subtype is usually more invalidating and carries a higher risk of comorbidity. Age of onset does not differ between the subtypes.

Differential diagnoses for social anxiety disorder are: major depression with social withdrawal, panic disorder with social avoidance, agoraphobia, GAD, OCD, and body dysmorphic disorder. Another important disorder to differentiate from social phobia is the DSM-IV axis II avoidant personality disorder. Although often seen as a comorbid disorder, it is becoming increasingly clear that much avoidant personality disorder as defined by DSM-IV merely denotes a subgroup of patients with axis I generalised social phobia (Moutier and Stein, 1999).

Among the anxiety disorders social phobia nowadays is considered the third most common psychiatric disorder (13.3%), exceeded in lifetime prevalence only by major depression (17.1%) and alcohol dependence (14.1%) (Kessler et al., 1994), at least in the United States according to the NCS data. Prevalence rates for social phobia have increased in last decades. Earlier surveys, based on DIS and DSM-III criteria gave figures ranging from 2% to 4% (Pe´lissolo and Le´pine, 1998). The ECA survey, for example, found one-month prevalence of 1.3%, a six-month prevalence of 1.5% and a lifetime prevalence of 2.8% (Schneier et al., 1992). Subsequent studies, based on DSM-III-R criteria and CIDI interviews which explore more abundant and diversified social situations, reveal higher lifetime prevalences for social phobia, between 4.1% and 16%. The NCS study found a one-month prevalence of 4.5% and a lifetime prevalence of 13.3% (Magee et al., 1996).

A study by Weiller and others (1996) conducted in a general health care setting revealed a one-month prevalence of 4.9%, and a lifetime prevalence of 14.4%. They also stress that social phobia is underdiagnosed by general practitioners, in only 24.2% of the social phobics a diagnosis of anxiety disorder was made. When occurring with a comorbid depression, even fewer patients were diagnosed as having a social phobia, although the presence of a comorbid depression increased the chance of diagnosing a psychological disorder. Nevertheless, it should be noted that in some epidemiological studies conducted in the Far East much lower lifetime prevalences are found, about 0.5% (Le´pine and Lellouch, 1995). It is unclear whether this occurs on account of a cultural bias of response or because of true psychopathological cross-cultural differences.

Demographics and Risk Factors
Most surveys mention a slight preponderance of women in social phobia (1.5 times as many as men). The NCS reports lifetime prevalence for women of 15.5% and for men 11.1% (Magee et al., 1996). In a study specifically addressing gender differences in social anxiety disorder (Weinstock, 1999), the authors state that although women are more likely to have social phobia, men are more likely to seek treatment, possibly explained by differences in gender roles and social expectations. There seems to be a difference in feared items between men and women: concerns about eating in restaurants and writing in public were more common in men, problems with using public restrooms and speaking in public were more common in women.

Social phobia is more frequently found at a younger age (18 to 29 years), among the less educated, the single, and the lower socio-economic classes (Schneier et al., 1992). The Weiller et al. study (1996) showed an unemployment rate of 9.3%, compared with 1.3% for the control group. Employment status was also poor in the ECA study, social phobics changed their jobs more often and showed more absenteeism (Davidson et al., 1993).

Natural Course
Typically social phobia has an onset in puberty and is often preceded by general shyness in early youth (Liebowitz, 1999). The natural course tends to be chronic, unremitting and in course of time increasingly complicated by comorbid disorders.

Because of the early age of onset, the disorder strongly influences further psychological development, formation of relationships, educational choices and career perspectives (Davidson et al., 1993).

As is the case for panic disorder, in social phobia as well, the comorbidity rate is high.

Around 80% of social phobia co-exists with other disorders (Le´pine and Pelissolo, 1996; Montgomery, 1998). In particular, lifetime depression is high, about 70%, as well as other anxiety disorders. Panic disorder was diagnosed in 49%, GAD in 32% andOCDin 11% of social phobics (Van Ameringen et al., 1991). However, this study only comprised 57 subjects. Analysis of a part of ECA data with 123 social phobics revealed that 11.6% of them had lifetime panic disorder, 45% had comorbid agoraphobia, 60.8% had specific phobia, and 26.9% had GAD (Davidson et al., 1993). The data from the NCS showed a comorbidity with panic disorder in 10.9% of cases, with agoraphobia in 23.3%, GAD in 13.3% and specific phobia in 37.6% (Magee et al., 1996). Because of the early onset of social phobia, most often (in 70% of cases) the comorbid disorders appear secondary to the social phobia (Schneier et al., 1992).

The relationship between social phobia and alcoholism is a complex one. Reported prevalence rates vary widely, due to differing definitions, and methodological differences (Le´pine and Pelissolo, 1998). Most studies looking for social phobia in patients with alcohol problems, abuse or dependence report prevalences of about 10% to 20%. Studies addressing social phobic patients report alcoholism in about 14% to 40% of cases. The social phobia most often predates the onset of alcohol problems. Although many social phobia sufferers use alcohol in an attempt to self-medicate their distressing anxiety symptoms, it appears that alcohol can actually increase anxiety, and a cycle may develop in which the sufferer drinks in order to relieve increasing levels of anxiety (Le´pine and Pelissolo, 1998).

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