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Social Anxiety Disorder: A Common, Underrecognized Mental Disorder

American Family Physician, Nov 15, 1999 by Timothy J. Bruce, Sy Atezaz Saeed

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Comorbidity and Detection

Approximately one half of patients with social phobia have comorbid mental, drug or alcohol problems.(6,7) The disorder increases a patient's lifetime risk of depression approximately fourfold.(3) Up to 16 percent of patients who present with social phobia have alcohol abuse problems(8); conversely, many patients presenting for treatment of substance abuse problems meet the criteria for social phobia.(9) Interestingly, longitudinal data show that social phobia precedes approximately 70 percent of these comorbid conditions,(3) suggesting that some comorbid conditions arise in response to the phobia. Importantly, the presence of comorbidity in social phobia has been associated with an increased lifetime incidence of suicidal ideation and suicide attempts.(3) Although these data underscore the need for early detection, social phobia often goes undetected.

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In a recent epidemiologic study of 2,096 primary care patients in France,(10) it was found that approximately 5 percent of those detected through screening met the criteria for social phobia. Of those patients with early onset (before age 15), 70 percent had comorbid major depression. Interestingly, of patients presenting with social phobia alone, only 46 percent were initially recognized as having any psychiatric disorder. Of patients presenting with social phobia and depression, 76 percent were recognized as having psychiatric problems, although the social phobia was specifically identified in only 11 percent. These data reemphasize the importance of comprehensive psychiatric screening and highlight the need to screen for social phobia, particularly in patients who present with other common mental health disorders, such as depression or substance abuse.

As with all psychiatric conditions, detection can be facilitated by the use of a brief screening instrument that assesses for the primary features of disorders. This method is particularly relevant for social phobia, because patients often avoid volunteering their fears face-to-face. Some general screening devices for mental disorders (e.g., the Structured Clinical Interview for DSM-IV-Screen [SCID-Screen]) include questions related to social phobia but are quite lengthy, requiring up to 25 minutes to complete; others do not screen for social phobia (e.g., the Primary Care Evaluation of Mental Disorders [Prime-MD]). Instruments designed specifically to measure social phobia (e.g., the Fear of Negative Evaluation Scale, the Social Avoidance and Distress Scale)(11) are extensive and more applicable to monitoring outcome than to screening.

In the absence of a brief yet thorough instrument for detecting social phobia, family physicians can improve detection by adding selected questions to their existing screening instrument. In a recent study of 9,375 managed care patients, the following yes-or-no statements were sensitive to detecting 89 percent of social phobia cases: (1) being embarrassed or looking stupid are among my worst fears; (2) fear of embarrassment causes me to avoid doing things or speaking to people; (3) I avoid activities in which I am the center of attention. Positive responses can be followed up to determine whether the phobia is a problem for which the patient desires treatment. A number of obstacles to prompt recognition and effective treatment have been identified (Table 4). When these obstacles are overcome, social phobia is responsive to specific pharmacologic and psychologic interventions.

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Social Anxiety Disorder: A Common, Underrecognized Mental Disorder

American Family Physician, Nov 15, 1999 by Timothy J. Bruce, Sy Atezaz Saeed

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