Social Phobia in the Primary Care Medical Setting
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ORIGINAL RESEARCH Social Phobia in the Primary Care Medical Setting Murray B. Stein, MD; John R. McQuaid, PhD; Charlene Laffaye; and Margaret E. McCahill, MD San Diego, California BACKGROUND. Social phobia (social anxiety disorder) is a common disorder that is receiving more attention as new treatments become available. Little is known about social phobia as it appears in the primary care setting. The purpose of our study was to determine the prevalence of social phobia in a primary care clinic, the rates of comorbidity with other anxiety and mood disorders, the extent of disability, and patterns of healthcare utilization. METHODS. A total of 511 English-speaking adults presenting for routine medical care participated in a 2-stage screening consisting of the administration of a self-report measure for social phobia followed by a structured diagnostic interview. We determined current (1-month) prevalence of social phobia, current comorbid disorders, and we ascertained use of health care in the previous 6 months. We also administered brief functional impairment and disability indices. RESULTS. A lower-bound estimate of 7.0% of primary care attendees suffered from social phobia as defined in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition. Comorbidity with major depression (58.3% of cases of social phobia) was extensive, somewhat less so with panic disorder (27.8%) and generalized anxiety disorder (30.6%). Social phobics reported significantly more impairment in all functional domains than pri mary care patients without mental disorders; this was most pronounced in patients with the generalized subtype of social phobia. Social phobics made greater use of health care resources than patients who were not mentally ill, yet few (<20%) were receiving appropriate psychotropic medications. CONCLUSIONS. Patients with social phobia frequently present to primary care medical settings, and manifest impairment in multiple functional domains. But, on the basis of the low rate of psychotropic prescription, it seems that social phobia is either undiagnosed or felt by physicians to be unlikely to benefit from such treatments. Social phobia is highly comorbid with major depression and with other anxiety disorders in the primary care set ting. Attention by family physicians to the presence of depression or panic attacks should signal the need to query patients about possible social phobia. KEY WORDS. Social phobia; social anxiety disorder; major depression; primary care; health care utilization. (J Fann Pract 1999; 48:514-519) ocial phobia (also known as social anxiety gatherings, and so forth), they are said to suffer from disorder) is defined in the Diagnostic and the generalized subtype of social phobia; persons who Statistical Manual fo r Mental Disorders- fear fewer situations are referred to as suffering from Fourth Edition (DSM-IV) as the fear of being the nongeneralized subtype. observed or evaluated by others. In social sit Social phobia is a prevalent, often disabling condi Suations, persons with social phobia are fearful that theytion.17 Several recent community surveys have placed will embarrass themselves or fail to achieve some stan the one-year prevalence of social phobia in the range of dard of performance, and that humiliation will result. 2% to 7% of adults, with lifetime prevalence as high as Consequently, persons with social phobia often avoid 13.0%.w In these surveys, social phobics were noted to situations where such scrutiny may take place; if not have rarely received mental health care interventions avoided, these situations are endured with intense dis for their disorder.3'4 This raises the question of how tress. When social phobics fear and/or avoid a majority often social phobics are encountered in the general of social situations (eg, speaking in public, meeting new medical health care system. Patients with other psychi people, talking to people in authority, attending social atric disorders, such as depression, present more often in medical settings than in mental health clinics.8 If true Submitted, revised, May 10, 1999. of patients with social phobia, then their attendance in From the Department of Psychiatry and the Department of Family and Preventive Medicine, School of Medicine, primary care might represent an opportunity for identi University of California, San Diego, and the San Diego VA fication and intervention. Healthcare System. Requests fo r reprints should be addressed Several prior studies have demonstrated that anxiety to Murray B. Stein, MD, Department o f Psychiatry (0985), disorders are highly prevalent among general medical 9500 Gilman Drive, La Jolla, CA 92093-0985. clinic attendees.911 Although social phobia was not a pri- 514 The Journal o f Family Practice, Vol. 49, No. 7 (July), 1999 1999 Dowden Publishing Co/ISSN 0094-3509 SOCIAL PHOBIA IN THE PRIMARY CARE MEDICAL SETTING mary focus of these studies, in one of these it was noted cation, 4.0% of patients did not complete high school, that social phobia was associated with meaningfully 14.2% completed high school, 30.6% had some college or reduced role functioning and sense of well-being.11 In the post-secondary education, 10.1% completed 3 years of only in-depth study to date of social phobia in the gener college, and 41.2% had more than 3 years o f college. al medical health care system, the investigators found a one-month prevalence of 4.9% in a French primary care Social Phobia Screening M easure clinic, but poor recognition of the disorder on the part of We used a new self-reported screening instrument, the general practitioners.1213 Social Phobia Questionnaire (SPQ), to identify possible We attempted to replicate and extend these findings cases of social phobia. This instrument (available from by determining the prevalence of DSM-IV social phobia the authors upon request) begins with 2 yes or no ques in a US primary care clinic, focusing on issues of comor tions: “When you are around other people do you often bidity, impairment, disability, and health care utilization. feel nervous, self-conscious or uncomfortable?” and “Do Furthermore, given that various social phobia subtypes you often avoid situations where you could be the center (ie, generalized versus nongeneralized)1 manifest differ of attention?” Patients who answer yes to either o f those ent levels of severity and associated impairment,114'16 we 2 questions are asked to complete the remainder o f the designed the study to enable us to ascertain subtype questionnaire, which asks about anxiety (on a 4-point specificity and its relationship to functional and utiliza scale, where 0 = “wouldn’t make me anxious at all,” and tion variables. 3 = “would make me extremely anxious”) and avoidance (also on a 4-point scale, where 0 = “would never avoid,” METHODS and 3 = “would always avoid if I could”) in the following 10 social situations: speaking in front of a large group of Subjects and Procedures people; speaking to a small group of people; eating in We asked 668 consecutive English-speaking adults aged public; writing while being watched; using public toilets; 18 and older at a community-based, University-affiliated being introduced to a stranger; going to a party; dealing primary care clinic in San Diego to participate in this with authority figures such as a teacher or boss; return study at the time of their visit to their family physician. ing items to a store; looking someone you don’t know Patients were approached by an undergraduate research well straight in the eyes. The SPQ result is considered assistant who invited them to participate in a study of positive for subjects who answer affirmatively to either “the relationship between physical and mental health.” of the 2 initial yes or no questions, and report extreme They were informed that the study consisted of 2 parts, anxiety or extreme avoidance (ie, a score o f 3) in any of the first being a short set of questionnaires and the sec the 10 social situations (with the exception of public ond a phone interview of a subset of participants. speaking, where both extreme anxiety and avoidance Subjects gave informed written consent to participate in are required to select only those subjects with abnormal this study, which was approved by the University of levels of difficulty in what is a commonly-feared situa California, San Diego, Faculty of Medicine Committee on tion).17 One hundred sixty-nine (33.1%) of the 511 sub the Use of Human Subjects in Research. jects who completed the screening measures had a pos Those patients who consented to participate were itive test result on the SPQ. administered a packet of questionnaires that assessed demographic variables and current psychiatric symp Psychometric Properties of the SPQ toms. The assessment took approximately 15 minutes to Factor analysis (principal components analysis with complete. The research assistant reviewed the informa varimax rotation) o f the SPQ administered to the first tion, then approached patients who met specified cut 435 patients in this study showed that the SPQ items offs and invited them to participate in a follow-up diag load onto 2 factors: an observation factor consisting of 6 nostic interview. Patients who agreed were contacted by items that account for 41% of the variance, and a per phone within 10 days of the screening assessment, and forming and interacting factor of 4 items that account for completed the diagnostic interview and disability and an additional 12% of the variance. The SPQ has good utilization questionnaires over the phone. Patients were internal consistency (Cronbach’s (a) = 0.91). The anxiety paid $20 for the follow-up interview. and avoidance subscale totals of the SPQ are highly cor A total of 157 subjects (23.6%) refused to participate, related (r = 0.81; df = 434; P <.0005), which led us to drop leaving a sample of 511 patients (170 men and 341 the avoidance subscale in a subsequent revision to this women) who completed the screening questionnaire.