Social Anxiety Disorder: Comorbidity and Its Implications Social Anxiety Disorder: Comorbidity and Its Implications R. Bruce Lydiard, M.D., Ph.D. Social anxiety disorder is an extremely common and potentially disabling psychiatric disorder. Generalized social anxiety disorder, a subtype of the disorder, is believed to be the most common and © Copyrightmost severe form. It is2001 also the formPhysicians that is most often associatedPostgraduate with other psychiatric Press, disorders. Inc. Unless the clinician has a high index of suspicion, social anxiety disorder may remain undetected. The clinical and treatment implications of the most common psychiatric comorbidities associated with social anxiety disorder are discussed in this article, with a focus on major depression, panic disorder, posttraumatic stress disorder, and alcohol abuse/dependence. Other psychiatric disorders and some medical conditions commonly associated with social anxiety disorder are briefly mentioned. Finally, a differential diagnosis of social anxiety disorder is described. Individuals who present for treatment of other anxiety disorders, mood disorders, or alcohol/substance abuse disorders should be considered at risk for current but undetected social anxiety disorder. (J Clin Psychiatry 2001;62[suppl 1]:17–23) One personal copy may be printed ocial anxiety disorder, or social phobia, is an ex- suggested. Patients who present with depression, other Stremely common and potentially disabling psychiatric anxiety disorders, or alcohol use disorders should be con- disorder. Table 1 itemizes the key diagnostic features of sidered at risk for current but undetected social anxiety social phobia according to the Diagnostic and Statistical disorder. Diagnostic assessment for social anxiety disor- Manual of Mental Disorders, Fourth Edition (DSM-IV).1 der should be a routine part of any psychiatric evaluation. Social phobia affects women twice as often as men and tends to persist over time if not treated effectively. Social COMORBIDITY OF PSYCHIATRIC DISORDERS phobia often coexists with other psychiatric disorders and may remain undetected in many individuals unless the cli- The National Comorbidity Survey (NCS)10 was a U.S. nician takes a careful history and has a high index of suspi- population survey conducted in the early 1990s to assess cion. Community studies and clinical samples suggest that the coexistence of psychiatric disorders (i.e., psychiatric there is a high rate of comorbidity in individuals with anx- comorbidity). In this study, a population sample of 8098 iety disorders, including social anxiety disorder,2–8 and noninstitutionalized individuals, aged 18 to 54 years, were there is evidence that social anxiety disorder and general- evaluated for the presence of one or more psychiatric dis- ized anxiety disorder are almost always associated with orders via the Composite International Diagnostic Inter- one or more additional anxiety disorders and/or depressive view (CIDI), a structured interview. One of the many valu- disorder.9 This review focuses on the comorbidity of social able findings from the NCS was that psychiatric disorders phobia with major depression, panic disorder, posttrau- were not randomly distributed in the population. Rather, matic stress disorder (PTSD), and alcohol abuse/depen- they tended to aggregate in a small percentage of the popu- dence. Brief mention of other comorbidities is included, lation. Individuals with 3 or more psychiatric disorders and a differential diagnosis of social anxiety disorder is constituted only about 14% of the U.S. population but had 59% of all mental disorders and 88% of all serious mental disorders in the prior 12 months. Many of these individuals with a disproportionate share From the Mood and Anxiety Program, Medical University of of multiple psychiatric disorders suffered from comorbid South Carolina, Charleston. anxiety and depression; exhibited greater limitations in job, This article is based on “Social Anxiety Disorder: Its Relationship With Other Psychiatric Disorders,” a presentation family, and employment; and utilized a disproportionately made by Dr. Lydiard at a symposium entitled Advances and high level of health care resources.11 The comorbid states Emerging Treatments in Social Phobia. The symposium took of anxiety and depression tended to be more persistent than place on January 10, 2000, in Atlanta, Ga. Advances and Emerging Treatments in Social Phobia was sponsored by Duke pure anxiety or depression. Furthermore, the authors esti- University School of Medicine and supported through an mated that detection and treatment of comorbid anxiety and unrestricted educational grant from Pfizer Inc. Reprint requests to: R. Bruce Lydiard, M.D., Ph.D., 67 mood disorders could greatly lessen the workplace costs President St., P.O. Box 250861, Charleston, SC 29425. (e.g., reduced productivity) of psychiatric disorders. Impor- J Clin Psychiatry 2001;62 (suppl 1) 17 R. Bruce Lydiard Table 1. Key Diagnostic Features of Social Anxiety Disorder Figure 1. Lifetime Rates of Psychiatric Disorders in (social phobia)a Individuals With and Without Social Anxiety Disordera Fear that words or actions will prove humiliating or embarrassing Panic Disorder Social Anxiety Disorder Exposure to or thinking about entering feared situations causes (N = 361) Anxiety OCD No Social Anxiety Disorder Physiologic symptoms (flushing, sweating, tremulousness) Major Depression (N = 13,176) Fear recognized as excessive or unreasonable Bipolar Depression Avoidance of feared situation or endurance of it with distress Dysthymia Social or occupational problems, or marked distress, arising from Alcohol Abuse avoidance, fear, or anxious anticipation Drug Abuse Unrelated to other Axis I or Axis III disorders Somatization Disorder aBased on DSM-IV.1 © Copyright 2001 Physicians PostgraduateAgoraphobia Press, Inc. 01020304050 Percentage tantly, preexisting anxiety, including social phobia, was the strongest predictor of subsequent development of major aData from Schneier et al.13 Abbreviation: OCD = obsessive- compulsive disorder. depression.10,11 Since anxiety disorders, including social phobia, tend to appear earlier than most other psychiatric disorders, they constitute a risk factor for the development Table 2. Diagnostic Subtypes of Social Anxiety Disordera of other psychiatric disorders. As comorbidity occurs, the 10 Generalized risk for additional disorders also increases. Anxiety precipitated by most social interactions (except those with The public health implications of the NCS findings are family or close friends) clear. Detection and treatment of psychiatric disorders, Most severe form of social phobia One personal copy mayLikelihood be printed of comorbid psychiatric conditions, including avoidant such as anxiety disorders, early in life might prevent the personality disorder appearance of subsequent disorders, thus reducing both Nongeneralized the considerable financial12 and psychosocial burden im- Limited to specific social situations (eg, public speaking, posed by comorbidity in the U.S. population. performance as an actor or musician) aBased on DSM-IV.1 Social Anxiety Disorder (Social Phobia) and Psychiatric Comorbidity second subtype, which affects approximately one fourth of Social phobia is the most common anxiety disorder and individuals with social anxiety, includes one or a few cir- is more frequently associated with secondary depression cumscribed social fears, usually involving performance (22.4%) than any other anxiety disorder.11 In individuals situations such as public speaking. Individuals with the with social phobia, major depression occurred a mean of generalized subtype are 3 times more likely to suffer from 11.9 years after onset, and a mean of 4.3 disorders affected comorbid anxiety disorders and 2 times more likely to those with secondary major depression. These findings, as suffer from mood disorders than those with the nongener- well as those from the earlier Epidemiologic Catchment alized subtype.20,21 Adolescents who suffer from social Area (ECA) study (Figure 1),13 suggest that comorbid dis- phobia are more likely to suffer from major depression, orders often complicate the clinical picture in many pa- academic difficulties due to attentional disruption related tients with social phobia. Of the individuals identified as to social anxiety, truancy and other behavioral problems, having social phobia in the NCS, approximately 80% had and alcohol and other substance abuse.21–26 At this point, more than one psychiatric disorder.11 there are too few data to evaluate whether comorbidity af- The NCS estimates of the lifetime (13.8%) and 1-year fects treatment outcome for social anxiety disorder. One (7.9%) prevalence rates for social phobia10 are higher than large naturalistic study,27 which observed a cohort of pa- the estimates from the ECA study.14 One possible reason tients with social anxiety disorder, showed that the clinical for this difference is that there were 6 stem questions in the status at 65 weeks was not affected by comorbidity. Nota- CIDI employed in the NCS, compared with 3 used in the bly, there was a low rate of remission of social anxiety dis- ECA study. order over this follow-up period. Social anxiety disorder is a particularly difficult prob- The consequences of comorbidity in social anxiety dis- lem to detect, since it begins early in life (primarily in the order are substantial. Compared with individuals with so- first 2 decades6,13,15) and the affected individuals may