اختلال اضطراب اجتماعی در درمانگاه های مراقبت های اولیه کهنه سربازان

To examine the prevalence and correlates of social anxiety disorder (SAD) in veterans, 733 veterans from four VA primary care clinics were evaluated using self-report questionnaires, telephone interviews, and a 12-month retrospective review of primary care charts. We also tested the concordance between primary care providers’ detection of anxiety problems and diagnoses of SAD from psychiatric interviews. For the multi-site sample, 3.6% met criteria for SAD. A greater rate of SAD was found in veterans with than without post-traumatic stress disorder (PTSD) (22.0% vs. 1.1%), and primary care providers detected anxiety problems in only 58% of veterans with SAD. The elevated rate of comorbid psychiatric diagnoses and suicidal risk associated with SAD was not attributable to PTSD symptom severity. Moreover, even after controlling for the presence of major depressive disorder, SAD retained unique, adverse effects on PTSD diagnoses and severity, the presence of other psychiatric conditions, and suicidal risk. These results attest to strong relations between SAD and PTSD, the inadequate recognition of SAD in primary care settings, and the significant distress and impairment associated with SAD in veterans.

Social anxiety disorder (SAD) is the third most prevalent psychiatric condition in the United States with epidemiological studies estimating a lifetime prevalence rate of 13.3%, and a 1-year prevalence rate of 7.9% in community samples (Kessler et al., 1994). Rates apparently have increased over the past few generations (Heimberg, Stein, Hiripi, & Kessler, 2000). Left untreated, SAD is a persistent and disabling condition that involves the often paralyzing fear of interacting or doing things in front of other people because of social evaluative concerns. Individuals with SAD experience high levels of functional impairment at work and school (Schneier et al., 1994; Wittchen, Fuetsch, Sonntag, Mueller, & Liebowitz, 2000). As for interpersonal functioning, SAD is associated with smaller social networks, less social support and acceptance, a high probability of being single or divorced, a low probability of being in a romantic relationship, and less sexual satisfaction (Davidson, Hughes, George, & Blazer, 1994; Schneier et al., 1994; Wittchen et al., 2000). Over 70% of individuals with SAD meet criteria for comorbid anxiety, mood, and alcohol abuse disorders (e.g., Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996; Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992), and these individuals are at high risk for suicidality (Schneier et al., 1992). The present study was interested in expanding the study of SAD to trauma-exposed veterans with and without post-traumatic stress disorder (PTSD). Several studies have shown that PTSD is associated with significant social functioning difficulties and impaired social relations (e.g., Frueh, Turner, Beidel, & Cahill, 2001; Jordan et al., 1992; Riggs, Byrne, Weathers, & Litz, 1998). In particular, the presence of PTSD is associated with social skills problems, less satisfaction in intimate relationships (e.g., romantic, parent–child), and social interactions and relationships that tend to be characterized by more conflict and hostility, poorer communication, and less emotional expressiveness, intimacy, and positive sharing. Despite increased attention to SAD and its role in psychological functioning, the study of SAD in trauma-exposed veterans (or any trauma survivors) is in its infancy. For the few published examinations of SAD in veterans, samples have ranged from 41–47 veterans (Crowson, Frueh, Beidel, & Turner, 1998; Hofmann, Litz, & Weathers, 2003; Orsillo, Heimberg, Juster, & Garrett, 1996); the exception (n=304n=304) narrowly focused on rates of SAD in veterans with and without PTSD (Orsillo, Weathers, Litz, Steinberg, Huska, & Keane, 1996). For those studies using diagnostic interviews, 15% (Hofmann et al., 2003; Orsillo et al., 1996) and 72% (Orsillo et al., 1996) of veterans with PTSD met criteria for a diagnosis of SAD compared to 5% (Hofmann et al., 2003), 7% (Orsillo et al., 1996), and 22% (Orsillo et al., 1996) of veterans without PTSD. Although Orsillo et al. (1996) reported very high rates of SAD in veterans, only 41 veterans were examined and interviewers were not blind to hypotheses. Overall, existing data support a significant, albeit neglected, relation between these psychiatric conditions. Only one published study has examined the correlates of SAD in veterans (Orsillo et al., 1996), finding post-war social anxiety to be positively associated with war-related shame and adverse homecoming experiences. Although Orsillo's seminal work on SAD and PTSD was published almost a decade ago, only three additional studies have been conducted on the topic with each narrowly focusing on relations among PTSD, SAD and depressive symptoms. Moreover, the sample sizes of these studies were small and the recruitment process tended to lack generalizability, relying on advertisements (Hofmann et al., 2003) and outpatients from mental health specialty clinics (Crowson et al., 1998; Orsillo et al., 1996). There are reasons to expect the presence of SAD to amplify the difficulties of veterans with and without PTSD. Individuals who are especially concerned about being rejected and embarrassed are more sensitive to social threat cues, and tend to interpret neutral and ambiguous social situations as threatening (e.g., Clark & Wells, 1995; Rapee & Heimberg, 1997). These information-processing biases lead to intense negative emotions, and negative emotions tend to be misinterpreted as evidence of social failure, further intensifying initial fears and social cognitive biases. Depending on the severity and intensity of this cyclical process, ultimately, individuals engage in some level of experiential avoidance as a means of coping. One of the by-products of experiential avoidance is that the prerequisites to positive social interactions, such as the ability to properly display and read social cues, as well as emotional self-disclosure, expressiveness, responsiveness are disrupted. Thereby, social fears can lead to less positive social activity and relationships, and greater social impairment. The manifest behaviors of PTSD and SAD, such as distress in social interactions, behavioral inhibition, social avoidance patterns, and impaired social relationships may be similar. However, the etiological and maintaining factors can be expected to diverge across these conditions. With SAD, these behaviors derive from core fears of being negatively evaluated and rejected, whereas with PTSD, these behaviors could derive from symptoms such as feeling detached from others, experiencing a restricted range of positive and negative emotions, and avoidance of social stimuli associated with trauma experiences. Thus, whether SAD develops before, after, or concomitantly with PTSD, there is reason to believe that SAD will have an incremental adverse association with indices of distress, impairment, and well-being in veterans. Overall, there is a general absence of empirical data on the complex relation between SAD and PTSD, and outcomes related to the presence of SAD in veterans. The examination of SAD in veterans is of clinical importance because: (a) positive social activity is arguably the largest contributor to well-being and quality-of-life (Baumeister & Leary, 1995; Ryff & Singer, 2000), (b) high levels of social support offer resilience for post-trauma recovery (King, King, Fairbank, Keane, & Adams, 1998; Solomon, Mikulincer, & Avitzur, 1988), (c) social difficulties tend to be a primary complaint of clients treated for PTSD (Herman, 1992), and (d) facilitating social and emotional skills has been evaluated as a useful target of PTSD intervention (Frueh, Turner, Beidel, Mirabella, & Jones, 1996). Factors that impede social functioning, such as the social fear and avoidance, and functional impairment associated with SAD, represent a critical area to examine in individuals who have experienced trauma or are at risk for adverse stress-related outcomes. Primary care providers tend to be the initial, and sometimes only, professionals to recognize, diagnose, and manage anxiety disorders in the large majority of medical patients (Fifer, Mathias, Patrick, Mazaonson, Lubeck, & Buesching, 1994; Kirmayer, Robbins, Dworkind, & Yaffe, 1993; Ormel, Koeter, van den Brink, & van de Willige, 1991). Benefits of examining SAD in veterans recruited from Veterans Affairs (VA) primary care clinics are that findings can be generalized to those veterans who use the VA for their healthcare (as opposed to samples recruited from mental health or specialty clinics), and primary care providers are at the frontline of psychiatric evaluations and treatments. Thus, using a primary care veteran sample with assessment information from primary care providers allows for an examination of prototypical psychiatric assessment and treatment. To our knowledge, there are no published data on the prevalence and nature of SAD using primary care veteran samples. The present study was designed to extend the small body of work on SAD in veterans in several ways. First, we used a large-scale multi-site sample of veterans from four VA primary care clinics. To maximize generalizability, we began with an initial sample of every veteran with at least one primary care appointment in the year under study (as opposed to randomly selecting patient arrivals, which oversamples for heavy health service users). Second, we were interested in correlates of SAD in veterans. We examined a broad range of socio-demographic and clinical characteristics including comorbidity, suicidal risk, and dimensions of psychological and physical quality-of-life. For all variables related to the presence/absence of SAD, we examined the specificity of SAD effects by controlling for (1) PTSD severity and (2) the presence of depression. Third, because primary care providers tend to be the first, and sometimes only, professionals that evaluate psychological distress in veteran and non-veteran populations, we examined whether or not primary care physicians detected the presence of SAD in their patients. We compared the recognition rate of anxiety problems in veterans (a liberal test) compared to the presence of SAD diagnoses as assessed by validated, semi-structured psychiatric interviews. We hypothesized a strong relationship between SAD and PTSD in veterans. Upon examining SAD as the index disorder, SAD was expected to increase the risk for other psychiatric conditions, greater suicidal risk, and lower quality-of-life. Due to an absence of research on the topic, relations between SAD and socio-demographic and clinical characteristics were exploratory. Additionally, we expected that primary care providers would fail to detect anxiety problems in a large percentage of their patients diagnosed with SAD by structured psychiatric interviews.