اختلال اضطراب اجتماعی در 300 بیمار بستری برای اعتیاد به الکل در برزیل: شیوع بالا و تحت درمان

Abstract Background Although the frequency of social phobia is high among alcoholic patients, this anxiety disorder is often neglected because treatment tends to be focused exclusively on alcohol dependence. Methods A total of 300 hospitalized alcoholic patients were interviewed using Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and Liebowitz Social Anxiety Scale as well a questionnaire to check the use of medication for social phobia among alcoholics and the relationship between social phobia and alcohol use. Results A prevalence of 30.6% was found for specific phobia, 24.7% for social phobia, 22.2% for anxiety disorder induced by alcohol, 19.3% for generalized anxiety disorder, 5% for obsessive-compulsive disorder, 4.6% for posttraumatic stress disorder, and 2% for panic disorder with agoraphobia. Social phobia preceded alcohol dependence in 90.2% of the patients. The frequency of the use of medication for social phobia among social phobic alcoholics was 20.3%. Conclusions The study confirms the high prevalence of anxiety disorders among alcoholics, particularly of social phobia. It also suggests that social phobia precedes alcohol dependence but shows that the use of medication for social phobia is still infrequent. Further studies are required to check if the failure to identify this comorbidity can make the recovery of alcoholics even more difficult.

. Introduction The occurrence of anxiety disorders and disorders because of alcohol abuse or dependence in one same patient, characterizing a comorbidity, has been the object of many studies. Earlier works found an increased frequency of this comorbidity among specific populations in therapeutic settings for the treatment of drug dependence, mental disorders, or in other healthcare settings [1], [2] and [3]. Later, with the performance of larger epidemiological studies, including the above-mentioned groups as well as in large community samples, it has been shown that such increased frequency was not confined to those environments, rather extending in a general way [4] and [5]. Several studies have reported that patients who are dependent on psychoactive substances have a higher prevalence of anxiety disorders than expected, and, on the other hand, patients with anxiety disorders have a higher prevalence of abuse or dependence on alcohol and other drugs than expected [3] and [4]. Nevertheless, these comorbidities are often ignored in alcoholic patients, and the focus of therapeutic attention is limited to the alcohol dependence. Among anxiety disorders, social phobia is specially important because it is a frequent, disabling, and treatable condition. Patients with social phobia often report that they consider alcohol to be useful in fearful situations and that they drink to minimize anticipatory anxiety [2]. Hence, patients with social phobia develop alcohol-related problems, and patients with alcohol abuse or dependence have a high risk for social phobia, resulting in one of the most frequent comorbid conditions found in clinical practice [1] and [4]. Lepine and Pelissolo [6] reviewed investigations on the prevalence of social phobic disorder in alcoholic populations and of alcoholism in groups of social phobic patients. The prevalence of social phobia ranged from 2.4% to 57% (mean 21%) in alcoholic samples. Reciprocally, the diagnosis of alcoholism in samples of social phobic patients ranged from 14.3% to 43.3% (mean 26.5%). Among community epidemiological studies, the National Comorbidity Survey found similar results: the prevalence of lifetime social phobia to be 10.8% in males and 24.1% in females with a history of alcohol abuse. Among those with alcohol dependence, the percentage was 19.8% in males and 30.3% in females [5]. From the data of the Epidemiologic Catchment Area, a lifetime prevalence of 27.6% of alcohol abuse or dependence was found among social phobics [7]. The data from the Epidemiologic Catchment Area and National Comorbidity Survey point to a 2- or 3-fold greater risk for the development of alcohol abuse or dependence among social phobics as compared with non–social phobics, with an odds ratio between 2.2 and 3.5 [6]. Since the 1980s, social phobia has been considered a neglected anxiety disorder in the medical literature despite its social and personal damages [8]. Although at present this disorder is the focus of many studies, it is still underdiagnosed in spite of its high prevalence [9], [10] and [11]. The overlap of psychiatric disorders is also one of the factors contributing to general clinicians' and psychiatrists' negligence concerning social phobia. This is clearly observed in the low frequency of adequate treatment of this disorder [8], [10] and [11]. In the case of a patient with phobic anxiety who is prone to an addictive behavior, the more apparent problem of drug abuse often becomes the focus of attention, and the basic state of anxiety is neglected and, as a consequence, the patient is inadequately treated [12]. Patients with social phobia have significantly more comorbid disorders than patients suffering from other psychiatric disorders, and social phobia usually precedes other diagnoses [6], [10], [13] and [14]. The evaluation of the chronological order of appearance of social phobia and alcoholism can help the investigation of the self-medication hypothesis for the initial use of alcohol and dependence. According to the self-medication hypothesis, social phobia would precede the development of any problem with alcohol use. Alcohol would be initially used to reduce anxiety [15] and [16]. The observation that alcohol mitigates anxiety dates back to antiquity. Kushner et al [15] quote Hippocrates' saying that “drinking wine as much as water wards off anxiety and the terrors.” The same author ascribes to Westphal the observation, made in 1871, that “the use of beer or wine enables an agoraphobic patient to go through feared places comfortably.” Until today, the anxiolytic effects of alcohol as a form of self-medication promoting abuse and dependence are under investigation. On the other hand, the view that alcohol-related disorders induce anxiety disorders in the long-term has been object of several studies. Kushner et al [15] report that drinking can increase the response to stress and exacerbate anxiety states, suggesting that an anxiolytic effect in the short term may develop into anxyogenic ones in the long term, producing a spiraling vicious circle of alcohol use and anxiety symptoms. The aims of this study are (a) to evaluate the frequency of anxiety disorders, especially social phobia, in a sample of alcoholic patients; (b) to check the use of medication for social phobia among social phobic alcoholics; (c) to identify the chronological order of the appearance of social phobia and drinking-related disorders; and (d) to assess the effect of alcohol use in the clinical condition of social phobia.

3. Results The sample consisted predominantly of males (91.7%). The mean age of patients was 41.5 ± 8.6 years. The subgroup of patients who were married or lived together as a married couple was the largest one, accounting for 42.5% of the sample. Patients who had few years of elementary grade studies or finished elementary school accounted for 53% of the sample. There were no significant differences between social phobic and non–social phobic alcoholic patients with respect to age, marital status, or gender. A higher educational level among non–social phobics was detected (Table 1). Table 1. Social demographic characteristics of the sample of alcoholic patients on treatment from Porto Alegre, Brazil (N = 300) Total Social phobics Non–social phobics Gender Male 275 (91.7) 65 (87.8) 210 (92.9) Female 25 (8.3 ) 9 (12.2) 16 (7.1) Marital status Single 79 (26.3) 19 (25.7) 60 (26.8) Married 129 (43) 33 (44.6) 96 (42.5) Divorced/Separated 87 (29) 22 (29.7) 65 (28.8) Widowed 5 (1.7) 0 (0) 5 (2.2) Highest level of schooling (complete or incomplete) Elementary school 159 (53) 43 (58.1) 116 (51.3) High school 92 (30.6) 26 (35.1) 66 (29.2) College 49 (16.3) 5 (6.7) 44 (19.5) χ2 = 19.91; df = 5; P = .0013 Age (y, mean ± SD) Total 41.5 ± 8.6 Phobics 40.5 ± 8.3 Nonphobics 41.9 ± 8.7 Values are presented as number (percentage). Table options As to the type of drugs used by the alcoholic patients, 29.6% used other drugs besides alcohol, and cocaine was the most frequently used illicit drugs by this group. No differences could be established between social phobics and non–social phobics in other drugs used (Table 2). Table 2. Types of psychoactive drugs used by alcoholic patients (N = 300) Drug Total Social phobics Non–social phobics Alcohol 211 (70.4) 48 (64.8) 163 (72.1) Alcohol + cocaine 39 (13) 10 (13.5) 29 (12.8) Alcohol + cocaine + marijuana 22 (7.3) 6 (8.1) 16 (7.1) Alcohol + marijuana 18 (6) 7 (9.4) 11 (4.8) Alcohol + benzodiazepines 3 (1) 0 (0) 3 (1.3) Alcohol + other 7 (2.3) 3 (4.1) 4 (1.8) Values are presented as number (percentage). Table options Anxiety disorders were diagnosed in 59% of the respondents. The anxiety disorders more frequently were specific phobia, social phobia, anxiety disorder induced by alcohol, and generalized anxiety disorder (Table 3). Table 3. Frequency of anxiety disorders in alcoholic patients on treatment (N = 300) Disorder n (%) Specific phobia 92 (30.6) Social phobia 74 (24.7) Alcohol-induced anxiety disorder 67 (22.2) Generalized anxiety disorder 58 (19.3) Obsessive-compulsive disorder 15 (5) Posttraumatic stress disorder 14 (4.6) Panic disorder with agoraphobia 6 (2) Panic disorder without agoraphobia 2 (0.6) Agoraphobia 1 (0.3) Table options Among social phobics, social phobia preceded alcohol-related disorder in 90% of the patients. Concerning the chronic alcohol effects on phobic symptoms, there was worsening of social phobia symptoms during alcohol abstinence, at the same time as the phobic patients reported improvement of symptoms during alcohol intoxication (Table 4). Table 4. Relationship between alcohol and social phobia in a sample of social phobic alcoholic patients on treatment (n = 74) n % Temporal relationship Social phobia onset before alcohol use 67 90.5 Social phobia onset after alcohol use 7 9.5 Alcohol effect during intoxication Improvement of social phobia 65 87.8 Worsening of social phobia 7 9.5 No reported effect 2 2.7 Alcohol effect during abstinence Improvement of social phobia 0 0 Worsening of social phobia 41 55.4 No reported effect 33 44.6 Table options Among social phobic alcoholics, 28.4% had light social phobia, 43.2% had moderate social phobia, and 28.4% had severe social phobia. The frequency of use of medication for social phobia among the diagnosed patients was 20.3%. When the prescription of drug therapy was assessed relative to the severity of social phobia, 9.5% of patients with light social phobia, 28.1% of those with moderate social phobia, and 19% of those with serious social phobia were found to receive medication (Table 5). Table 5. Severity of social phobia and frequency of drug therapy in social phobic alcoholic patients (n = 74) Severity of social phobia On drug therapy Light 21 (28.4) 2/21 (9.5) Moderate 32 (43.2) 9/32 (28.1) Severe 21 (28.4) 4/21 (19) Total 74 (100) 15/74 (20.3) Values are presented as number (percentage).