درمان جویی برای اختلال اضطراب اجتماعی در یک محیط روانپزشکی سرپایی عمومی

Abstract Many individuals with social anxiety disorder (SAD) seek treatment principally for another psychiatric disorder, but when directly asked, a majority of these individuals also desire treatment for SAD. Several reasons may exist for why individuals with SAD do not seek treatment for it, such as the severity or functional impairment related to SAD. The aim of the current study was to examine factors related to SAD severity, impairment, and comorbidity, to gain a better understanding of what factors may be related to treatment-seeking for SAD. In 819 psychiatric outpatients with SAD, initial results showed that age, duration of SAD illness, number of social fears endorsed, Clinical Global Impression score, Sheehan Disability Scale ratings for social life and distress, presence of major depressive disorder, and presence of depressive disorder not otherwise specified (DDNOS) were associated with treatment-seeking for SAD status. However, a regression analysis found that DDNOS was the most robust predictor of treatment-seeking for SAD status, followed by the number of feared social situations. Other factors should be examined in the future, such as knowledge of SAD and available treatment options.

1. Introduction Social anxiety disorder (SAD) is the fourth most prevalent psychiatric disorder based on epidemiological samples (Kessler et al., 2005), and one of the most common anxiety disorders in clinical samples (Brown et al., 2001 and Dalrymple and Zimmerman, 2008b). The presence of SAD is associated with significantly lower wages, lower probability of earning a college degree, lower probability of being in a managerial, technical, or professional occupation, lower work and home productivity, greater disability in family, romantic, and social relationships, and a greater lifetime history of suicide attempts compared to individuals with no psychiatric disorder (Katzelnick et al., 2001). Despite the significant impairment associated with SAD, most individuals with SAD do not describe it as their chief complaint when presenting to general psychiatric outpatient settings. A prior report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project indicated that only 4% of patients with SAD noted it as their principal reason for seeking treatment (Zimmerman et al., 2008). Most of these patients had a mood disorder or another anxiety disorder as their principal reason for seeking treatment. Other studies also have found that individuals with SAD tend to seek treatment for more acute conditions, such as Major Depressive Disorder (MDD; Weiller et al., 1996). Although most SAD patients seek treatment principally for another psychiatric condition, 75% of these patients report that they would like treatment for SAD once directly asked (Zimmerman and Chelminski, 2003). In addition, individuals with SAD demonstrate a longer delay from symptom onset to treatment seeking compared to other psychiatric conditions such as other anxiety disorders (Wagner et al., 2006). There could be several reasons why individuals with SAD do not initiate treatment for it; one reason could be that, as with many disorders, the level of severity and impairment related to SAD may need to reach a certain threshold before someone will consider treatment for it. A study based on individuals participating in the 1996 National Anxiety Disorders Screening Day found that compared to individuals without SAD symptoms, those with SAD symptoms were more likely to report the following barriers to previously seeking treatment: uncertainty over where to go for treatment; a fear of what others might think or say; a lack of insurance; and an inability to afford treatment (Olfson et al., 2000). Other studies have examined barriers to treatment for individuals with SAD, such as demographic characteristics (Coles et al., 2004). However, these studies typically are conducted in specialty anxiety clinics. Therefore, it was the aim of the current study from the MIDAS Project to examine some of these factors, particularly variables related to severity and impairment, in a general outpatient psychiatry setting. Gaining further understanding of these possible factors could help to determine what efforts may be needed to improve the identification and treatment of SAD. For example, if there is no difference in severity between individuals with SAD seeking versus not seeking treatment for it, then perhaps other variables such as awareness of the disorder and its treatment would need to be improved. This is important, given the disorder's chronic and unremitting course without treatment (Davidson et al., 1994 and Herbert and Dalrymple, 2005), its association with reduced quality of life (Wittchen et al., 2000), and its significant public health impact (Schneier et al., 1992 and Wittchen et al., 2000). A prior study from the MIDAS Project examined desire of treatment for SAD in patients seeking treatment primarily for MDD, and found that the number of social fears endorsed and work functioning differentiated patients who did versus did not desire treatment for comorbid SAD (Dalrymple and Zimmerman, 2008a). In the current study, it was hypothesized that patients who cited SAD as their principal reason for seeking treatment would demonstrate a greater number of social fears, greater social impairment, an earlier age of SAD onset, and a longer duration of SAD compared to individuals with comorbid SAD not seeking treatment principally for it. It was also hypothesized that individuals with comorbid SAD who desired treatment for it in addition to their chief complaint would report greater severity on the above variables compared to patients with comorbid SAD who did not desire treatment for it.

3. Results 3.1. Prevalence of SAD Of the sample of 3000 patients, 27.3% (n = 819) met current criteria for SAD. Only 3.8% of those 819 patients had SAD as the principal diagnosis (principal SAD-Tx group; n = 31). Most of the principal SAD-Tx patients had a current comorbid depressive disorder (n = 20/31; 64.5%), and nearly half had at least one current comorbid anxiety disorder (n = 14/31; 45.2%). The majority of the 819 patients with SAD had it as a comorbid diagnosis but also desired treatment for it (comorbid SAD-Tx group; 74.5%, n = 610). Among those patients, depressive disorders were the most common principal diagnoses (n = 285/610; 46.7%), followed by other anxiety disorders (n = 99/610; 16.2%). An additional 178 out of the 819 SAD patients (21.7%) had SAD as a comorbid diagnosis, but did not want treatment for it or were unsure whether or not they wanted treatment for it (comorbid SAD-No Tx group). Among this group of patients, the most common principal diagnoses also were depressive disorders (n = 92/178; 51.7%) and other anxiety disorders (n = 21/178; 11.8%). 3.2. Demographics, age of onset of SAD, and duration of SAD As shown in Table 1, the comorbid SAD-No Tx group was significantly older compared to the principal SAD-Tx and comorbid SAD-Tx groups (Mann–Whitney U = 1953.0, Z = 2449.0, P = 0.01; Mann–Whitney U = 43641.5, Z = −3.99, P < 0.001, respectively). There were no significant differences on the other demographic variables. The average age of onset of SAD for the entire sample was 12 years (S.D. = 8.6), with no differences between the groups. The average duration of SAD was 25 years (S.D. = 13.7), and patients in the comorbid SAD-No Tx group experienced a longer duration of SAD compared to patients in the principal SAD-Tx (Mann–Whitney U = 1695.5, Z = −3.42, P = 0.001) and comorbid SAD-Tx groups (Mann–Whitney U = 42404.5, Z = −4.45, P < 0.001; see Table 2). The correlation between duration of SAD and age of onset of SAD was moderate and significant (r = −0.51, p < 0.001). 3.3. Comorbidity A greater percentage of comorbid SAD-Tx patients met current criteria for MDD compared to those in the principal SAD-Tx group (χ2 = 9.93, d.f. = 1, P = 0.003; see Table 3). Those in the comorbid SAD-No Tx group also were more likely to have a current MDD diagnosis compared to the principal SAD-Tx group (χ2 = 9.39, d.f. = 1, P = 0.003). A greater percentage of patients in the principal SAD-Tx group met current criteria for DDNOS compared to patients in the comorbid SAD-Tx group (χ2 = 18.99, d.f. = 1, P = 0.001) and the comorbid SAD-No Tx group (χ2 = 15.21, d.f. = 1, P = 0.001). Patients in the principal SAD-Tx group were also given lower CGI scores compared to patients in the comorbid SAD-Tx (Mann–Whitney U = 6256.0, Z = −3.35, P = 0.001) and the comorbid SAD-No Tx groups (Mann–Whitney U = 1889.0, Z = −2.91, P < 0.01; Table 2). Although the overall chi square test for presence of at least one anxiety disorder was significant, no significant differences at the alpha = 0.01 level were found for the follow-up comparisons. 3.4. Social fears As indicated in Table 2, patients in the principal SAD-Tx group endorsed a greater number of social fears compared to the comorbid SAD-No Tx group (Mann–Whitney U = 248.5, Z = −3.40, P = 0.001). The comorbid SAD-Tx group also reported a greater number of social fears compared to the comorbid SAD-No Tx group (Mann–Whitney U = 7908.0, Z = −3.56, P < 0.001). However, when examining social fears categorically via subtype, there was no difference between the three groups on frequency of the generalized/specific subtypes. 3.5. Functioning There was no significant difference between the groups on presence of prior suicide attempts, or on the SADS items of work functioning and past or current social functioning (Table 2). However, differences were found on the social life and distress scales of the SDS, with the principal SAD-Tx group reporting greater impairment in social life in the past month compared to the comorbid SAD-No Tx group (Mann–Whitney U = 113.5, Z = −3.30, P = 0.001). The comorbid SAD-Tx group also reported greater impairment in social life compared to the comorbid SAD-No Tx group (Mann–Whitney U = 4424.5, Z = −3.27, P = 0.001). Both the principal SAD-Tx and comorbid SAD-Tx groups reported greater distress about their social anxiety in the past month compared to the comorbid SAD-No Tx group (Mann–Whitney U = 120.5, Z = −3.17, P = 0.002; Mann–Whitney U = 4403.0, Z = −3.31, P = 0.001, respectively). 3.6. Relative association of significant variables The post-hoc multinomial logistic regression analysis was conducted twice, first with the principal SAD-Tx group as the reference category (to compare the comorbid SAD-Tx and comorbid SAD-No Tx groups to the principal SAD-Tx group), and second with the comorbid SAD-No Tx group as the reference category (to allow comparison between the comorbid SAD-Tx and the comorbid SAD-No Tx groups). Variables found to be significant at the P = 0.01 level in the analyses above were included as predictors (age at time of presentation, duration of SAD, number of social fears endorsed, CGI score, presence of MDD, presence of DDNOS, and presence of at least one other anxiety disorder). Number of additional, current Axis I diagnoses also was included in the analysis to control for differences in the number of additional diagnoses between groups. 1 However, the SDS social life and distress ratings were excluded from the regression, due to the small number of individuals in the principal SAD-Tx group with that data (n = 9). Results showed that the overall model was significant (Likelihood Ratio Test χ2 = 50.54, d.f. = 16, P < 0.001), with the variables of number of social fears endorsed (χ2 = 21.49, d.f. = 2, P < 0.001) and DDNOS (χ2 = 7.14, d.f. = 2, P = 0.03) significantly predicting membership into the groups. When comparing the principal SAD-Tx group to the comorbid SAD-Tx group, the odds of being in the comorbid SAD-Tx group decreased by a factor of 0.75 for every additional social fear endorsed. In addition, the odds of being in the comorbid SAD-Tx compared to the principal SAD-Tx group increased by a factor of 8.13 when DDNOS was not present. In comparing the principal SAD-Tx group to the comorbid SAD-No Tx group, it was found that the odds of being in the principal SAD-Tx group increased by a factor of 1.66 for every additional social fear endorsed. Finally, when comparing the comorbid SAD-Tx and comorbid SAD-No Tx groups, results showed that the odds of being in the comorbid SAD-Tx group increased by a factor of 1.25 for every additional social fear endorsed (see Table 4).