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Clinical features and co-morbidity of social phobics in Turkey
Eur Psychiatry 2001 ; 16 : 115-21 © 2001 Éditions scientifiques et médicales Elsevier SAS. All rights reserved S092493380100548X/FLA
ORIGINAL ARTICLE
Clinical features and co-morbidity of social phobics in Turkey P.G. Gökalp1*, R. Tükel2, D. Solmaz1, T. Demir2, E. Kiziltan2, D. Demir2, A.N. Babaoðlu1 1 2nd Department of Neurosis, Bakirköy State Hospital for Psychiatric and Neurologic Diseases, Istanbul, Turkey; 2 Department of Psychiatry, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
(Received 30 April 1999; revised 30 July 2000)
Summary – The aim of this study is to investigate the clinical features and frequency and importance of related co-morbid disorders of social phobia in a clinical sample. Eighty-seven patients meeting DSM-III-R diagnostic criteria for social phobia were studied. All patients were assessed by using a semi-structured socio-demographic form, the Structured Clinical Interview for DSM-III-R, Manual for the Structured Clinical Interview for DSM-III-R Personality Disorders, Liebowitz Social Anxiety Scale, Hamilton Rating Scale for Depression and Hamilton Rating Scale for Anxiety. Sixty-eight (78.2%) of the group were male, 19 (21.8%) were female. The ages varied between 16–58 years, with a mean of 26.2 years (SD = 8.5). Fifty-one point seven percent of the subjects were assessed as having a co-morbid axis I disorder, of which 12.6% consisted of panic disorder and 10.3% agoraphobia. An additional axis II disorder had been found in 67.8% of the subjects, and 54.0% of them had been diagnosed as having avoidant personality disorder. The frequency of co-morbid disorders in our social phobic sample is lower than most of the studies in the literature. The interface between social phobia and avoidant personality disorder needs to be studied and discussed further. © 2001 Éditions scientifiques et médicales Elsevier SAS anxiety / clinical features / co-morbidity / depression / personality disorders / social phobia
INTRODUCTION The term social phobia was first introduced to psychiatric nomenclature by Marks and Gelder in 1966 [15]. The term defined fear of being humiliated or the fear of situations such as eating, drinking, trembling, blushing, speaking, writing or vomiting in the presence of others. Social phobia is defined today as the fear of being ashamed or humiliated in various social settings, such as speaking in public or participating with a group of unfamiliar people and avoiding these situations due to excessive anxiety [2].
*Correspondence and reprints. E-mail address: [email protected] (P.G. Gökalp).
Even though social phobia is a relatively young term, the concept underlying social phobia was already known. In the 1960s, when social phobia was introduced as a different category of phobias, it was thought to be a rather rare phenomenon, representing 8% of all the phobias [30]. Surveys in recent years have shown that the incidence of this disorder is high [4]. The National Comorbidity Survey has shown that social phobia is the third most common psychiatric disorder, with a prevalence rate of 13.3%, after major depressive episode (17.1%) and alcohol dependence (14.1%) [9]. Epidemiologic findings indicate that in community samples the lifetime rates of social phobia are higher for
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females. The age of onset is the mid-teens and social phobia starts before any other psychiatric disorder [28]. Social phobia has been defined as having two subtypes, generalized and specific, in the DSM-III-R [1]. The generalized subtype is defined as social phobia causing fear in most social situations, whereas specific social phobics experience fear in one or two social situations in the same symptom cluster, performance or interaction situations. The reliability and validity of these two diagnostic subgroups have been studied and it has been reported that generalized social phobia can represent a distinct entity [14]. In spite of the studies showing the high prevalence rate of social phobia, it has been the least studied, or ‘neglected’ among the anxiety disorders, as Liebowitz has stated [13]. The aim of this study is to investigate the clinical and demographic features of 87 social phobics from two outpatient clinics in Istanbul, Turkey. SUBJECTS AND METHODS Subjects Consecutive patients referred to the outpatient departments of the Istanbul University Faculty of Medicine Department of Psychiatry (IUDP) and Baky´ rköy State Research and Training Hospital for Psychiatric and Neurologic Diseases Department of Neurosis (BRTH) were assessed by one of the investigators with a checklist consisting of DSM-III-R criteria for social phobia. Then, 87 outpatients from these two psychiatric institutions in Istanbul, (43 patients from IUDP and 44 patients from BRTH), who were diagnosed as social phobics and gave informed consent to be a part of the study, were included in the study [1]. Instruments A semi-structured interview form, prepared by the authors, was used to investigate the demographic and clinical features as well as the clinical history of the patients. The Structured Clinical Interview for DSM-III-R (SCID) was used to diagnose the axis I disorders [21]. The Manual for the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) was used to diagnose the axis II disorders in the sample [22]. The Liebowitz Social Anxiety Scale (LSAS) was used to assess the phobic anxiety and avoidance levels and identify the situations feared and/or avoided by the
patients. The scale has 24 items of which 13 are about performance and 11 are about social interactions. The items are rated by the clinician according to the patient’s anxiety or avoidance levels from 1 to 4. With LSAS, in this study, the most common situations that caused anxiety or avoidance have been identified by those items scored 3 or 4. The Hamilton Rating Scale for Depression (HAMD) and Hamilton Rating Scale for Anxiety (HAMA) were used to identify the subject’s severity of depression and anxiety [7, 8]. These scores are thought to bring some insight into the clinical picture of those subjects with different co-morbidity status. Procedure Social phobia and other axis I disorders were diagnosed by SCID, whereas personality disorders were diagnosed by SCID-II. Diagnoses were made by one of the two senior psychiatrists, whereas the scales were given by another investigator. Generalized social phobia is defined as social phobia where most social situations are feared and avoided; on the other hand, one or two situations from the same cluster (performance or interaction) are feared and avoided in specific social phobia. Generalized and specific social phobia subgroups were identified by consensus of two senior psychiatrists. Statistical tests were done by SPSS 6.1 software. The t-test was used to evaluate differences between groups on continuous variables. RESULTS The mean age of the 87 social phobic patients was 26.2 years (SD = 8.5), with a range of 16–58. Sixty-eight (78.2%) were male and 19 (21.8%) were female. Sixtyfour (73.6%) were single, 23 (26.4%) were married or co-habitant. Thirty-six (41.4%) had a university degree, while 31 (35.6%) were high school, eight (9.2%) were middle school and 12 (13.8%) were elementary school graduates. Professions of the subjects were as follows: 33 (37.8%) students, 19 (21.8%) businessman, 12 (13.8%) jobless, nine (10.3%) government employees, seven (8.0%) were workers, five (5.7%) were housewives, and two (2.3%) were retired. When evaluated according to the work status, 48 (55.2%) had a stable job, 29 (33.3%) were not working due to other reasons, and ten (11.5%) were not working due to social phobia. Eur Psychiatry 2001 ; 16 : 115–21
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Table I. Comparison of female and male social phobic patients on the measures of anxiety, depression and social phobic fear and avoidance. All cases (N = 87) mean (SD)
Female patients (N = 19) mean (SD)
Male patients (N = 68) mean (SD)
Age of onset
16.2
(7.1)
14.8
(6.6)
16.6
(7.2)
Duration (years)
10.2
(8.5)
7.7
(5.3)
10.9
(9.1)
HAMA
17.4
(7.5)
16.2
(5.2)
17.7
(8.1)
HAMD
11.8
(6.0)
11.7
(4.8)
11.8
(6.3)
LSAS – fear
65.0
(12.8)
66.2
(12.6)
64.7
(12.9)
LSAS – avoidance
61.0
(12.9)
59.5
(10.8)
61.4
(132.5)
Mann-Whitney U = 526.0 z = –1.16 Mann-Whitney U = 527.0 z = –1.14 Mann-Whitney U = 554.0 z = –.77 Mann-Whitney U = 593.0 z = –.36 Mann-Whitney U = 607.0 z = –.40 Mann-Whitney U = 590.5 z = –.57
HAMA = Hamilton Rating Scale for Anxiety; HAMD = Hamilton Rating Scale for Depression; LSAS = Liebowitz Social Anxiety Scale.
The mean age of onset of social phobia was 16.2 years (SD = 7.1): the range was between 7 and 38 years. The mean duration of social phobia was 10.2 (SD = 8.5) years (table I). There were 11 (12.6%) patients who abused alcohol due to their social phobias. The rate of suicide attempts in the sample was 4.6% (N = 4). The mean HAMA score was 17.4 (SD = 7.5), while the mean score for HAMD was 11.8 (SD = 6.0). The mean score for anxiety in LSAS was 65.0 (SD = 12.8),
whereas the mean score for avoidance was 61.0 (SD = 12.9) (table I). The comparison of male and female social phobic subjects on the measures of anxiety, depression and social phobic fear and avoidance, as well as age of onset and duration of disorder, showed no statistically significant difference between the two groups (table I). The three most feared situations were acting, performing or speaking in front of an audience, speaking
Table II. Liebowitz Social Phobia Symptom Scale: situations causing ten most frequent anxiety and avoidance cases. Situations causing anxiety 1. Speaking up at a meeting without advance preparation 2. Acting, performing, or speaking in front of an audience 3. Giving a prepared oral report to a group 4. Being the center of attention 5 Talking to someone in authority 6. Trying to make someone’s acquaintance for the purpose of a romantic/sexual relationship 7. Entering a room when others are already seated 8. Returning goods or merchandise to a store to obtain a refund 9. Working while being observed 10. Going to a party Eur Psychiatry 2001 ; 16 : 115–21
N (%) 80 (92.0) 80 (92.0) 69 (79.3) 67 (77.0) 64 (73.6) 63 (72.4) 58 (66.7) 56 (64.4) 55 (63.2) 54 (62.1)
Situations causing avoidance 1. Speaking up at a meeting without advance preparation 2. Acting, performing,or speaking in front of an audience 3. Giving a prepared oral report to a group 4. Being the center of attention 5. Trying to make someone’s acquaintance for the purpose of a romantic/sexual relationship 6. Talking to someone in authority 7. Returning goods or merchandise to a store to obtain a refund 8. Entering a room when others are already seated 9. Going to a party 10. Working while being observed
N (%) 77 (88.5) 76 (87.4) 64 (73.6) 62 (71.3) 61 (70.1) 50 (57.5) 50 (57.5) 49 (56.3) 49 (56.3) 46 (52.9)
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Table III. Comparison of specific and generalized social phobic patients on the measures of anxiety, depression and social phobic fear and avoidance. Specific social phobia (N = 17) mean (SD) Age of onset
Generalized social phobia (N = 70) mean (SD)
17.6
(5.3)
15.8
(7.4)
9.8
(6.6)
10.3
(8.9)
HAMA
14.5
(6.9)
18.0
(7.5)
HAMD
9.9
(5.0)
12.2
(6.1)
LSAS–fear
55.5
(12.0)
67.3
(11.9)
LSAS–avoidance
52.9
(14.7)
62.9
(11.7)
Duration (years)
Mann-Whitney U = 425.5 z = –1.50 Mann-Whitney U = 547.5 z = –.14 Mann-Whitney U = 385.0 z = –1.62 Mann-Whitney U = 430.5 z = –1.09 Mann-Whitney U = 289.0 z = –3.28** Mann-Whitney U = 360.0 z = –2.52*
(*) P = .01, (**) P = .001. HAMA = Hamilton Rating Scale for Anxiety; HAMD = Hamilton Rating Scale for Depression; LSAS = Liebowitz Social Anxiety Scale.
than one or two situations were included in the generalized group. The two groups were compared according to age of onset, duration of disorder, severity of anxiety, depression and social phobic fear and avoidance. The groups had a statistically significant difference on the measures of social phobic fear and avoidance (table III). In the sample, 51.7% had an axis I diagnosis, with the following results: dysthymia 16.1% (N = 14), panic disorder 12.6% (N = 11), agoraphobia 10.3% (N = 9),
up in a meeting without any preparation, and presenting prepared oral information to a group, while the three most avoided situations were speaking up in a meeting without any preparation, acting, performing or speaking in front of an audience and presenting prepared oral information to a group (table II). The sample was divided into two groups as generalized (N = 70) and specific social phobic (N = 17) groups. Those who had fear and avoidance for more Table IV. Social phobia and axis I co-morbidity. Axis I diagnosis
N
(%)
Dysthymia Panic disorder Agoraphobia Obsessive-compulsive disorder Major depression Simple phobia Gen. anxiety disorder Alcohol use disorders Delusional disorder Axis I disorders (total)
14 11 9 8 6 6 3 2 1 45
(16.1) (12.6) (10.3) (9.2) (6.9) (6.9) (3.4) (2.3) (1.1) (51.7)
No co-morbid axis I disorder One co-morbid axis I disorder Two co-morbid axis I disorder Three or more co-morbid axis I disorder
42 27 15 3
(48.3) (31.0) (17.2) (3.4) Eur Psychiatry 2001 ; 16 : 115–21
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Social phobics in Turkey Table V. Social phobia and axis II co-morbidity. Axis II diagnosis
N
(%)
Avoidant Paranoid Obsessive-compulsive Dependent Passive-aggressive Schizoid Narcissistic Schizotypal Histrionic Borderline Self-defeating Axis II disorders (total)
47 23 19 12 9 6 5 4 4 2 1 59
(54.0) (26.4) (21.8) (13.8) (10.3) (6.9) (5.7) (4.6) (4.6) (2.3) (1.1) (67.8)
No co-morbid axis II disorder One co-morbid axis II disorder Two co-morbid axis II disorder Three or more co-morbid axis II disorder
28 21 17 21
(32.2) (24.1) (19.5) (24.1)
obsessive-compulsive disorder 9.2% (N = 8), major depression 6.9% (N = 6), simple phobia 6.9% (N = 6), generalized anxiety disorder 3.4% (N = 3), and alcohol abuse and somatization disorder 2.3% (N = 2) each (table IV). In the sample, 67.8% (N = 59) had an axis II diagnosis, with the following results: avoidant personality disorder 54.0% (N = 47), paranoid personality disorder 26.4% (N = 23), obsessive-compulsive 21.8% (N = 19), dependent 13.8% (N = 12), passive aggressive 10.3% (N = 9), schizoid 6.9% (N = 6), narcissistic 5.7% (N = 5), histrionic and schizotypal 4.6% (N = 4) each, borderline 2.3% (N = 2) and self-defeating 1.1% (N = 1) (table V). There were multiple co-morbid disorders in a number of subjects. Thirty-one percent (N = 27) had one co-morbid disorder, 17.2% (N = 15) had two, and 3.4% (N = 3) had three or more axis I co-morbid disorders. When the sample was evaluated according to personality disorders, 24.1% (N = 21) had one co-morbid personality disorder, 19.5% (N = 17) had two, and 24.1% (N = 21) had three or more axis II co-morbid disorders. DISCUSSION Epidemiologic studies suggest that social phobia is more frequent in females than males in community samples. On the other hand, contradicting results have been obtained from clinical samples, stating female preponderance in some studies and male preponderance in Eur Psychiatry 2001 ; 16 : 115–21
others [19, 23, 28]. The majority of subjects (78.2%) in our study are male. This difference might stem from the higher expectancy society has of males in their roles as providers and professionals, thus causing males to seek treatment more than females. This is also true for Turkey. It is already known that help-seeking behavior is influenced by cultural factors. Although there are fewer studies in non-Western countries on this subject, in the study from India it has been reported that more male patients have been referred to mental health facilities [17]. An additional cultural feature of social phobia is the so-called suitability of social phobic features such as shyness and avoidance of social situations to the female gender. This might cause the fewer number of female social phobics seeking help from clinical mental health facilities. There have been data about gender differences in the clinical picture and coping styles [25]. Our sample shows no statistically significant differences by the severity of depression, anxiety and social phobic fears and avoidance, and history of the disorder. More extensive research is needed to clarify the motivations based on help-seeking and links between sex role and social anxiety. In various studies, single, divorced or widowed subjects have higher prevalence rates (38–65.7%) than controls [29]. Among our subjects, 73.6% never got married. That this rate is among the highest in the literature might be due to the fact that social phobics have difficulties in forming romantic relationships, and
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the majority of our subjects were students, who are younger than the average marrying age. There have been contradicting results concerning the relationship between social phobia and educational status. Social phobics are said to have a lower educational status than the controlled subjects, due to the negative effect of social phobia on academic success. According to other studies, social phobia is seen in people from higher educational status [12, 19]. This was explained by the fact that the higher educated the people, the more they report disability and seek treatment. Fortyone point four percent of our sample belong to the group of university graduates, and 35.6% are high school graduates. Social phobia is a disabling disorder of early onset, with a chronic course, generally starting at adolescence; the mean age of onset ranges between ages 14.6 and 23.5 years [3, 6, 20]. The mean age of onset in our sample is 16.2 years and the duration of the disorder was 10.2 years, which is in accordance with the findings in the literature. Early onset is a reason for the difficulty in differentiating social phobia from avoidant personality disorder. In a community study on social anxiety, speaking in public was the most feared situation (55%). In our study, we based our conclusions on those situations that are scored 3 or 4 in the LSAS. The most feared and avoided situations were all situations concerning performing or speaking in public, which is similar to the results of the related literature. Generalized type social phobia was defined in the DSM-III-R as a “social phobia including most social situations,” whereas specific social phobia was defined as a clinical subtype confined to one or two situations [26]. The reliability and validity of these subtypes were investigated and compared on clinical characteristics by other authors [14]. The two groups in our sample were significantly different on the levels of social phobic fear and avoidance. This result could be expected since the more situations the subject feared or avoided the higher the increase in the mean LSAS score. The majority of our sample had a diagnosis of generalized social phobia, which might be due to the increased need for seeking psychiatric help. The Epidemiological Catchment Area (ECA) study in the U.S.A. suggests that 69% of social phobics had another lifetime axis I diagnosis [19]. We found that 51.7% of our sample had a lifetime axis I diagnosis. The Zurich Study Group investigated the association between social phobia and agoraphobia and found that
the course of the two disorders was similar. In the ECA study, the co-morbid disorder with the highest prevalence rate was simple phobia (59%) and agoraphobia (44.9%) [23]. In a clinical sample, on the other hand, depressive disorders were the most prevalent disorders, while panic, generalized anxiety, simple phobia and obsessive compulsive disorders were seen consecutively among anxiety disorders [27]. Our results are roughly similar to these results. The frequency of subjects with more than one co-morbid axis I disorder in our sample suggests the possibility of having another co-morbid disorder if already one other disorder accompanies social phobia. The relationship between social phobia and alcohol and drug abuse has been investigated thoroughly in recent years [16]. It has been reported that social phobics abuse alcohol twice as frequently as the normal population [11]. In a community sample, 19% abused alcohol and 17% abused anxiolytics, while in a clinical sample 28.1% abused alcohol and 15.8% abused drugs [19]. Almost 50% of social phobics use alcohol and anxiolytics in social situations with which they have to cope. Two patients in our sample abused alcohol, whereas none of our subjects abused drugs or anxiolytics. Our results show that alcohol and drug abuse is not a major problem in our clinical sample compared to other results in the literature. It has been reported that social phobics tend to have suicidal thoughts more often than the general population, whereas those social phobics with co-morbid conditions make a suicide attempt five times more frequently than the normal population [5, 19]. In a study by Amies et al. [3], the rate of attempted suicide in social phobics has been reported to be 14%. The attempted suicide rate in our study is 4.6%, which is higher than the general population in Turkey, but lower than the rates in similar studies conducted in Western societies. This might be the result of a lower general suicide rate in Turkish society either due to the structure of the society or the effect of the Islamic religion, where suicide is considered to be sinful behavior. Another reason might be that those with a more severe depressive state with serious suicidal tendencies are generally hospitalized and are not followed up in this outpatient department. Jansen et al. [10] reported that 56.3% of social phobics have at least one personality disorder, the most common being avoidant, dependent, obsessivecompulsive and paranoid personality disorders. The most common axis II disorders in our sample were Eur Psychiatry 2001 ; 16 : 115–21
Social phobics in Turkey
avoidant (54.0%), paranoid, obsessive-compulsive and dependent personality disorders, which is similar with the results of the related literature [12, 18, 19, 24]. The high percentage of co-morbid avoidant personality disorder brings forward once again the issue of the interface between social phobia and avoidant personality disorder. The scrutiny and perfectionist style of obsessivecompulsive personality disorder might form a basis for the social anxiety and feelings of easily experiencing a failure by social phobics. CONCLUSION General characteristics of our sample show that this group of social phobic patients is young, male, and single with relatively high educational status. The frequency of axes I and II co-morbidity is close to the rates in the literature. Work status, alcohol and drug abuse and suicidality rates are lower than the rates in similar studies in the literature. The high co-morbidity of avoidant personality disorder with social phobia suggests the necessity of long-term follow-up studies with larger community samples to shed light on the issue of overlap between these two clinical conditions. REFERENCES 1 American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 3rd ed, rev. Washington, DC: American Psychiatric Association; 1987. 2 American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994. 3 Amies PL, Gelder MG, Shaw PM. Social phobia: a comparative clinical study. Br J Psychiatry 1983 ; 142 : 174-9. 4 Bisserbe JC, Weiller E, Boyer P, Lepine JP, Lecrubier Y. Social phobia in primary care: level of recognition and drug use. Int Clin Psychopharmacol 1996 ; 11 (Suppl 3 ) : 25-8. 5 Cox BJ, Direnfeld DM, Swinson RP, Norton GR. Suicidal ideation and suicide attempts in panic disorder and social phobia. Am J Psychiatry 1994 ; 151 : 882-7. 6 Davidson JRT, Hughes DC, George LK, Blazer DG. the epidemiology of social phobia: findings from the Duke Epidemiologic Catchment Area Study. Psychol Med 1993 ; 23 : 709-18. 7 Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959 ; 32 : 50-5. 8 Hamilton M. Development of a rating scale for primary depressive illness. Br J Clin Psychol 1967 ; 6 : 278-96. 9 Hirschfeld RM. The impact of health care reform on social phobia. J Clin Psychiatry 1995 ; 5 Suppl : 13-7. 10 Jansen MA, Arntz A, Merckelbach H, Mersch PPA. Personality disorders and features in social phobia and panic disorders. J Abnorm Psychol 1994 ; 103 : 391-5.
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11 Kushner MG, Sher KJ, Beitman BD. The relation between alcohol problems and the anxiety disorders. Am J Psychiatry 1990 ; 147 : 685-95. 12 Lepine JP, Pélissolo A. Comorbidity and social phobia: clinical and epidemiological issues. Int Clin Psychopharmacol 1996 ; 1 (Suppl 3 ) : 35-41. 13 Liebowitz MR, Gorman MJ, Fyer AJ, Klein DF. Social phobia. Review of a neglected anxiety disorder. Arch Gen Psychiatry 1985 ; 42 : 729-36. 14 Mannuzza S, Schneier FR, Chapman TF, Liebowitz MR, Klein DF, Fyer AJ. Generalized social phobia. Arch Gen Psychiatry 1995 ; 52 : 230-7. 15 Marks IM, Gelder MG. Different onset ages in varieties of phobia. Am J Psychiatry 1966 ; 123 : 218-21. 16 Marshall JR. The diagnosis and treatment of social phobia and alcohol abuse. Bull Menninger Clin 1994 ; 58 (Suppl A) : 59-65. 17 Raguram R, Bhide VA. Patterns of phobic neurosis: a retrospective study. Br J Psychiatry 1985 ; 147 : 557-60. 18 Schneier FR, Spitzer RL, Gibbon M, Fyer AJ, Liebowitz MR. The relationship of social phobia subtypes and avoidant personality disorder. Compr Psychiatry 1991 ; 32 : 496-502. 19 Schneier FR, Johnson J, Hornig CD, Liebowitz MR, Weissman MM. Social phobia: comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry 1992 ; 49 : 282-8. 20 Solyom L, Ledwidge B, Solyom C. Delineating social phobia. Br J Psychiatry 1986 ; 149 : 464-70. 21 Spitzer RL, Williams JBW, Gibbon M. Structured Clinical Interview for DSM-III-R. Washington, DC: American Psychiatric Press; 1987. 22 Spitzer RL, Williams JBW, Gibbon M, First M. Manual for the Structured Clinical Interview for DSM-III-R Personality Disorders. Washington, DC: American Psychiatric Press; 1990. 23 Stein MB, Tancer ME, Gelernter CS, Vittone BJ, Uhde TW. Major depression in patients with social phobia. Am J Psychiatry 1990 ; 147 : 637-9. 24 Tran GQ, Chambless DL. Psychopathology of social phobia: effects of subtype and avoidant personality disorder. J Anxiety Disord 1995 ; 9 : 489-501. 25 Turk CL, Heimberg RG, Orsillo SM. An investigation of gender differences in social phobia. J Anxiety Disord 1998 ; 12 : 209-23. 26 Turner SM, Beidel DC, Townsley RM. Social phobia: a comparison of specific and generalized subtypes and avoidant peronality disorder. J Abnorm Psychol 1992 ; 101 : 326-31. 27 van Ameringen M, Mancini C, Stayn G, Donyson D. Relationship of social phobia with other psychiatric illness. J Affect Disord 1991 ; 21 : 93-9. 28 Weissman MM, Bland RC, Canino GJ, Greenwald S, Lee CK, Newman SC, et al. The cross-national epidemiology of social phobia: a preliminary report. Int Clin Psychopharmacol 1996 ; 11 (Suppl 3) : 9-14. 29 Wittchen HU, Beloch E. The impact of social phobia on quality of life. Int Clin Psychopharmacol 1996 ; 11 (Suppl 3 ) : 15-23. 30 WPA Social Phobia Task Force. Social phobia: clinical review. Montgomery SA, Ed. City: World Psychiatric Association; 1995.
ORIGINAL ARTICLE
Clinical features and co-morbidity of social phobics in Turkey P.G. Gökalp1*, R. Tükel2, D. Solmaz1, T. Demir2, E. Kiziltan2, D. Demir2, A.N. Babaoðlu1 1 2nd Department of Neurosis, Bakirköy State Hospital for Psychiatric and Neurologic Diseases, Istanbul, Turkey; 2 Department of Psychiatry, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
(Received 30 April 1999; revised 30 July 2000)
Summary – The aim of this study is to investigate the clinical features and frequency and importance of related co-morbid disorders of social phobia in a clinical sample. Eighty-seven patients meeting DSM-III-R diagnostic criteria for social phobia were studied. All patients were assessed by using a semi-structured socio-demographic form, the Structured Clinical Interview for DSM-III-R, Manual for the Structured Clinical Interview for DSM-III-R Personality Disorders, Liebowitz Social Anxiety Scale, Hamilton Rating Scale for Depression and Hamilton Rating Scale for Anxiety. Sixty-eight (78.2%) of the group were male, 19 (21.8%) were female. The ages varied between 16–58 years, with a mean of 26.2 years (SD = 8.5). Fifty-one point seven percent of the subjects were assessed as having a co-morbid axis I disorder, of which 12.6% consisted of panic disorder and 10.3% agoraphobia. An additional axis II disorder had been found in 67.8% of the subjects, and 54.0% of them had been diagnosed as having avoidant personality disorder. The frequency of co-morbid disorders in our social phobic sample is lower than most of the studies in the literature. The interface between social phobia and avoidant personality disorder needs to be studied and discussed further. © 2001 Éditions scientifiques et médicales Elsevier SAS anxiety / clinical features / co-morbidity / depression / personality disorders / social phobia
INTRODUCTION The term social phobia was first introduced to psychiatric nomenclature by Marks and Gelder in 1966 [15]. The term defined fear of being humiliated or the fear of situations such as eating, drinking, trembling, blushing, speaking, writing or vomiting in the presence of others. Social phobia is defined today as the fear of being ashamed or humiliated in various social settings, such as speaking in public or participating with a group of unfamiliar people and avoiding these situations due to excessive anxiety [2].
*Correspondence and reprints. E-mail address: [email protected] (P.G. Gökalp).
Even though social phobia is a relatively young term, the concept underlying social phobia was already known. In the 1960s, when social phobia was introduced as a different category of phobias, it was thought to be a rather rare phenomenon, representing 8% of all the phobias [30]. Surveys in recent years have shown that the incidence of this disorder is high [4]. The National Comorbidity Survey has shown that social phobia is the third most common psychiatric disorder, with a prevalence rate of 13.3%, after major depressive episode (17.1%) and alcohol dependence (14.1%) [9]. Epidemiologic findings indicate that in community samples the lifetime rates of social phobia are higher for
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females. The age of onset is the mid-teens and social phobia starts before any other psychiatric disorder [28]. Social phobia has been defined as having two subtypes, generalized and specific, in the DSM-III-R [1]. The generalized subtype is defined as social phobia causing fear in most social situations, whereas specific social phobics experience fear in one or two social situations in the same symptom cluster, performance or interaction situations. The reliability and validity of these two diagnostic subgroups have been studied and it has been reported that generalized social phobia can represent a distinct entity [14]. In spite of the studies showing the high prevalence rate of social phobia, it has been the least studied, or ‘neglected’ among the anxiety disorders, as Liebowitz has stated [13]. The aim of this study is to investigate the clinical and demographic features of 87 social phobics from two outpatient clinics in Istanbul, Turkey. SUBJECTS AND METHODS Subjects Consecutive patients referred to the outpatient departments of the Istanbul University Faculty of Medicine Department of Psychiatry (IUDP) and Baky´ rköy State Research and Training Hospital for Psychiatric and Neurologic Diseases Department of Neurosis (BRTH) were assessed by one of the investigators with a checklist consisting of DSM-III-R criteria for social phobia. Then, 87 outpatients from these two psychiatric institutions in Istanbul, (43 patients from IUDP and 44 patients from BRTH), who were diagnosed as social phobics and gave informed consent to be a part of the study, were included in the study [1]. Instruments A semi-structured interview form, prepared by the authors, was used to investigate the demographic and clinical features as well as the clinical history of the patients. The Structured Clinical Interview for DSM-III-R (SCID) was used to diagnose the axis I disorders [21]. The Manual for the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) was used to diagnose the axis II disorders in the sample [22]. The Liebowitz Social Anxiety Scale (LSAS) was used to assess the phobic anxiety and avoidance levels and identify the situations feared and/or avoided by the
patients. The scale has 24 items of which 13 are about performance and 11 are about social interactions. The items are rated by the clinician according to the patient’s anxiety or avoidance levels from 1 to 4. With LSAS, in this study, the most common situations that caused anxiety or avoidance have been identified by those items scored 3 or 4. The Hamilton Rating Scale for Depression (HAMD) and Hamilton Rating Scale for Anxiety (HAMA) were used to identify the subject’s severity of depression and anxiety [7, 8]. These scores are thought to bring some insight into the clinical picture of those subjects with different co-morbidity status. Procedure Social phobia and other axis I disorders were diagnosed by SCID, whereas personality disorders were diagnosed by SCID-II. Diagnoses were made by one of the two senior psychiatrists, whereas the scales were given by another investigator. Generalized social phobia is defined as social phobia where most social situations are feared and avoided; on the other hand, one or two situations from the same cluster (performance or interaction) are feared and avoided in specific social phobia. Generalized and specific social phobia subgroups were identified by consensus of two senior psychiatrists. Statistical tests were done by SPSS 6.1 software. The t-test was used to evaluate differences between groups on continuous variables. RESULTS The mean age of the 87 social phobic patients was 26.2 years (SD = 8.5), with a range of 16–58. Sixty-eight (78.2%) were male and 19 (21.8%) were female. Sixtyfour (73.6%) were single, 23 (26.4%) were married or co-habitant. Thirty-six (41.4%) had a university degree, while 31 (35.6%) were high school, eight (9.2%) were middle school and 12 (13.8%) were elementary school graduates. Professions of the subjects were as follows: 33 (37.8%) students, 19 (21.8%) businessman, 12 (13.8%) jobless, nine (10.3%) government employees, seven (8.0%) were workers, five (5.7%) were housewives, and two (2.3%) were retired. When evaluated according to the work status, 48 (55.2%) had a stable job, 29 (33.3%) were not working due to other reasons, and ten (11.5%) were not working due to social phobia. Eur Psychiatry 2001 ; 16 : 115–21
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Table I. Comparison of female and male social phobic patients on the measures of anxiety, depression and social phobic fear and avoidance. All cases (N = 87) mean (SD)
Female patients (N = 19) mean (SD)
Male patients (N = 68) mean (SD)
Age of onset
16.2
(7.1)
14.8
(6.6)
16.6
(7.2)
Duration (years)
10.2
(8.5)
7.7
(5.3)
10.9
(9.1)
HAMA
17.4
(7.5)
16.2
(5.2)
17.7
(8.1)
HAMD
11.8
(6.0)
11.7
(4.8)
11.8
(6.3)
LSAS – fear
65.0
(12.8)
66.2
(12.6)
64.7
(12.9)
LSAS – avoidance
61.0
(12.9)
59.5
(10.8)
61.4
(132.5)
Mann-Whitney U = 526.0 z = –1.16 Mann-Whitney U = 527.0 z = –1.14 Mann-Whitney U = 554.0 z = –.77 Mann-Whitney U = 593.0 z = –.36 Mann-Whitney U = 607.0 z = –.40 Mann-Whitney U = 590.5 z = –.57
HAMA = Hamilton Rating Scale for Anxiety; HAMD = Hamilton Rating Scale for Depression; LSAS = Liebowitz Social Anxiety Scale.
The mean age of onset of social phobia was 16.2 years (SD = 7.1): the range was between 7 and 38 years. The mean duration of social phobia was 10.2 (SD = 8.5) years (table I). There were 11 (12.6%) patients who abused alcohol due to their social phobias. The rate of suicide attempts in the sample was 4.6% (N = 4). The mean HAMA score was 17.4 (SD = 7.5), while the mean score for HAMD was 11.8 (SD = 6.0). The mean score for anxiety in LSAS was 65.0 (SD = 12.8),
whereas the mean score for avoidance was 61.0 (SD = 12.9) (table I). The comparison of male and female social phobic subjects on the measures of anxiety, depression and social phobic fear and avoidance, as well as age of onset and duration of disorder, showed no statistically significant difference between the two groups (table I). The three most feared situations were acting, performing or speaking in front of an audience, speaking
Table II. Liebowitz Social Phobia Symptom Scale: situations causing ten most frequent anxiety and avoidance cases. Situations causing anxiety 1. Speaking up at a meeting without advance preparation 2. Acting, performing, or speaking in front of an audience 3. Giving a prepared oral report to a group 4. Being the center of attention 5 Talking to someone in authority 6. Trying to make someone’s acquaintance for the purpose of a romantic/sexual relationship 7. Entering a room when others are already seated 8. Returning goods or merchandise to a store to obtain a refund 9. Working while being observed 10. Going to a party Eur Psychiatry 2001 ; 16 : 115–21
N (%) 80 (92.0) 80 (92.0) 69 (79.3) 67 (77.0) 64 (73.6) 63 (72.4) 58 (66.7) 56 (64.4) 55 (63.2) 54 (62.1)
Situations causing avoidance 1. Speaking up at a meeting without advance preparation 2. Acting, performing,or speaking in front of an audience 3. Giving a prepared oral report to a group 4. Being the center of attention 5. Trying to make someone’s acquaintance for the purpose of a romantic/sexual relationship 6. Talking to someone in authority 7. Returning goods or merchandise to a store to obtain a refund 8. Entering a room when others are already seated 9. Going to a party 10. Working while being observed
N (%) 77 (88.5) 76 (87.4) 64 (73.6) 62 (71.3) 61 (70.1) 50 (57.5) 50 (57.5) 49 (56.3) 49 (56.3) 46 (52.9)
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Table III. Comparison of specific and generalized social phobic patients on the measures of anxiety, depression and social phobic fear and avoidance. Specific social phobia (N = 17) mean (SD) Age of onset
Generalized social phobia (N = 70) mean (SD)
17.6
(5.3)
15.8
(7.4)
9.8
(6.6)
10.3
(8.9)
HAMA
14.5
(6.9)
18.0
(7.5)
HAMD
9.9
(5.0)
12.2
(6.1)
LSAS–fear
55.5
(12.0)
67.3
(11.9)
LSAS–avoidance
52.9
(14.7)
62.9
(11.7)
Duration (years)
Mann-Whitney U = 425.5 z = –1.50 Mann-Whitney U = 547.5 z = –.14 Mann-Whitney U = 385.0 z = –1.62 Mann-Whitney U = 430.5 z = –1.09 Mann-Whitney U = 289.0 z = –3.28** Mann-Whitney U = 360.0 z = –2.52*
(*) P = .01, (**) P = .001. HAMA = Hamilton Rating Scale for Anxiety; HAMD = Hamilton Rating Scale for Depression; LSAS = Liebowitz Social Anxiety Scale.
than one or two situations were included in the generalized group. The two groups were compared according to age of onset, duration of disorder, severity of anxiety, depression and social phobic fear and avoidance. The groups had a statistically significant difference on the measures of social phobic fear and avoidance (table III). In the sample, 51.7% had an axis I diagnosis, with the following results: dysthymia 16.1% (N = 14), panic disorder 12.6% (N = 11), agoraphobia 10.3% (N = 9),
up in a meeting without any preparation, and presenting prepared oral information to a group, while the three most avoided situations were speaking up in a meeting without any preparation, acting, performing or speaking in front of an audience and presenting prepared oral information to a group (table II). The sample was divided into two groups as generalized (N = 70) and specific social phobic (N = 17) groups. Those who had fear and avoidance for more Table IV. Social phobia and axis I co-morbidity. Axis I diagnosis
N
(%)
Dysthymia Panic disorder Agoraphobia Obsessive-compulsive disorder Major depression Simple phobia Gen. anxiety disorder Alcohol use disorders Delusional disorder Axis I disorders (total)
14 11 9 8 6 6 3 2 1 45
(16.1) (12.6) (10.3) (9.2) (6.9) (6.9) (3.4) (2.3) (1.1) (51.7)
No co-morbid axis I disorder One co-morbid axis I disorder Two co-morbid axis I disorder Three or more co-morbid axis I disorder
42 27 15 3
(48.3) (31.0) (17.2) (3.4) Eur Psychiatry 2001 ; 16 : 115–21
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Social phobics in Turkey Table V. Social phobia and axis II co-morbidity. Axis II diagnosis
N
(%)
Avoidant Paranoid Obsessive-compulsive Dependent Passive-aggressive Schizoid Narcissistic Schizotypal Histrionic Borderline Self-defeating Axis II disorders (total)
47 23 19 12 9 6 5 4 4 2 1 59
(54.0) (26.4) (21.8) (13.8) (10.3) (6.9) (5.7) (4.6) (4.6) (2.3) (1.1) (67.8)
No co-morbid axis II disorder One co-morbid axis II disorder Two co-morbid axis II disorder Three or more co-morbid axis II disorder
28 21 17 21
(32.2) (24.1) (19.5) (24.1)
obsessive-compulsive disorder 9.2% (N = 8), major depression 6.9% (N = 6), simple phobia 6.9% (N = 6), generalized anxiety disorder 3.4% (N = 3), and alcohol abuse and somatization disorder 2.3% (N = 2) each (table IV). In the sample, 67.8% (N = 59) had an axis II diagnosis, with the following results: avoidant personality disorder 54.0% (N = 47), paranoid personality disorder 26.4% (N = 23), obsessive-compulsive 21.8% (N = 19), dependent 13.8% (N = 12), passive aggressive 10.3% (N = 9), schizoid 6.9% (N = 6), narcissistic 5.7% (N = 5), histrionic and schizotypal 4.6% (N = 4) each, borderline 2.3% (N = 2) and self-defeating 1.1% (N = 1) (table V). There were multiple co-morbid disorders in a number of subjects. Thirty-one percent (N = 27) had one co-morbid disorder, 17.2% (N = 15) had two, and 3.4% (N = 3) had three or more axis I co-morbid disorders. When the sample was evaluated according to personality disorders, 24.1% (N = 21) had one co-morbid personality disorder, 19.5% (N = 17) had two, and 24.1% (N = 21) had three or more axis II co-morbid disorders. DISCUSSION Epidemiologic studies suggest that social phobia is more frequent in females than males in community samples. On the other hand, contradicting results have been obtained from clinical samples, stating female preponderance in some studies and male preponderance in Eur Psychiatry 2001 ; 16 : 115–21
others [19, 23, 28]. The majority of subjects (78.2%) in our study are male. This difference might stem from the higher expectancy society has of males in their roles as providers and professionals, thus causing males to seek treatment more than females. This is also true for Turkey. It is already known that help-seeking behavior is influenced by cultural factors. Although there are fewer studies in non-Western countries on this subject, in the study from India it has been reported that more male patients have been referred to mental health facilities [17]. An additional cultural feature of social phobia is the so-called suitability of social phobic features such as shyness and avoidance of social situations to the female gender. This might cause the fewer number of female social phobics seeking help from clinical mental health facilities. There have been data about gender differences in the clinical picture and coping styles [25]. Our sample shows no statistically significant differences by the severity of depression, anxiety and social phobic fears and avoidance, and history of the disorder. More extensive research is needed to clarify the motivations based on help-seeking and links between sex role and social anxiety. In various studies, single, divorced or widowed subjects have higher prevalence rates (38–65.7%) than controls [29]. Among our subjects, 73.6% never got married. That this rate is among the highest in the literature might be due to the fact that social phobics have difficulties in forming romantic relationships, and
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the majority of our subjects were students, who are younger than the average marrying age. There have been contradicting results concerning the relationship between social phobia and educational status. Social phobics are said to have a lower educational status than the controlled subjects, due to the negative effect of social phobia on academic success. According to other studies, social phobia is seen in people from higher educational status [12, 19]. This was explained by the fact that the higher educated the people, the more they report disability and seek treatment. Fortyone point four percent of our sample belong to the group of university graduates, and 35.6% are high school graduates. Social phobia is a disabling disorder of early onset, with a chronic course, generally starting at adolescence; the mean age of onset ranges between ages 14.6 and 23.5 years [3, 6, 20]. The mean age of onset in our sample is 16.2 years and the duration of the disorder was 10.2 years, which is in accordance with the findings in the literature. Early onset is a reason for the difficulty in differentiating social phobia from avoidant personality disorder. In a community study on social anxiety, speaking in public was the most feared situation (55%). In our study, we based our conclusions on those situations that are scored 3 or 4 in the LSAS. The most feared and avoided situations were all situations concerning performing or speaking in public, which is similar to the results of the related literature. Generalized type social phobia was defined in the DSM-III-R as a “social phobia including most social situations,” whereas specific social phobia was defined as a clinical subtype confined to one or two situations [26]. The reliability and validity of these subtypes were investigated and compared on clinical characteristics by other authors [14]. The two groups in our sample were significantly different on the levels of social phobic fear and avoidance. This result could be expected since the more situations the subject feared or avoided the higher the increase in the mean LSAS score. The majority of our sample had a diagnosis of generalized social phobia, which might be due to the increased need for seeking psychiatric help. The Epidemiological Catchment Area (ECA) study in the U.S.A. suggests that 69% of social phobics had another lifetime axis I diagnosis [19]. We found that 51.7% of our sample had a lifetime axis I diagnosis. The Zurich Study Group investigated the association between social phobia and agoraphobia and found that
the course of the two disorders was similar. In the ECA study, the co-morbid disorder with the highest prevalence rate was simple phobia (59%) and agoraphobia (44.9%) [23]. In a clinical sample, on the other hand, depressive disorders were the most prevalent disorders, while panic, generalized anxiety, simple phobia and obsessive compulsive disorders were seen consecutively among anxiety disorders [27]. Our results are roughly similar to these results. The frequency of subjects with more than one co-morbid axis I disorder in our sample suggests the possibility of having another co-morbid disorder if already one other disorder accompanies social phobia. The relationship between social phobia and alcohol and drug abuse has been investigated thoroughly in recent years [16]. It has been reported that social phobics abuse alcohol twice as frequently as the normal population [11]. In a community sample, 19% abused alcohol and 17% abused anxiolytics, while in a clinical sample 28.1% abused alcohol and 15.8% abused drugs [19]. Almost 50% of social phobics use alcohol and anxiolytics in social situations with which they have to cope. Two patients in our sample abused alcohol, whereas none of our subjects abused drugs or anxiolytics. Our results show that alcohol and drug abuse is not a major problem in our clinical sample compared to other results in the literature. It has been reported that social phobics tend to have suicidal thoughts more often than the general population, whereas those social phobics with co-morbid conditions make a suicide attempt five times more frequently than the normal population [5, 19]. In a study by Amies et al. [3], the rate of attempted suicide in social phobics has been reported to be 14%. The attempted suicide rate in our study is 4.6%, which is higher than the general population in Turkey, but lower than the rates in similar studies conducted in Western societies. This might be the result of a lower general suicide rate in Turkish society either due to the structure of the society or the effect of the Islamic religion, where suicide is considered to be sinful behavior. Another reason might be that those with a more severe depressive state with serious suicidal tendencies are generally hospitalized and are not followed up in this outpatient department. Jansen et al. [10] reported that 56.3% of social phobics have at least one personality disorder, the most common being avoidant, dependent, obsessivecompulsive and paranoid personality disorders. The most common axis II disorders in our sample were Eur Psychiatry 2001 ; 16 : 115–21
Social phobics in Turkey
avoidant (54.0%), paranoid, obsessive-compulsive and dependent personality disorders, which is similar with the results of the related literature [12, 18, 19, 24]. The high percentage of co-morbid avoidant personality disorder brings forward once again the issue of the interface between social phobia and avoidant personality disorder. The scrutiny and perfectionist style of obsessivecompulsive personality disorder might form a basis for the social anxiety and feelings of easily experiencing a failure by social phobics. CONCLUSION General characteristics of our sample show that this group of social phobic patients is young, male, and single with relatively high educational status. The frequency of axes I and II co-morbidity is close to the rates in the literature. Work status, alcohol and drug abuse and suicidality rates are lower than the rates in similar studies in the literature. The high co-morbidity of avoidant personality disorder with social phobia suggests the necessity of long-term follow-up studies with larger community samples to shed light on the issue of overlap between these two clinical conditions. REFERENCES 1 American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 3rd ed, rev. Washington, DC: American Psychiatric Association; 1987. 2 American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994. 3 Amies PL, Gelder MG, Shaw PM. Social phobia: a comparative clinical study. Br J Psychiatry 1983 ; 142 : 174-9. 4 Bisserbe JC, Weiller E, Boyer P, Lepine JP, Lecrubier Y. Social phobia in primary care: level of recognition and drug use. Int Clin Psychopharmacol 1996 ; 11 (Suppl 3 ) : 25-8. 5 Cox BJ, Direnfeld DM, Swinson RP, Norton GR. Suicidal ideation and suicide attempts in panic disorder and social phobia. Am J Psychiatry 1994 ; 151 : 882-7. 6 Davidson JRT, Hughes DC, George LK, Blazer DG. the epidemiology of social phobia: findings from the Duke Epidemiologic Catchment Area Study. Psychol Med 1993 ; 23 : 709-18. 7 Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959 ; 32 : 50-5. 8 Hamilton M. Development of a rating scale for primary depressive illness. Br J Clin Psychol 1967 ; 6 : 278-96. 9 Hirschfeld RM. The impact of health care reform on social phobia. J Clin Psychiatry 1995 ; 5 Suppl : 13-7. 10 Jansen MA, Arntz A, Merckelbach H, Mersch PPA. Personality disorders and features in social phobia and panic disorders. J Abnorm Psychol 1994 ; 103 : 391-5.
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