Brief report
Prevalence of social phobia in a clinical sample of drug dependent patients

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Abstract

Introduction

Social phobia is among the most frequent psychiatric disorders and can be classified into two subtypes, nongeneralized and generalized. Whereas it significantly worsens the morbidity of comorbid substance abuse disorders, and it often is associated with reduced treatment responses, there is still lacking data on its prevalence in clinical populations of drug abusing patients.

Methods

The study sample consisted of 75 inpatients and 75 outpatients meeting DSM-IV criteria for drug dependence. Symptoms of social phobia were assessed with the French-language version of the Liebowitz Social Anxiety Scale (LSAS).

Results

Prevalence rate were 20% for the generalized subtype and 42.6% for the nongeneralized subtype. Gender difference emerged in the severity of fear, women reporting significantly greater fear relating to performance situations than men.

Conclusions

An important proportion of patients with substance dependence present a comorbid generalized or nongeneralized social phobia. Early recognition of social phobia and adequate interventions is warranted for these patients in order to improve their treatment response with regard to quality of life and relapse prevention.

Introduction

Social anxiety disorder (SAD) is one of the most common mental disorders (Liebowitz, 1999). The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) distinguishes a generalized (GSP) and a nongeneralized subtype (NSP). Persons with GSP exhibit fear in a broad range of social and performance situations whereas NSP is primarily associated with one distinct performance fear. GSP is usually more persistent, more disabling, and associated with more psychiatric comorbidities (Heimberg et al., 2000, Sareen and Stein, 2000, Stein and Chavira, 1998).

Furmark et al. (1999) estimated SAD lifetime prevalences ranging from 1.9% to 20.4% depending on the method used to identify cases. In the National Comorbidity Survey, the lifetime prevalence of SAD was 13.3% (8.5% for GSP and 4.8% for the NSP) in the US population (Kessler et al., 1998, Magee et al., 1996, Rapaport et al., 1995), making it the third most frequent psychiatric disorders behind major depressive episode (17.1%) and alcohol dependence (14.1%) (Kessler et al., 1994). In Switzerland, Angst and Dobler-Mikola (1985) reported a prevalence of 4.3% of phobic states in a sample of young adults, and Wacker et al. (Wacker et al., 1992, Wacker, 1997) observed a prevalence rate of 16%.

Despite the fact that SAD is common in general practice settings, it is often under-recognized and under-treated (Sareen and Stein, 2000), which may be particularly be true in case of comorbid disorders.

One of the most frequently used clinician-administered scales for the assessment of SAD is the Liebowitz Social Anxiety Scale (LSAS) (Liebowitz, 1987). It has been shown to be reliable, valid and treatment sensitive (Heimberg et al., 1999, Mennin et al., 2002a).

The onset of SAD occurs typically prior to or during adolescence, during which social interpersonal relationships are important for identity formation. This may, among others, explain why SAD commonly precedes comorbid mental disorders such as alcohol and drug abuse, major depression disorder, dysthymia, obsessive–compulsive disorder, panic disorder and specific phobias (Angst and Dobler-Mikola, 1985, Brunello et al., 2000, Judd, 1994, Katzelnick and Greist, 2001, Kessler et al., 1999, Lipsitz and Schneier, 2000, Rapaport et al., 1995, Stein, 1997, Wittchen, 2000). Early identification and treatment of SAD, especially GSP, may therefore prevent the development of other disorders. Whereas several psychotherapeutic and pharmacotherapeutic approaches are presently well validated (Blanco et al., 2002, Zamorski and Ward, 2000), the recognition and treatment is poor (Zamorski and Ward, 2000, Weiller et al., 1996, Bisserbe et al., 1996). This may especially be true for drug dependent patients, as anxious symptoms often are induced by substance use or withdrawal. Its recognition in substance abuse patients is challenging but essential as anxiety disorders worsen the course of the addictive disorder (Thomas et al., 1999).

Besides a study published by Myrick and Brady (1997), who found 22 of 158 (13.9%) patients entering a pharmacological treatment trial for cocaine dependence meeting DSM-III-R criteria for SAD, there is, to our knowledge, no data on prevalence of SAD in clinical samples of drug abusing patients. The aim of the present study is to estimate the prevalence of SAD in drug dependent patients.

Section snippets

Study subjects

Two groups of totally 150 drug dependent patients participated to the survey. The first group of patients consisted in 75 subjects consecutively attending a University affiliated outpatients facility, and the patients of the second group (n=75) were recruited consecutively in the detoxification unit of the psychiatric university hospital of Lausanne. All patients met DSM-IV criteria for dependence of at least one of the following drugs: heroin, methadone, and cocaine. Exclusion criteria were:

Results

Table 1 presents the characteristics of inpatient and outpatient participants. The two groups were comparable with regard to age and gender. Inpatients drug use was more important than outpatients use considering severity assessed by the ASI drug's composite score (t(148)=2.37, p<0.05), amount of money spent for drug in the past 30 days (t(148)=4.47, p<0.05), and heroin use in the past 30 days (t(148)=5.18, p<0.05). On the other hand, methadone and benzodiazepines use in the past 30 days was

Discussion

The present study sought to examine the prevalence of SAD in drug-addicted inpatients and outpatients. Compared SAD prevalence in the Swiss general population, which ranges between 4.3% and 16% (Angst and Dobler-Mikola, 1985, Wacker et al., 1992), the proportion of drug dependent subjects reaching the LSAS cut-off for GSP was 20% in our survey. Furthermore, the proportion of patients presenting an NSP was 42.6%. In their survey on patients entering a pharmacological treatment trial for cocaine

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