Do your patients have social anxiety disorders?
Study finds 8.2% of HMO members affected
Your patient consistently refuses to attend a disease specific support group.
Another appears unwilling to keep follow-up appointments or schedule routine checkups.
If one of these scenarios strikes a familiar chord, it may be time to ask yourself whether your noncompliant patient may be suffering in silence from a disabling psychiatric disorder.
More than 10 million Americans suffer from social anxiety disorder. It is the third most common psychiatric illness in the United States, following closely behind depression and alcoholism. Yet, despite its prevalence, only 5% of patients with social anxiety disorder receive some form of treatment. (See box, below, for studies on social anxiety disorder.)
"Most patients with social anxiety disorder go untreated because the symptoms don’t shout at you like those of depression, or panic attacks," notes Jonathan R.T. Davidson, MD, professor in the department of psychiatry and behavioral science at Duke University Medical Center in Durham, NC, and director of the Anxiety and Traumatic Stress Program. "These people are quiet and reticent. Doctors aren’t trained to take them seriously."
Yet, left untreated, social anxiety disorder can be both socially and economically devastating to individuals and society. In addition, from a disease management perspective, one study found that 70% to 80% of patients with social anxiety disorder suffer from additional psychiatric conditions that add to the cost of treatment.
Presentation in Puerto Rico
A study of more than 9,000 members of a large health maintenance organization (HMO) presented by Davidson and several colleagues at the 37th annual meeting of the American College of Neuropsychopharmacology in Puerto Rico late last year found an 8.2% prevalence rate of generalized social phobia (GSP). Compared with HMO members without GSP, patients with social phobia had significantly more missed work hours, lower work and home productivity, greater overall disability, and more limitations on education. (See box on p. 79 for more data on this study.)
There are some behaviors which should cause providers to investigate the possibility of social anxiety disorder, notes Davidson. (See assessment tool, inserted in this issue.)
They include:
• Absenteeism at critical times. "If you have a patient out on disability due to a chronic illness such as congestive heart failure who fails to show up for an important evaluation or return-to-work conference, it may be a form of avoidance that is the hallmark of this disease."
• Excessive sweating.
• Nervous trembling.
• Blushing easily.
• Avoidance of eye contact. "People with social anxiety disorder feel very uncomfortable making eye contact, especially with authority figures," says Davidson.
• Substance abuse. "People with this disorder often use alcohol as a form of self-treatment. This tends to be more prevalent in men than women."
The good news is that social anxiety disorder is easily treatable, notes Davidson.
"These patients are easy and pleasant to work with. They want to please others and are grateful for any improvement," he notes.
There are several classes of drugs that are very effective in the treatment of social anxiety disorder, including selective serotonin reuptake inhibitors (SSRIs), monamine oxidase inhibitors (MAOIs), and benzodiazepines. In addition, patients sometimes benefit from cognitive or behavioral therapy, says Davidson.
Not only are effective treatments available, but most patients have remarkable improvement within three months of treatment. "If you have a patient who has been on drug therapy for social anxiety disorder for more than 12 months without improvement, you need to investigate why," he notes.
"There are great economic advantages in providing maximum health benefits and facilitating access to treatment for patients with social anxiety disorder," Davidson notes. "We must treat this as a real illness."
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