At a time when family physicians are being asked to do more in less time for less pay, how should they react to the article1 in this issue of American Family Physician that calls for physicians to diagnose and treat social phobia?
A physician's first reaction might be something like this: “Social phobia? Let's get real here. Hypertension, yes. Diabetes, yes. Depression, okay. But social phobia? Why in the world should I care about social phobia?” There are a number of reasons why family physicians should care. Social phobia (also known as social anxiety disorder) is the most prevalent of the anxiety disorders. It affects over 5 percent of the general population and between 7 and 10 percent of patients who visit family physicians. So, it is extremely common, but is it a serious condition that deserves the attention of family physicians?
Social phobia is not the kind of illness that kills—unless, of course, the patient becomes depressed, which happens frequently to those with social phobia, and then the risk for suicide escalates. Rather, it is the kind of illness that robs patients of quality of life. Social phobia causes children to drop out of school early and to become lonely and isolated. Social phobia makes it difficult or impossible for adolescents to date or to go on to college. It causes people to turn down job promotions or to stay in dead-end, unrewarding positions because they fear having to interview for a new job. To cope, some people turn to alcohol, which can help relieve social anxiety in the short term but can lead to alcoholism and all of its complications down the road.
Even if social phobia is a serious problem, is it something that family physicians should be treating? Is being inordinately shy, self-conscious and nervous around other people really a medical disorder? Is this just an attempt by the pharmaceutical industry to find another indication to sell their drugs?
The fact of the matter is that if family physicians cannot afford to make treatment of social anxiety disorder a priority—and I use the term “afford” because it is a matter of economics of time, energy and money—then it will simply not get treated. Why do I say this? Because primary care physicians have become (or maybe always have been) the main providers of mental health care in developed countries. Few other outlets exist for patients to seek care. Even though school counselors, social workers and psychologists are alternatives, patients often have limited access to them. Moreover, therapists themselves often do not know much about this condition. It is true that highly effective nonpharmacologic treatments (e.g., behavioral and cognitive-behavioral therapies) exist for the treatment of social anxiety, but finding a therapist who is skilled in the application of these treatments can be difficult, if not impossible for a lay person. So, for most patients, the family physician is it.
Is social phobia a new disorder? No. Social phobia has been around forever, but physicians have tended to ignore it. Why has it been ignored? In part because good treatments have not been available, and in part because patients did not know that physicians recognized it as a treatable disorder (and, until recently, they were right), and so they did not seek help from us. This is about to change. Now that there is a medication labeled by the U.S. Food and Drug Administration for the treatment of social anxiety disorder—and probably more medications to come soon—patients will be exposed to publicity about the disorder and they will come to see their family physician, with magazine article in hand. Is this a good thing or a bad thing?
It depends on the situation. Family physicians in the business of treating illness (or, perhaps, promoting wellness) will be pleased with the opportunity to provide relatively simple interventions that can improve the functioning of those whose lives are constricted and embittered by social anxiety. Insurers who are in the business of paying for medical costs might be less than enthusiastic about being asked to pay for treatment of a “new” psychiatric disorder. I would submit that insurers have been paying for much of the treatment of social phobia anyway, but without knowing it—in many of the cases of chronic depression and some of the cases of alcohol dependence that have been covered. By identifying social anxiety disorder in these patients and implementing treatments specifically directed at the disorder, patient functioning and well-being are likely to improve.
After having been overlooked for years, social phobia is now in the spotlight. I am hoping that family physicians will choose to add it to the ever-growing list of maladies that they diagnose and treat. It is my experience that the treatment of anxiety disorders such as social phobia can be tremendously rewarding: patients frequently get better, often remarkably so. Family physicians should not be afraid to take this opportunity to learn about social anxiety disorder and its management.