Am Fam Physician. 2000;61(11):3245-3252
to the editor: The article by Bruce and Saeed1 and the accompanying editorial by Stein2 state that social phobia, “an intense, irrational, and persistent fear of being scrutinized or negatively evaluated by others,” is the third most common “psychiatric disorder” in the United States. The definition includes such ordinary symptoms as shyness and fear of public speaking—if they cause “significant distress.”1 The authors of the article advise family physicians to make the diagnosis and treatment of patients with this condition a top priority.
This advice is troubling for several reasons. First, claims about the prevalence of social anxiety are speculative. Bruce and Saeed1 cite a one-year prevalence of 7.9 percent, but the recent Surgeon General's report3 cites a prevalence of 2.0 percent. Far from being “the most prevalent of the anxiety disorders,” as Stein asserts,2 social phobia is less common than simple phobia (8.3 percent), agoraphobia (4.9 percent), post-traumatic stress disorder (3.6 percent), generalized anxiety disorder (3.4 percent) and obsessive-compulsive disorder (2.4 percent).
Second, calling social anxiety a “psychiatric disorder” is troubling. At what point do the intense difficulties, fears and sadness of daily life become “diseases”? Is stage fright (which can qualify as social phobia1) pathologic? Giving it a code from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV)4 offers a diagnostic label (and invites pharmaceutical companies to earn millions of dollars from a new “indication”). However, it trivializes mental illness and weakens the argument, in health policy circles, that mental illness deserves parity with physical diseases. Calling social phobia a psychiatric disorder places it in the company of major depression, bipolar disorder and schizophrenia—all diseases that cause great morbidity. When being fearful at a party becomes the “disease” of social phobia and when the unbridled energy of children is branded as attention-deficit/hyperactivity disorder, we find ourselves on a slippery slope whereby all emotional irregularities become illnesses. New diseases beget new treatments, usually drugs, and often before good data are available to show that patients benefit. Pharmaceutical companies are understandably enthusiastic, but physicians should be wary.
Third, although social phobia causes pain, severe distress in public is no more painful or worthy of scrutiny by family physicians than severe distress in other life domains (e.g., marriage, work, parenting). Distress with one's self is probably the most important source of torment. So many problems of our time, ranging from depression to substance abuse, jealousy, domestic violence and racism, stem from poor self-acceptance and self-esteem. Seasoned physicians understand that getting help for these root causes is a greater priority than preoccupation with secondary symptoms. To launch a campaign around one such manifestation (social phobia) and to infer that reducing anxiety with a behavioral exercise or a medication (paroxetine [Paxil]) constitutes “treatment” misses the physician's larger duty.
Finally, even if social phobia outranks other forms of unhappiness, should it compete with the extant priorities of family physicians (e.g., heart disease, cancer, diabetes)? Too often, advocates call for greater attention to a disease without considering the long-term consequences. Tobacco use, the leading cause of death in the United States, claims 400,000 lives each year, but busy physicians counsel only 40 percent of smokers to quit.5 Those who do counsel patients devote an average of 90 seconds.6 Is it sound public policy for physicians to divert themselves from such counseling or from other interventions that have been proven to reduce morbidity and mortality, to inquire whether patients get nervous in public?
in reply: Dr. Woolf and Ms. Friedman question the difference between prevalence rates for social phobia cited in the Surgeon General's report1 and those referenced in our article.2 The Surgeon General's report1 considered two studies, the Epidemiological Catchment Area (ECA) study of the early 1980s and the National Comorbidity Study3 (NCS) of the 1990s. The Surgeon General's report1 footnotes, “For any mood and any anxiety disorder, the lower estimate of the two surveys was selected, which for these data was the ECA.” We cited the NCS3 data. The NCS attempted improvements over the ECA study, including the use of a national sample, younger subjects, a more comprehensive risk factor battery and an interview schedule modified to better match current diagnostic criteria (Composite International Diagnostic Interview, Version 1.0, University of Michigan [UM-CIDI])4 than the ECA study measure Diagnostic Interview Schedule (DIS).5 Authors of the NCS noted, “The assessment of social phobia, in particular, is more thorough in the UM-CIDI than in the DIS, and this may explain why the NCS estimate of the prevalence of social phobia is much higher than the ECA estimate.”3
Throughout their letter, Dr. Woolf and Ms. Friedman mischaracterize social phobia, then argue against those mischaracterizations. They equate psychiatric disorders with “diseases,” describe subthreshold examples of social phobia, and then question the validity of calling these diseases. The social phobia syndrome is not “being fearful at a party,” or “other forms of unhappiness,” or “getting nervous in public” any more than clinical depression is “feeling down” or dementia is “forgetfulness.” These trivializations ignore extensive basic and clinical research that support the syndromal validity of social phobia and its descriptive psychopathology.6 They ignore qualitative differences in features as well as the crucial distinction between a feature operating within a significantly distressing and disabling syndrome and one occurring in part and on a continuum in most people without significant impact. Ignoring these distinctions mistakenly qualifies any similar feature for the diagnosis and accounts for why most of us, on first read, seem to meet the criteria for most mental disorders. Establishing medical necessity for the treatment of social phobia is important, but rarely equivocal.
That pharmaceutical companies may profit from indications and have the greatest means for informing the public about any medical condition or treatment heightens our professional responsibility to provide evidence-based information to our colleagues, our patients and the public. We believe it not to be grounds for dismissing the evidence base that supports the validity of a syndrome or effective treatments—a data base for social phobia that predates recent pharmaceutical company interests by nearly two decades.
The claim that social anxiety disorder is one of many manifestations of “poor self-acceptance and self-esteem” is speculative and ignores extensive and empirical literature that supports developmental and therapeutic models on which effective treatments have been built.
To physicians and scientists who have worked with patients with this disorder, social phobia has demonstrated a capacity to cause significant distress and disability and lead to serious comorbidity and increased suicide risk, but it responds to specific interventions. We wrote this article to inform family physicians of these data at a time when patients with social phobia are being encouraged to seek their help. We recognize that by doing so, unfortunately and inevitably, demands are placed on health care providers, the payers of health care costs and the society of those who do not have social phobia, and also risks stigmatization of care-seekers by those inclined. To have not informed family physicians would have been to neglect our obligation to patient care.
in reply: Dr. Woolf and Ms. Friedman call into question the statement in my editorial1 that social anxiety disorder is “the most prevalent of the anxiety disorders.” In fact, the lifetime prevalence of social phobia was 13.3 percent in a recent cross-national epidemiologic survey, eclipsing that of all other anxiety disorders.2 The Surgeon General's report3 they allude to unfortunately contains data from a much earlier survey that had methodologic inadequacies with respect to the diagnosis of social phobia (and several other diagnoses, such as obsessive-compulsive disorder).
But let's not quibble about numbers. Let's look at the core of Dr. Woolf and Ms. Friedman's complaint. They argue that social anxiety disorder is unimportant and does not belong “in the company of major depression, bipolar disorder and schizophrenia—all diseases that cause great morbidity.” In fact, social anxiety disorder—like many other anxiety disorders—is associated with tremendous morbidity, reduced quality of life and economic costs to society.4,5
Even more troubling is their impression that “the physician's larger duty” is not to reduce suffering or to improve functioning, but to get at the “root causes” of mental illness. This is an argument that has imperiled the treatment of mental illness for decades. Yes, things like “low self-esteem” are part of the phenomenology of most depressive and some anxiety disorders. This is not to say that they are etiologic. At this stage of the game we, unfortunately, know little about the “root causes” of most psychiatric problems. But this has not stopped us from developing effective treatments. Numerous double-blind, randomized clinical trials have proven that anti-depressants and well-defined, focal psychotherapies are extremely effective in treating many patients with depressive and anxiety disorders, including social anxiety disorder.
Finally, Dr. Woolf and Ms. Friedman argue that it is not “sound public policy” for physicians to identify or treat social anxiety disorder. They trivialize social anxiety disorder by equating it with getting “nervous in public” in the same way critics in the past trivialized major depression by equating it with “unhappiness.” Although major depression was once maligned as an “indication” for pharmaceutical companies to treat the worried, the tide has turned. Now recognized as a top public health problem, major depression has become the focus of intense efforts to improve its detection and patient treatment in primary care settings.6
Will history repeat itself? Time (and further research) will tell us to what extent social anxiety disorder should be prioritized in the grand scheme of society's health agenda. Until that day arrives, I believe we owe it to our patients with social anxiety disorder to relieve their symptoms and lessen their morbidity whenever we have the capacity to do so.