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Social Phobias |
Overcoming Anxiety (Home) > Social Phobias > Comorbidity Comorbidity: Definition and Anxiety Bipolar DisorderThe SP seldom occurs in its ‘‘pure’’ form and it has been estimated in most of epidemiological studies that a large part of patients with SP (from 70–80% to 92% in various general population samples) have at least one other psychiatric disorder during their life. The commonest comorbid disorders with SP, considering lifetime diagnosis, are panic disorder with agoraphobia (PDA), generalised anxiety disorder (GAD), major depressive episode (MDE), obsessive-compulsive disorder (OCD), AGO, simple phobia, eating disorders, alcohol and substance abuse/dependence. Moreover, SP often coexists with axis II disorders, especially avoidant personality disorder and obsessive-compulsive personality disorder. Comorbidity increases severity of social anxiety, causes greater disability and increases suicidality. The overall burden of the comorbid disease is greater both for the patient (greater disability) and for the health care services (greater use of medical services). However, comorbidity in SP may result in at least one positive thing: increased recognition and treatment, because in absence of comorbidity the level of recognition of the disorder is very low. The presence of comorbidity increases the number of suicide attempts: Davidson showed that the proportion of patients with suicidal thoughts rose from approximately 40% in those with SP and one comorbid disorder to about 60% in those with two or more comorbid disorders. Similarly, lifetime suicide attempts increased from 2% to 21%. Overall, the level of suicidality in SP is comparable with that for panic disorder. Recent findings (the NCS) have reported that the prevalence of comorbid conditions is higher in patients with complex (generalised) SP than in patients with speaking-only SP. This is especially true for mood disorders and other anxiety disorders whereas substance abuse showed little difference. Using DSM-IV criteria for detecting comorbidity, some association may be artificially increased, as different categories may have overlapping criteria, but it is clear that some relationship between SP and other disorder does exist. They may be interpreted in three ways:
When the temporal relationship between SP and comorbid psychiatric disorder has been investigated, SP precedes the comorbid disorder in the majority of patients. SP seems to be rarely a secondary complication of other disorders or to have an onset in the same year or in the same episode as another disorder. This consideration suggests that SP may be a risk factor for additional psychiatric disorders, but it is unclear whether SP is an aetiologic factor in the development of other disorders or whether SP and comorbid disorders result from common predisposing factors. It may also be that the occurrence of another disorder worsens social anxiety, thus rendering SP clinically evident. Major depression is one of the commonest conditions associated with SP. SP may have an aetiologic role for it; alternatively, major depression may be a consequence of the chronic disability associated with SP. For the SP sufferers, the extreme anxiety associated with social or performance situations often results in the abuse of, and ultimately dependence on, alcohol and BDZ. However, excessive alcohol consumption may actually precipitate anxiety symptoms, and thus a vicious circle between anxiety and alcoholism is established: in fact, although the subjects showed decreased anxiety shortly after drinking, they reported an increase in anxiety and dysphoria as they continued to drink. The physical consequences of prolonged and heavy drinking such as gastrointestinal disturbances and sleep disturbances may overlap with anxiety symptoms. Generalised anxiety disorder is also highly prevalent in all the anxiety disorders and its presence in social phobic patients indicates that a large number of them suffer from a pervasive pattern of maladaptive anxiety in addition to their more circumscribed social fears. The coexistence of SP with axis II diagnosis, as avoidant personality disorder and obsessive-compulsive disorder, may suggest that the fear of criticism and rejection, along with the tendency to be obsessional, are important features in the personality make-up of social phobics.
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