Social phobia in obsessive-compulsive disorder: Prevalence and correlates

Abstract

Background

Social Phobia (SP) is an anxiety disorder that frequently co-occurs with obsessive-compulsive disorder (OCD); however, studies that evaluate clinical factors associated with this specific comorbidity are rare. The aim was to estimate the prevalence of SP in a large multicenter sample of OCD patients and compare the characteristics of individuals with and without SP.

Method

A cross-sectional study with 1001 patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders using several assessment instruments, including the Dimensional Yale–Brown Obsessive-Compulsive Scale and the Structured Clinical Interview for DSM-IV Axis I Disorders. Univariate analyses were followed by logistic regression. Results: Lifetime prevalence of SP was 34.6% (N=346). The following variables remained associated with SP comorbidity after logistic regression: male sex, lower socioeconomic status, body dysmorphic disorder, specific phobia, dysthymia, generalized anxiety disorder, agoraphobia, Tourette syndrome and binge eating disorder.

Limitations

The cross-sectional design does not permit the inference of causal relationships; some retrospective information may have been subject to recall bias; all patients were being treated in tertiary services, therefore generalization of the results to other samples of OCD sufferers should be cautious. Despite the large sample size, some hypotheses may not have been confirmed due to the small number of cases with these characteristics (type 2 error). Conclusion: SP is frequent among OCD patients and co-occurs with other disorders that have common phenomenological features. These findings have important implications for clinical practice, indicating the need for broader treatment approaches for individuals with this profile.

Introduction

Psychiatric comorbidity is the rule rather than the exception in obsessive-compulsive disorder (OCD). Up to 90% of OCD patients have at least one additional diagnosis (Pigott et al., 1994, Yaryura-tobias et al., 2000, Tükel et al., 2002, Denys et al., 2004, Lasalle et al., 2004, Torres et al., 2006, De Mathis et al., 2008, Ruscio et al., 2010), which can increase not only the levels of distress, impairment and suicide risk, but also the likelihood of treatment seeking (Mayerovitch et al., 2003, Angst et al., 2005).

Depression is the most frequent comorbid psychiatric disorder in OCD (Pigott et al., 1994, Tükel et al., 2002, Denys et al., 2004, Torres et al., 2006, Kalra et al., 2008, Quarantini et al., 2010). Nevertheless, as a group, anxiety disorders are more prevalent (Weissman et al., 1994, Tükel et al., 2002, Torres et al., 2006). Among the latter, Social Phobia (SP) stands out (Douglass et al., 1995, Eisen et al., 1999, Denys et al., 2004) because it has been associated with longer duration of OCD (Diniz et al., 2004) and poorer response to pharmacological treatment (Carrasco et al., 1992).

Epidemiological studies have described the prevalence of SP in OCD ranging from 15.0% to 43.5% (Douglass et al., 1995, Grabe et al., 2001, Torres et al., 2006, Ruscio et al., 2010), whereas in clinical samples, the prevalence rates reported were: 14.0% (Austin et al., 1990), 15.6% (Tükel et al., 2002), 21.8% (Brakoulias et al., 2011), 23.4% (Eisen et al., 1999, Lasalle et al., 2004), 26.0% (Rasmussen and Eisen, 1988, Rasmussen and Eisen, 1992), 36.2% (Masi et al., 2006) and 42.0% (Crino and Andrews, 1996).

OCD and SP share several characteristics, such as increased autonomic response to certain stimuli and avoidant behaviors (Black and Noyes, 1991), overestimation of risks and catastrophic cognitions (Rapee and Heimberg, 1997), early onset of symptoms and a chronic waxing and waning course (Michels and Torres, 2004), considerable interference in social and occupational activities (Wittchen and Beloch, 1996; Lecrubier et al., 2000, Lipsitz and Schneier, 2000; Wittchen et al., 2000, Lochner et al., 2003, Niederauer et al., 2007, Torresan et al., 2008, Ruscio et al., 2008), preserved insight and treatment response to serotonin reuptake inhibitors and cognitive-behavioral therapy (Black and Noyes, 1991, Ponniah and Hollon, 2008, Baldwin et al., 2008).

Despite the high co-occurrence and the phenomenological overlap, little is known concerning the characteristics of OCD associated with SP (Baldwin et al., 2008). Therefore, the objectives of this study were to estimate the prevalence of SP in a large multicenter clinical sample of OCD patients and to investigate the sociodemographic and clinical characteristics associated with this specific comorbidity. In addition, we aimed to estimate the mean age at onset of other comorbid conditions associated with SP. Based on the literature, we hypothesized that OCD patients with comorbid SP, compared to OCD patients without SP would: (1) be more frequently male (Tükel et al., 2004), single, unemployed and have lower educational level (Wittchen and Beloch, 1996, Lecrubier et al., 2000, Wittchen et al., 2000, Lipsitz and Schneier, 2000, Acarturk et al., 2008); (2) present earlier age at onset of OCD symptoms (Jaisoorya et al., 2003), longer duration of OCD (Diniz et al., 2004), greater clinical severity, greater suicidality (Angst, 1993, Nelson et al., 2000, Dunner, 2001, Stein et al., 2001) and more symptoms of the hoarding dimension (Samuels et al., 2002, Samuels et al., 2007, Wheaton et al., 2008); (3) be more likely to present comorbidity with depression (Pigott et al., 1994, Merikangas and Angst, 1995, Essau et al., 1999, Lecrubier et al., 2000, Lipsitz and Schneier, 2000, Nelson et al., 2000, Stein et al., 2001, Dunner, 2001, Wittchen and Fehm, 2001, Wittchen and Fehm, 2003, Chartier et al., 2003, Hong et al., 2004) and other anxiety disorders (Merikangas and Angst, 1995, Chartier et al., 2003), body dysmorphic disorder (Wilhelm et al., 1997, Gunstad and Phillips, 2003), eating disorders (O'Brien and Vincent, 2003, Baldwin et al., 2008) and alcohol use disorders (Mullaney and Trippett, 1979, Merikangas and Angst, 1995, Lépine and Pélissolo, 1998, Essau et al., 1999, Lecrubier et al., 2000, Lipsitz and Schneier, 2000, Nelson et al., 2000, Wittchen and Fehm, 2001, Wittchen and Fehm, 2003, Myrick and Brady, 2003, Chartier et al., 2003, Buckner et al., 2008).